Assisted Reproductive Technologies

Mamas on Bedrest: Not all C-Sections are bad

January 24th, 2014

Mamas,

Vanessas-birth

My daughter at birth

Having a c-section is not the worst thing that can happen to you. I say this from the perspective of having had 2. While chatting with mamas in this community, one mama stated how she is terrified at the thought of having a c-section. I realized that c-sections have become demonized in the birth world and this is not a good thing.

On this blog, all over the web there and in numerous chats there are articles and points of view touting “normal”  and “natural” (meaning vaginal) delivery. I’ll admit that I am a proponent of minimal intervention. Having went through what I went through to have my children, I know the potential pitfalls of too much intervention. Intervention must be balanced with “watch and wait” and not overdone. Even though labor and delivery is a marathon process, there are many physiologic benefits for mamas and babies who endure the process and emerge victorious on the other side. So for women who can, I most certainly advocate for “natural, vaginal birth”  whenever possible.

Well, the sad truth is that this isnt always possible. Many years ago, many women (and babies) died as a result of being unable to deliver “naturally” and doctors and midwives of the day not having the skills or technique of cesarean section. Thankfully (for me and my daughter at least) clinicians have those skills and expertise and many mamas and babies are alive today. But what is a very viable and useful method of delivery and one that saves lives in critical situations has become an overused, overdone process. Cesarean sections are the second most performed surgery in the US second only to Hysterectoies. And while they are a critical tool in the obstetrical arsenal, their overuse has contributed to many mamas and babies are not faring so well during the childbirth process.

Currently cesarean sections account for a full one third of all births in the United States. According to the CDC, rates of C-section deliveries-especially first time c-section deliveries-have leveled off and are declining. This is good news because a first c-section is often an indication for subsequent c-sections. C-sections are often scheduled for the following reasons and these indications are responsible for 85% of all cesarean deliveries:

  • “large babies”
  • uterine/placental/vaginal issues,
  • fetal distress or shoulder dystocia
  • breech presentation
  • The leading indication for cesarean delivery is previous cesarean delivery

I doubt anyone would argue the necessity of a cesarean section for a mama and/or baby in distress; i.e. mama’s blood pressure skyrocketing and not responding to medication, a decrease in fetal heart rate, decreased fetal movement which may indicate a problem, or other complication. But in this country, c-section has (or had) become the norm for twins, mamas who have gone beyond 39 weeks (as late as 42 weeks is still considered full term!), induction (a whole other topic for a blog in and of itself!), “big baby” and several other “nebulous” reasons. C-sections became a way to “control” birth and to be able to dictate specifically when a baby would be born and who would be attending.

That is where we here in the US fell into problems. Birth is a wild and unpredictable process. Because we can never be exactly sure when conception and implantation occur (except in cases of assisted reproductive technology), clinicians really are guessing the age and developmental status of an infant in utero. Granted, we have some very sophisticated technology that we can use now and get a pretty accurate “guestimate”. But we are still guessing, and sometimes the guesses are off way more that expected. there also seems to be this need to control the process. Birth should not be controlled. It is as it is for a reason; so that mama’s and baby’s physiologies can interplay and together navigate the birth process. That process, that delicate physiologic communication is disrupted when clinicians intervene. Again, sometimes intervention is waranted. But historically in the US, the interventions are often more disruptive than beneficial.

So what should a mama do? How does she decide? Mamas, always have frank and open discussions about your care with your health care providers. Ask them what they hope to accomplish by performing a cesarean section and why they believe it is the best course of action in your particular case. Get as much information as you can; read, get second opinions if you feel uneasy. Make sure that in the end, whatever route of delivery you choose, you are comfortable with the decisions made and the procedures being performed.

Not all c-sections are bad. Many are lifesaving (as was the case with me and my daughter!). Just be sure that you are fully informed and fully at peace with your decision for the procedure before you signed the “informed consent”.  Remorse and regret following a birth that has not gone well can haunt a mama for years. It can have lifelong (negative) implications for the baby. And sadly, it cab alter the interaction between mama and child if not just initially, for many years to come.

What are your thoughts of C-section? Share your thoughts in the comments sections below.

Mamas on Bedrest: Did any of you undergo “preconception” counseling before becoming pregnant?

March 18th, 2013

Good Morning Mamas!!

Question: Did any of you undergo “preconception” counseling before becoming pregnant? 

I ask this question because a couple of days ago, I was trolling twitter and inserted myself into the #acogchat. The topic of discussion was preconception evaluations. When I entered the discussion, I’m thinking a good 20-30 minutes into the chat, the group was discussing how more women need to be aware of their health histories and essentially should have all their “medical ducks in a row” prior to becoming pregnant to avoid complications. Well you all know me. The statements were making my neck hairs stand on end because they seemed to be saying that when pregnancy complications arise, it’s because of something mamas haven’t addressed prior to getting pregnant, a sort of negligence. In my experience with Mamas on Bedrest that simply isn’t true. For many mamas, there is no rhyme or reason that they have the complications they have. And on that note, I jumped into the conversation.

Let me begin by saying that the moderators and participants of the chat were very gracious and receptive to me and my views. I didn’t exactly “tip toe” my way into the chat, I went in full throttle in defense of mamas! But as the chat progressed, we all reached a really good consensus about preconception health care and health care in general. With a candid discussion about the limitations of our current health care climate as well as cultural and societal opinions, we all left the chat with the following “agreement” regarding preconception evaluations/examinations/counseling:

A Preconception Exam/Evaluation is really preventive maintenance. As the chat progressed, we all realized that if health care providers ask, AT EACH AND EVERY VISIT, about a person’s medical history; if any new complications have arisen, if the patient has any new concerns, is there any change in family history…Then we are doing preconception counseling-the way that it should be done. A woman’s health (or anyone’s health) should always be optimized at any doctor/patient interaction. When we providers don’t ask these questions and update a patient’s record each and ever visit, we drop the ball not the patient.

Preconception Exams/Evaluations must be done for men as well as women! Conception takes 2 PEOPLE!! We focus so much on women (as the carriers) but we cannot forget the fact that the sperm quality will also affect whether or not conception takes place and has just as significant an impact on the health of the baby as the quality of the egg and mama’s health. Just as it’s important for mamas not to smoke or drink if they are trying to get pregnant, fathers who smoke, drink or have other health issues won’t impart healthy genes to their offspring and may also be impeding the conception process.

Preconception Exams/Evaluations must begin in pediatrics. This is one area in which there was some controversy. We all know that teen pregnancy is an issue in the United States. Yet, there is no consensus on when/how to teach sex education in schools. What we as a group came up with is that if we teach children to always take exemplary care of their bodies; stressing the importance of not smoking, not drinking alcohol in excess, avoiding recreational drugs, maintaining a healthy weight for height, getting regular exercise, avoiding risky sexual behavior, etc…We are teaching not only good health habits, but imparting good preconception habits.  By focusing on good health, we can reduce the stress many parents feel regarding “sex education” and not step on toes. For example, talking to a teenager about how condoms work and how they prevent the spread of disease is a different conversation than, “You should use condoms at every sexual encounter. ” We impart the medical information and allow parents to speak to the moral implications as they see fit. (And while we know that many parents won’t speak with their children about sex, it is still the parents’ right to impart their moral code on children, not ours-no matter how much we feel it is needed. We can suggest to parents that they discuss certain issues with their children, but in the end, as it was brought up by a parent on the chat, it’s the parent’s obligation, responsibility and right to educate their children (or not) about sex.)

Do discuss medical costs. I brought this to the attention of the group that many insurance companies don’t cover maternity care and require a separate rider on policies. So many woman have been caught by this. Who wouldn’t? It’s natural to assume that if you have insurance, it will cover you if you become pregnant. This just isn’t the case! So as clinicians, we must ask our patients at each and every visit if their insurance has changed, and to give them a simple “heads up” that many treatments and procedures aren’t covered and they should review their insurance policies annually (and most especially if they are planning to become pregnant).

Make Sure Pre-Existing Conditions are Well Controlled Prior to Conception. Again, this was a topic that got us wound up for a minute. But as we discussed it, we all realized, that if health care providers are truly monitoring their patients’ medical conditions, say diabetes, then the goal should always be tight control. At each office visit the importance of blood sugar control should be discussed and emphasized-whether the patient is trying to become pregnant or not. So again, it’s not a question of preparing the patient for pregnancy, it’s about making sure the patient is in optimum health always.

 

I really am glad that I “crashed the chat”. I had the opportunity to speak on behalf of Mamas on Bedrest and to contribute to a really great discussion on patient care. The one area we were not able to address is the notion that all of this can be done in 8-12 minutes. But I am confident that given the passion and dedication to this group of health care professionals, even that “obstacle” will soon be eliminated.

Mamas on Bedrest: Is Being on Bedrest a (More) Common Occurence?

February 6th, 2013

I was speaking with my mom the other day and we were chit chatting away about my work. My mom is really interested in “this bed rest stuff” as it was not really common when she was having us in the late 50’s and early 60’s. My mom asked me, “Is bed rest really that common?”

Bed rest is certainly more common now than when my mom was having kids and there are a myriad of reasons. Just to bring folks up to speed, according to the CDC the numbers are still holding at some 750,000 women going on bed rest annually in the United States. But my mom’s question is one that hounds me. Why are so many women going on bed rest? I tried to find a specific answer and while the literature is not specific, here is what I have been able to gleen.

1. Bed rest is more common right now because we have more diagnostic tools to diagnose conditions for which bed rest is recommended. When my mom was having my sisters and I, many of the ultrasound machines and fetal monitors that are used today to evaluate a mama and her unborn child simply didn’t exist. If a woman had a short cervix, she simply had a short cervix. Now I can hear the collective cyber gasp at that statement. But at the same time it makes you wonder, “How many women over the centuries had a shortened cervix during pregnancy and had a completely healthy baby?” One could give the opposing view, “Well how many women lost babies due to shortened cervix?” We don’t know the answers to these questions, but it does make for interesting mental gymnastics.

I am currently researching the life and career of my great grandmother, a “granny midwife” in the south from the late 1910’s to the early 1950’s. I hear tell that she had an uncanny way of knowing which women were going to have problems and which women were going to be “good breeders”. I also am learning that she had phenomenal clinical skills. I wonder if she was able to examine a woman and note if her cervix was shortened? Or if she would have preterm labor? I do know that she saw a lot of women through their pregnancies and advised them when to stop working (most were farm women) and to rest. It’s an interesting historical perspective and as I learn more, I will certainly share with you all.

2. Bed rest is more common because we have more women having children later in life. I don’t know if I completely agree with this. My grandmother gave birth to my dad at age 43 and he was her 15th child, 13th pregnancy (2 sets of twins, yikes!!) Now one could argue that her body was accustomed to having kids (one about every 18 months!).  But one could also argue that her body was “worn out”. As far as I know, she had no problems during pregnancy, no bed rest and no still births. She did lose the twin boys to infant illnesses.

One thing that my reproductive endocrinologist told me when I was in the “height of my childbearing years” is that ovarian age can be uncertain. By that he meant that some women may be 20 yet have the ovarian age of a 40 year old, and some 40 year old women will have more youthful ovarian tissue and function than their much younger counterparts. There is no way to predict which women will have “youthful” ovarian function and which women will not. Likewise, there is no way to predict when a woman will cease to have ovarian function. When we speak of advanced maternal age, we know that in general, as a woman ages, her ovarian function decreases as well as the quality of her eggs. However, we all know of older women who have had completely healthy, unassisted pregnancies, labors and deliveries, and young 30 somethings who have struggled.  The best that we can say for now is, relatively speaking, as a woman ages, her chances of having difficulty conceiving and having complications during her pregnancy are increased and continue to increase as she ages.

3. Assisted Reproductive Technologies (ART). Today there are thousands of women who become pregnant as a result of assisted reproductive technologies (IVF, GIFT, ZIFT, IUI, ICI, Surrogacy/gestational carrier).  The use of ARTs is a relative risk factor for a woman being prescribed bed rest because women who use ART are often older and often have pre-existing reproductive issues that would predispose them to complications any way. Additionally, women who conceive via ART are at greater risk for having a multiple pregnancy which increases the risk of going on bed rest.

3. Stress. I have written extensively in previous blogs about the role that stress plays on a woman’s ability not only to become pregnant but to maintain that pregnancy. Today more than ever women are balancing the demands of a career, a family that they have created, caring for family members from family of origin (parents or even grand parents) or have other pressing responsibilities not common to women 30 or more years ago. The work of Kathleen Kendall-Tackett PhD and others shows that the stress response has a direct effect on the cervix and preterm labor. Women who are under stress are releasing neurochemicals that soften the cervix and “ripen” it in preparation for labor and delivery-even if it isn’t time.  Stress also increases a mama’s blood pressure and may cause her not to eat or take optimum care of herself so her baby may experience Intrauterine growth retardation (IUGR).  It is critical that pregnant women avoid stress as much as possible not only for their own health but also for the health of their unborn babies.

4. Litigation. I hate bringing this topic into the argument, but in our current culture, litigation is probably closer to the top as opposed to the bottom of the list of reasons some OB’s put patients on bed rest. Currently, there is not scientific or medical evidence that bed rest is beneficial in preventing preterm labor or preterm birth. In a review article published just over a year ago, I reviewed the current medical literature regarding the efficacy of bed rest and again found no solid medical or scientific evidence for the use of bed rest as a treatment to prevent preterm birth. But as a former clinician, I also understand why OB’s prescribe bedrest. If on the off chance an OB discovered an anomaly with the pregnancy, yet did not prescribe bed rest and the pregnancy had an unhappy ending, that OB can count on being sued and would likely lose his or her ability to practice as an obstetrician. At the current time, medicine in the United States (or globally) has not discovered any other, more effective ways to deal with the complications of pregnancy that often result in the bed rest prescription. Until that occurs, bed rest, effective or not, will remain a “standard of care” in the management of pregnancy complications.
Now whether or not a woman should be put on bed rest is still a heated debate. Given that there is no scientific or medical evidence that bed rest is effective in the treatment of preterm labor, one could argue that we are potentially creating more problems for mamas and babies than solving. But to mamas who have been on bed rest and now have healthy babies, there is no other route to go and no talking her out of the fact that bedrest saved her baby’s life.

I pass no judgement because I know that when I was having my kids, if my OB had told me to spin on my head and shoot marbles out of my nose, I would have done it. I think that high risk pregnancy is an emerging field and one in which there is still much to learn. I am very excited to watch what is emerging in the medicine and science, and I am very excited to be a part of the public health solution of supporting mamas on bed rest.