Reducing Infant Mortality

[thanka2]

I submitted my last post without finishing the list.

Here is the continuation:

epinephrine
* Studies on animals show adverse effect and toxicity on fetus.
* No adequate and well controlled studies done on pregnant women.
* Drugs should be given only if the potential benefit outweighs the potential risk to the fetus.
# Teratogenic (capable of causing developmental abnormalities) in some animals.
# No well controlled human data but suggested possible association with eye, ear, digital defects and club foot during first trimester exposure, and with musculoskeletal defects and umbilical hernia during exposure anytime during pregnancy.
# It may cause uterine vessels spasm and potentiate the effects of oxytoxic drugs on the uterus resulting in fetal hypoxia and bradycardia.

morphine
* Studies on animals show adverse effect and toxicity on fetus.
* No adequate and well controlled studies done on pregnant women.
* Drugs should be given only if the potential benefit outweighs the potential risk to the fetus.
* Crosses human placenta rapidly.
* No adequate data in first trimester exposure but reported association with inguinal hernia after anytime use during pregnancy.
* Chronic maternal use of the drug causes neonatal withdrawal and respiratory depression.

So, the things that stick out about this information to me are:
-in every case "no adequate and well controlled studies [have been] done on pregnant women"
-almost every item has been found to have adverse effects and toxicity to the fetus in animals
-the reason why the narcotics are given is to make the effects of the drug last longer, otherwise there would be little point in going through the trouble of putting the needle in if the drugs would not hold for the length of the labor or c-section
-the drugs all pass the placenta and in the case of morphine it does so "rapidly" (as I had heard several people argue that "oh, these drugs only effect you--they don't ever get to the baby")
-and something I may or may have not mentioned is that right now at 7 months pregnant I'm allowed to take up to two panadol "safely" for any pain I have (and I've had some really serious back pain this time--that renders me incapable of working some days) and the doctor will continue to tell me that this is the appropriate dosage of pain medicine. I asked if I might use a topical pain reliever called voltaren which is simply a cream that is applied to the skin that many people use for arthritis pain or cramps. I was told strictly that this could be harmful to the baby and I should not do it. This is a rather "weak" topical treatment compared with an epidural. Yet, if I go to the hospital and I'm in labor, the thing that was deemed "harmful to the baby" the day before all of a sudden is administered without any reference to the possible risks. To me, that seems very unbalanced. I wonder if you ask most pregnant women, "So, what exactly is in an epidural and what are the potential side-effects and risks to mother and baby? Did your doctor go over this with you?"--how many women could say, "Yes, I was informed about this by my doctor" unless the woman herself was very proactive and asked the doctor and then hounded him for specific information. Maybe I'm completely wrong and doctors here and elsewhere do a great job of informing their patients of the risks.

In an unrelated thought--it is similar with birth control pills which carry an increased risk for blood clotting problems. I was never informed of this when I was prescribed the medication and not only that the doctor didn't even ask about my family history to see if I was at risk for this (which I am--my maternal grandmother had blood clotting problems and died of a blood clot and my mother has also had issues in the past). Eventually I started having chest pains and problems and only then discovered the risk I was taking with "the pill." I wonder how many other women experience this sort of situation.

 

[thanka2]

I also find myself wondering what is classified as a heavy narcotic. All narcotics are opiate-based; the drug in spinal epidurals most certainly is not.

What are the types of epidurals?

There are 2 basic epidurals used today. However, hospitals and anesthesiologists vary on the dosages and the combinations of medication they use. You will want to ask your care providers at the hospital about their protocol.
? Regular Epidural: After the catheter is in place, a combination of narcotic and anesthesia is administered through either a pump or periodic injections into the epidural space. The narcotic, such as fentanyl or morphine, is given to replace some of the higher doses of anesthetic, such as bupivacaine, chloroprocaine, or lidocaine, which helps reduce some of the adverse effects of anesthesia. You will want to find out your hospitals policies about staying in bed and eating.
? Combined Spinal-Epidural (CSE) or ?Walking Epidural?: An initial dose of narcotic, anesthetic or a combination of the two, is injected beneath the outermost membrane covering the spinal cord, and inward of the epidural space. This is the intrathecal area. The anesthesiologist will pull the needle back into the epidural space, threading a catheter through the needle, withdrawing the needle and leaving the catheter in place. This allows you to move more freely in the bed and change positions with assistance. With the catheter in place you may decide later to request an epidural if the initial intrathecal injection is not enough. You will want to find out your hospital?s policy on moving around and eating/drinking after the epidural has been placed. With the use of these drugs, muscle strength, balance and reaction is reduced. CSE should provide pain relief for 4-8 hours.

 

[thanka2]

I was one of the women who wanted a drug-free vaginal birth with no interventions. But hey, things changed, and I asked for an epidural after a couple hours on oxytocin. We all have different pain thresholds. I didn't feel it would adversely affect my baby. Furthermore, since I later had a c-section, I received more of the drug into my epidural, and then some more since it wasn't working well. My son came out kicking and screaming like a wild animal and got perfect responses in his apgar. He has not had a single serious health issue coming up on 2 years now. I can't say the same would have been true if he was born vaginally, who knows what might have transpired?

Granted, if you have to have an emergency c-section, of course you're going to have to have to have pain medication for that. I've just heard a lot of my friends say very lightly, "Oh, well, if it hurts, I'll just take an epidural but, I'm going for a drug-free birth."

Yes, there are situations that are out of our hands and there is a time and place for everything but it just makes me wonder how informed women really are about what they're putting into their bodies that could influence their child--if it's just as easy to choose an epidural (which if a woman plans to use one and it's not administered in an unplanned or emergency case, is administered in early labor before one would know for sure if they need it or not) as it is to pop a couple of panadols--as far as the thought process that goes into that choice (for many of my friends and acquaintances at least).

And one of the things that hasn't been adequately studied, I feel, is the long-term effects of these drugs on childrens' development. They may be breathing fine at birth and pass all the initial vital sign testing but that doesn't tell us down the road if the drugs have had any cognitive effect on the child. And I think maybe some of the problems children come up against in development later that are attributed to other things (or attributed to "we don't know why") possibly could linked back to things such as drug exposure at birth. No way to know because although "adequate studies have not been conducted" the drugs are assumed to be safe.

 

[thanka2]

If you would like to read an excelent book on this topic I recommend,
Impact of Birthing Practices on Breastfeeing by Linda J. Smith
(To be truthful the book is about how interventions in our birth affect the next stage of reproduction - but then that is my area of knowlegde!)
Best wishes,
SARAH

This is an Podcast interview with her that I came across. She is talking about the subject matter from her book. Worth a listen.

http://www.llli.org/mp3/LLL_Podcast_ImpactOfBirthingPracticesOnBreastfeeding.mp3

A few quotes from the interview:

"When I was having my children I learned one La Leche League's ten concepts...alert and active participation in birth makes a difference initiating breastfeeding."

"As a lactation consultant in the early 90s, as the epidural rate started going up I started encountering more and more normal, healthy, full-term babies that couldn't suck and this was very distressing to me because it wasn't the mother's motivation, these were kids who were otherwise fine but would open their mouth, go to breast and stop. So, I started digging and researching and I found at least five contributing factors that were responsible for the types of babies I was seeing and those five were caesarean birth, epidural anaesthesia, induction, forceps and vacuum. Now, not every baby that has those comes up with sucking problems, on the other hand, of the babies I saw for a three-year period, over 70% of the suck problems were attributed to one or more of those. It was only a survey of my clients in one mid-western city. I started digging further...."

She goes on to talk specifically of a large medical study published in the British Journal of OBGYN talking about fentanyl (one of the drugs I posted about further up that is routinely used in epidurals) showing that it is dose-related to problems with infant feeding.

She speaks of how OBGYNs often don't focus on infant outcomes and often pediatric doctors often don't feel that they have any say or influence in OBGYN care. The focus of the OBGYN is essentially the mother and her welfare and comfort and the baby secondary to that.

She also sites other studies that show that when two drugs from the list (in epidurals, posted above) bupivacaine and sufentanil were administered, the babies often had motor delays (which affects the sucking reflex) for up to a month after they are born--and the study stopped measuring children at a month old so they don't know how much longer the affect is present.

She added that many will argue that the drugs and methods of administration have changed over the year (and presumably better) but she adds that in her line of work the effects that they see have not changed.

She talks about the fact that vaginal birth is healthy for the baby as it forces the release of endorphins in the baby but when the baby and there are quite a few interesting things surrounding that--that actually this eventually affects the quality of milk that the mother can give (milk has natural pain relievers in it--but because of anaethesia those pain relievers are dulled and not present in the milk after the birth).

Anaesthetic drugs reach the baby in 15 seconds to 2 minutes according to Hale and other pharmacologists. They are designed to go to the nerve centers in the mother's brain. They are very fat-soluable drugs because the brain is very high fat--it's over 50% fat. And they [the drugs] go to the baby's brain very quickly. The anaesthsia literature shows that it [the drugs] shows up in cord blood. Some of it [the drugs] that take 20-30 minutes to be half gone [the half-life] from the mother may take 8 or more hours to be half gone from the baby. And it takes about 5 half-lives for it [the drugs] to clear 98.something% from the baby's body--if the liver is doing well....assuming there are no other injuries to the baby [forceps caused etc.] and that the baby is healthy and thriving otherwise...

She also points to the fact that the research shows that having a trained advocate or birth partner or doula assisting cuts the c-section rate in half and dramatically decreases womens' use of drug pain relief and results in better outcomes for babies and mother.

Research has shown that mothers mother their babies the same way they were cared for in labor.

She points out that women should be free to move about and adopt any position to help facilitate labor, allowed to eat and drink freely--self-regulated (it gives her more energy allowing the uterus to contract better), allowed to get into a tub of water or use water birth--all of these things help facilitate labor

Squatting opens the pelvis by some 30% and allows the baby to descend easier...If you're laying horizontal...I mean, who wants to push uphill? Gravity works.

 

[laial]

1. Voltaren is a non-steroidal anti-inflammatory, which has a completely different mode of action to opioids. It can cause premature closure of the fetal ductus arteriosus and is absolutely contraindicated especially in the third trimester. On the other hand, opioids, despite being considered a “stronger” analgesic, have different pharmacological properties and are not contraindicated.

2. Perinatologist = neonatologist

3. It is true that there are “no adequate and well controlled studies done on pregnant women” for most drugs, and this is largely because it is very difficult to get ethics approval for most things in pregnancy. Do the studies done on fetuses in animals take into account things like drug levels in maternal circulation? (because most epidural drugs are only in small quantities in the maternal circulation and have minimal effect on the fetus at this level, however at higher levels they can cause adverse effects). Also for risk of being sued, drug companies will rarely say that any drug is 100%safe in any situation – they will usually caution every little thing (take a look at your paracetamol packet info next time you take some – they have lots of cautions on them, however we still take them like lollies). It is known that paracetamol causes adverse effects when taken at doses exceeding the 4g/day, but that won’t stop you from taking it below that threshold. To have a truly holistic approach, one would not even take paracetamol for back pain – one would try other “natural remedies”.

4. The squatting position does indeed help bub descend easier, but it has also been associated with an increased risk of 3rd and 4th degree tears. Gravity is great, but it doesn’t control the rate at which bub comes out – hence the perineum bears the grunt of it. So as I’ve said previously, there are pro’s and con’s to everything and it is up to the individual to decide on where they place their priorities.

5. “Obstetricians don’t focus on infant outcomes” – if this was the case, why are obstetricians often guided by fetal heart rate traces and fetal scalp blood samplings when it comes to whether or not to do an emergency delivery? Why would obstetricians do so many ultrasounds (apart from the insurance money) to monitor baby’s growth and wellbeing? Everyone wants a healthy baby. Obstetricians, however, as it is their specialty, also have to focus on the mums; where as the paediatrician’s specialty is to focus on bubs. There’s a reason that there are different specialties. If I was having a caesarean section, I certainly wouldn’t not want a paediatrician to be doing it. Lets not forget that obstetric emergencies can also be extremely serious for mums. What’s the point in having a healthy baby if mum has died during childbirth?

6. Intervention in pregnancy and labour (as with the rest of medicine) is continually under research and evolving all the time. It is not without its flaws (neither is anything else), which is why there is so much research. No intervention is ever done without being proved by research. But I do wonder how much research goes into “non-intervention” and not doing anything? – eg if bub’s heart rate has been sitting at 60beats per minute for the past 10 minutes, why don’t we do a trial and see what would happen if we didn’t run for an emergency caesarean section? (that was sarcastic by the way). If you were in an emergency situation and bub was in distress, a truly holistic approach would be to decline an emergency delivery and let the baby deliver “naturally” with your doula present. It’s not very nice to be saying that obstetricians are bad and you “take what they say with a grain of salt” because they intervene too much, but when push comes to shove and bub’s getting distressed, you expect them to come and deliver your baby.

7. Bottom line is, as this thread is about “infant mortality” – it has been shown that infant mortality rates in the western world is significantly better than those in the developing world. The main reason for this is medical advances and “intervention”. All intervention have benefits and risks – it’s all well and good to go on about how risky they are and how much harm they are doing, but let’s not forget the benefit that they can also provide.

 

[laial]

By the way, if a mum wants to have an epidural, she is a grown adult and can make her own decisions - so let her have one. It is not for anyone else to judge her decision. Same goes with caesarean sections and everything else - even though I am an advocate for normal vaginal deliveries, if a mum wants a caesarean for whatever her reasons are, given that she knows the facts, it is not for anyone else to judge or comment her decision.

 

[Shenzhennifer]

My favourite person during my labour was the anaestesiologist (until my doc delivered my baby, of course). He was the only person in the whole process that properly helped me with that awful pain
It's nice to say that I would like to have a drug free natural birth, but when push came to shove and my pitocen-inspired contractions were frequent, long and tripling up, with a still closed cervix, I welcomed relief.

 

[thanka2]

1. Voltaren is a non-steroidal anti-inflammatory, which has a completely different mode of action to opioids. It can cause premature closure of the fetal ductus arteriosus and is absolutely contraindicated especially in the third trimester. On the other hand, opioids, despite being considered a “stronger” analgesic, have different pharmacological properties and are not contraindicated.

Thanks for clearing that up.

2. Perinatologist = neonatologist

Thanks for clearing that up.

3. It is true that there are “no adequate and well controlled studies done on pregnant women” for most drugs, and this is largely because it is very difficult to get ethics approval for most things in pregnancy. Do the studies done on fetuses in animals take into account things like drug levels in maternal circulation? (because most epidural drugs are only in small quantities in the maternal circulation and have minimal effect on the fetus at this level, however at higher levels they can cause adverse effects). Also for risk of being sued, drug companies will rarely say that any drug is 100% safe in any situation – they will usually caution every little thing (take a look at your paracetamol packet info next time you take some – they have lots of cautions on them, however we still take them like lollies). It is known that paracetamol causes adverse effects when taken at doses exceeding the 4g/day, but that won’t stop you from taking it below that threshold. To have a truly holistic approach, one would not even take paracetamol for back pain – one would try other “natural remedies”.

I never said that I have taken paracetamol. I took one dosage (in October this year at about 20 weeks pregnant) because I was in pain but I had misgivings about it for exactly the reasons you mentioned. I have just sucked it up and not taken anything for pain since and there has been a lot of pain to deal with. But, I did inquire with the doctor to see what the treatments are as a friend had mentioned voltarin but the three doctors I've seen have said the same thing.

4. The squatting position does indeed help bub descend easier, but it has also been associated with an increased risk of 3rd and 4th degree tears. Gravity is great, but it doesn’t control the rate at which bub comes out – hence the perineum bears the grunt of it. So as I’ve said previously, there are pro’s and con’s to everything and it is up to the individual to decide on where they place their priorities.

Interesting. I totally advocate the squatting position or kneeling (tried both and many other variations on position) but at the time when I actually gave birth I was exhausted and my legs were cramping so neither ended up working for me. I physically didn't have the strength.

5. “Obstetricians don’t focus on infant outcomes” – if this was the case, why are obstetricians often guided by fetal heart rate traces and fetal scalp blood samplings when it comes to whether or not to do an emergency delivery? Why would obstetricians do so many ultrasounds (apart from the insurance money) to monitor baby’s growth and wellbeing? Everyone wants a healthy baby. Obstetricians, however, as it is their specialty, also have to focus on the mums; where as the paediatrician’s specialty is to focus on bubs. There’s a reason that there are different specialties. If I was having a caesarean section, I certainly wouldn’t not want a paediatrician to be doing it. Lets not forget that obstetric emergencies can also be extremely serious for mums. What’s the point in having a healthy baby if mum has died during childbirth?

I think what the heart of what I was saying that the obstetricians primary focus is the mother and the baby is secondary to that--of course they are both priority. Too bad you can't have the benefits of having a doctor who is equally specialized in both fields. Yes, there are emergencies but not every birth is an emergency. A great many births might be pulled off without a hitch were it not for unneccessary interference, in my opinion.

6. Intervention in pregnancy and labour (as with the rest of medicine) is continually under research and evolving all the time. It is not without its flaws (neither is anything else), which is why there is so much research. No intervention is ever done without being proved by research. But I do wonder how much research goes into “non-intervention” and not doing anything? – eg if bub’s heart rate has been sitting at 60beats per minute for the past 10 minutes, why don’t we do a trial and see what would happen if we didn’t run for an emergency caesarean section? (that was sarcastic by the way). If you were in an emergency situation and bub was in distress, a truly holistic approach would be to decline an emergency delivery and let the baby deliver “naturally” with your doula present. It’s not very nice to be saying that obstetricians are bad and you “take what they say with a grain of salt” because they intervene too much, but when push comes to shove and bub’s getting distressed, you expect them to come and deliver your baby.

Hmmm....I disagree that a truly holistic approach means that you "do nothing"--there are many things that you can do that don't involve major interventions. A good doula or midwife will do just as good of a job as a doctor--I know this because I had one. It's not that they "do nothing"--they just do things very differently with a very different mindset/approach. They don't take a completely hands-off approach and to consider holistic medicine as a completely hands-off approach is a pretty big misunderstanding. But, it's like this analogy. Giving birth (especially for the first time) is similar to swimming. It's something that the body can and was designed to do. Doctors and midwives should be seen as lifeguards. If I know how to swim and I'm in the pool swimming but maybe I'm breathing a little hard or it's difficult, is it appropriate for the lifeguard to jump in and try to yank me out of the water in an effort to save me? Actually, these professionals are there in case something goes truly wrong. My main argument is that the more they meddle with the natural course of things (I'm not talking about truly emergency situations here as well--which seems I've been misunderstood on this point. I suffered a truly emergency situation myself during my birth and my midwife responded appropriately--she in no way took a hands-off approach.) the more chance there is for things to actually turn into an emergency.
I wasn't speaking only of obstetricians when I said I take what most doctors say "with a grain of salt." I never said that they were bad (another phrase that was put into my mouth). I do believe that the culture/mindset of the profession is to meddle. Not all doctors do. But, I have noticed in Hong Kong especially that the system is very "doctor centric"--many doctors do carry an attitude of, "Sit down, shut up because I'm the doctor." Very rarely have I encountered actual discussions about my health where I was a respected contributor. The doctors here are used to just giving out orders without discussion from their patients--most people don't question their doctor here, I think. The majority of traditional doctors I've see, obstetrician or otherwise, have not done much good for me healthwise and I have simply found from personal experience much more relief and genuine healing in holistic methods.

7. Bottom line is, as this thread is about “infant mortality” – it has been shown that infant mortality rates in the western world is significantly better than those in the developing world. The main reason for this is medical advances and “intervention”. All intervention have benefits and risks – it’s all well and good to go on about how risky they are and how much harm they are doing, but let’s not forget the benefit that they can also provide.

Why do you think then, that over the past 20 years (since the rates of c-section, induction and epidural went up significantly) infant mortality rates have done a reversal and started to rise, whereas in the previous 50+ they were falling? One other culprit that I've read about may be obesity. What do you think? When you say "it has been shown" what are you referring to? Also, what do you make of the correlation between elective c-section rates in the United States and infant mortality vs. say, statistics from Europe?

Could it also be that infant mortality rates in the western world are significantly lower because women eat better, have access to medical care and give birth in sterile environments? I don't think that this video was at all saying that interventions have not in many cases added a great deal of good to the health of mothers and babies. I think this video talked about their overuse.

 

[TNT]

I am very interested in this discussion because I agree with the basic premise of the video that interventions are on the whole over used. I did a natural birthing course before the birth of my first child and a number of the very same points were raised, in the context that it was important to understand this medicalisation of child birth when aiming for a natural birth in a medical setting. As I was giving birth at a private hospital with very high casesarean rates and also being an older first time mother the odds were not in my favour, but I wouldn't be accepted at a birthing centre (due to my medical history and age). The aim was to help me and others understand that the priority for many in that hospital setting was not an invervention free birth and therefore both myself and my husband would likely have some work to do to achieve this. As a result we bought our own private midwife along to the birth as a doula and it made a hugh difference. Unfortunately I didn't achieve an intervention free birth the first time, but having her there made me totally confident that we have done all that we could (at least in that setting) to avoid it and so I was very comfortable with the outcome.
I also realised going into the birth that it would be very, very painful and hard work (the course was very blunt about this and we saw lots of vidoes etc which made it clear it would not be easy) and so I really understand what thanka2 is sayng in this context; I think most people would say they wanted a drug free birth but because of their lack of knowlege about what is actually involved - totally normal- and how long they are likely to be in a lot of pain for when labour actually starts (and you can labour for a very long time before you are even 3 cm and ?fficially' in labour) and the fact that it is likely you will be offered an epidural or pain relief when you are at your most vulnerable, means it is very difficult to achieve unless you have fully prepared yourself - and even then you may not.
Having said all that I totally understand the 'screaming for an epidural' situation - I did this myself at transition with my second birth. Luckily for me the very supportive midwife who recognised I was in transition and knew how important a drug free birth was to me suggested I go the the toilet before the anaesthatist arrived; being in this position lead to 3 massive contractions which meant I was fully dilated and ready to push. The other midwife was ready to give me the epidural (they were both from the hospital this time, but one I had met several times before the birth and we had discussed birth and interventions in details) and if she had been the only one there, I would've accepted it at the time and regreted it later. The enviroment and people involved can make all the difference.
I did not have either of my babies in HK and if I had one here I would be making a lot of enquiries to carefully choose my ob as for many of the reasons given by thanka2 I think it would very hard to achieve for a first time mum here, having done it before gives both the mother and the dr greater confidence that it is possible.

 

[thanka2]

By the way, if a mum wants to have an epidural, she is a grown adult and can make her own decisions - so let her have one. It is not for anyone else to judge her decision. Same goes with caesarean sections and everything else - even though I am an advocate for normal vaginal deliveries, if a mum wants a caesarean for whatever her reasons are, given that she knows the facts, it is not for anyone else to judge or comment her decision.

My question is are women really informed of the facts in detail? Is that common practice? Is it required? Are they given the facts and studies about the drugs in some abridged form to look over before they even set foot in a hospital so they can truly make an informed choice? In my country, even when I go to the supermarket pharmacy to pick up my prescription drugs, the law dictates, that I must have a consultation with the pharmacist in which they go over the specifics of the medication and any possible side-effects/dangers of taking it. Then, I must sign a form stating that I was informed. This is simply if I want to pick up an antibiotic for strep throat. It would be interesting to know if the same sort of system exists when it comes to informed consent with birth interventions.

Women do and will make their own decisions as it should be. My problem arises from a system that seems to skim over topics that should be discussed in more detail. It's one thing to say, "I was informed. I know and I choose this for myself and my child" (in the case of elective interventions) than to say, "Well, it can't possibly do any harm--my doctor/nurse/midwife etc. did not present any information to the contrary so I make this decision believing that the risks are nil." And from my experiences with doctors in Hong Kong that often do a lot to scare their patients right off the bat ("you'd better do this, this and this or your child will end up with this, this and this"), it is strange to me that they wouldn't make it a point to really paint use of interventions in the most graphic light possible as it seems they have a knack for, and for lack of a better expression, fear mongering.

 

[thanka2]

I am very interested in this discussion because I agree with the basic premise of the video that interventions are on the whole over used. I did a natural birthing course before the birth of my first child and a number of the very same points were raised, in the context that it was important to understand this medicalisation of child birth when aiming for a natural birth in a medical setting. As I was giving birth at a private hospital with very high casesarean rates and also being an older first time mother the odds were not in my favour, but I wouldn't be accepted at a birthing centre (due to my medical history and age). The aim was to help me and others understand that the priority for many in that hospital setting was not an invervention free birth and therefore both myself and my husband would likely have some work to do to achieve this. As a result we bought our own private midwife along to the birth as a doula and it made a hugh difference. Unfortunately I didn't achieve an intervention free birth the first time, but having her there made me totally confident that we have done all that we could (at least in that setting) to avoid it and so I was very comfortable with the outcome.
I also realised going into the birth that it would be very, very painful and hard work (the course was very blunt about this and we saw lots of vidoes etc which made it clear it would not be easy) and so I really understand what thanka2 is sayng in this context; I think most people would say they wanted a drug free birth but because of their lack of knowlege about what is actually involved - totally normal- and how long they are likely to be in a lot of pain for when labour actually starts (and you can labour for a very long time before you are even 3 cm and ?fficially' in labour) and the fact that it is likely you will be offered an epidural or pain relief when you are at your most vulnerable, means it is very difficult to achieve unless you have fully prepared yourself - and even then you may not.
Having said all that I totally understand the 'screaming for an epidural' situation - I did this myself at transition with my second birth. Luckily for me the very supportive midwife who recognised I was in transition and knew how important a drug free birth was to me suggested I go the the toilet before the anaesthatist arrived; being in this position lead to 3 massive contractions which meant I was fully dilated and ready to push. The other midwife was ready to give me the epidural (they were both from the hospital this time, but one I had met several times before the birth and we had discussed birth and interventions in details) and if she had been the only one there, I would've accepted it at the time and regreted it later. The enviroment and people involved can make all the difference.
I did not have either of my babies in HK and if I had one here I would be making a lot of enquiries to carefully choose my ob as for many of the reasons given by thanka2 I think it would very hard to achieve for a first time mum here, having done it before gives both the mother and the dr greater confidence that it is possible.

I appreciate your input TNT. You said very well many things that I was thinking, actually. We also attended a lengthy natural birthing course (would be interesting to know which one you did--you can PM me if you like) that lasted 12 weeks and required a lot of research and homework as well as practical practice for labor. I feel like I was also well-prepared (as much as I could be for a first birth) for the painful reality of labor and a gameplan for how I was going to deal with it. And I chose to commit early on to a natural childbirth, despite the pain. I didn't leave myself "a way out" (so to speak) but just set in my mind that "Okay, labor is going to be painful and difficult and unpredictable but no matter what, as long as it is within my power to choose (barring true emergencies) I choose a non-intervention birth." I think having that mindset changed my entire perspective for the duration of my pregnancy and birth.

I felt I was also educated about the medicalisation of labor and birth as well as interventions. We watched numerous videos on c-sections, epidurals and augmentation just to prepare myself mentally. I felt it was important that although my choice was not to utilize any of the above, to have a knowledge of what they are and how they are administered should an emergency arise that required some intervention. I guess I didn't give myself the "benefit" of remaining in the dark on these subjects. (and I HATE to see blood and surgeries in videos so it really took some effort to watch these!)

And your point about the hospital systems having different goals from that of a couple seeking to go through an non-intervention birth is spot on! It really is a collision of different views and schools of thought when it comes to this topic, I think. The training that OBGYNs, midwives and doulas go through is similar in some ways but differs on key points. It's a difference in approach and priorities, I think. And yes, yes, yes, I agree that the setting makes a HUGE difference. For example, a relaxing, calming atmosphere with professionals who see you as a person and not a medical problem to be dealt with, coupled with a woman's confidence in herself, her body and her choice of medical personnel can create a more stress-free atmosphere which is conducive to birth. I think the psychological impact of the birthing environment are far too often downplayed and we all know the power that our mind has over our bodies. If a woman is stressed because she starts to experience major birth pain that she had not mentally anticipated and then medical personnel are all too willing to try to work things out for her, this can create a fear response and in the throes of labor it's simply too overwhelming to mentally sort things out--the body tenses up which inhibits labor and in turn makes things more painful--it's a vicious cycle.

Anyway, thank you for sharing. Appreciate it!

 

[thanka2]

My question is are women really informed of the facts in detail? Is that common practice? Is it required? Are they given the facts and studies about the drugs in some abridged form to look over before they even set foot in a hospital so they can truly make an informed choice? In my country, even when I go to the supermarket pharmacy to pick up my prescription drugs, the law dictates, that I must have a consultation with the pharmacist in which they go over the specifics of the medication and any possible side-effects/dangers of taking it. Then, I must sign a form stating that I was informed. This is simply if I want to pick up an antibiotic for strep throat. It would be interesting to know if the same sort of system exists when it comes to informed consent with birth interventions.

Women do and will make their own decisions as it should be. My problem arises from a system that seems to skim over topics that should be discussed in more detail. It's one thing to say, "I was informed. I know and I choose this for myself and my child" (in the case of elective interventions) than to say, "Well, it can't possibly do any harm--my doctor/nurse/midwife etc. did not present any information to the contrary so I make this decision believing that the risks are nil." And from my experiences with doctors in Hong Kong that often do a lot to scare their patients right off the bat ("you'd better do this, this and this or your child will end up with this, this and this"), it is strange to me that they wouldn't make it a point to really paint use of interventions in the most graphic light possible as it seems they have a knack for, and for lack of a better expression, fear mongering.

"Because I'm an obstetrician...I read the American College of Obstetricians and Gynecologists website--and throughout the website for their physicians there is sentence after sentence about the sanctity of the woman's right to self-determination and how we should never interfere with her ability to either choose or refuse a procedure. What happens, though, in modern medicine is that patients are not given true informed consent...what they're given is skewed informed consent."- Stewart Fishbein, MD, FACOG, Obstetrician

 

[thanka2]

The Other Side of the Glass

 

[thanka2]

 

[thanka2]

Why Mothers Die (UK)

 

[thanka2]

 

[thanka2]

[video]http://www.zshare.net/videoplayer/player.php?SID=dl033&FID=62983863&FN=The%20Business%20of%20Being%20Born.avi.flv&iframewidth=648&iframeheight=415&width=640&height=370&H=62983863bf35922e&ISL=1[/video]

 

[thanka2]

As for the stress, I read or heard somewhere that each contraction is not only painful for the mother, but also for the baby, as he get pushed through the birth canal. It may be more difficult for my baby due to the cephalopelvic disproportion. Forceps doesn't sound fun either. This was going to be my first one, and we know that usually it takes longer time for the first one to come out... and we are not talking about how his little head may get stuck on the birth canal! Also my sister got induced at week 42, and after long hours of pain, she didn't dilate enough and had to go for an emergency C section. So I didn't want to suffer in vain. I really wish labor were like in the movies! On the movies, they are always fast!

It's total misinformation that vaginal birth, in itself is stressful or more harmful/painful for a baby than a c-section. There are many benefits of the labor process for baby and mother and some are listed below.

The fact that your sister was induced set her up for a c-section. It is a well-known phenomenon that women who go in to be induced often end up with a c-section because basically they are forcing their bodies into labor before the cervix is really ready--it is not surprising that she didn't dilate. That c-section was an emergency that might have been prevented by not inducing and waiting for the body to go into labor naturally. There are a lot of "man-made" (doctor-made) emergencies happening in the labor and delivery departments of the world for this very reason.

In the movies labor is made out to be this horrifying and catastrophic event that women need doctors to rescue them from. Just like most things in Hollywood--couldn't be further from the truth. And it needn't be that way.

Vaginal Birth Benefits for Baby from here.

1.

Babies born naturally are usually born when they are ready. Elective caesareans typically take place a week or two before the expected due date. However, many babies if left to be born naturally are born at 41 or 42 weeks. If there was any miscalculation, a baby removed surgically could be at risk for prematurity and encounter respiratory problems as a result of under-developed lungs.

2.

Babies born by vaginal birth have considerable lower risk of respiratory problems. The compression of the baby?s thorax expels the amniotic fluid during the birth process and helps to prepare the lungs to breathe air. There is a high risk of respiratory distress syndrome in babies born by cesarean and a high risk of asthma.1
3.

The passage through the birth canal stimulates the baby?s cardiovascular system, which boosts blood circulation and primes the baby for birth. There is evidence that this process also has long term benefits for the baby?s co-ordination. Cranial osteopaths are reported to be able to determine whether a baby was born vaginally or by caesarean.

4.

Babies born vaginally receive protective bacteria as they pass through the birth canal. These bacteria colonise in the intestine and are crucial for developing a balanced immune system, from childhood right through to adulthood.2

5.

During a natural, vaginal birth babies benefit from hormonal surges in catecholamines during labor, which results in them being more alert and able to connect with their mothers at birth.3

6.

Similarly, endorphins, nature?s ?feel-good hormones, which are secreted during an unmedicated childbirth have been found in the placenta and umbilical cord. These hormones may help the baby adjust to life outside the womb as well as make the birth passage more comfortable for baby.

7.

Babies born by vaginal birth exhibit more interest in pre-breastfeeding behaviours such as sucking and massaging the mother's breasts. They are also reported to nurse for longer periods within the first 90 minutes after birth, which has many benefits for both the mother and the baby.
8.

A European study in 2008 found that babies born vaginally had a 20% lower risk of developing type 1 diabetes than babies born surgically.

9.

The process of labor is reported to enable babies born vaginally to cope with stress better than those born dramatically by cesarean. Cesarean birth triggers a dramatic stress response which could set up a child to always over-respond to stress.4

10.

If the vaginal birth was drug-free, the baby will not experience any side-effects of medication administered during the process.
11.

Skin-to-skin contact between the mother and baby can occur easily after a natural birth. This has many physiological benefits to the baby including optimal brain development as well as better attachment and breastfeeding success.
12.

Newborns are less likely to be admitted to the intensive care unit if delivered vaginally.

 

[thanka2]

Time Magazine (January 31, 2011):
Too Many Babies Delivered Too Early: Doctors Should Just Say No

 

[MommyTo3]

Time Magazine (January 31, 2011):
Too Many Babies Delivered Too Early: Doctors Should Just Say No

I thought that was a very good article. I am all for intervention when needed, but the bottom line is that there should be NO intervention unless medically necessary. Doctors shouldn't push, mothers shouldn't ask! I know a lot of doctors want to schedule things, but way too often I have heard moms whining about the fact that they're soooooo tired, and they're pushing their doctors for c-sections or inductions at 37 weeks (which is just an estimate in the end) since it's full term! That's just absolutely crazy. And then they give birth to a 6-7 pound baby, wow!? What's 2, 3, 4 weeks more if there is no medical reason to do anything, when mom and baby are doing just fine?! Isn't there a reason the baby isn't coming out? The difference in outcome between a 37 and 39+ weeker are substantial.

I have 3 children. Oldest was born naturally 9 days late at 9lbs2oz. With the twins I was induced at 38w2d, because most doctors believe there the risks start outweighing the benefits with multiples past 38 weeks. Plus I was being monitored for having blood clots in my legs since one leg was severely swollen, but nothing was found at 36 and 37 weeks. They were born naturally and were close to 8lbs (almost 3500 grams each) and came home with me 2 days later. Leg was back to normal within 6 hours after giving birth (weight issue pushing on some blood vessels). Of course, it wasn't great, it was tiring, I didn't sleep much after 32 weeks (they were estimated 9lbs combined at 30 weeks), but what can you do? You make the best of it. You do what you need to do, you go on, for the sake of your children, because you never want to regret anything.