Tuesday, October 5, 2010

Routine Practices That Shouldn't Be Routine

(Sorry for the long post! I started typing and couldn't stop. If you make it through, thank you!!!)
Working as a Homebirth Midwifery Apprentice has opened my eyes about a lot of things that are done in the hospital and at home that are completely unnecessary. These are things that people learn and are part of their routine practice that they don't change because they don't know or understand the new research, or they just like to keep their old ways of practice regardless of the research.

Some of these things are still perpetuated through fear and worry, such as suctioning a newborn because fluids are dangerous, or immediately cutting the umbilical cord because the baby might bleed out or get too much blood.

So much research has been done on routine practices lately, especially since they are not improving the maternal and infant mortality rates, and yet these practices are still used, and we are still afraid if we hear they aren't necessary.

Amniotomy and 24 Hour Rule:

These both deal with your bag of waters. If you are giving birth, and your water hasn't broken yet, a lot of doctors and midwives will break your water to either keep your labor going, as a way of induction, to put you on the clock for delivery (the 24 hour rule), or to insert monitors into your uterus whether to monitor your contractions or to monitor your baby. There are other reasons, but these are the basic ones used every day.

Amniotomy is where they manually break your water with a hook. It looks almost like a crochet hook. As they are checking your cervix for dilation, they will pass this hook into their hand and clip the bag so it ruptures. This tells yoru body that labor needs to start, or needs to kick up a notch if it hasn't already. When you are induced, this is one of that practices that go alone with either a cervical ripener or pitocin.

Childbirth Connection, in their 2006 Listening to Mothers survey, reported that 59% of women had their waters artificially broken during labor. Most women that have this done are told that it will speed their labor, or it has to happen so they will dilate. This is so completely false.

Your water is a cushion. It keeps the full strength of the contractions off the baby, and it makes it so the mother isn't feeling bone on bone during contractions. As I said, it is a cushion. Taking away that cushion puts more pressure on the baby and the mother and can make your labor so much more intense.

As with any procedure, there are risks! From Birth Sense:
Consider the potential risks of AROM:

  • infection, especially if labor is prolonged or multiple vaginal exams are done

  • cord prolapse (umbilical cord washes down in front of the baby’s head and becomes compressed

  • increased cord compression due to lack of cushioning from fluid

  • life-threatening hemorrhage of the baby if there are fetal blood vessels running through the membranes at the point the water is broken (this is rare)

  • increased risk of amniotic fluid embolism (very rare)

When your water is broken, you are also put on a clock. In the 1960's, a "study" was done. This "study" was only a data collection for births that were already done. They took both term and preterm infants and collected the data on if their water was broken for 24 hours and if they got an infection. Not only was this not a formal study, but preterm infants are more likely to have an infection because their bodies aren't prepared for birth. When you mix the data from them with term infants, you are bound to get a higher rate of infection. After this, doctors started their "24 hour" rule.

If your water has been broken for 24 hours, you will be subjected to either augmentation of your labor, induction if your contractions haven't started, or you will head straight to a cesarean. Your baby, after the birth, could have multiple blood draws to check for infection, maybe a spinal tap, and most times they will receive antibiotics "just in case".

When they went back and looked at this collection of data, they found that the women who were more likely to pass an infection to their infant were ones where the water broke prematurely, or broke because they had an infection in their uterus. Not because their water had been broken for a certain number of hours.

This "study" is still used as reason for amniotomy and the 24 hour rule.

Talk to your doctor or midwife before you give birth. See how often they artificially break the water. Make sure you get a number, not just a vague response. Research has shown there are ZERO benefits of routinely breaking women's water just to "keep labor going."

Routine Suctioning:

When your baby's head is born, a lot of providers will suction their mouth and nose before your next push. When the baby is born completely, they will suction it completely to get all the mucus out of their mouth and throat so the baby will cry. If there was any meconium, they will deep suction, away from the mother and on a warmer.
A lot of people think this is normal, since the baby will try to breathe, and could possibly aspirate the mucus and need to intubated. Not only is this completely false, but it is not evidence based.

When a baby is born, their lungs are filled with fluid. When they take their first breath (which IS NOT necessary until the placenta has detached or the cord is cut since they are still receiving oxygen) the mucus in their lungs is released and helps keep the lungs open. After a few breaths, they have expelled the mucus themselves without the aid of suctioning.

If the baby is having a little issue pinking up after birth but is breathing and doing okay, one of the better things to do is tip it so its head is lower than the body, and in a few seconds, they are able to get that mucus out either through a cough, cry, sneeze, or just regular breathing.

Remember, a crying baby is a breathing baby. A sneezing baby is a breathing baby. A snorting baby is a breathing baby. You can see a baby pink up. It is one of the greatest sights. The best part is they do this without any help at all. When you touch a baby whether it is to suction them or rub them, you are interfering with how they are born into this world. Watching the mother's reactions when the baby is touched to either suction or rub is completely different from a mother that is left to help her own baby.

The homebirths I have been to, we don't touch the baby at all unless there is a true issue. The mothers are holding their babies, and they instinctively know how to help their own babies. If I was to jump in there and do it myself, they would rely on me instead of their own instincts. From their very beginning, we would be hampering the relationship between mother and infant.

One of the best posts I have found on this is on Nurturing Hearts Birth Services. Baby has a transition period just like mom does. Leave them alone! If you have ever watched a true unassisted birth (not just unassisted, but also where mom is in charge of her care no matter where and with whom she is birthing), mom is holding baby. Mom is talking to baby. Mom is rubbing baby. She knows what to do.

When you suction a baby, research has shown that when you routinely suction an infant from clear amniotic fluid, you can cause bradycardia (a slower heart rate than normal). It has also been shown that infants that are suctioned can have a harder time breastfeeding because of the forceful bulb that is placed in their mouth and down their throat at birth. You are interfering with a normal process. Babies were made to work out their own fluid. Babies were made to cough and sneeze and grunt and snort to get it out. It is completely and totally normal.

Babies have been born for centuries before routine suction came along. Wiping their face to help them is better than sticking a tube down their throat for no other reason than you don't know the alternative. Let mom hold her baby. Let the mom talk to her baby, position her baby. The first thing in that baby's mouth should be its mother's breast, not a hard piece of plastic.

Early Cord Clamping:

The cord is your baby's lifeline. It has given them nutrients and oxygen for the last 10 months. It contains the baby's blood, not the mother's. When a baby is born, even if they are outside the womb and are breathing on their own, they are still receiving oxygen through this cord until the placenta has detached.

When you cut the cord, the baby has an initial instinct to gasp. Their body knows that their oxygen supply has been cut off, so it forces the baby to breathe, even if they aren't ready. So much happens when the baby is born, and clamping the cord can interfere with that.

When a baby is born, they have to change their entire circulatory system. A valve in their heart closes so that air is now coming from their lungs and not from their umbilical cord. The lungs perfuse with blood, they expand and finally a breath is taken. When you cut the cord, instead of the baby's body doing this in its own time, you are speeding it up.

Not only that, but a lot of the baby's blood is in the placenta. It is the baby's blood! If you allow the cord to remain intact until it stops pulsing, the baby can end up with three times more blood than if you cut it prematurely. Babies that have their cord cut early have more cases of jaundice and anemia.

Giving Birth Naturally has a great post on Early Cord Clamping and the side effects. Your baby needs this blood. They are healthier, they have an easier transition to life outside the womb, and they are so much less likely to need more interventions such as deep suctioning, lights for jaundice, and supplements for anemia.

Bathing The Baby:

When a baby is born, they are covered in all sorts of things. Vernix (it looks like a white lotion all over the baby), blood, and amniotic fluid just to name a few. When you watch shows and even at some women's own births, they never held their baby before they were bathed and "clean". Some nurses, doctors, and midwives will even tell patients that their baby is a biohazard and could pass diseases to the parents from the vernix, fluid, and blood.

Not only is this so false, but the baby has a specific smell after birth and before they are bathed. Have you ever seen a birth movie, and the mother is holding her baby and smelling their head? They have a specific smell that helps the mother bond. Mothers can recognize their baby's cry, and if they are left unbathed, they can also recognize them just by that special unique scent.

When you bathe a baby, there are certain things that you are washing away. Vernix is nature's natural moisturizer. A baby's skin is so sensitive, and since they have been floating in fluid the last 10 months when they hit the air, their skin can dry out really fast. Rubbing this vernix into their skin moisturizes and keeps the air out a little longer. No man made product can do this.

Also, when you bathe a baby, you are washing off their fluid, and other things in their skin that help them stay warm. They are under water, and as most people have noticed, when you step out of a warm shower, you cannot wait to be wrapped up in a towel to get warm again. Babies can't control their heat as well as adults can, so when they get out of that water, their body temperature doesn't rise as fast as ours, which can make it so they have to be placed under a warmer until they regulate. You can also use skin to skin to regulate their temperature, but a lot of hospitals aren't up on that research and don't realize it is better than the warmer for term infants.

A baby is so sensitive to touch after birth. They have been floating in fluid, and basically the only squeezing or pushing they have had is during birth. Would you, after living in a very soft and comfortable environment, want to be scrubbed with a washcloth, even the ones that are made for infants? They need to be held close by their family. They don't need to be shocked by water and then scrubbed clean.

Your baby does not need to be bathed. Your baby is not contagious. Your baby is coated by the best products so that their transition to life outside the womb can be easier.

So much more is done to babies at birth, and also to mothers near the end of pregnancy and during labor and postpartum. Routine practices need to stop. No mother or baby is the same as another. One's care should not be the same as someone else's. We need to start evaluating not only patients if you are a care provider, but also ourselves as individuals. Your diet isn't the same as another person's, so why would the care we receive through life be the same as our best friend?

Be your own advocate. Research, read, inform yourself! Talk to your provider about what their routine practices are. Help them decide what care would be best for you. It is your care. It should be about you.


Anonymous said... [Reply to comment]

My first child was born at 34 weeks, due to an infection (only detected later in pathology). But the infection isn't really the point here. The point is that they clamped her umbilical cord immediately, and I'm still irritated by that, 5 1/2 years later. Particularly because she WAS preterm, and it seems to me that she really needed everything she could have gotten. As it was, she was severely jaundiced.

Incidentally, I also retained her placenta and hemorrhaged severely. I've heard some claims that allowing the blood to drain out reduces this. I don't know if that's true or not, but now I'll always wonder if they are in some way connected.

Natasha said... [Reply to comment]

I LOVE this post. So much valuable information in one place. I wish every mother/mom-to-be would read this!

Kayce Pearson said... [Reply to comment]

Natasha - Thanks :)

Amber - I have the same issues with my daughter. She was born at 36/37 weeks and is classified a late term preemie since she was so much younger than they thought. Cut her cord right away, had issues breathing, and almost needed a transfusion because her jaundice levels got so high. I also had a lot of bleeding during my cesarean, and I wonder if that is why also. I need to definitely see if they are connected though!

Anonymous said... [Reply to comment]

Kudos to you for such a well-written & informative piece. I gave birth to both my children (now 14 and 11 years old) at home with midwives, and I had many reasons, least of all those that you've listed in your post. Those experiences were the best and most significant in my life and serve to give me strength when I think back on them. I have no regrets making the choice to give birth at home, and although I did have concerns and apprehensions while I was pregnant, these were alleviated by the excellent care I received from my midwives.

Annie said... [Reply to comment]

What a great post! That 24 hour rule has been ingrained in our skulls so much! I was at a birth center and after my water naturally broke contractions started (yay!) but I had this 24 hour rule in my stinkin' head. Not by the midwives, by me. 24 hours later I was only a 3cm and labor was stalling. I broke down and asked for a c-section.

I also had no idea about the bathing the baby. Of course I have never held a vermix covered baby since I have only had c-sections and while they are sewing me up they are cleaning up the baby. But I wonder what it is like.

Tara said... [Reply to comment]

a lot of the points you made were in my birth plan... however, to make a story short... I ended up with a c-section due to my baby being breech & overdue. I am fortunate though b/c I still had my midwife who let us hold our son immediately, before he was cleaned up and we asked that he not be bathed for a day. He was a little bit jaundice, but not too bad.

Great information! I wish that more people would realize that birth is a natural process and mother and baby have intuition about what to do... and that there would be less medical interference.

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