Labour & Delivery
A pregnant woman posted a document she received from her obstetrician to a forum on AllNurses.com prefaced with the following:
I’m 26 weeks with my 3rd (1st 2 were hospital births) and at my last appointment my OB folding a piece of paper in half and handed it to my husband. He told us it was information on hospital policies and things and we could discuss at my next visit. All I saw was the title Dr. ________ “Birth Plan” and I was amused because I know that birth plans can be irrational and badly researched. After I read it I was less amused and now plan on finding another care provider. I do believe the OB is a good doctor and I plan on sending a polite but honest letter and I would also like to cite research in order to leave some possibility that he will rethink his position. I am having trouble finding research.
Here is the doctor’s alleged birth plan that this Texas doctor hands out to his patients.
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DR. ________ “BIRTH PLAN”
As your obstetrician, it is my goal and responsibility to ensure your safety and your baby’s safety during your pregnancy, delivery, and the postpartum period. My practice approach is to use the latest advances in modern obstetrics. There is no doubt that modern obstetrical advances have significantly decreased the incidence of maternal and fetal complications. The following information should clarify my position and is meant to address some commonly asked questions. Please review this information carefully and let me know if you feel uncomfortable in any way with my approach as outlined below.
* Home delivery, underwater delivery, and delivery in a dark room is not allowed.
* I do not accept birth plans. Many birth plans conflict with approved modern obstetrical techniques and guidelines. I follow the guidelines of the American College of Obstetrics and Gynecology which is the organization responsible for setting the standard of care in the United States. Certain organizations, under the guise of “Natural Birth” promote practices that are outdated and unsafe. You should notify me immediately, if you are enrolled in courses that encourage a specific birth plan. Conflicts should be resolved long before we approach your due date. Please note that I do not accept the Bradley Birth Plan. You may ask my office staff for our list of recommended childbirth classes.
* Doulas and labor coaches are allowed and will be treated like other visitors. However, like other visitors, they may be asked to leave if their presence or recommendations hinder my ability to monitor your labor or your baby’s well-being.
* IV access during labor is mandatory. Even though labor usually progresses well, not too infrequently, emergencies arise suddenly, necessitating an emergency c-section. The precious few minutes wasted trying to start an IV in an emergency may be crucial to your and your baby’s well being.
* Continuous monitoring of your baby’s heart rate during the active phase (usually when your cervix is dilated 4cm) is mandatory. This may be done using external belts or if not adequate, by using internal monitors at my discretion. This is the only way I can be sure that your baby is tolerating every contraction. Labor positions that hinder my ability to continuously monitor your baby’s heart rate are not allowed.
* Rupture of membranes may become helpful or necessary during your labor. The decision as whether and when to perform this procedure is made at my discretion.
* Epidural anesthesia is optional and available at all times. The most recent scientific data suggest that epidurals are safe and do not interfere with labor in anyway even if administered very early in labor.
* I perform all vaginal deliveries on a standard labor and delivery bed. Your legs will be positioned in the standard delivery stirrups. This is the most comfortable position for you. It also provides maximum space in your pelvis, minimizing the risk of trauma to you and your baby during delivery.
* Episiotomy is a surgical incision made at the vaginal opening just before the baby’s head is delivered. I routinely perform other standard techniques such as massage and stretching to decrease the need for episiotomies. However, depending on the size of the baby’s head and the degree of flexibility of the vaginal tissue, an episiotomy may become necessary at my discretion to minimize the risk of trauma to you and your baby.
* I will clamp the umbilical cord shortly after I deliver your baby. Delaying this procedure is not beneficial and can potentially be harmful to your baby.
* If your pregnancy is normal, it should not extend much beyond your due date. The rate of maternal and fetal complications increases rapidly after 39 weeks. For this reason, I recommend delivering your baby at around 39-40 weeks of pregnancy. This may happen through spontaneous onset of labor or by inducing labor. Contrary to many outdated beliefs, inducing labor, when done appropriately and at the right time, is safe, and does not increase the amount of pain or the risk of complications or the need for a c-section.
* Compared to the national average, I have a very low c-section rate. However, a c-section may become necessary at any time during labor due to maternal or fetal concerns. The decision as to whether and when to perform this procedure is made at my discretion and it is not negotiable, especially when done for fetal concerns.
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The Society of Obstetricians and Gynecologists of Canada will launch program to teach physicians breech vaginal deliveryRead Full Post | Make a Comment ( None so far )
The Mother-Infant Wellness Lab at UBC is conducting a survey to better understand pregnant women’s feelings about labour and delivery. If you are over 18 and pregnant, you can participate!
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The Society of Obstetricians and Gynaecologists of Canada says 20 per cent fewer caesarean sections could be performed if doctors and hospitals followed guidelines aimed at lowering unnecessary surgeries.
One of those key guidelines is management of dystocia — difficult or abnormal labour. Research has shown that doctors frequently violate “best practice” recommendations for managing the first stage of labour.
“We think that sometimes the guidelines are not implemented in the way they were proposed,” says Dr. Andre Lalonde, executive vice-president of the obstetrician’s group.
Canada’s caesarean-section rate reached an all-time high in 2007-08, with surgical births accounting for nearly 28 per cent of all deliveries.
Experts say more needs to be done to provide Canadian women with the support they need to give birth normally. That means making doula and labour support the norm, reserving interventions like inductions for women who truly need them and allowing freedom of movement throughout labour.
A recent survey of more than 6,000 women in Canada who gave birth in 2006 or 2007 found 48 per cent said they gave birth lying flat on their back.
More than half — 57 per cent — said their legs were in stirrups when their baby was born.
“I thought that went out with the ark,” says Ottawa midwife Paula Salehi.
Research has shown that women who labour in an upright position — standing, crouching, propped up or sitting — have shorter labours, and fewer medical interventions, including C-sections.
“Our labours progress by mobilizing women or getting them active in labour — walking up and down stairs if need be,” says Salehi. Remaining upright allows the baby’s head to push down on the mother’s cervix, which helps to release oxytocin, the hormone that causes contractions.
But in labour rooms across the country, the hospital bed is typically “front and centre,” says Ellen Hodnett.
That sends a powerful message to women that that is where they are supposed to be in labour, says Hodnett, professor and Heather M. Reisman chair in perinatal nursing research at the University of Toronto’s Bloomberg Faculty of Nursing.
“Why wouldn’t you want to use gravity, and the basic forces of nature to help that baby get out, instead of pushing upstream?”
Hodnett has just completed a pilot study to see whether simple, but radical changes to the physical environment can promote a greater sense of calm and confidence in women.
She started by taking out the bed.
A double-sized foam mattress with large, comfortable cushions was set up in the corner of the “ambient” labour room.
Sixty-two women were sent at random to either the ambient labour room or a standard labour room at two Toronto teaching hospitals.
In the end, women in the ambient labour room used significantly less artificial oxytocin to speed up slow labours — a 28 per cent drop in infusions compared to women in the standard hospital rooms.
More than 65 per cent of the labouring women in the ambient room, compared to 13 per cent in the standard labour room, reported they spent less than half their hospital labour in bed.
Dr. Larry Reynolds says many complications of labour that can lead to interventions are relieved when women are comforted, supported, “and aren’t feeling kind of terrorized.
“The environments of birth can be quite intimidating for women and their partners,” says Reynolds, a professor of family medicine at the University of Manitoba.
“We know that women who have continuous one-to-one doula support in labour have half the caesarean section rate, half the forceps rate. They have much shorter labour, half the length of labour.”
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By Sharon Kirkey, Vancouver SunAugust 4, 2009
Claudia Villeneuve often hears those words at the support group for women who have had caesarean sections.
She has heard women describe the sensation of their babies being pulled from their bodies, of feeling helpless, and sometimes ignored by the operating room staff, as if somehow she weren’t present.
“The birth of your children, those days are marked in your soul forever,” says Villeneuve, president of the International Cesarean Awareness Network of Canada.
“If that experience was demeaning in any way, or if you felt helpless, there is a lot of internal conflict.”
As Canada’s caesarean section rate climbs, calls are growing for more research into the psychological effects of surgical births on women, and on early mother-baby bonding. Recent experiments are offering new insights into how modes of delivery may affect the postpartum brain.
Dr. Larry Reynolds says some research suggests that some women who have had a caesarean section have a variant of post-traumatic stress disorder.
“Often that’s a caesarean section under emergency conditions, where things are going along, and all of a sudden something bad happens, and you’re rushed to have a caesarean section to either save your life, or your baby’s life,” says Reynolds, a professor of family medicine at the University of Manitoba and a family doctor who has been involved in childbirth care for more than 30 years.
“Some of these women also describe an experience where, because they weren’t conscious when their baby was born, being uncertain that this was actually their baby.” They wonder, he says, ‘could the baby have been mixed up? Is this really my baby?’
Normal or vaginal delivery involves massive spikes in a number of different hormones, including oxytocin, the hormone linked to emotional connections and to feelings of love and trust, scientists say.
“With a C-section, you go right in and incise the uterus and remove the baby, and all of that vaginal, cervical stimulation that is part of labour, usually over hours, is bypassed,” says Dr. James Swain, a Canadian and professor of child psychiatry at the University of Michigan.
Research in animals shows caesarean deliveries delay the onset of normal parenting behaviours — things such as licking, grooming, nursing and nesting — in new mothers.
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Sharon Kirkey, The Ottawa Citizen; Canwest News Service
Published: Saturday, August 01, 2009
Dr. Jan Christilaw was in the operating room the day a routine incision was made into a young mother’s abdomen to deliver her baby.
What happened next, says Christilaw, “is something we never want to see.”
Normally, the placenta separates from the wall of the uterus after birth. It’s lacy almost, and not like solid tissue. “You can take your hands and sort of scoop it up, it’s like breaking cobwebs as you go,” says Christilaw, an obstetrician and president of B.C. Women’s Hospital and Health Centre in Vancouver.
But the placenta had eroded through the wall of the uterus, a condition known as placenta accreta. As soon as they stretched the opening of the uterus to deliver the baby, “the placenta started bleeding everywhere.”
They couldn’t stop the bleeding. The woman was losing two cups of blood every 30 seconds.
“You get into this place where you think, OK, this is what I’m trained to do, I know exactly how to do this,” says Christilaw, who was a senior resident at the time. “You don’t panic, but you’re calling in everybody you can possibly get into the room.” People had to squeeze the bags of blood, because the pump could not put it in fast enough.
The only way to stop the bleeding was an emergency hysterectomy. The woman was in the operating room for eight hours, and lost 15 litres of blood.
It used to be that obstetricians might see one or two cases of placenta accreta in their practice lifetime.
Although still rare, placenta accretas — one of the most feared complications of pregnancy — are increasing as a consequence of the rising caesarean section rate, say obstetricians across Canada.
Virtually all placenta accretas occur in women who have had a previous C-section, and the risk increases with each additional one. The placenta attaches to the old C-section scar. Scars don’t have a proper blood supply to feed a placenta, so it keeps burrowing into the uterus until it finds one, sometimes pushing through the uterus into the bladder or other organs.
Ultrasound can detect the condition, but not always. “You almost never see it in a woman who has not had a C-section,” Christilaw says.
Today, about 28 per cent of babies born in Canada are delivered by caesarean. In 1969, Canada’s rate was five per cent.
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Jane Weru is meticulously wheeled into the operation theatre. Minutes later, she is the proud mother of a bouncing baby boy. Although still very drowsy from the effects of the anaesthesia, Jane is affording a jolly smile, seeing that all has gone well.
Her baby is just one of the growing numbers of babies delivered through the Caesarean section, popularly known as CS. While this procedure is normally performed with the advice of an obstetrician as a result of medical complications, Jane’s was performed at her own counsel — she did it because she did not want lengthy labour, plus it is the method in vogue.
Caeserean section is the delivery of a baby through a surgical incision in the mother’s lower abdominal wall and the uterus as opposed to normal vaginal birth procedure. According to statistics from three private hospitals in Nairobi, CS deliveries account for almost 48 per cent of all maternity cases. For example, one hospital in Nairobi recorded 151 out of 324 deliveries between July and September last year were through CS. Out of the 151 cases, only 53 were as a result of medical conditions necessitating the procedure. The remaining 98 were on request by the mothers who preferred Caesarean section to vaginal birth. This procedure, usually planned for before labour starts, is referred to as an elective caesarean.
The British medical journal of November 2007 reports higher figures in Latin America with the cases rising to as high as 50 per cent of the total registered births. Australian reports indicate that about 40 per cent of all the babies delivered in private hospitals are through the CS.
According to Choices In Childbirth (CIC), an American maternity care advocacy organisation, the Caesarean section is the most performed procedure in the United States of America. In fact, more than one in every four babies (27.6 per cent) in America are delivered by CS.
This, however, has become the case only since 1996 onwards. In 1970 for instance, a paltry seven per cent of births were by CS in the US, according to the US National Library of Medicine, Cesarean Section.
According to Dr Irungu Mwangi an obstetrician at the Mater Hospital, mothers are increasingly demanding to be operated even without a medical condition warranting the operation. The big question therefore: Is CS safe enough to be adopted as a substitute for vaginal births? Already, leading medical agencies such as the World Health Organisation have sounded the alarm, calling upon the medical fraternity to reduce the rate of CS births. However, this seems not to have deterred a majority of middle and upper class women, who find the procedure an easier and posh way to give birth.
Could cause problems
Njeri Muthomi delivered her child through elective C-section. When asked, she said there was no problem with CS as long as one could afford it. Another woman, Pamela, said that she did it because she did not want to risk getting vaginal infections or tampering with her womanhood.
Unknown to these two women and others, however, is the fact that CS is not so posh after all in the long run. It comes with many health issues for both the mother and child.
According to a report titled: A Mother’s Right to Know: New York City Hospitals Fail to Provide Legally Mandated Maternity Information, by Betsy Gotbaum, a Public Advocate, C-sections can result in a variety of problems, including infections, haemorrhage, injury to other organs, anaesthesia complications, infertility, and psychological trauma. “C-sections also result in a higher maternal mortality than do vaginal deliveries,” it reads in part.
Irungu says that mothers who deliver their babies through Caesarean section risk developing conditions that could lead to hysterectomy (removal of the uterus), not to mention that sometimes such mothers have to undergo an otherwise avoidable blood transfusion.
The permanent scaring of the abdomen is another aspect of CS that needs to be mentioned. In the event that the woman who has delivered a baby through a Caesarean section desires to have another child, she should be prepared to undergo more CS’ because it would be difficult to convince a doctor to allow her to have a normal vaginal birth for fear of health and legal repercussions.
To the infant, the Caesarean delivery can increase the risk of premature birth and respiratory problems, both of which can result in the child being placed under intensive care, as well as asthma in childhood and adulthood.
The British medical journal of December 2007, found out that babies delivered normally had significantly lower rates of breathing difficulties compared to those delivered by elective CS.
This was because those babies delivered by CS miss out on the hormonal and physiological changes that occur during labour, which are necessary for the infant’s lungs to develop.
This is the information that mothers (and their spouses) usually do not get when deciding to go for an elective Caesarean, hence the need for consumer education. The report says that in order to make the best decisions about their care, women must have access to information about the risks and benefits of vaginal delivery, Caesarean process, and other medical interventions that may occur during labour and birth.
Irungu argues that a mother should deliver a baby through a C-section if she has the following conditions:
• Prolonged or ineffective labour. When labour is prolonged for various reasons, including insufficient contractions of the uterus, a Caesarean section may be necessary to speed the birth process.
• Placenta Previa. This condition exists when the placenta (or afterbirth) becomes positioned abnormally low within the uterus, and there is a possibility that it could completely block the cervix. This condition could prevent the baby from advancing through the birth canal and it also could cause haemorrhaging (severe bleeding).
• Placenta Abruptia. Sometimes the placenta can suddenly separate from the wall of the uterus prior to delivery of the baby, possibly causing the mother to haemorrhage, and the baby to have an abnormal heart rate.
• Disproportion. This condition occurs when the baby’s head is too large or the mother’s birth canal is too small to allow for safe vaginal birth.
• Abnormal presentation: In some instances, the baby’s position in the uterus may make vaginal birth dangerous or impossible. This problem may occur when the baby is in a breech (buttocks or feet first) or traverse (side or shoulder first) position.
• Prolapsed cord. This condition exists when the umbilical cord precedes the baby through the vagina during labour. A prolapsed cord could strangle the baby as it is being born, or block the baby’s progress through the vagina during normal delivery.
• Foetal distress. If the baby has a slow or very rapid heart rate, deceleration of heart rate, or a heartbeat that does not fluctuate, it may be advisable to speed the delivery by performing a Caesarean section.
• Medical problems. The mother may have medical problems, such as diabetes, genital herpes, hypertension, cardiac disease, toxemia (presence of toxins in the blood), or ovarian or uterine cysts or tumours that could make labour hazardous to both the mother and the baby.
• Multiple birth. Multiple births, such as twins and triplets, may sometimes be delivered more safely via C-section (particularly if one or more of the babies’ position in the uterus will result in an abnormal presentation).
• Previous Caesarean delivery. Women who have had a Caesarean before are likely to deliver subsequent births by the same method.
• Birth defects. Some babies with birth defects diagnosed by ultrasound could fare better if delivered by Caesarean section.
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Epidural or not? Women share their stories
Laura Bickle | Today’sParent.com
Omigod, I don’t know if I can do this. There was a point in each of my labours where this thought ran through my mind. With my first child, Paige, this thought occurred 15 hours after being induced, 10 hours after getting an epidural and two hours after I started pushing. I was exhausted. When it entered my mind in my second labour, I had been pushing for about 15 minutes and was just a few moments from delivering baby Zoe — without an epidural. This time the thought came because of pain.
Of course, I did end up delivering and my fears were washed away with the joy of holding my babies. But I learned that choosing whether to have an epidural isn’t just a simple question of pain relief. With Paige, the onslaught of intense contractions due to induction made an epidural almost a necessity. With Zoe, the freedom of walking around the hospital actually helped me deal with the contractions.
There are many aspects of the birth experience that can be affected, positively or negatively, by either choice. Who would know these pros and cons better than women who have experienced both?
First, a caveat: Each of the many women we spoke with had a different experience and a different take. So what you’ll find here is not a definitive answer, but insights that may help you make the right decision for you in the unique circumstances of your labour.
Sure, you hear of women whose contractions felt like mild menstrual cramps and who delivered their babies in two pushes. But, really, the mere existence of the epidural is admission that labour is usually painful, and sometimes excruciating. “Every woman reacts differently to labour and stress,” says Isabelle Baribeau, a labour and delivery nurse at BC Women’s Hospital and Health Centre in Vancouver. “Epidurals are a tool — something to assist you. If less invasive methods don’t work, an epidural is an option.”
Stephanie Adams, of Oakville, Ont., delivered her first child, Michelle, without drugs after six hours of labour. “I was able to get through it with breathing in and out,” she says. Labour with second child Sam, however, was a different story. “I thought I wouldn’t need an epidural because I didn’t need it the first time.” But after eight hours of intense contractions, she asked the nurses to call the anesthesiologist. “The epidural worked wonders in the sense that I could relax.”
When Susan Morrison, of Dartmouth, NS, was pregnant with her first child, she knew that the hospital in the town where she lived at the time didn’t administer epidurals, but she thought she’d be fine without one. “I didn’t realize the contractions would be so intense and constant. I did the breathing exercises they taught in my prenatal class. None of that mattered. Demerol made me sick, and the laughing gas was too late to have much effect.”
While the epidural usually provides excellent pain relief, the process itself gives some women pause. The thought of a long needle inserted into your back can, well, make shivers run up your spine. Add to that the fact that you need to stay perfectly still in the midst of earth-shaking contractions, and you can see why some women hesitate.
While usually the needle is inserted easily with little discomfort, sometimes an anesthesiologist may have difficulty getting it into the epidural space. It was the administration of the needle during her first labour that led Christine Iacobucci, of Newmarket, Ont., to opt for a non-medicated labour with her second baby. “It took repeated tries to get it in.” As a result, her back was badly bruised. “It was more painful than any other aspect of the birth.”
More common side effects are itchiness and shivering after the injection. Says Angie Cossette of Weyburn, Sask., who had an epidural with her first child, Isaac: “The effects felt strange. My legs felt like they weighed a million pounds and I was itchy all over.” (The itchiness may be treated with medication.)
Epidurals can increase the need for interventions such as forceps or vacuum delivery, episiotomy and Caesarean section. Michelle Rogers-McEwen of Nepean, Ont., had an epidural for her first labour and says, “When a contraction would come across the monitor, the nurse would have to tell me to push because I was so numb.” This went on for several exhausting hours. “They wheeled me into the OR in case I needed a C-section.” But before going that route, the doctor successfully tried forceps and suction. However, the delivery resulted in considerable tearing and a long recovery.
Sometimes it’s the intervention itself that necessitates an epidural. When Cossette went into labour with Isaac, she thought she might try going without medication. However, she was induced and labour came on fast and intensely: “The epidural calmed me down. I enjoyed the birth experience.”
Baribeau explains that when a woman goes into labour on her own, she tends to progress gradually. With an induction, labour often comes on fast and intensely. That’s stressful to deal with and can quickly lead to fatigue, says Baribeau. “And the more fatigued you are, the less tolerant you are of pain.”
I remember walking the halls of the maternity ward with my husband for hours during my second labour. The moment I would lie down, the contractions would slow down. I put off the epidural, partly because the pain was manageable but also because I liked not being encumbered by tubes and monitors.
Once you have an epidural, you’re generally confined to bed and hooked up to an IV. And many hospitals continuously monitor fetal heart rate electronically. Anji Sharpe, of Markham, Ont., says of her non-epidural experience: “It was more intimate, no poking and prodding, less invasive.”
However, an epidural can allow you to rest through the contractions. Iacobucci recalls how laid-back she and her husband were after she had an epidural and they were waiting for the pushing stage of labour to begin: “He was eating Indian food. We were relaxed.”
Research shows that epidurals can lengthen the second stage of labour. Part of this may be a result of not being able to push effectively, says Baribeau: “In order to push the baby out, you have to be able to feel that you have to push. If you’re very frozen, you can’t feel where to push.”
That was Cossette’s experience. She pushed for two hours with an epidural: “I didn’t know what I was doing with Isaac. I couldn’t feel the need to push.” But her second son, Alex, was delivered after three pushes without an epidural: “I learned to use the contractions. I had better control of my body.”
However, the pain of unmedicated labour, coupled with fatigue, can overwhelm some women. Says Iacobucci, who delivered her second child, Alexandra, without drugs: “I was in so much pain, I couldn’t focus. I wasn’t in control. I lost it.”
Morrison feels that the epidural actually helped her push. “I could prepare myself to push, I could focus more on what I had to do, instead of just managing contractions as I did without the epidural.” And, she says, she and her husband “enjoyed the experience more together. He was a lot more relaxed because I wasn’t in pain.”
Baribeau adds that it’s important for women who have had an epidural to be careful not to overextend their hip joints. It’s a common risk of an epidural because women don’t feel the pain that would alert them that they’re pulling their legs too far back. Cossette, for example, experienced severe pain in her hamstrings for several days after delivery.
Feelings about birth
While the bottom line in childbirth is a healthy mother and child, how a mother feels about the birth experience is important too and can impact her well-being as she heads into the intense job of caring for a newborn.
Morrison’s first labour (no epidural) was so traumatic for her and her husband, David Garlock, that he was reluctant to have a second child. “He didn’t want to see me in so much pain again.” So when they did decide to have another baby, she made sure the hospital administered epidurals and she asked for one right away. “I was more energized in the days afterward. I was a more relaxed new mom.”
Baribeau says that “some women who opt for the epidural feel they have copped out.” Her response? “Regardless of whether a woman has an epidural, giving birth is hard work. The fact that you had a baby, carried it for nine months, that is an accomplishment. You should be proud.”
That said, Baribeau adds that she and her fellow nurses have noticed a look of exhilaration on the faces of women who laboured naturally: “It’s so powerful, it’s hard to explain.” Cossette agrees: “I was elated after Alex was born; with Isaac, I was just zonked out.”
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