Archives for posts with tag: Epidural

In February, the New York Times ran six short pieces on home birth in its “Room for Debate” online feature.  I am going to discuss each of the pieces in posts over the next few days.

One of the featured pieces is titled “Home Birth is Not Safe,” written by two doctors who have made a number of anti-home-birth contributions to the medical literature.  Their NYT bio line says,

Amos Grunebaum is the director of obstetrics and Frank Chervenak is the obstetrician and gynecologist-in-chief at New York-Presbyterian Hospital, Weill Medical College of Cornell University.

Their work brings up a number of interesting issues to consider about home birth safety, but they also appear to conduct their research with an anti-home-birth agenda–Chervenak has written articles stating that it is unethical for MDs to participate in home births in any way and that it is the professional responsibility of all health workers to forcefully persuade women to birth in hospitals.  All birth data in the United States has limits, but Grunebaum and Chervenak’s use of vital records data to draw sweeping conclusions about home birth outcomes has been broadly criticized (e.g. here, here, and here).

Grunebaum and Chervenak say,

[i]n our research we have found that in the United States at least 30 percent of home births are not low-risk and that two thirds of home births are delivered by midwives who are not properly credentialed.

While I have argued that a woman has the right to birth wherever she chooses, regardless of risk, one might ask why a woman at high risk would choose to give birth at home when she has a hospital as an alternative.  Some women may be compelled to do so for religious reasons (and may not have full control of their choices), but it is also true that some well-educated, well-informed women also make the choice to have high-risk births at home.

Grunebaum and Chervenak acknowledge some of the problems with hospital-based obstetrical care that drive women to seek out home births even when their medical profiles indicate that they may need the kinds of medical interventions that are only available in a hospital-based setting.  They particularly note high numbers of “unnecessary C-sections” and lack of “compassionate care” in hospital births.

They propose as a solution that “the profession [of obstetrics] should strive for home-like hospital births.”

We know from his bio that Chervenak is in charge of the obstetrics unit at NY Presbyterian-Weill Cornell Medical College (NYP-WC).  If women are to shun home birth in favor of hospital birth, a good hospital environment must already be in place.  Let’s take a look at what he and his colleagues are doing to reduce unnecessary C-sections, provide compassionate care, and strive for home-like settings.

New York state now requires hospitals to report certain data, including C-section rates.  NYP-WC’s is 31.6%, a smidge below the national average, but hardly indicative of a culture that is eschewing unnecessary C-sections.  For the last year reported, there were only 38 VBACS at NYP-WC.

NYP-WC’s episiotomy rate is a whopping 25.7%.  Episiotomy is rarely necessary, and this rate is far, far above the home birth rate of under 2%.  According to a 2005 JAMA review by Katherine Hartmann and her colleagues, a national episiotomy rate of less than 15% should be “immediately within reach”–10 years later, NYP-WC is not on board, even though the national rate was already close to 15% by 2010.  Nearby Bellevue Hospital has a rate around 2%.   Compassionate care should not include cutting gashes in women’s vaginas for no reason.

Planned home births are generally attended by midwives.  Both certified professional midwives (who cannot attend hospital births) and certified nurse midwives (who most commonly work in hospitals) subscribe to “The Midwives Model of Care.”  The American College of Nurse Midwives summarizes this philosophy of care on its website–some notable components include:

  • Complete and accurate information to make informed health care decisions
  • Self-determination and active participation in health care decisions
  • Acknowledg[ing] a person’s life experiences and knowledge
  • […] therapeutic use of human presence and skillful communication
  • Watchful waiting and non-intervention in normal processes
  • Appropriate use of interventions and technology for current or potential health problems

Grunebaum and Chervenak brag that “we have a midwife teach our residents at NewYork-Presbyterian.”  However, they do not employ midwives to attend births.  Zero births at NYP-WC are attended by a midwife.  In addition, because they are a teaching hospital, NYP-WC has many births attended by residents whom the woman may not even know.  No one invites complete strangers into their home to attend their births.  Most women who have home births are seeking the Midwives Model of Care, but though Grunebaum and Chervenak acknowledge that CNMs can safely attend hospital births, they choose not to offer this option.

The hospital’s maternity unit has a “Patient and Visitor Guide: During Your Stay” that lays out standard processes and procedures on the unit, gives prospective patients an overview of what to expect, and lays out hospital and maternity unit policies.

The guide begins by saying that the hospital offers “Family Centered Care,” though what this means is not explained other than to say that rooming-in with the baby is encouraged.

They proceed to say that the woman’s care team may involve “your attending obstetrician, who is often your personal obstetrician or the doctor who admitted you, …[and] other medical or surgical specialists, as well as fellows or residents…[and] a pediatrician.”  But that’s just the doctors!  They say that the nursing staff is “constantly present” and indicate that there will be many nurses involved in care.  Other people involved in the hospital birth experience are care coordinators, unit clerks, physician assistants, lactation consultants, social workers, dieticians, nutrition assistants, housekeepers, patient escorts, and volunteers.  There is also a Rapid Response Team for emergencies.

I don’t know about you, but I’m not sure that many people could fit in my house.

The Labor and Delivery Unit is described as “comfortable, family-friendly, [and] private with soothing natural light.”  The birthing rooms are

spacious and light-filled birthing rooms [that] combine comfort with leading-edge technology. All suites are private and equipped with a special multi-positioned birthing bed, as well as state-of-the-art equipment for monitoring and delivering your baby. Your progress will be monitored regularly throughout labor, and your nurses will help you explore which comfort measures work best for you.

My home has a queen sized bed.  The most leading-edge technology in it is my iPhone.

Then we move on to pain management, and the real trouble starts.  Many women choose home birth because they want to be able to access a wide variety of non-pharmacological pain management strategies.  In my research, a frequent complaint from women who were not interested in epidurals was the pressure from hospital staff to have an epidural.  Here is what the guide says about pain management (emphasis mine):

The intensity of discomfort during labor and delivery varies from person to person. Some women may manage well with relaxation and breathing techniques. However, most women choose some type of pain relief. The majority of women receive analgesia (relief from pain without losing consciousness) from an anesthesiologist….The most effective methods for relief of labor pain are regional anesthetics in which medications are placed near the nerves that carry the painful impulses from the uterus and cervix, lessening pain and facilitating your participation in your delivery. Our anesthesiologists commonly use an epidural, spinal, or combined spinal-epidural to minimize pain.

Nothing is mentioned other than relaxation, breathing, and calling the anesthesiologist.  However, in home settings (and even at other hospitals) many women choose “pain relief” from any number of options that do not require an anesthesiologist, such as walking, changing position frequently, sitting on a birth ball, taking a warm shower, or submerging in warm water.  They may also get pain relief assistance from massage or from non-drug-based interventions such as acupuncture.  This is not a complete list.  It should be noted that all of these other options could be made available at home–the only one that could not is the anesthesiologist.  No mention is made of the risks of anesthesia nor of what can be done in the event that the epidural or spinal doesn’t work.  Choosing pain relief does NOT have to mean choosing an epidural–unless you are at this hospital, where according to the state more than 85% of women have epidurals (and that doesn’t include spinals and other medical methods).

Many of NYP-WC’s policies and standard procedures would preclude use of most pain relief options anyway.  Here’s what happens once a women is admitted to her birthing room:

your nurse will assess your blood pressure, pulse, and temperature, and place you on a fetal monitor. The nurse will monitor you throughout your labor and help you explore which comfort measures work best for you. An intravenous line may be placed to give you medication and fluids. You may also receive ice chips to help quench your thirst. Do not eat any food without your physician’s permission.

Not only are these policies not home-like, they aren’t even evidence based:

  • According to the Cochrane Reviews, continuous electronic fetal monitoring (EFM) in low-risk births increases a woman’s risk of an unnecessary C-section. Because the risks-benefits ratios of EFM and intermittent auscultation, in which a health care provider listens to the fetal heart rate with a Doppler or fetoscope at regular intervals, are similar, Cochrane recommends that women be given information and then choose for themselves.
  • IV fluids can also lead to complications, such as too much fluid in the mother or newborn.  In addition, having an IV in place is conducive to starting a cascade of interventions, as having the IV in place makes it easier to begin a Pitocin drip.
  • The Cochrane Review on eating and drinking in labor concludes, “Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labour for women at low risk of complications.”

cascade of interventions

(see original here)

Only two people can be with the woman in labor.  Last I checked, I was allowed to have whoever the heck I want in my house.

The hospital does not allow videorecording of the birth.  At home, you could live stream your birth if you were so inclined.

Rooming in is offered but not required.  Obviously at home, there is no nursery staffed by nurses.  In addition, rooming in is the standard for Baby Friendly Hospitals, as non-medically necessary separations can negatively impact breastfeeding.

One of the things many women appreciate most about their home births is the freedom to move around and to birth in any position they choose.  An acquaintance of mine who had an accidental home birth said that although she hadn’t planned it, she liked the experience, especially because “no one made me get on the little table.”  Another acquaintance said that as she was birthing, her OB asked that she get on her back for each contraction because, the OB said, “that’s the way I prefer to deliver.” Still another friend said that although there was a squat bar available in her birthing room, her OB refused to let her use it and threatened to leave if she would not lie on her back.

Notably, NOTHING is said in the guide about freedom of movement or position during labor or birth.  If a woman is tethered to a monitor and has an epidural, her movement would be curtailed even if hospital policy did not restrict her.

Finally, in the “Patient Responsibilities” section, the guide lists this “responsibility” (all emphasis mine):

Follow the treatment plan recommended by the health care team responsible for your care and the care of your baby. This group may include doctors, nurses, and allied health personnel who are carrying out the coordinated plan of care, implementing your doctor’s orders, and enforcing the applicable Hospital rules and regulations.

In your own home, you make the rules.

If Grunebaum and Chervenak want women to choose their hospital’s maternity care over a home birth, they’ve got a lot of work to do.

I have heard that some women have painless labors, though I have never met one of these women personally. However, from my personal experience, childbirth was not the worst pain I ever experienced–having my wisdom teeth out was much, much worse.  Plus, after the oral surgery, all I got was some stumpy, bloody teeth.  It was much more fun to get a baby.

That said, women are often terrified of childbirth pain, and analogies abound: take your lower lip and pull it over your head; piss a pingpong ball; poop a watermelon.

So generally women want to plan for some pain relief in labor and birth.  For reasons I don’t completely understand, what this relief entails becomes a matter of controversy.

The Bible justifies pain in birthing as a punishment for Eve’s sin in the Garden of Eden.  The New International Version of the Bible translates Genesis 3: 16 as, “I will make your pains in childbearing very severe; with painful labor you will give birth to children.”  You can read the predictions of  birth agony in various translations here: http://biblehub.com/genesis/3-16.htm

As such, when chloroform, ether, and other chemical/pharmaceutical/medical forms of pain relief became available in the 1800s, there were objections to their use on religious grounds because great pain and suffering during childbirth were seen as being ordained by God.  I am not Jewish or Christian, but it seems to me there is not a marked difference in the use of pain relief among Biblical believers vs. non-believers (except perhaps on the most extreme end of the spectrum).  You can read more about the social history of anesthesia here: http://ecti.english.illinois.edu/reviews/52/vannatta-snow.html

Some people now proclaim that wanting “natural” childbirth, or childbirth without chemical, pharmaceutical, or medical forms of pain relief, is anti-woman or anti-feminist.  And certainly denying women these forms of pain management (in a process involving shared decision making and informed consent) would be a terrible thing to do.  However, forcing women to have this kind of pain management or not informing them of their other options hardly seems “pro-woman.”

There are many ways to relieve pain.  We go through pain all the time in major and minor ways–sometimes we medicate it and sometimes we don’t.  Techniques such as deep breathing, distraction, counter pressure, heat, cold, water, massage, acupressure, dim light, and myriad other things can be effective in managing all kinds of pain, including labor and birth pain.  No one should tell women that these are her only possible options for pain relief either (unless she is in a situation where that is actually true, such as a surprise birth on the bus).

However, some people discount non-chemical, pharmaceutical, or medical forms of pain relief as no pain relief at all.  For instance, a recent article in Harvard Magazine about rising cesareans rates said that one woman profiled had “written up a “birth plan” that included trying to go without pain relief.”  I really, really doubt that her goal was to go without pain relief.  Who in their right mind says, “Let me feel every bit of  pain.  Let’s heighten the pain potential–bring it on!” (the article is available here : http://harvardmagazine.com/2012/11/labor-interrupted)

As such, while birthing centers are quite clear that they do not offer chemical, pharmaceutical, or medical forms of pain relief, hospitals are not always clear that they do not offer, suggest, or support non-chemical, pharmaceutical, or medical forms of pain relief.  For instance, if you ask a hospital if they have tubs for laboring women (birthing centers sometimes call these “aquadurals”), they may say “we don’t allow water birth.”  Getting water-based pain relief in first stage labor does not mean one has to deliver in the tub (though through shared decision making and informed consent, it seems that choice should be up to the woman as well).  Some hospitals will say a woman can bring her own tub.  It’s hard to imagine a situation where it would be suggested that a woman bring her own epidural.

No one gives marathon runners a hard time for wanting to run marathons.  In fact, running a marathon is usually seen as an achievement to be lauded.  To laud a women who wants to birth without an epidural or other drugs, however, is somehow seen as demeaning to women who do want epidurals or drugs.  Is a marathon runner demeaning to non-marathon runners?  Even if the marathon runner is actually proud of having run the marathon while you get a little winded when you go up the stairs too fast?

Women are capable of making their own decisions about pain relief, but first they need to know their options.  These options then need to be available.  Having a plan for an unmedicated birth also does not mean a woman can’t change her mind–just as deciding to run a marathon does not make it mandatory to finish it.  Even in a birthing center, a woman may choose to transfer to a hospital in order to get an epidural.  This happens.  And just as the marathon runner might be disappointed not to have finished the race, there is nothing wrong with a woman feeling a little disappointed if her pain relief  or other birth plans went awry.

There is no reason to demean any woman’s informed choice about pain relief in labor and birth, nor to deny or denigrate the forms of pain relief a woman ultimately chooses.  What it is important to do is provide complete and accurate information, make a full array of choices available, and support a woman’s plans and ultimate decisions.  That is being pro-woman.

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