Thursday, March 31, 2011

Essay on "What You Think is the Most Troubling Aspect of the Current State of Affairs Concerning Birth in the US"

I think the most troubling aspect of the current state of affairs concerning birth in the US is the total loss of a cultural memory or understanding of the normalcy of birth in the life of a human female. While increasing numbers of American women are seeking safer, more natural alternatives to the typical highly-medicalized and managed birth, it remains within the context of a medical procedure. Even those women who seek out midwives and home birth do so with the caveats of “safety,” “technology,” and “professionalism.” The end result is that the natural childbirth movement is making a lot of noise, but not a lot of progress.

In the 1970s, the natural childbirth movement first began to catch on. However, the focus of the movement was on the reduction of intervention and the humanizing of the birth management process. Having been removed from the natural biology of labor and childbirth by a couple of generations at that point, women were not able to conceive of labor and childbirth outside the scope of medicine. So, even though many women began advocating for home births and midwives, the movement was still very much dependent on the medical establishment for information, support, and legitimization. In her book, Spiritual Midwifery, Ina May Gaskin, perhaps the movement’s biggest and most successful midwife, describes how she began learning to attend women outside of the hospital setting by studying from an obstetrics manual. She heavily relied on the book and the advice and support she received from a close obstetrician friend, and throughout her own accounts, speaks of doing several procedures which we now know to be at best unreliable, and at worst, physically harmful (such as measuring dilation through the anus, and routine episiotomy for breech presentation). The result of this skewed paradigm was that the natural childbirth movement of the 1970s did not accomplish its intended goal of returning childbirth to the mother. Because the focus of the movement was so limited, childbirth remained within the bounds of medical knowledge, only succeeding in forcing the medical establishment to respond to women’s demands by changing medical protocols, and introducing more “humane” procedures and medicines. The majority of American women continued to flock to the hospital to give birth, now more than ever attracted by the “natural” focus, while the medical profession worked to eliminate midwifery as a profession, thereby eliminating any competition.

Thirty years later, the natural childbirth movement has regained some steam. After thirty years of advancement in medical technology, the medical profession continues to dominate in labor and delivery, under the guise of safety and the illusion of choice. With the advent of the information age and the internet, women are now able to network, research, and study, and are learning exactly what each procedure and medication means and what its risks are. Once again, women are clamoring for the reduction of intervention and the humanizing of the birth management process, and yet still, women are unable to conceive of childbirth outside of the medical model. The focus is still on medical management of birth, and the current midwifery licensure movement reflects this. Mothers, midwives, and doctors alike, rather than trying to re-examine the childbirth model as a natural process, are seeking to legitimize midwifery as a medical profession. Now, medical organizations are bowing to outside pressure to legitimize midwifery, but with the stipulation that they can state the terms of licensure. Midwives are now being allowed to practice, but only under such restriction that most women will still be subject to medical testing and interventions, both at home and in the hospital. In addition, the movement for licensure is reinforcing the cultural identification of birth as a medical process which requires a licensed medical professional. Ultimately, no real or lasting changes will be made in the natural childbirth movement following this model.

As long as American culture continues to view childbirth as a process which belongs within the scope of medicine, no meaningful changes will be made. Some small, piecemeal concessions may occur along the way, some new forms of technology or less-invasive procedures will be developed, but birth will still be firmly in the realm of pathology. Women must shift their paradigm, and come to an understanding of childbirth as a normal part of human biology. They must take their understanding of the physiology of childbirth and remove it from its medical setting, and place it back where it once was, as a rite of passage and social event for women. Medical professionals, including midwives, must be relegated to the position of consultant, and their role in childbirth should be considered as an adjunct to the natural process of labor. Once women can re-frame birth, and birth professionals, in this light, they can begin to heal from the loss of generations of valuable knowledge. Once our culture begins to remember the true, unhindered physiology of labor and birth, they can then regain their autonomy, and be able to take advantage of medical technology in its proper sphere, rather than the other way around.

Sunday, October 17, 2010

Low amniotic fluid is NOT an emergency

Hey, guess what time it is? It's been a good while since I busted my last OB myth, but I think it's time to get that ball rolling again.

This time I am tackling the myth of "low amniotic fluid." It seems that the more silly excuses OBs give for induction get shot down, the more they like to come up with. What baffles me is how they can justify doing so, knowing all the literature out there that does NOT support active management in most cases...but they do anyway. And since the average pregnant woman in America has neither the time nor the inclination to go read a bunch of research articles, I have dedicated my precious time to doing it for you. Let's look at the issue:

Disclaimer: This post is discussing the merits, or lack thereof, of inducing labor for low AFI levels, at term, and in the absence of any other risk factors. I do not address preterm labor, preterm premature rupture of membranes, or congenital defects. If any of these things apply to you, then this post does not.

This website describes the basics of low amniotic fluid (oligohydramnios), or low AFI. The level of amniotic fluid is determined by measuring, by ultrasound, an estimate of the various pockets of fluid around the baby. This is important because too much or too much fluid might indicate some sort of problem. A fluid level of between 5 and 18 cm. is considered normal. The level of fluid cycles, and so can fluctuate daily, or even hourly. You may begin to see for yourself the margins for error with this diagnostic tool.

First of all, what's the big deal with low AFI anyway? Extremely low, and/or persistent low AFI can be associated with various congenital defects, such as uteroplacental insufficiency, congenital anomalies, viral diseases, idiopathic fetal growth restriction (FGR), premature rupture of the fetal membranes, fetal hypoxia, meconium-stained fluid, and/ or postmaturity syndrome. It can also contribute to malpresentations, umbilical cord compression, and difficult or failed external cephalic version. (ref) For these reasons, doctors have typically associated low AFIs with poor fetal outcomes. However, as Leeman and Almond discuss, "A number of studies over the past 15 years have shown an association between oligohydramnios and poor fetal outcomes. These were predominantly retrospective studies, which failed to control for the presence of factors known to be associated with oligohydramnios such as intrauterine growth restriction (IUGR) and urogenital malformations."

In other words, though low AFI might be associated with some of these conditions, it doesn't necessarily mean the baby is in any immediate danger with a low AFI, with no other indicators. That is, low AFI by itself doesn't really mean much. In addition, there have been several studies which also show no correlation between low AFI and poor outcomes. (here, here, here, here, among others)

Knowing this, it would make sense if doctors chose not to actively manage low AFI in the absence of any other factors, as it doesn't usually mean negative outcomes, but this is not the case. According to this survey, submitted to perinatologists across the nation, ninety-two percent of respondents consider isolated low AFI (IO) to be a risk factor for various adverse outcomes. With a favourable cervix, 82% would consider inducing labour without documented lung maturity prior to 39 weeks. When asked whether induction of labour in cases of IO reduces perinatal morbidity, 45% were unsure and 21.4% thought it would not. Only 33% believe induction could decrease adverse outcomes. So most of the respondents considered low AFI to be a risk factor of some sort (it can be), and a full 78% either didn't know or thought induction would result in improved outcomes (it doesn't). This is pretty consistent with my own (anecdotal) experience with different mothers I have come in contact with in my own personal life. In every case of mothers that I have personally known being induced for low AFI, there was not a single other supporting factor. In both this and this blog post, I have mentioned before that I believe that low AFI is more likely to be used as a convenient "medical" reason to induce a woman who is postdates, especially if she refuses an induction for convenience.

Questionable motivations aside, let's assume for a moment that low AFI by itself can mean serious problems for the baby. How does one determine a dangerously low AFI? It is assessed by using ultrasound to measure the levels of fluid around the baby. Naturally, this is not an exact science. Gloria LeMay, in her article, "Low Amniotic Fluid....I don't think so," she describes the process like this:

What the ultrasound technician is doing could be compared to viewing an adult in a see-through plexiglass bathtub from below the tub. In such a scenario, it would be difficult to assess how much water is in the tub above the body that is resting on the bottom of the tub. You might be able to get an idea of the water volume by measuring how much water was showing below the elbows and around the knees, but if the elbows were down at the bottom of the tub, too, you might think there was very little water. This is what the technician is trying to do in late pregnancy—find pockets of amniotic fluid in little spaces around the relatively large body of an 8 lb. baby who is stuffed tightly into an organ that is about the size of a watermelon (the uterus). If most of the amniotic fluid is near the side of the uterus closest to the woman’s spine, it can not be seen or measured. This diagnosis of low amniotic fluid frightens the parents-to-be into acquiescing to an induction of labour.
That is to say, it can easily be inaccurate. In the above referenced article from, it is even admitted that ultrasound measurements can be wrong:

If there were to turn out to be a normal amount of fluid with rupture of membranes during an induction, then the low AFI that prompted the induction was either temporary or wrong. It happens, but ultrasound's the best thing we have to go by, even with its inherent error. (emph. added)
This article quotes a 1998 study, which concludes, "that indexing amniotic fluid by measuring the pockets of amniotic 'a poor screening test' to identify infants at risk." In this article, several studies and factors can explain the inaccuracies inherent in this method of measurement:

Although the AFI is widely accepted as the standard to diagnose oligohydramnios in the United States,[1] many studies have found it to be an inaccurate method for assessing the actual amount of amniotic fluid, especially in the lower or higher ranges.[3,4,6-9] Rutherford et al.[10] point that poor intra- and interobserver reliability may account for some of the low positive predictive value. Serial measurements have shown mean differences of 1 cm of amniotic fluid volume when conducted by the same ultrasound operator, and 2 cm variance in measures of volume when conducted by multiple operators. Variation can exist because of subjectivity of the ultrasonographer, the amount of pressure applied to the abdomen, and fetal position or movement.[4] Additional variables that may alter AFI summation of the 4 uterine quadrants of amniotic fluid is the influence of the environmental temperature, altitude, maternal glucose control in diabetes, maternal hydration, and the status of the amniotic membranes.[6] (original linked references in article)

Many factors can influence the measurement of the AFI, not the least of which involve subjectivity on the part of the sonographer(s). Observing and approximating measurements through a solid surface, around a moving object, under constantly changing conditions, is a guess, at best.

So if induction for low AFI does nothing to improve fetal outcomes, what does it accomplish? In short, a higher risk of induction complications, including c-section.

"Although small and insufficiently powered, these studies suggest that isolated oligohydramnios does not appear to be associated with adverse outcomes, but it may cause fetal intolerance of labor, which does result in higher cesarean rates." (ref)

"In a case-control study by Conway, 183 low-risk, term parturients with oligohydramnios were matched to 183 women of similar gestational age and parity who presented in spontaneous labor. The patients with isolated oligohydramnios were induced and showed an increased cesarean delivery rate. The increased rate of cesarean delivery was not due to nonreassuring fetal surveillance and was attributed to the induction process (LOE: 2).25" (ref)

"CONCLUSION: Active induction of labor in term low risk gestations with isolated oligohydramnios translated into higher labor induction, operative vaginal delivery and cesarean section rates. This led to increased maternal risk and an increase in costs with no differences in neonatal outcome." (ref)

"CONCLUSION: Isolated oligohydramnios is not associated with adverse perinatal outcomes. However, it increases the risk for labour induction and Caesarean section." (ref)

One other interesting note. In this article, the question is asked, " Is the increase in cesarean section secondary to fetal intolerance of labor from low AFI or the induction process itself?" I would submit that the question is moot. If the fetus is experiencing stress related to low AFI, would it make sense to add more stress by inducing? In either case, it is clear that induction is a strong contributor to another completely unnecessary c-section, and therefore, that induction for a diagnosis of low AFI is yet another unsubstantiated OB myth.

For more technical information and analysis of various studies and factors related to the assessment of oligohydramnios, check out these two articles: 1 and 2

Saturday, October 9, 2010

Neither seen NOR heard

Once again, mainstream parents have managed to shock me with the lengths they are willing to go to to avoid interacting with their babies.

Today's hottest "must-have" baby accessory

The latest trend on infant accessories is the car seat canopy. This is an outgrowth of the already-established practice of throwing a blanket over the top of a car seat, only these have straps to keep them attached. According to this website, some of the benefits to having one of these things include:

  • Protection from weather and wind
  • Darker/more secure environment for sleep
  • Privacy

You know, I just can't get over how oppressive and bizarre these seem to me. A friend on Facebook posted a link to unnecessary baby products, and I commented this ought to be one of them. Another commenter said this:
i covered up all my kids in the carseat and it was NOT because i didn't want to touch or look at my sweet kids. One would be crazy not to cover up their babies during a WI winter in the middle of 0 degree weather. When you have a newborn in winter the removable carseats are a lifesaver for keeping them warm on snowy/cold days.
While I agree with this, I have yet to see this thing in action during adverse weather conditions. I see them in the store, in church, and anywhere else you don't want to be disturbed by your baby's sights or sounds. I've seen car seats sitting on the floor or in carts, covered the entire 20 minutes, or even 2 hours. I've seen mothers and fathers *only* lift up the cover to give a bottle, and in some cases, prop the bottle and cover it back up again. I've heard babies crying and seen mothers and fathers furiously rocking the car seat without even lifting the cover. But as the above website claims, this is a good thing.

We want our babies protected from the wind and to be warm.

We want our babies to have privacy.

We want our babies to be able to sleep better.

Seems like I've heard and seen this philosophy before...

I believe it makes her feel secure so I try to cover her even though some times I forget.. It also keeps her warm.

I cover the sides to prevent drafts and keep [her] warm

It helps protect them from drafts, helps me to control the amount of light they get, and it seems to make them feel safer and cozier.

it will prevent light and may keep the cage warm. it makes your [baby] feel protected and safe.

I cover night and she has no problem with it. On the contrary, it allows her to get some sleep while I'm up into the night working on book reports and such.

I think it is very important to cover [them]...... Not only do they get a SECURE sleep they need darkness & coziness.. Sleep is VERY IMPORTANT for their health

I only cover them when it's cold out seeing it can get 0 degrees in the winter...

Covering your [baby] doesn't stop them from hearing noises, it stops them from seeing things. My [baby] has a tendancy to start playing...

I got these testimonials from this website. It discusses whether or not to cover your PET BIRD.

Look familiar?

"But Emily," you might say, "How else am I going to keep my baby warm, protected from the weather, protected from germs, and asleep and quiet?" IDK, how about holding your baby?

It won't be long before we start covering their, cribs...too. Oh wait...

Oh, erm, well at least it's only used with babies. It's not like they will remember, and it won't scar them for life. Anyway, it is just a harmless way to keep them covered; we will stop using it when they get older.