Ultrasounds

Ultrasound was invented by an English physician by the name of Ian Donald. It was first tested in 1957 & one year later, was used on a pregnant woman. I won’t go into the history, but if you are a history buff, you might like this link: http://www.ob-ultrasound.net/history1.html (I like history about as much as I like eating sand after being in the desert for two days with no water)..

A prenatal ultrasound test uses high-frequency sound waves, inaudible to the human ear, to transmit through the abdomen via a device called a transducer to look at the inside of the abdomen. With prenatal ultrasound, the echoes are recorded and transformed into video or photographic images of your baby.

There are several reasons why an ultrasound is done, and they can be quite beneficial. However, (I didn’t say BUT!) I’m finding a lot of women are having them done a LOT - and there is really not a benefit to this in most cases. Let me explain.

Ultrasounds are often done at around 20 weeks, with another one in the third trimester. Depending on the doctor, it might be around 32 weeks, or 36-37 weeks. They are looking for lots of things. More than one baby, size of the baby for dates, placental location and various problems and/or deformities of the baby.

I mentioned that the use of ultrasounds is on the rise. Some doctors are using them at each prenatal visit. I know three people who just had to sign a form at their doctors’ office saying that they had to consent to *at least* three ultrasounds during their care. To add fuel to my fire, all three of these pregnant mothers, signed this form AFTER already having three ultrasounds. Many doctors do an ultrasound on the first visit to confirm pregnancy! What happened to a good ol’ blood test or a urine test?

A short story of my own: With my fourth child, I had my first prenatal at 9 weeks. A vaginal ultrasound was done to confirm pregnancy. I went back in at 13 weeks for my second prenatal. The doctor could not get fetal heart tones using her Doppler. (Back then, I was not aware that this was not uncommon for this gestational age - especially with a mother with ..ahem “padding”). Another vaginal ultrasound was done immediately to see if there was in fact a beating heart. I had a routine ultrasound at 20 weeks. (So far three ultrasounds). I had a history of preterm labor with all my children, so my doctor thought it would be wise to share my care with a perinatolgist. During these visits they would do an ultrasound to check for funneling and cervical effacement. I had an ultrasound once a week from weeks 25-28. They didn’t catch anything. At 28 weeks and 6 days I went in for my regular OB prenatal, and I was found to be 1cm dilated and 90% effaced. She sent me to the hospital (though I was not contracting at the time). BUT, before I was to go to labor and delivery, she ordered...an ultrasound. She said she wanted to know how big baby was according to gestational age. I hope that wasn’t all that she wanted, because I had 7 ultrasounds so far, with the last one just a few days earlier. I didn’t know any better. I just did what the doctor told me - because they are the ones who went to school. My son is autistic. I will live the rest of my life wondering if these ultrasounds, along with 40 minutes a day of external fetal heart monitoring for two weeks straight, had a role in the cause for his autism.

My concern is that we do not have enough research to prove the safety of ultrasounds. They have been done for 30 years, but what are the long term effects? How could they know? According to a report in an edition of Proceedings of the National Academy of Science, exposure to ultrasound can affect fetal brain development.. When pregnant mice were exposed to ultrasound, a small number of nerve cells in the developing brains of their fetuses failed to extend correctly in the cerebral cortex."These disorders range from mental retardation and childhood epilepsy to developmental dyslexia, autism spectrum disorders and schizophrenia.” The researchers also said “Our study in mice does not mean that use of ultrasound on human fetuses for appropriate diagnostic and medical purposes should be abandoned," -Pasko Rakic, chairman of the neurobiology department at Yale University School of Medicine.

So what DO we know about ultrasounds?

1) Ultrasounds cause heat
2) Ultrasounds cause “cavitation”. Cavitation is the development of bubbles which expand and collapse.
3) In 1993 the FDA raised the maximum output of ultrasound machines used in obstetrics eightfold, from 94 up to 720 milliwatts per square centimeter. The higher the milliwatts the higher chance of heat and cavitation.

We also know that ultrasounds are not always accurate. When they measure the baby, it can be off by as much as one pound in either direction. This can sometimes mean a difference between a preterm or term baby, or even an overdue baby. Sometimes there is uncertainty in what is seen; maybe the normal structure was not seen well, or something out of the ordinary was missed. Case in point - 2% of ultrasounds are wrong about the sex of the baby! Often, a mother worries over something that was “seen” in an ultrasound that turns out to be completely normal. And most of these cases had to be confirmed with another ultrasound (sometimes later in pregnancy) with a consult to a specialist. Sometimes the specialist can not confirm the ‘problem’ anyway.

I can understand one or two routine ultrasounds during pregnancy. I can see the need for one or two more in such cases as something like placental previa (to see if the placenta moves up away from the cervix). I don’t understand why they should increase ultrasounds for the rest of the women.

3-D, 4-D ultrasounds anyone? Your doctor may let you have one of these. If not, you can go to a shopping mall around the corner, and pay out of pocket for one! When the FDA raised the milliwatts per square centimeter they also required manufacturers to add two on-screen safety indexes. One measures the heating of bone or tissue; the other “mechanical” effects, including cavitation caused by the expansion of gas bubbles, sheering forces within tissues, and induced flows within fluids. My point is that the FDA expected sonographers to be well trained in using the on-screen safety indexes properly. These safety features would help keep patients from getting greater levels of ultrasound exposure than under the previous system of regulation. According to ultrasound experts, the actual state of sonographer training is dismally inadequate. Dr. Jacques Abramowicz, Professor of Obstetrics and Gynecology and Radiation at the University of Chicago, said, “Only two to three percent of the population doing ultrasound really know what the thermal index and the mechanical index mean.” In other words, going down the road to “Ultrasounds R Us” may not be such a good idea after all. The other problem with 3 and 4D ultrasounds is the time that it takes. Research shows that there is damage to fetal mice brains after ultrasound exposure of 30 minutes or more. Common sense tells *me* that I probably don’t want to take any risks, or have an ultrasound longer than necessary -no matter how much I want to see my baby.

I get wanting to see our babies! I’m sure women from the dawn of time have wished there was a window to their uterus. Ultrasounds are a pretty close second. Can they help women connect to their babies? You bet. We can ad this to our list of pros. We all have to decide what risks we are willing to take, and for what reason. There is no clear cut evidence - but I don’t see studies being done here in the US to make sure that the other studies are right or wrong. I wonder if there is just too much money in ultrasounds?
.
Here are some more links if you want to research this further. I do not provide them as true evidence - just food for thought.
http://www.ob-ultrasound.net/
http://www.obgyn.net/ultrasound/ultrasound.asp?page=/fm/news_articles/fda_ultrasoundequip0304
http://www.fda.gov/fdac/features/2004/104_images.html
http://www.vaclib.org/basic/ultrasound.htm#twelve
http://www.alternamoms.com/ultrasound.html
http://www.telegraph.co.uk/news/uknews/1365441/Ultrasound-safety-review-over-brain-damage-fears.html

The "E" Word

The word for today is Epidural. Sometimes they call it “epi” for short, but it doesn’t have a ring to it like “pit”. Epidural anesthesia, a form of regional anesthesia. Drugs are injected through a catheter that is placed into the epidural space. This causes both a loss of sensation (anaesthesia) and a loss of pain (analgesia), by blocking the transmission of signals through nerves in or near the spinal cord. If done correctly you should have a numbing sensation in this area:
Most everyone knows what an epidural is, and most laboring women (in hospitals) ask for it by name. There are hospitals in the USA with a 98% epidural rate for laboring women. Our government statistics are hard to find, but according to polls - hospital epidural rates run between 70-98% (with many in the business saying their hospital has an 85% or higher rate).

When I had my first child 15 years ago, I was terrified. Our hospital was small and didn’t even offer epidurals back then. I asked for a cesarean just so I could avoid the pain of childbirth all together. . Thankfully, I had a doctor who didn’t just *do* cesareans out of patient request. I won’t go into my birth story, but in my case the fear was much worse than the contractions. My point is, that had my hospital offered epidurals -I would have had one placed weeks in advance. As it turns out, even if I could have had an epidural, I had no time to get one anyway. I went from 5cm to 10cm in 20 minutes. I can honestly understand the fear that many women feel, and I can relate to them wanting an epidural. I believe that our society has made birth such a scary event, and women are convincing themselves that they cannot endure a birth without pain relief. This is a sad thing.

If epidurals were risk free, they would be the best invention of all time!  I’d still cringe that women had lost the ability to trust their bodies, and strengths, but I could still live with it. I’ve actually heard stories of nurses telling mom’s that epidurals are RISK FREE! Hello! If they were risk free, you wouldn’t have to sign a waiver before the Anesthesiologist did the deed! Let us go over the pros and cons of epidural anesthesia:

One of the biggest concerns that I have is the increase risk of cesarean delivery which itself comes with a ton of other risks for both mom and baby.  I like this simple graph:

http://transform.childbirthconnection.org/wp-content/uploads/2013/05/cascade-of-intervention.jpg

Here are you advantages to an epidural:
1. Almost always a complete relief in pain
2. Sometimes labor can progress more rapidly

The disadvantages are:
*Not always effective - 10-30% of women will not have adequate relief
A) Sometimes added boluses are needed and anesthesiologist needs to be called in
B) Sometimes anesthesiologist cannot make it in time so you labor without it anyway
* Stopping the progress of labor, increased need for Pitocin by about 90%
* hypotension (a drop in blood pressure) 12 - 23% -sometimes medication is needed to bring it back up.
* maternal fever - (then unnecessary antibiotic therapy - then the yeast infection - then.....)
An astounding 96% of all women who get a fever in labor have had an epidural. 86% of newborns are put on full-spectrum antibiotics, and have full septic workups while in the NICU have been born to mothers who had epidurals in labor. (This is just precautionary).
*itching
* inadvertent spinal (causing excruciating headaches, which a blood patch does not always a cure)
* nausea and vomiting.
* backache - this has become very common -and may last weeks and even months afterwards.
* fluid overload- because IV’s are needed and they run a risk of fluid overload that may lead to pulmonary edema.  Fluid overload can also cause your baby to weigh more at birth, and when they pee off that excess weight in those few days right after birth, your pediatrician may see that drastic weight loss as a reason to supplement with formula. 
* infection from epidural site
* respiratory arrest
* anaphylaxis
* nerve damage
*Decrease in the ability to push effectively. The build up of anesthetic simply weakens muscles to the point of ineffectiveness. Mother may not be able to push enough to effectively help the baby to rotate and descend.
*Cesarean: Eight primary studies revealed that the rate of cesarean section was 10 percentage points higher in the women who had received epidural anesthesia. One study actually found that the cesarean rate increased to 50 percent when the epidural was given at 2 cm dilation, 33 percent at 3 cm, and 26 percent at 4 cm. (The primary reason for section is fetal positioning is compromised).
*Mother feels detached from the process and becomes an observer; others may reduce emotional support. The nurse can no longer assess labor progress by observing the mother and must rely more on the monitor and vaginal exams. Sometimes mom may describe the birth as more cold - this can be due to mother not being in her left brain - where the birth memory is a little more ‘warm and fuzzy’.


Indirect increase in:
* operative delivery (forceps, vacuum, C/S) which all have their own risks
* episiotomy/tears (due to either the forceps, vacuum, or mom simply not being able to control the pushing stage effectively or move into a position that helps reduce tearing).
* oxytocin augmentation
* fetal scalp electrodes and intrauterine pressure catheters (IUPC)
* intrauterine infection - related to the increase in vaginal exams, IUPCs, etc.
*breastfeeding and infant behaviour - depending on amount of narcotic and anesthetic the baby has been exposed to. (Yes, they often use a narcotic for the local part of the epidural).

Risks to baby:
* fetal distress- bradycardia - one study reported 11% occurrence within 5 - 20 minutes of administration. Can cause fetal heart to drop or become irregular (leading to emergency c-section)
* Medication crosses placenta -especially the narcotic
* Septic workup and NICU care if maternal fever develops (may include Lumbar Puncture)
* Complications due to forceps, vacuum or cesarean section delivery
* Respiratory depression
* Increased likelihood of fetal distress due to mother's low blood pressure
* Short-term neurobehavioral changes, including irritability and inconsolability
*Drowsiness at birth
*Poor sucking reflex
*Poor muscle tone and strength for the first few hours after birth

Very Rare Cases (really rare)!:
convulsions
respiratory arrest
cardiac arrest
allergic shock
nerve injury (1 in 10,000) usually causing numbness in one leg that will subside in weeks or months afterwards - seldom is it a permanent side effect.
Epidural abcess
maternal death

There *are* benefits of a drug free birth. The pros for a drug free birth are much longer, and the cons are much shorter. In our society, women are convincing themselves that childbirth is like a dental procedure. You may have heard the comment “well you wouldn’t have a tooth filled or pulled without Novocaine”! Birth is no where near this type of procedure. Our bodies do not treat the pain the same way.  We were made to do this, and in most every case, it is very do-able. It takes a lot of things to make it do-able - and we need the support of our care-providers and hospitals to make it more manageable.  We need to reduce the induction rate, because Pitocin definitely makes the contractions harder to deal with for almost all women.  Women need to be able to move into positions that ease the intensity of labor, they need the option to labor in a tub and shower when everything is going well.  There are so many things that we can do to help ease the intensity of contractions - and many women not only find it bearable, some find it virtually painless.  Get a doula to help you manage those contractions! 

There is absolutely a time and a place for an epidural!  I like how Penny Simkin discusses the difference between pain and suffering.  You can have pain without suffering, and you can suffer without pain.  When the two merge together, it's time for an epidural.  I just mothers to be informed, to not fear labor, and take it one contraction at a time.  

Here are some ideas for those who would still like to have an epidural: 

• Don't get an epidural until you are having nice, regular contractions
  (and try to wait until at least 5cm to get it).
• Make sure baby is an optimal position before getting the epidural.  Head down is only half your battle, make sure that baby is facing the right way, etc.  You won't be able to get into many positions to help facilitate baby's rotation after the epidural.  
•  Once the epidural is working, consider getting off your back and alternate laying on your left and right side, (providing that it doesn't interfere with baby's heart beat).
•  Labor down:  This just means that even though your cervix may be fully dilated, your baby still needs come down a bit more.  If you wait until baby is lower into the vagina, you won't push as long, and you will also reduce your risk of needing an instrumental delivery.  "Laboring down" is common practice now at most hospitals, and it's something to take advantage of. 
• Use a peanut ball!  A hospital in Arizona discovered it had some great benefits and the results were compelling:  "Those who used the ball decreased the first stage of labor by nearly 90 minutes and the second stage by 23 minutes compared with a control group that did not use the ball.
  The real payoff came through lower C-section rates. The C-section rate for the group of women who used the ball was 13 percentage points less than for the group that did not use the peanut ball."
  Read more: http://www.azcentral.com/arizonarepublic/business/articles/2011/09/04/20110904banner-health-peanut-ball-reinvent.html?nclick_check=1#ixzz2lP3Sckve
• (ignore this bullet it doesn't seem to want to go away)!

If you are still afraid to give birth without an epidural, remember that you do not have anything to lose by trying.  Take a quality out-of-hospital childbirth class, hire a doula, and you still don't have to make a decision until you are actually in labor.  Consider finding a hospital that will allow you to labor in the tub in an uneventful labor.  Talk to your care provider.  REALLY, talk to him or her.  You want their support no matter what you choose right?  Why not make sure your provider will truly support your decision either way.  During labor, take it one contraction at a time, and if you are doing well, just keep going until you hit the wall.  Consider waiting a little longer after you hit that wall, you are stronger than you think ;-)

I just want women to make informed choices.  I tell all of my doula clients that I have their back (no pun intended), no matter what their choices are!  I don't want anyone out there to feel like "a failure" because they could not endure labor. EVER.   I'm just proud of you for thinking about it!

Happy Birthing,

~The Birth Teacher

The "P" Word

The P word.

Ahhh Pitocin. Many in the medical field call it “Pit”, and I think that is a suitable name. If you live in the USA, chances are that you have heard of this wonder drug. Unless you live in a cave, it’s pretty safe to say that you or somebody you know has had this drug during labor. What is it? It’s a synthetic version of oxytocin. You know, that stuff that makes you have contractions.

Pitocin is used in several ways. 1) To induce labor. 2) To speed labor up (or as some may put it, make the contractions more effective). And 3)to aid in the expulsion of the placenta during the third stage and 4) reduce bleeding/prevent hemorrhage.

I’m a firm believer in using interventions when medically necessary. BUT - (and you probably knew there would be a “but” and yes I also realize you should never start a sentence with the word but..) Why is the pitocin rate climbing to a staggering 80-98 % rate? (a 1992 survey by a medical anthropologist at the University of Texas found that 81% of women in US hospital receive Pitocin to either induce or augment labor). According to the Centers of Disease Control (CDC), the induction rate for women 15 years ago was 9.5%. My question is WHY has its use jumped up so much?  Are the uteri of women in our country incompetent? The short answer is no.

So why am I concerned? What is the big deal? I’m sure you are thinking that a healthy baby at the end of the day is the most important thing. I agree. But (yep, there’s that word again - you may as well get used to it :-), is it safe for the mother and the baby? What are the consequences, or side effects?

One of the almost guaranteed side effects, is an indirect one.. and that is increases pain. Harder contractions, longer contractions and sometimes double peaking contractions. Most women find the contractions so difficult to work through and stay on top of, that an epidural is needed.  The baby doesn’t like the harder contractions either, and often we see babies go into ‘fetal distress’ because of the effects of the Pit. Fetal distress can lead to a cesarean.  Since I'm all about trying to reduce the cesarean section in the US, I think we should save it for when it's needed -when the safety of mom or baby is at risk, and when staying pregnant is more dangerous than being induced.  Pitocin is also being linked to lower APGAR scores, and an increased need for baby to visit and possibly stay in the NICU for a while.*1 

I love this clip from "The Business of Being Born": 

Pitocin has another indirect consequence in that it interferes with the bonding process. Those who do not have pain medications, and Pitocin during birth have a wonderful balance of hormone cocktails that aid in our ability to cope with the pain and bond with our baby at birth. These hormones are also produced in high amounts and passed on to the baby. They provide us with the feelings of love, the inclination to protect, and care for our baby. When we use Pitocin, our bodies shut off our own oxytocin production to varying degress. We loose the benefits of this harmonic role our body plays in birth, and perhaps it causes a long term effect to the bonding process as well. I’m not saying that you don’t love your baby any more than the person next to you that did not have Pitocin. I’m sure you love your baby very much!  Can bonding be harder with Pitocin?  Some will say yes, it can be a side effect.  Dr. Michel Odent has been studying the hormones of labor for a really long time, and he certainly has some concerns:

Finally we have the question of the autism/pitocin connection. Now I am open to answers on autism. Perhaps it is not just one thing that causes it. It could be a combination of things. However, autism rates when up with the use of Pitocin rates. Pitocin blocks the love hormone that is also associated with socialization. Funny, I know a lot of autistic kids who have problems with socialization. There is a lot of discussion about the correlation between autism and Pitocin. The jury is still out here, but here are some pretty compelling articles (based on the latest research) worth viewing: 
http://www.autismspeaks.org/science/science-news/study-links-inducingaugmenting-labor-modestly-higher-autism-risk
http://www.theblueroomforum.org/f41/oxtocyn-possible-cure-being-tested-autistic-adults-296/

What are the actual (direct) side effects of the drug itself?  According to the package insert (which you can read here) here are the possible reactions: 

ADVERSE REACTIONS

The following adverse reactions have been reported in the mother:

Anaphylactic reaction

Postpartum hemorrhage

Cardiac arrhythmia

Fatal afibrinogenemia

Nausea

Vomiting

Premature ventricular contractions

Pelvic hematoma

Subarachnoid hemorrhage

Hypertensive episodes

Rupture of the uterus

Excessive dosage or hypersensitivity to the drug may result in uterine hypertonicity, spasm, tetanic

contraction, or rupture of the uterus.

The possibility of increased blood loss and afibrinogenemia should be kept in mind when administering

the drug.

Severe water intoxication with convulsions and coma has occurred, associated with a slow oxytocin

infusion over a 24-hour period. Maternal death due to oxytocin-induced water intoxication has been

reported.

The following adverse reactions have been reported in the fetus or neonate:

Due to induced uterine motility:

Bradycardia

Premature ventricular contractions

and other arrhythmias

Permanent CNS or brain damage

Fetal death

Neonatal seizures have been reported

with the use of Pitocin.

Due to use of oxytocin in the mother:

Low Apgar scores at five minutes

Neonatal jaundice

Neonatal retinal hemorrhage

The thing is, Pitocin does not always cause the cervix to dilate. It causes the uterus to contract, but that does not always cause the cervix to open. Often women are labeled as “failure to progress” during an induction, simply because their cervix was not ripe enough prior to the induction.  No wonder our cesarean rate is so high!  

 My point is Pitocin is given out way too easily these days. There are risks. There are side effects. Sometimes it is necessary, and the risks still outweigh the risks of major abdominal surgery. Most of the time, it used to make it easier on the hospitals, doctors and nurses -and it gives them added protection against lawsuits (and it's our fault as a society that it has come down to our providers feeling the pressure to induce because we might sue for whatever X reason).  

What can you expect if you need to be induced:
Mom can expect to have an IV (if she doesn’t have one already), and continuous fetal monitoring.  If she planned to labor in a tub, she may not be able to do this unless the hospital has wireless monitoring, and they can monitor baby well while she labors in the tub.  (It's rare, but it can happen sometimes). Contractions might be harder, so an epidural is more likely (but it's not impossible, I have had a few moms give birth without any pain meds while they were being induced). 
Remember you still have options when it comes to Pitocin - specifically how much you receive!
  You can opt to try starting your labor with Pitocin, and then turning it off once you are in a good contraction pattern (some providers would like that to be 3 minutes apart and lasting about one minute). You may or may not continue to labor on your own.  If your body does not kick, the induction process will start over.
  If you are in a good active labor pattern, and they are increasing the Pitocin, you can request that they NOT increase it so that you might be able to continue to labor without the use of pain management.  You can also request that it be turned down if you are having a hard time coping through those frequent, hard contractions.


References:
1. http://www.acog.org/About%20ACOG/News%20Room/News%20Releases/2013/Study%20Finds%20Adverse%20Effects%20of%20Pitocin%20in%20Newborns.aspx
http://www.autismspeaks.org/science/science-news/study-links-inducingaugmenting-labor-modestly-higher-autism-risk
http://www.theblueroomforum.org/f41/oxtocyn-possible-cure-being-tested-autistic-adults-296
http://abcnews.go.com/Health/study-pitocin-harm-babies/story?id=19148043
http://chriskresser.com/natural-childbirth-vi-pitocin-side-effects-and-risks
http://www.jhppharma.com/products/PI/June-11-2008/Pitocin-Full-Prescribing-Information.pdf

Another video I often show my childbirth class students:
http://www.oneworldbirth.net/videos/when-and-how-is-oxytocin-released-during-birth/

Welcome to my blog

Hello,

Welcome to my new blog. I am a Certified Childbirth Educator and Certified Labor Doula.. I'm a also a wife, and a mother.


I'm really not sure what direction this blog is going to go, but I had to at least say that I gave blogging a try. I have a million opinions (just like everyone else I suppose), but I still support the fact that everyone has the right to an opinion opposite of my own. I am ever-learning and every now and then, I claim the right to change my opinion. So, should my opinions start popping up on this blog, please go easy on me. I'll do the same for you!

Hope you all have a wonderful day,

~The Birth Teacher