We hear from practitioners about women whose goal it is to avoid a cesarean and have uninterrupted contact with her baby in the first hours of her baby’s emergence into our world.  It seems that these practitioners find it completely illogical for women to desire this goal because women are often out of it, exhausted, or undergoing surgery by the time second stage arrives.  In their experience, women are begging for epidurals, asking for c-sections, are completely unprepared for “the realities” of labor.  The practitioners are completely oblivious as to their role and influence in the outcome of the birth.  They are aware, though, that the public’s awareness of the need to question the application of protocols in general is on the rise.  Chaos ensues when the practitioner no longer takes on the responsibility of learning about normal birth, remaining current on research, does not hone his/her listening skills (read: bedside manner) and does not exercise patience, a critical element for a healthy birth outcome for both mother and her baby(ies).  How can we expect them to see they are the main contributing factor to what a laboring mother’s second and third stage will be?

It doesn’t strike practitioners as odd that they’ve come to believe and accept myths or oft-repeated misinformation as fact.  Peer research concludes the use of consensus in scientific matters is not infallible.  If the Michigan AMA Resolution 710 proposed above isn’t difficult enough for expectant mothers to fight their way through, there is also the medical birth community’s attempt at blaming mothers for dismal service results including the rising cesarean rate.   It seems mothers are darned if they do (they’re identified as hostile) and darned if they don’t (they’re asking to be cut open).

For example, back in the news again is a protocol that has not changed since last highlighted three years ago, but if it did revert back to its historically safe use has the power to change our country’s maternal and newborn statistics: pitocin.

Pit to distress” is the formal name of a protocol by which a mother is given pitocin to  either induce or speed up her labor at a rate that subsequently distresses the baby and leads to an automatic c-section.   Independent Childbirth member Jennifer Riedy explains the protocol on her blog and follows up in our post stating First…nurses (and doulas, and OB’s…and any type of care provider) need to realize that what happens in their area of practice is not the same as what happens in another area.  Even as a doula I see vastly different practices in two hospitals that are part of the same hospital system and located only 20 minutes drive from each other.  If a particular hospital has implemented guidelines to avoid “Pit to distress” that is great.  But don’t fall into the trap of believing that it isn’t happening (in another L&D room).

Just because it isn’t *called* “Pit to distress” does not mean that isn’t what is done.  If an order is given to put a woman on a certain dose of Pitocin, then up that dose every 15 minutes up to some maximum dose, then the unwritten part of the order is “or until the baby shows signs of distress.”

…Bottom line, the package insert says to start the Pit at 0.5-1 microunit per minute, and raise at 1-2 microunit per minute increments every 30 to 60 minutes.  More aggressive protocols raising the drip rate every 15 minutes –even if it is using those same doses–also put a mother and baby at the risk of being “Pit to distress” because it takes over 30 minutes for the Pitocin to equilibate, so while baby may tolerate well the dose that was set at noon, you will not really know that until after 12:30, and if the dose was raised at 12:15 and 12:30…you may have hit the “distress point” with the 12:15 dose.”

There are other mothers who will tell you they experienced pitocin at levels that they instinctively knew were not right for their bodies because their bodies were not only in pain their bodies were also signaling signs of fight or flight response.  They begged to have the pitocin turned off, only to have practitioners refuse to document their request and outright deny it as well.   A Rockville General (hospital) doctor in Connecticut was cited by one such mom when she birthed there in 2007.  She went on to share that the practitioner believed her mother was trying to influence her decision to ask for the pitocin to be turned off and attempted to remove her mother from the birth room (labelled hostile perhaps?).  Another doctor at UConn in Connecticut has stated that he is known for having the most aggressive pitocin protocol and achieving more vaginal births that way.  But, at what cost?  Certainly we were present for one such birth where a mother experienced an adverse pitocin reaction and rather than document it as such her files were noted that she refused pitocin.  Incidentally this same doctor is infamous for telling mothers who desire a natural birth that “80% of women ask for epidurals” (could that be because of the pitocin rate you employ???).  This is not an indictment of UConn, where we have also been present for healthy natural childbirth experiences with other doctors.  It is to exemplify the need for mothers to research their practitioner options and to confirm Jennifer’s observations that two vastly different scenarios can take place in the same hospital!

Jennifer Riedy’s well researched conclusions on the use and abuse of pitocin being common are backed up by the medical community as well.  Doctors Gary Ventolini and Ran Neiger state (Contemporary OBGyn; Sept 2004): “Oxytocin is also abused when one attempts to induce labor, especially in patients with unfavorable uterine cervix, and ‘induction failure’ is diagnosed shortly thereafter, before the onset of active labor.  We feel that as long as the fetal condition is reassuring cervical ripening should precede labor induction.  Once labor induction has begun, don’t abandon it in favor of a (cesarean) delivery before the cervix has started changing only because a set length of time has elapsed.”

On the subject of routine induction at 41 weeks as another example, there are also practitioners who see the fallacy of consensus in the medical community, specifically from practitioners Leung and Lao of the Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong, China (Routine induction of labour at 41 weeks of gestation: “nonsensus consensus”; BJOG Volume 109, Issue 12, Dec 2002):

Sir,

We read with great interest the commentary by Menticoglou and Hall published in May 2002 and want to echo the point of increasing caesarean section rate as a result of this nonsensus consensus. Our unit has adopted the practice of routine induction of labour at 41 weeks of gestation for several years on the basis of the findings of the Cochrane Review1, which suggested that this approach can reduce perinatal mortality. Women are admitted to the hospital at 41 weeks of gestation for cervical assessment with the Bishop’s score and induction of labour.  If the cervix is favourable, combined induction of labour with
artificial rupture of membranes and oxytocin infusion is performed on the following morning. If the cervix is unfavourable, a vaginal prostaglandin E2 3-mg tablet is used to prime the cervix. Combined induction is performed on the following morning if the cervix becomes favourable. If not, another dose of vaginal prostaglandin is given and induction is delayed for another day. In the case of labour occurring after cervical priming with vaginal prostaglandin, it is counted as induction of labour.

We have analysed the caesarean section rate for nulliparae undergoing induction of labour at 41 weeks of gestation from our hospital obstetric database. In the year 2000, 183 nulliparous women were induced under this consensus and 59 of them (32.2%) had caesarean sections. This caesarean section rate was significantly higher than that for term,
singleton, vertex presenting fetuses in nulliparous women in the same year (excluding those 183 women with induction at 41 weeks), which was 368/2271 or 16.2% ( 2 test, P < 0.0001). More alarming is that the caesarean section rate for nulliparous women undergoing induction of labour at 41 weeks of gestation increased even further to 35.0%
(63/180) in the year 2001 and 41.1% (23/56) in the current year (January to May).

We agree with the authors that it is now time to reconsider the consensus on routine induction of labour at 41 weeks of gestation, particularly in nulliparous women.

Reference
1. Crowley P. Interventions for preventing or improving the outcome
of delivery at or beyond term [Cochrane review]. The Cochrane Library,
1. Oxford: Update Software, 2002.

Simply put, you can’t get there (a normal second and third stage) from here (a medically managed first stage) without hitting a whole lot of long shots along the way.   We’ve read the book many times and the ending never changes.  Straightforwardly put, neither medical model practitioners nor mothers will ever know how different a birth experience might have been, and that has reverberations throughout a mother’s  lifetime and her baby’s lifetime.

The responsibility for knowing normal birth truly lies with mothers today as the majority of practitioners cannot get out of their own way in preventing injury to mothers and their babies.  You can, however, keep them out of your way.  Learn from the experts: other normal birth experienced support resources. The educated mother can choose her practitioner wisely and ‘get there.’