OBOS Post: Expanded Discussion of Nitrous Oxide for Labor Pain Relief

Today at Our Bodies Our Blog, we have additional discussion of a topic raised last week, nitrous oxide for pain relief in labor, including a lengthy commentary from midwife/epidemiologist Judith Rooks in reply to a comment left on the original post.

The original post linked above also has a bit of background on nitrous oxide and its popularity in other nations, and citations for additional reading.

Big thanks to Web Manager Extraordinaire Kiki Zeldes for coordination and editing on this one.

OBOS Post: Laughing Gas for Labor

Over at Our Bodies Our Blog today, we’re wondering why nitrous oxide (”laughing gas”) isn’t a more widely available option for labor pain relief in the United States, given its availability in Europe and Canada. Come on over to find out more and share your thoughts!

OBOS Post: Judy Norsigian Talks About New Pregnancy & Birth Book

Today at Our Bodies Our Blog, we’re featuring a video segment from a Philadelphia NBC affiliate who interviewed Judy about Our Bodies, Ourselves: Pregnancy and Birth. Links to the video, transcript, and upcoming book-related events are also provided.

OBOS Post: Is Teen Pregnancy Really Up or Down?

Today at Our Bodies Our Blog: “You may have seen recent headlines such as “US teen pregnancy rate near historic low” and been somewhat confused (I certainly was). After all, didn’t the CDC just announce that teen pregnancy rates were going up?” - Find out why recent reports conflict.

Nation’s Largest Hospital to Ban Vaginal Birth, NY State Likely to Follow

New York City’s St. Sister Mercy General Regional Hospital, which is the nation’s largest hospital and presides over more births than any other facility, announced today* that it would no longer offer vaginal deliveries. Hospital spokesperson John Smith stated, “We were on track to reach a 75% c-section rate within the year, and believe that women unnecessarily suffer when they attempt labor with a very small chance of being successful in our facility. Because most of our patients will eventually need repeat cesareans anyway, we believe that we are getting them off to the best possible start. We are encouraging other hospitals to adopt the same policy.” The hospital is also letting go its team of certified nurse midwives, banning doulas, and banishing fathers back to the waiting room. According to Smith, “Given our new policy of cesarean birth for all women, we feel that support personnel are not needed for our patients, and simply get in the way of the physicians’ work.”

Asked about women who arrive at General unexpectedly in labor and whether they can offer informed consent to a mandatory c-section and implicitly agree to this by showing up at the hospital, Smith responded, “These women have a 75% chance of having a c-section to begin with - we all know that women are less capable of giving birth vaginally than they were just 20 years ago. We simply can’t treat unplanned patients any differently, or it would encourage women to just drop in when they’re in labor, and that would be a nightmare. We’ll bring in the machine that goes “ping,” and that will let us know they need a cesarean anyway, and proceed from there.”

At least one General patient agrees with the new policy. Consulted following her own primary cesarean, Jane Downt said, “I’ve always thought that birth would be so much easier if women’s bodies were designed differently, if they could just pop open a little panel and remove the baby. A c-section is just like that, opening a window into the body to pull the ‘bun out of the oven,’ so to speak.”

Women’s health, birth, and reproductive rights advocates, along with an aging hippie community in the city, have reacted strongly to the decision. One activist responded, “General had a very high c-section rate, and the CNMs were the only thing keeping it from reaching 100% already [the hospital banned VBAC five years ago]. They already insist that all women take home formula samples, even those who aren’t yet pregnant, keep the lights very bright, and allow women to leave the hospital without calling Child Protective Services if those women don’t plan to breastfeed. This is just another appalling new development, and it will drive women into their homes for birth.”

Smith responded, “The last thing we want women to do is give birth at home. To that end, we have proposed legislation that would ban pregnant women from being in their homes, or other homes or shelters, from week 30 of pregnancy until the birth. We believe in general that the safest way to give birth is not to do so at all, so we are working on a long-term plan to prevent any babies from being born in New York State. We just have to work out a feasible plan that will accommodate the rush of women eager to have their fertility and reproduction controlled by the State. We hope the visionaries in Washington, D.C. will take note of our leadership, and implement similar plans for the Nation.”

*Mark it on your calendar

Update: Now that the holiday has passed, I feel the need to explicitly point out that this was an April Fools’ piece, not intended so much to be funny, but to seem plausible on a quick read and play around with some of the stereotypes and extreme rhetoric that tends to surround birth discussions.

How are a Long Cervix and Having a C-Section Related?

A study in the current issue of the New England Journal of Medicine has been widely reported with headlines such as “Longer Cervix Associated with Higher C-Section Risk” and “Cervical Length Predicts C-Section.” The authors, performing their research at several hospitals in the UK, used data on women having their first baby during the study period who had cervical length measure sometime between 22-24 weeks, and ultimately delivered at term.

Information on mid-pregnancy cervical length was compared with medical records for the 27,472 women, including information on “the mode of delivery, the gestational age at birth, whether the patient was in labor, whether the onset of labor was spontaneous or induced, and the indications for operative delivery. Outcome data for the infant were also recorded, including whether the birth was a live birth or stillbirth, the birth weight, and the sex.” The authors then tried to determine whether cervical length predicted c-section, and whether the indication for c-section was failure to progress.

The authors grouped women into four groups by cervical length, and found that those with the shortest mid-pregnancy cervical length were least likely to have a c-section, with likelihood of the surgery increasing for each increasing length group. Ultimately, 5,542 women (or about 20%) delivered via cesarean section, and for 83.3% of these, failure to progress was listed as one of the indications for the procedure.

Although this was a planned second look at the data from the authors’ original study, certain data that might be interesting/important were not available, such as how long the women were in labor, dilation and effacement progress, whether standardized definitions of failure to progress were in place and whether these definitions were always followed across different physicians and hospitals. It’s also not entirely clear how often “failure to progress” was the main indication for c-section, as opposed to “one of” the indications, so we don’t really know if other, possibly more important, things were happening.

Rita Rubin of the new USA Today health blog also touches on another question, which is whether the generally accepted duration of labor is maybe not appropriate on an individual basis. Is it possible that women who start out with a longer cervix simply need a little extra time to fully efface and dilate? Could this need for extra time lead to a “failure to progress” label? Although the authors found that mid-pregnancy cervical length predicted c-section, and that “the increased risk of this event among women who had a long cervix in mid-pregnancy was explained by the increased risk of poor progress during labor,” several questions seem to remain about how and why that happened.

Citation: Smith GC, Celik E, To M, Khouri O, Nicolaides KH; Fetal Medicine Foundation Second Trimester Screening Group. Cervical length at mid-pregnancy and the risk of primary cesarean delivery. N Engl J Med. 2008 Mar 27;358(13):1346-53. PMID: 18367737

How Do You *Not* Know You’re Pregnant?

The Iowa Hawk Eye recently published an article on an Army National Guard private who returned from Iraq on a two-week leave intending to propose to his girlfriend, only to be surprised when she gave birth to his son. Apparently she was surprised, too:

Malmberg first started noticing stomach pains last Saturday night when she was with Novak [her solider boyfriend], who was visiting his brother in Burlington. She went to bed early that night, hoping some rest would relieve her situation. “I just thought it was menstruation cramps. I was hoping they would go away,” she said. Other than an extra 20 pounds, Malmberg’s body gave no indication of her pregnancy. Her menstruation cycles continued at an irregular pace, which Malmberg attributed to physical exertion from all the time she spends playing competitive soccer.

Seriously? If I thought I wasn’t menstruating regularly because I was exercising so hard/much, I’d be suspicious about gaining 20 pounds at the same time. I’m always baffled by these stories, and usually chalk it up to denial in young women - Malmberg is 18. She did accept her boyfriend’s proposal - unfortunately has to return to Iraq to spend 3 more months looking for roadside bombs.

Pregnant Drug Users in Alabama Getting Jail Time Instead of Help

A recent New York Times article profiles the problem of pregnant drug users, focusing on an Alabama law used to jail the women and a district attorney who apparently believes this is a reasonable solution. An excerpt:

The environment can be unforgiving. Rachel Barfoot, 31, who had been charged before with beating her niece, told her probation officer that she was pregnant. When she tested positive for cocaine, she was arrested.

 

“I was in shock,” said Ms. Barfoot. “I told the truth, but the truth got me nowhere,” she said in an interview. Three months pregnant, already a mother of four, she spent five weeks in the Covington County Jail.

 

“It was hell,” said Ms. Barfoot, now jobless and struggling. Police affidavits make it clear that local doctors are cooperating in these investigations.

 

The women are sent off to county jails, state prisons, or drug rehabilitation clinics, and often emerge bitter at the collaboration of police, prosecutors, judges, doctors and social workers they say is less keen on help — Mr. Gambril insists otherwise — than punishment.

 

“In Covington County, I don’t think they’re interested in helping mothers,” Ms. Hitson said. “They’re just sending people straight to prison. It doesn’t help their drug problems.”

Although the article doesn’t point to the specific new law that is used to jail these women, but I assume it is Section 26-15-3.2 of Alabama code, which makes it a class C felony to “Knowingly, recklessly, or intentionally causes or permits a child to be exposed to, to ingest or inhale, or to have contact with a controlled substance, chemical substance, or drug paraphernalia as defined in Section 13A-12-260. A violation under this subdivision is a Class C felony.” This piece of law makes no distinction for pregnant women to take into account the dismal health care of prison and the inappropriateness of that environment for a pregnant woman. It also ignores the option of rehabilitation as a potentially more socially responsible fix, at least on a situation-by-situation basis. The article does note that some women have been sent to rehab, but the law as written doesn’t seem to specifically call for that option.

The times should have spoken with someone from National Advocates for Pregnant Women on this issue; the organization explains their position:

By combining claims of fetal rights with the war on drugs, new laws that punish pregnant women and families are being enacted and enforced. There is consensus in the medical community that addiction is a public health issue and that treating drug use during pregnancy as a crime undermines the health of both women and children. Yet fetal rights advocates in some states have convinced police, prosecutors, judges that addiction itself may be punished if the addict or drug user is a pregnant woman and that a pregnant woman’s addiction should be treated as a form of civil child abuse. These cases and statutes are having a devastating effect on women’s reproductive and human rights as well as public health, drug policy reform efforts, family life, and efforts for racial equality.

More information on this issue is provided at http://www.advocatesforpregnantwomen.org/issues/punishment_of_pregnant_women/

Friday Fun Question: for the Moms in the Audience

I’ve read several blog posts about pain and labor pain recently, especially concerning individual differences and tolerance. As a late Friday topic of discussion, I have a question for the moms, especially those in healthcare or with a tendency to accidentally injure oneself - How might labor pain compare to hobbling around on a broken kneecap for six weeks because some yahoo in the ED missed it on the x-ray? Or, you know, to other excruciating things you may have experienced, if your hometown ED wasn’t as incompetent as mine? Discuss.

Other dumb accidents from your blogger (feel free to share your own):
-Falling out of a van and onto a sidewalk in front of the security office for the National Institutes of Health. In a skirt.
-Falling stiffly (like a felled tree) face-first into a hot tub. Which was occupied.
-Falling backwards off a porch, bouncing off a dogloo, falling some more, and landing butt-first on a water spigot.
-I’ve also fallen up stairs on several occasions. We won’t even talk about accidentally stapling my own finger.

That New York Times Doula Article

On Sunday, the New York Times ran a piece, “And Doula Makes Four,” which is very critical of doulas who interject themselves into the birth and have their own agenda for how birth should go, such as whether the woman should receive pain meds. One women said of her doula, “She was so set on my having a natural birth, she offended me, she offended the nursing staff, she offended my O.B.” One doula is quoted as indicating that she will not take on clients who may consider having an epidural (she seems to be some mix of philosophically opposed and not interested), and providers interviewed were critical of doulas’ interference in medical decision-making.

I’m not entirely sure what to make of this piece. I find it difficult to believe that all doulas are this way, yet the Times didn’t go out of their way to offer different perspectives from other doulas, so the overall impression is of meddling busybodies who shouldn’t be there. Professionally, if you look at the DONA code of ethics, that really shouldn’t be the case - it states, “The doula should make every effort to foster maximum self-determination on the part of her clients,” which I would interpret to mean that they are there to help fulfill the wants and needs of the woman, not to try to override her decisions. Again, I don’t think this is the case with all doulas, and I think the article should have done better about presenting other viewpoints.

I’ve been kind of kicking around the doula topic since I read the NY Times piece. One woman interviewed for the story said, “The doula was supposed to be my advocate at the hospital and help us carry out our birth plan.” I don’t really get that. I have respect for the comfort measures a doula can provide. Ultimately, I don’t want anyone else thinking they are responsible for having my care and experience go a certain way, even if I change my mind, though - that’s my job. I’d be very interested in what you all think about the “proper” role of doulas, and whether talking about the “proper” role of a group of helping women is obnoxious in the first place. No flames please, just discussion.