What Do You Think?
Editor's note: In this issue we are continuing to publish responses to a news item
[Issue 3:23] about an American obstetrician who believes vaginal birth creates
"needless" pelvic floor disorders later in a woman's life. The news story
appeared to favor cesarean section as an acceptable alternative.
From a lecture by Marsden Wagner M.D. in New York City, April 2001
"Women will only agree to cesarean section (CS) if they are convinced it
is safe for them and their baby. One of the first efforts of obstetricians promoting
CS has been to take the scientific evidence on risks of CS and torture the data
until it confesses to what they want it to say. One example: Obstetric hype in
popular and professional magazines says research shows 60% of women who have vaginal
birth have urinary and fecal incontinence. But a careful reading of the research
papers they refer to reveals something very different. The hype lumps all women
with vaginal birth together instead of doing what the researchers did---dividing
them into risk groups. When analysis of risk was done, they found that women at
high risk for urinary and fecal incontinence have had large numbers of births;
have had babies weighing over ten pounds at birth; and most importantly, have
been the victims of unnecessary, aggressive obstetric interventions during their
labor and birth.
What are these aggressive, invasive obstetric interventions that have been proven
scientifically to cause permanent damage to the pelvic floor and urinary tract
and also lead to more otherwise unnecessary CS? One example is the use of powerful
and dangerous drugs to start or accelerate labor, a practice that has doubled
during the past 10 years. These drugs make labor abnormal with violent contractions
that can damage the uterus and pelvic floor. The only reason women agree to such
induction is because they are not told the truth about the drugs, for example
that Pitocin (oxytocin), a drug used for decades to induce labor, doubles the
chance the woman will have urinary incontinence in the future. By withholding
such facts doctors seduce to induce.
Induction with drugs is not the only aggressive, invasive intervention that
is frequently used in vaginal birth and is associated with damage to the urinary
system, pelvic floor and rectal areas. Episiotomy has been scientifically shown
to result in more pelvic floor damage than a natural tear. When an effort was
made in the 1980s to reduce CS in the United States, the rate of using forceps
or vacuum extractor to pull the baby out went up--some doctors just can't stop
doing invasive interventions. And there is good data that using forceps or vacuum
to pull the baby out has more risk of pelvic floor damage than any other form
of birth.
Obstetricians have turned birth into a surgical procedure and done damage to
women's bodies and now suggest the solution is to promote yet even more radical
and aggressive surgery, CS. The solution is less unnecessary invasive surgical
procedures during birth, not more."
[Re: the E-News article, Issue 3:23]: The two obstetricians tried to say that
vaginal birth can damage a woman, but they never pointed out the ways in which
CS can do harm not only to the woman but to the baby as well. The following excerpt
from my article "Choosing Cesarean Section" in The Lancet of
November 11, 2000 reviews some of the dangers associated with CS, the alternative
to vaginal birth that some doctors are trying to promote:
"In addition to the increased risk the woman will die with an elective
CS, there are other risks for the woman including the usual morbidity associated
with any major abdominal surgical procedure--anesthesia accidents, damage to blood
vessels, accidental extension of the uterine incision, damage to the urinary bladder
and other abdominal organs. (1) Some of these risks are common: 20% of women develop
fever after CS, most due to iatrogenic infections requiring diagnostic fever evaluation
for both woman and baby. (1)
There are also risks women carry to subsequent pregnancies due to scarring of the uterus including decreased fertility, increased miscarriage, increased ectopic
pregnancy, increased placenta abruptio, increased placenta previa (1,2,3). Recently
in the United States the widespread use of the unapproved drug misoprostol (Cytotec)
for labor induction has created a new risk of CS in subsequent pregnancies. Women
attempting VBAC who are given misoprostol have a rate of uterine rupture of 5.6%
compared with a rupture rate of 0.2% for women attempting VBAC not given misoprostol,
a 28-fold increase in risk of uterine rupture. (4) For women choosing CS, all
of these risks exist in all of their subsequent pregnancies even if the original
CS was not an emergency. The increased risks of ectopic pregnancy, abruptio placenta,
placenta previa and ruptured uterus are all life-threatening to both woman and
baby.
For whatever reasons women choose CS, very few are clearly informed about fetal
risks. In an emergency CS where the baby has developed a problem during the labor,
the risks to the baby of doing the CS will likely be outweighed by the risks to
the baby of not doing it. In an elective CS where the baby is not in trouble,
the risks to the baby from doing a CS still exist, meaning the woman who chooses
CS puts her baby in unnecessary danger. That some women are choosing CS strongly
suggests women are not told this scientific facts.
The first danger to the baby during CS is the 1.9% chance the surgeon's knife
will accidentally lacerate the fetus (6.0% when there is a non-vertex fetal position).
(5) Obstetricians may be less aware of this risk--in one study only one of the
17 documented fetal lacerations was recorded by the obstetrician doing the surgery.
(5)
A much more serious risk to babies born by CS is respiratory distress. Many
reports in the scientific literature document the CS procedure per se is a potent
risk factor for respiratory distress syndrome (RDS) in preterm infants and for
other forms of respiratory distress in mature infants. (1) RDS is a major cause
of neonatal mortality. The risk of newborn RDS is greatly reduced if the woman
is allowed to go into labor prior to the CS.
Another serious risk to the baby born by CS is iatrogenic prematurity (the baby
is premature because the CS was performed too early). Even with repeated ultrasound
scans, the standard deviation for estimating gestational age is large, creating
errors in judging when to do an elective CS. Doing the elective CS after the woman
goes into spontaneous labor would markedly reduce this risk as well. A vast literature
documents the increased mortality and morbidity, including neurological disability,
associated with premature birth."
1. Wagner M, 1994. Pursuing
the Birth Machine: The Search for Appropriate Birth Technology, Sydney, Australia:
ACE Graphics.
2. Enkin M, Keirse M, Renfrew M, Neilson J, 1995. A
Guide to Effective Care in Pregnancy and Childbirth , 2nd ed, Oxford University
Press.
3. Goer, H, 1999. The
Thinking Woman's Guide to a Better Birth. Putnam, New York: Penguin.
4.Plaut M, Schwartz M, Lubarsky S, 1999. "Uterine rupture associated with
the use of misoprostol in the gravid patient with a previous cesarean section,"
Am J Obstet Gyn 180:1535-42.
5. Smith J, Hernandez C, Wax J, 1997. "Fetal laceration injury at cesarean
delivery," Obstet & Gynecol 90:344-6.
So beware. Surgeons try to sell surgery. Never forget that obstetricians are,
after all, surgeons. Women must be extremely cautious in the face of this hard
sell and get the facts from those who do not have a vested interest in surgery.
- Marsden Wagner, M.D., M.S.P.H.
To read full-length articles by Dr. Marsden Wagner, go to Midwifery Today's
web site!
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Question of the Week Responses
Q: While listening to fetal heart tones late in labor
(when heard right above the pubic bone) it seems at times I hear cord sounds. This
usually happens when the baby comes with a nuchal cord. I now prepare myself for
a nuchal cord when I hear a cord pulsing at a woman's pubic bone, and I must say,
it is nice to anticipate this fairly unexpected event. Have any other midwives
found this to be true?
- Dawn
A: I noticed the same pulsations that you describe. I was at a particularly
long VBAC with an anterior placenta and a single sutured uterine scar. (This was
homebirth number 32 for me. Previously all deliveries were in the hospital with
fetal monitoring, not Dopplers, so I never noticed this phenomenon before. I've
been RN to at least 1000 if not 2000 laboring women). At this birth, as labor
progressed I began to hear the pulsation over the uterine scar. The ultrasound
report only said "anterior placenta." I assumed it was up high. When
I heard the pulsation below the FHTs and over the scar, I began to worry the placenta
was attached at the scar and there might possibly be an acreta. I wondered also
if it could be a nuchal cord? In fact, given the two situations, I was hoping
it was nuchal cord so that I would not have to transport mom for placenta acreta
post-delivery. Upon birth, there were two nuchal cords, and the placenta disattached
itself easily. My worry was for nothing. However, I was made aware of this phenomenon
with that birth and have since found it to be true, and it is nice to anticipate
a nuchal cord!
As a side note, I find it interesting that I never noticed this occurrence in
the hospital--nuchal cord was always a surprise. Variable decels were often not
related to a nuchal cord, and many times the monitoring strip looked beautiful,
yet there was a nuchal cord or two!
- Sandra
Oregon School of Midwifery
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Question of the Quarter for Midwifery Today Magazine
Theme for Issue No. 59: Prenatal
Question(s) of the Quarter: What are the essential elements of good prenatal care? How does prenatal care create better birth? As a midwife/doula, what do you hope to accomplish in the prenatal period with a pregnant woman?
Please submit your response by June 30, 2001 to editorial@midwiferytoday.com
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EDITOR'S NOTE: Only letters sent to the E-News official email address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER email addresses will not be considered.
In response to planned VBAC with expected dilation rate [Issue 3:24]:
I had a very long slow labor with my first beginning at about 4:00 am on a Thursday
morning when my waters broke after being up most of the night with gentle contractions.
I continued to have gentle contractions until 5:00 pm that evening when I finally
got to 5 cm. At that point labor settled and by midnight I was at 8 cm, by 4:00
am fully dilated and I delivered my son (8 lbs 6 oz. without episotomy, anesthetics
etc., in the position of my choice) by myself at 5:12 am. By the rules your doctor
is using I would have required a c-section. My doctor measured my progress by
things like how far the baby had descended toward the birth canal and how much
my cervix had thinned. These are much more accurate measures than the stupid centimeters-dilated
measure.
My doctor told me he had a rule for moms like me. Whenever he felt like interfering
he would go outside and have a smoke instead and then he would ask himself the
following:
1) Is the baby all right?
2) Is the mother all right?
3) Have we made any progress at all since the last time I checked even if it is something as simple as the head a little lower or the cervix a bit thinner?
If he could answer yes to all these questions, he would remind himself that 98% of the time nature knows best and he would wait a little longer. In his experience 98% of the time, no intervention would be needed later either.
He was a British doctor who had trained under midwives delivering babies at
home in England during WWII. He had the lowest c-section rates (2%) of any doctor
in the hospital and was very proud of it. He also had the lowest rates of complications
of moms and babies, intra- and postpartum, which he kept very careful track of
so it could be trotted out for comparison whenever his colleagues complained about
his methods, which at least one did every year.
My suggestion is to find a good midwife and leave the decision about when to
bring in an ob-gyn to her/him. A good one will know if s/he's in trouble and needs
a ob/gyn to take over. But otherwise avoid ob/gyns like the plague.
- Natalie Bjorklund
In response to Caroline's comments about oil of oregano [Issue 3:24]: Yes, some
oils are not to be used internally but many can be used without any harm to tissues
(see "Essential Oils Desk Reference" by Essential Science Publishing--espublishing.com
for specifics). North American Herb & Spice's oregano is backed up with a
whole host of uses spelled out in "The Cure is in the Cupboard" and
how to use it internally and externally. They agree that it should not be used
in pregnancy as very little research has been done. I did not suggest use in pregnancy
but in breastfeeding when there is a yeast/thrush infection. The only other alternative
to treat the deep-seated systemic infections is Diflucan which has serious liver
implications. It was designed to be given in one dose and yet most have to be
treated every day for two weeks to be effective. I think women should be told
that there is an alternative that has not had any serious side effects--the worst
being pizza breath.
- PJ Jacobsen, IBCLC
Regarding the episiotomy query, the only "new" method I know is never
to do one (unless there is foetal distress right at the end).
As for suturing, if you have to, use a material such as Vicryl Rapide along with
subcuticular suturing of the skin layer. This has been shown to reduce the amount
of perineal pain experienced. Further information can be obtained by reading Olah
(1994) British Journal of Midwifery 2 (2) 67-71 and Gemynthe et al (1996)
British Journal of Midwifery 4 (5) 230-234.
- Alison
Wales
There are many homeopathic remedies for hemorrhoids. Old farmers used to carry
horse chestnuts in their pockets to keep hemorrhoids away. Homeopaths use Aesculus--homeopathic
horse chestnut to treat them when they feel as if sticks were in them--sharp shooting
pains, purple painful, and worse standing and walking. Witch hazel can be applied
externally as well as taken internally homeopathically. Hamamelis is for hemorrhoids
that bleed profusely with soreness and a pulsation in the rectum. Homeopathic
sulphur is indicated specifically for hemorrhoids during pregnancy that burn,
are sore and may itch. Check out a homeopathic repertory (I like Robin Murphy's)
for more specific symptoms and remedies. Combination homeopathic creams can give
quick relief when you aren't sure which remedy to try.
- Cheryl
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