Labor and Delivery
Mamas on Bedrest are at increased risk of maternal mortality
March 16th, 2010
Mamas on Bedrest are at increased risk of labor and delivery complications due to their high risk pregnancies. Pre-Eclampsia, Gestational diabetes, multiple gestation and preterm labor along with other complications put a mama on bed rest at increased risk of having a cesarean section delivery, which in turn puts them at increased risk of death.
Although childbirth is one of the most natural processes in all of human nature, women have died in childbirth since the beginning of time. While much has been done to improve maternal morbidity and mortality surrounding childbirth, the very methods used to save women may be the very ones killing them.
Consider this. Despite having incurred the wrath of God and being banished from the Garden of Eden Eve, with only Adam at her side and no medical intervention whatsoever managed to give birth to twin boys Cain and Abel. (Genesis 4:1-15)
Fast forward hundreds of years to a young couple in Nazareth. A young virgin named Mary is impregnated by God. (Luke 1:26-38) After she and her betrothed Joseph go t Bethlehem to register for the census, Mary gives birth to the Christ child in a stable-on her own with only Joseph and the animals to help her. (Luke 2: 1-7)
Now many people are skeptical about the accuracy of these biblical accounts. Yet one cannot deny that in earlier times, women did have very natural births, were attended by midwives or family members and were cared for by the women of their tribes, villages and family members.
Despite the natural occurrence of childbirth, there are inherent dangers in childbearing such as hemorrhage, blood clots and embolisms and heart abnormalities and respiratory emergencies. I grew up in Massachusetts and my elementary education consisted of various trips to historical sites in and around Boston. One place that always intrigued me was the burial ground behind the Old North Church. Wandering through the various plots I was always struck by headstones that read something like, “Elizabeth Smith: 1832-1862. ” Then there was a headstones that said, “Baby Smith” and just one date like,” June 2, 1862″, indicating that both mother and child had both perished during childbirth. Some women had multiple little headstones beside theirs, indicative of the numerous children lost during the birth process.
Most recently California has come under intense scrutiny as their maternal mortality rate has steadily climbed since 1996 and is at an all time high of 16.9 in 2006, the last year for which data has been compiled. Physicians and researchers who are analyzing the data note that there are several contributing factors to the increase:
- obese mothers
- older mothers
- fertility treatments
- better reporting of outcomes and better record keeping
- Preterm labor inductions
- Rising Cesarean Section Rate
None of the people who have read the reports can deny the impact that cesarean sections may be having on maternal mortality not only in California, but also nationwide. In California, the cesareans section rate doubled between 1996 and 2006, the years for which maternal mortality showed it’s dramatic increase. Additionally, the rate of pre-term labor inductions also increased in the same time period and preterm labor induction is known to increase the rate of cesarean section. Many ask the question, “Can these results be extrapolated to other states?”
Obstetricians, midwives, birth professionals and concerned citizens are all trying to determine the proper role of cesarean section in childbirth. While no one wants to go back to the middle ages when women routinely died during childbirth, we can’t ignore that today’s infant and maternal mortality rates are rising at an alarming rate despite all of the medical advances.
The University of Illinois Medical Center’s Discovery Hospital notes early contributions to obstetrics from the Egyptians and Hebrews. The first successful cesarean section on a live woman is said to have been performed in the 1500’s in the Roman Empire by Jacob Nufer, a pig farmer who performed the procedure on his wife. Interestingly, the procedure initially was not widely performed because of its high mortality rate-some 85%. But with the advent of anesthesia and aseptic technique, cesarean sections became safer and more widely performed and accepted. Today in the United States nearly 1/3 of children are born via cesarean section. Conversely, it is reported that many of those surgical births are not medically necessary.
In response to this growing number of cesarean sections, in 2002 Dr. David Lagrew, the medical director of the Women’s Hospital at Saddleback Memorial Medical Center in Orange County set a rule: no elective inductions before 41 weeks of pregnancy, with only a few exceptions. The results, the operating room schedules opened up, the hospital saw fewer babies admitted to the neonatal intensive care unit, and fewer hemorrhages and fewer hysterectomies occurred.
While no hospital can be accused of performing cesarean sections as a way to increase revenues, few hospitals have been quick to adopt a “no preterm induction” policy. Likewise, hospitals that have adopted a no preterm induction and/or a low cesarean rate policy have been primarily non-profit facilities (See post on Indian Health Service). These hospitals have cesarean section rates more in line with the World Health Organiztion’s 10-15% and lower maternal and infant mortality rates.
So what is the answer? Clearly no one wants to sit by and watch US maternal mortality rates rise yet the medical community is very reluctant to completely change from its current structure. This country has already lived through treacherous times for childbirth during its infancy. The advent of technology, which initially lead to a decrease in infant and maternal mortality, now poses a threat to mothers and babies nationwide. Despite the inevitable outcry from those who benefit from the use of technology (Dr. Lagrew noted in his own hospital, revenues go down when procedures go down.), it is patently evident that its use has to be reined in.
Mamas on bed rest are at increased risk of maternal mortality. Voice your concerns in the comments section so that researchers and policy makers will put the health well being of mothers and their babies before technology, protocol and revenues.
NIH Post VBAC Conference Consensus Statement
March 12th, 2010Following the 3 days of meetings and discussions between the National Institutes of Health’s Consensus Development 
Program, various obstetrical experts and birth advocates on the viability of vaginal birth after cesarean section (VBAC), the NIH has released a consensus statement highlighting the key points from the discussion, where they believe subsequent research needs to focus and their recommendations to obstetricians about how to approach the subject of VBAC with their patients.
Here is a summary of the consensus statement.
- The panel affirmed that a trial of labor (TOL) is a reasonable option for many women with a prior cesarean delivery.
- Rigorous research shows that a trial of labor is successful in nearly 75 percent of cases, and maternal mortality is actually lower for women who have a trial of labor, regardless of whether they end up delivering vaginally or by cesarean, though those women who have an unsuccessful trial of labor and undergo a repeat cesarean delivery experience higher morbidity than those who have a successful VBAC.
- Concerns have arisen because although VBAC does reduce morbidity in mothers, there is a slightly increased risk of morbidity and mortality to the fetus. The Panel is asking for more research to see if these disparities can be resolved and definitive risks determined for both mother and baby.
- The panel is advocating for additional research to develop clear, evidence-based risk assessment tools to assist mothers and providers in the decision-making process from early pregnancy through delivery, accounting for individual risk factors, values, and preferences to see who is an appropriate candidate for TOL and VBAC and who is not.
- The Panel strongly recommended that policymakers and providers collaborate in the development and implementation of appropriate strategies to address malpractice concerns that may keep providers from recommending VBAC, such as increases in malpractice premiums and threat of litigation in the event of untoward events. These factors and others seem to be (along with other factors) exacerbating barriers to TOL for women with a previous cesarean delivery.
- The Pannel recommends that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess the requirements to have an obstetrician and anesthesiologist “immediately available” while any woman who is having a TOL is laboring. This recommendation has created a significant barrier to TOL and VBAC for many hospitals who cite the cost of having an obstetrician and anesthesiologist constantly on call is prohibitive. They ask the societies to compare VBAC risk relative to other obstetrical complications of comparable risk, risk stratification, to see if it is truly necessary in light of limited physician and nursing resources.
- The Panel recommends that Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. This will help the providers and patients better assess if a TOL really is a viable option for their situation.
- They recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate to develop integrated services that would reduce or even eliminate barriers to a trial of labor and subsequent VBAC.
The full NIH Consensus Statement is available Here.
Policy makers need to hear from us if we want to have choices in how we give birth to our children. I am in contact with many advocacy groups and will share your concerns. Please add your comments to the panel discussion in the comments section. ~DTL
Let’s Make Mother Friendly Childbirths available for Mamas on Bedrest
March 4th, 2010The Coalition for Improving Maternity Services (CIMS) is dedicated to improving the care provided to women and their families during the child birth process. They advocate a midwife model of care which accentuates freedom of movement while in labor, the ability to eat and drink freely while in labor, the freedom to choose where to deliver a baby (at home, in a birthing center or at a hospital) and who to have present at the birth (the partner as well as a doula or female labor support partner). While I am totally in favor of all that CIMS is doing, I am dismayed that little is being done to extend this same type of care to “mamas on bed rest” or high risk pregnant women.
I attended the Coalition for Improving Maternity Services (CIMS) annual forum for the first time this past weekend. I learned a lot about new research in pregnancy, labor and delivery and delivery of care for pregnant women and their families. But the one thing that kept nagging at me throughout the conference was that many of the findings and initiatives, including the Mother Friendly Childbirth Initiative (MFCI), are not available to “mamas on bed rest” or high risk pregnant women. While I wholeheartedly agree with the initiative, I kept wondering to myself, “What about mamas on bed rest?”
In my opinion, high risk pregnant women need mother friendly childbirths more than women having uncomplicated childbirths. When that red “High Risk” is stamped on a woman’s chart, she automatically loses the bulk of her power to choose the course of her pregnancy. She is told if she has to go on bed rest-there isn’t choice not to. She is told when she will deliver and where (often in a hospital operating room with a cesarean section). She will have medications and interventions-often without being told or asked if she wants to have them and all the while she will be told that if she wants to have a baby to bring home at all, this is how it has to be. Mother Friendly? Not in the least.
I don’t dispute that when a woman is having a high risk pregnancy that more medical intervention may be needed to sustain the pregnancy or to deliver the baby. What I am railing against is the powerlessness that high risk pregnant women have to succumb to in order to have a child. While many of us may already be humbled by infertility and conception difficulties, and threatened miscarriages and preterm labor, doesn’t it stand to reason that we need the support and comforting atmosphere of a mother friendly environment even more so? Can’t we apply even a few of the MFCI points to high risk pregnancy right now?
I know well how using even just a few of the MFCI points can make a huge difference. When I had my daughter, I went into preterm labor and all hell broke lose! I was admitted emergently by one of my OB’s partners because she was off. Since I was scheduled for a cesarean section I was admitted and prepped in a surgical anteroom. My husband was present at times, but for the epidural and other procedures, he was asked to leave and I was all alone to endure the clang of instruments being opened and laid out, bright lights directed at the OR table and draped and masked “blue people” I didn’t recognize telling me everything would be okay. It was unnerving to have my belly bared to a room full of strangers; some to care for me and some to “take” care of my baby .
Once the epidural was administered, I began vomiting profusely and little was done to stop it except adding things to the IV bag. When my husband came into the delivery room there was so much commotion he was completely overwhelmed. When my daughter was born I asked him what she looked like and he was completely undone by the “crater” they had created in me to get her out. My daughter was quickly whisked out for more “intensive” care due to breathing difficulties and was only paused briefly by my face. My husband went with the baby and once again I was on my own. I was alone in the recovery room, vomiting and in pain for 2 hours before being transferred to the post partum floor. A neonatologist briefly stopped by to tell me that my daughter was okay, they were checking her out and that I would see her shortly. She did not arrive while I was in recovery. We did roll by the nursery on my way to the floor. I still hadn’t held my baby and by now 4 hours had passed since her birth. On the floor I continued to vomit until 2 am when the anesthesiologist finally graced us with her presence and gave me something in the IV bag to stop the vomiting and put me to sleep. It was the next morning, 12 hours later, when I held my daughter for the first time before she was transferred to the neonatal intensive care unit.
The picture was completely different when I had my son 3 1/2 years later. First and foremost, he was nearly term, born at 39 weeks. I actually had him at a different hospital because I wanted to have my tubes tied and the first catholic hospital did not allow the procedure. The second hospital tried to make the surgical suites more friendly. It may seem strange, but a nice color and curtains at the windows does a lot to warm up a place. Every room was tastefully decorated with a place for a partner to sleep and a place for the baby’s bassinet. My OB delivered my son and I felt so much more comfortable with her attending the birth. My husband was so shell shocked from my daughter’s birth that we agreed he wouldn’t be present at my son’s birth. We flew my older sister in to be with me instead. She was by my side at all times and we were laughing so hard at one point, my OB had to ask us to stop giggling so she could stitch me up!
When my son was born, my doctor held him up so that I could see him. She did suction him (a midwife care no no) and then she laid him on my chest. He nursed with a vigor I didn’t know a newborn could muster! The nurses wiped him off and wrapped him up to go see my husband. That was the only time he was away from me. He and my sister rode with me to the recovery room where my husband, my parents, my sister and baby were all present. My son nursed at will and also rode with me to my room and stayed with me in my room until I was discharged.
One could argue that my second delivery was so much better because my son was a healthy term baby and my daughter was preterm and had breathing complications. I did not have lots of choices regarding my care or treatment for either birth. But even within those parameters, I believe that the “warmer” , friendlier environment, having my OB who tended me throughout my pregnancy deliver my child and having a friend/family advocate always at my side keeping my spirits high and making sure I had what I needed went a long way to making my second delivery much calmer, more memorable (in a positive way) and more “Mother Friendly” than the first. Small changes such as these and a few others would go a long way towards making “mother friendly” births for mamas on bed rest.
