2 hospital labour procedures you might want to avoid!

[ 15 ] 24/02/2014 |

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IMPORTANT NOTE: The purpose of this article is just to INFORM about procedures and that there can be other options! The article is based on my experience, and what I’ve read on my own (all sources included). One can always question and express concerns, but each case is different, and you should ALWAYS consult your doctor(s), as they know what’s best for you and your case. 

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Although I had a low risk, uncomplicated pregnancy, I had a difficult, complicated and extremely painful birth experience. I was very close to an emergency cesarean, which I avoided thanks to a wide pelvic bone, and my baby was born with episiotomy and vacuum extraction. You can read my birth story here. I decided to look more into certain common practices, for the sake of others, and for a future pregnancy of my own.

This is what I found out. PLEASE READ IT, SHARE IT WITH YOUR PREGNANT FRIENDS, inform yourselves and others, and talk to your doctor in advance about the different standard hospital procedures and protocols, your options and what YOU want for YOUR baby and YOUR body.

1) Artificial rupture of membranes (ARM) – midwife breaking your water

It seems to be common practice to ask you to break your water if you are in labour and it hasn’t broken already. My labour started naturally and I went to the hospital to give birth. When I went there and into the delivery room, and at the very beginning of the whole process and 3 or 4 cm dilated, I was asked if I would like to have my water broken artificially as this would speed up the process. I didn’t know any better, so I agreed.

Well, IT DIDN’T SPEED UP THE PROCESS, and I had not sufficient liquids to ease the baby out when this was needed. Plus, I was not informed about the RISKS involved, which apparently are quite a few.

Please read this:

‘The forewaters usually break when the cervix is almost fully open and the membranes are bulging so far into the vagina that they burst. This ‘fluid burst’ lubricates the vaginal and perineum to facilitate movement of the baby and stretching of the tissues’. ‘Around 80-90% of women start labour with their membranes intact. This is probably because the amniotic sac plays an important role in the physiology of a natural birth.’ (Source: In defense of the amniotic sac).

Moreover,

‘Your midwife may suggest breaking your waters to speed up your labour. Breaking your waters near the beginning of labour isn’t recommended, as it doesn’t make any difference to the length of labour. ‘

‘However, if the active stage of labour slows right down, breaking the waters can help get labour going again. This does tend to shorten labour by about an hour. If you agree to the procedure, here is how your midwife will do it. Once you are on the bed, she will remove the last section of the bed so that your bottom is right at the end. She may ask you to put your legs up in stirrups, or to just hold them apart. ‘

‘Your contractions may become much stronger after your waters have been broken. Be prepared to work hard with breathing and relaxation exercises. Or you can ask your midwife for some pain relief if you need extra help.’
(Source: Speeding up labour)

Keep on reading:

‘In a spontaneous labour the rationale for an ARM is that once the forewaters have gone the hard baby’s head will apply direct pressure to the cervix and open it quicker. However, a cochrane review of the available research states that “the evidence showed no shortening of the length of first stage of labour and a possible increase in cesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged.” The Royal College of Midwives (UK) have evidenced based guidelines about ‘rupturing membranes’ that you can download from their site.

There are also risks associated with an ARM:

  1. It may increase contraction intensity and pain which can result in the woman feeling unable to cope and choosing an epidural… and the intervention rollercoaster begins.
  2. The baby may become distressed due to compression of the placenta, baby and/or cord (as described above).
  3. Fok et al (2005) found amniotomy altered fetal vascular blood flow, suggesting there is a fetal stress response following an ARM.
  4. The umbilical cord may be swept down by the waters and either past the baby’s head, or wedged next to the baby’s head. This is called a ‘cord prolapse’ and is an emergency situation. The compression of the cord interrupts or stops the supply of oxygen to the baby and the baby must be born asap by c-section. The only cord prolapse I have been involved with happened after an ARM (not done by me – honest!). The outcome for the woman was a live baby born by emergency c-section. Her previous 2 babies had been vaginal births.
  5. If there is a blood vessel running through the membranes (see picture below) and the amni-hook ruptures the vessel, the baby will lose blood volume fast – another emergency situation.
  6. There is a slight increase in the risk of infection but mostly for the mother (not baby). This risk is minimal if nothing is put into the vagina during labour (ie. hands, instruments etc.).’

(Source: In defense of the amniotic sac - worth reading the whole article and comments!).

2) Discontinuation of epidural at 10cm dilation, during active labor

These two articles are super interesting to read, and related to the discontinuation of the epidural. I had epidural, they stopped it at 10cm dilation and the pain, I felt it was unbearable.

The following text is from the article Turning off the epidural for pushing

“Epidural anesthesia is a powerful form of pain relief commonly used in labor and delivery. It is strong enough to be used even for cesarean births, allowing a mother to be awake and alert for her baby’s birth without experiencing the pain of surgery. However, as with anything, the epidural does carry risks. One of the risks frequently associated with epidural anesthesia is an inability to push effectively and/or an increase in the use of forceps or vacuum extraction, called an instrumental vaginal delivery (IVD).

A theory began to emerge that if an epidural was turned down or discontinued to allow a mother to have better sensation during the pushing stage of labor, that these risks would decrease. Many women were requesting this in an attempt to have better control. However, it was discovered that this theory does not appear to work in this manner.

One problem is that of pain relief. Once the body has been numbed with the epidural, it stops producing as many of the helpful hormones that allow natural pain relief, because the mother isn’t experiencing pain. So to turn off the epidural at this point requires the body to catch up, in effect, to help alleviate pain naturally. This causes the mother even more pain than if she had chosen not to have an epidural.

The other issue is that we don’t really seem to be able to prove that there is a decrease in the instrumental vaginal deliveries. There is a call out for more research to find a way to lower the risks of forceps and vacuum extraction births. One other way that is currently being used more effectively, without discontinuing the epidural, is laboring down. This is basically just allowing women who choose epidurals to labor a bit longer before beginning to push, allowing the fetal head to come down naturally. Many institutions are having a lot of luck with this technique, be sure to ask about it at your prenatal care appointments and in your childbirth class.

Sources:

Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia. Torvaldsen S, Roberts CL, Bell JC, Raynes-Greenow CH. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004457. Review.

A retrospective case-controlled study of the association between request to discontinue second stage labor epidural analgesia and risk of instrumental vaginal delivery. Toledo P, McCarthy RJ, Ebarvia MJ, Wong CA. Int J Obstet Anesth. 2008 Jul 8.’

From another source, Doctors Urge Patience, And Longer Labor, To Reduce C-Sections

‘Women with low-risk pregnancies should be allowed to spend more time in labor, to reduce the risk of having an unnecessary C-section, the nation’s obstetricians say.

The new guidelines on reducing cesarean deliveries are aimed at first-time mothers, according to the American College of Obstetricians and the Society for Maternal-Fetal Medicine, which released the guidelines Wednesday online and in Obstetrics and Gynecology.
About one-third of all births in the U.S. are done by C-section, and most of those are in first-time mothers. There’s been a 60 percent increase in these deliveries since the 1990s, but childbirth hasn’t become markedly safer for babies or mothers.

That discrepancy has led many to conclude that the operation is being overused. A C-section is major surgery. The procedure can increase complications for the mother and raise the risk during future pregnancies.

Women giving birth for the first time should be allowed to push for at least three hours, the guidelines say. And if epidural anesthesia is used, they can push even longer. Techniques such as forceps are also recommended to help with vaginal delivery.

Early labor should also be given more time, the doctors say, with the start of active labor redefined to cervical dilation of 6 centimeters, rather than 4.’

PLEASE LOOK MORE INTO THESE COMMON PROCEDURES ON YOUR OWN, EDUCATE YOURSELVES, DISCUSS ABOUT THEM OPENLY WITH YOUR DOCTOR, AND AVOID RISKS, COMPLICATIONS AND EXCRUCIATING PAIN, THAT IS, IF THEY CAN BE AVOIDED.
All the best with your future births and babies,

Liza
xxx

 

Category: Birth Stories, Resources for Malta Mums

Comments (15)

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  1. Mariabba Pap says:

    I also had an epidural, discontinued during active labour, and ended up with an emergency cesarean :( I am still wondering whether it could have been avoided.

  2. Martha says:

    Thanks for sharing this!

  3. Kathi says:

    Thanks for sharing! For a while now I have been wondering whether one unnecessary intervention during labor increases the risk of having other interventions that lead to other interventions and in the worst case to emergency c-sections which could have been avoided.
    ARM is a good example in my opinion. I am not a doctor nor a researcher but my instincts tell me that if the waters are broken too early on in labor this might not increase the process of labor itself but it might increase the pain from one second to the other a million times. If women were left to labor in compliance with their bodies at their own speed, many women might be able to somehow to grow with each contraction and cope with breathing effectively. This might lead to a lower rate of epidurals (which can then lead to other complications as stated in the article above). To me it just seems so logical that if your waters are broken artificially and the pain increases by the minute, you get overwhelmed with sudden pain and ask for help of medication.
    Furthermore, I have read that apparently the labor pain with an intact amniotic sac is supposed to be smoother and not as sharp. A German midwife, Ingeborg Stadelmann, is convinced that not rupturing the amniotic sac artificially leads to decreased use of medical painkillers during labor. She puts it like this: Imagine the difference it makes to apply pressure onto an object with your bare fist or wearing gloves like boxers do (Ingeborg Stadelmann – A consultation with a midwife).

    Of course while in active labor you might not be able to decide what is best for you and you strongly rely on doctors and midwives to tell you. However, nowadays unfortunately what is best for your body is not always what is best for the operation of the hospital. Therefore as women we should really inform ourselves beforehand and maybe write down sth. like a birthing plan. Speak to your partner or whoever will be present during your birth experience and discuss with him what you want and what you don’t want, so your partner is aware and could speak for you.

    I wish everyone beautiful birth experiences!

    (Please note: Regarding everything I said I acknowledge that there are situations where medical intervention is necessary. I don’t refer to these situations but only to unnecessary but unfortunately routine procedures that seem to be common nowadays.)

  4. liza says:

    Without exaggerating, after they broke my water and I got to the point where I was 5cm dilated, I felt I was dying and in the utmost urgent need for an epidural. Once they stopped the epidural, I felt I was dying for the 2nd time. Before looking further into this, I felt happy that since everything went wrong at labour, I was in a hospital and my baby and I got taken care of. Now I now that most probably, if there were no unnecessary interventions, none of these would have happened.

  5. kelly says:

    It seems to me to make sense to leave your waters to break naturally, but for me I was ordered in at 40+2 to be induced. Being my first baby, I did what I was told. After the 2nd induction (the first didn’t work) I was in agony, with strong contractions and I cannot describe the relief I felt once they broke my waters. I’d had the pain for a few days and suddenly it was gone…to make way for a new pain!

    I opted for epidural, which gave me 2 hours nap time (as I’d not slept for 2 nights) but then it seems to only work on one side of my body so half of me could feel the contractions! Eventually they stopped it but all during delivery, I lost the use of my left leg, but at least it gave my husband something to do every time I had to push!
    Like Liza, my son’s head was at the wrong angle and had to be assisted with ventous, which came off on the first attempt! But eventually resulted in the successful birth of my boy.

    I also had an episiotomy, which I didn’t know about at the time but sure did the weeks after! I hear that they’re very keen on giving those here…
    However, the staff & my Midwife were incredible, the care and attention we received was second to none and although they do procedures that it may be recommended you avoid, I am totally happy going back there again in August for the delivery of my 2nd child (although I hope my waters break on their own accord this time!)
    You can only trust that with the amount of babies being born here, that they have the knowledge, skill and experience do to what’s best for you and your baby.

  6. liza says:

    What I fear is that sometimes they might want to rush things. In my case, one of the midwives who were attending me and who broke my water, she was expecting in this way I would give birth during her shift. That didn’t happen and 2 other midwives had to take over afterwards. In hospital terms, I can imagine this might mean more money spent on a patient.

  7. Kathi says:

    @Kelly: May I ask you whether you gave them your permission to do the episiotomy? From what I read it sounds they did not even inform you that they were going to perform one. If that is the case, I find this scandalous.

    Episiotomy is also one of those interventions that medicals nowadays seem to make frequent use of without always being necessary. I know for sure that in Germany the rate increased over the years but now criticism has arisen. An episiotomy might make healing harder and definitely more painful. I know of one woman (in Germany) who had trouble walking and sitting for three weeks post-birth. And it increases the risk of tearing the scar on further births. If you leave women to tear naturally (if so), usually the tissues tend to break at their weakest point, making healing easier. Seems to me that an episiotomy in many cases unfortunately is another measure to speed up the process of labor.

    Like Liza I think a lot of the procedures and measures taken nowadays are not necessarily related to an increase of risky births but to the economy of the hospitals. If hospitals can calculate and “schedule” births a bit better, they can be more efficient. What is good for the hospital is not always good for the patient. I was told that at Mater Dei they give you 4 hours to progress from arrival. If you do not make enough progress in their eyes they put you on the drip to help the contractions get stronger. I don’t know whether this is true but if it is the case, it shows that it is obviously done for reasons of getting the labor over with fast. Nearly the same counts for inductions (which are also more likely to end up in a c-section).

    I don’t want to talk anything bad or be overcritical. I am sure there are very dedicated and experienced good midwives and staff at Mater Dei. And I am sure they are very helpful and do whatever they can. But maybe with one public hospital for the whole island their situation is predetermined with thinking economically.

    However I still opted to give birth there (instead of St James) and I will leave a birth story here and share my own experience with Mater Dei afterwards.

  8. liza says:

    I’ve been reading the book ‘A Midwife’s Story’ and the midwife there describes (in the 60s-70s) how she felt hopeless working in a hospital cause she had to follow guidelines and procedures which were not for the benefit of the mother giving birth but for the hospital and for the sake of formality. She knew certain things could and should have been done differently, but she had no option. Things don’t seem to be much different nowadays. Hospital midwives, no matter the country, need to follow guidelines and procedures given by higher above.

  9. liza says:

    @Kathi “I was told that at Mater Dei they give you 4 hours to progress from arrival.” -> this is not true. At least it wasn’t true in my case. I was given a delivery room at around 11:00 in the morning and gave birth at 01:20 late at night.

    Regarding the episiotomy, I assume that like in my case, at this stage it was necessary for Kelly. The baby was descending with the wrong side of the head and they had to pull it out. I was in pain for at least 2 weeks after birth. Painful to sit, painful to go to the toilet, horrible.

  10. Kathi says:

    @Liza: Glad to hear this :) I hope I don’t go in to the hospital too early. Well, I will see

    I have no doubt that in your case the episiotomy was truly necessary. Again I was referring to completely normal progressing births. And I believe a lot of medical interventions that constrain women to the bed during labor might also make episiotomies more necessary. First of all, it is a lot harder to push your baby out when you are on your back and secondly all throughout labor changing position and using gravity helps (which is of course not possible any longer when you need to be on the monitor, have an epidural etc). But in any case, necessary or not, you should be informed before they cut you (Which I am sure they do. I must have misunderstood Kelly here).

  11. Aliki Douvou says:

    My doc made me the ARM and that lead me to a ceasarian directly… Better to be avoided.

  12. Aliki says:

    My doc made me the ARM and that lead me to a ceasarian directly… Better to be avoided.

  13. Charleen says:

    I worked as a nursing student for three months in the delivery suite and beleive m its not the midwives choice to induce laboure, to tell you the truth they are against it at all costs but once you ave orders from the ob/gyn you have to do them. I really enjoyed my work experience there and i learned a lot i am 21 weeks pregnant now and looking forward to experience it :)

  14. Let nature do its work unless there are actual or potential complications. Don't let anybody bother you by their stories. Every pregnancy and every birth has its own story. Midwives are trained to do their job and what is good for one birth may not have the same effect on the other. Enjoy your pregnancy. It is unique. Let God guide you. Good luck!

  15. Joanna Delia says:

    Hi all…. I am a mother of 2 and a doctor

    Please note that infant mortality rate has been reduced by 85% since the 50s due to interventions by doctors and midwives. Also note http://www.2womenshealth.com/Postpartum/Maternal-Mortality.htm – the graph is shocking…

    I would seriously recommend to please refrain from portraying personal experiences as sacro santo fact. Relax and try to relay on the proffessionals. I am sure that no one working at any hospital is intent on worsening anyone s labour experience, nor certainly to endanger anyone s life… Any procedure done is based on individual and circumferential parameters. And most importantly all are done to safegaurd life. (And quality of life… Episiotomies for instance, as horrible as they may sound, make sure the ‘natural tear’ does not happen in a way that makes you incontinent to urine or faeces for the rest of your life)

    Please relax… We are lucky to have good, trained professionals.

    Take a deep breath and prepare for a roller coaster ride… You will leave hospital with a story…an adventure… But also with a precious baby….

    And please feel free to tell your story to the world, but unless you have had 20 babies, witnessed 100s of labours, have a medical degree, and read 1000s of studies (and not just a handful), do not try to portray your story as a bible for what to do and what to avoid…

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