Friday, August 18, 2006

The Cascade of Intervention

Childbirth. Such a normal thing to occur in a woman, yet so many abnormal things can occur when you place yourself in the hands of doctors. Yes, I am skeptical, as my very own first experience birthing in the hospital was not a pleasant one. In the Journal of the American Academy of Pediactrics it is stated, "several studies have documented an increase in maternal temperature associated with use of epidural analgesia during labor." This was my experience. I "spiked a temp" of 104, and all of the sudden I was made to push on the spot (with no feeling, of course, which is extremely difficult), and when the babe finally arrrived he was whisked off to the NICU to be monitored for breathing and stability (which may be a problem because of the antibiotics that they had pumped us with while he was still en utero). 24 hours later I got to see him for the first time; 10 days later I got to bring him home. And all the while I was thankful we were at a "good hospital" where my baby was getting the "best of care." I found out later (not from the doctors or nurses) that this scenario isn't all that uncommon with epidurals. The link has been established- epidurals may cause fever to rise, generally one or two degrees per hour the epidural is at work in your spine.
So it has been labeled the Cascade of Intervention. When you intervene uneccessarily with nature's role, generally there is a waterfall of effects that occur because one things leads to another- as with my hospital incident. I was in labor, went to the hospital, and was strapped to a chair by the IV in my arm. This was the first intervention. I couldn't move to cope with the pain. It was in my back, but I had to lie on it. It became unbearable so I got an epidural- the second intervention; then my temperature got too high, and they had to give me antibiotics- third intervention. And to top it off they had to help me push. They had to monitor him, so I didn't even see him for the first 24 hours - fourth intervention, and the next 10 days of monitoring- the final intervention. And so it commonly goes with hospital intervention in childbirth.

This type of scenario, not wholly uncommon, is why I am skeptical of a doctor's knowledge of what the best thing is for a birthing woman. Sometimes I think it may have to do with convenience, but surely it is no convenience to cover your tracks:

  • A cesarean section poses documented medical risks to the mother's health, including infections, hemorrhage, transfusion, injury to other organs, anesthesia complications, psychological complications, and a maternal mortality two to four times greater than that for a vaginal birth.
  • An elective cesarean section increases the risk to the infant of premature birth and respiratory distress syndrome, both of which are associated with multiple complications, intensive care and burdensome financial costs. Even mature babies, the absences of labor increases the risk of breathing problems and other complications.

And sometimes I think it has to do with doctors getting paid more:

  • A cesarean costs nearly twice as much as a vaginal birth ($7,186 average vs. $4,334 average in 1989 in the US). It has been estimated that in Quebec, Canada, if the current rate of cesareans (18.8%) were reduced to that of Finland (11.9%), costs incurred by the provincial health care system could be reduced approximately $19 million per year.
  • Cesarean rates are influenced by non-medical factors. Rates are higher for women who have private medical insurance, are private rather than public clinic patients, are older, are married, have higher levels of education and are in a higher socio-economic bracket.

These facts, being presented to you from the ICEA Cesarean Options committee , suggests that it is just as likely to be the mothers wish that she go through as little pain as possible to get the baby here. Of course these are speculations of mine, and not every epidural leads to a cesarean, and some cesareans are necessary , but for the most part, here in the States we have become an instant gratification, no-pain culture. Here is what the CDC says about birthrates in 2003,
More than one fourth of all children born in 2002 were delivered by cesarean; the total cesarean delivery rate of 26.1 percent was the highest level ever reported in the United States.
No doubt it is higher now as the rates had been increasing for the last several years. Back to the fact sheet:
  • The World Health Organization (WHO) states that no region in the world is justified in having a cesarean rate greater than 10 to 15 percent.
  • In the past twenty years, the cesarean section rates have nearly quintupled in the US to 23.8% in 1989 and nearly quadrupled in Canada to 18.3% in 1987-8.
I generally don't care what the UN or any of their counterparts have to say about the States, but I agree with their assessment of too much intervention when it comes to childbirth. And with all this amazingly helpful interevention, we are still the 27th ranked country for infant mortatlity(Journal of the American Academy of Pediactrics).

And now for the catalyst of this rant against unnecessary intervention. My sister had her baby yesterday via cesarean. She was losing too much blood, so they had to take the baby down to NICU to make sure he wasn't the one bleeding (I would have had them check him in my room). While he was there they realized that his lungs were full of liquid. They said that because he was brought out through a cesarean his lungs didn't have the necesary pressure on them that they generally would have if he had been pushed out. And during all this they found that the doc had sliced one of my sister's arteries, and it took 90 seconds to find it and stop the bleeding. The doctor told my mother that after three minutes a woman will bleed to death. I just can't help seeing the obvious- if she had pushed him out, none of this would have happened. She still doesn't have her baby- he is in the care of the NICU because of his lungs. They are hoping to get him back this afternoon.
It makes me angry at the medical community for allowing such ridiculous amounts of cesareans to occur. That poor baby had to be carted down to NICU and kept from his mother (all that he knew) for 24 hours now, when all of it could have been avoided had the doctor not allowed (he possibly even encouraged) my sister to have a cesarean. These are the facts on VBACs:
  • In the US and Canada, over one-third of all cesareans are repeat cesareans. The American College of Obstetricians and Gynecologists (ACOG) recommends that the concept of routine repeat cesarean be replaced by a specific indication for surgery, and that most women can be counseled and encouraged to labor and have a vaginal birth after a cesarean (VBAC).
  • In 1989, 81.5% of all US women with a previous cesarean had a repeat cesarean. The VBAC rate was 18.5%. The VBAC rate is greater in every eastern and western European country.
  • The "once a cesarean, always a cesarean rule is outdated now that most of uterine incisions are low and horizontal and the risk of rupture of the old scar is almost nonexistent. A review of all VBAC literature from 1985-1990 found a rupture rate of 0.22% for low transverse scars in 22,000 planned labors after cesarean. (In developed nations the rupture rate was 0.18%.) By comparison, the incidence of other childbirth emergencies, such as prolapsed cord, placental separation, or sudden fetal distress is 1-3%.
  • ACOG states that the hospital requirements for VBAC are the same standards for all obstetrics. These include the capacity to respond to acute obstetric emergencies by performing a cesarean within 30 minutes. However, many hospitals in North America that offer maternity care do not allow or encourage women to labor and have a VBAC.
  • In a review of all the medical reports published on VBAC from 1926-1990, 75% of all women who planned labor after a cesarean gave birth vaginally. Several medical studies record VBAC rates of over 90%.
My sister was induced with her first. This procedure of inducment is very popular among doctors and mothers alike, and has it's own cascade of interventions. My sister was told she couldn't dilate, the baby wouldn't be able to come down, etc, and she had her first cesarean. The medical term is dystocia- failure to progress in labor. But don't forget that labor was never left to begin on it's own; she was induced. It seems pretty obvious that when a doctor intervenes to get labor started and it doesn't work, maybe they should have left the woman's body to do one of the main jobs it was created to do.

I understand the implications of this post. Who am I to tell anyone not to get an epidural...and really, it isn't what I'm trying to say. Doctors need to inform their patients of all the risks instead of assuming we don't need to know. It is our bodies, after all...
One more fact:
  • Of 11,814 women admitted for labor and delivery and attended by midwives to 84 free standing birth centers in the US, 15.8% were transferred to the hospital and 4.4% had a cesarean section. Although the women were lower than average risk of a poor pregnancy outcome, their cesarean rate is one-fifth of the national average.