Safety in Birth: Doctors vs Midwives

"Studies show it takes about takes seventeen years for medical research to get fully incorporated into medical practice. This means your doctor isn't always acting on the most recent knowledge." (in Spirit, page 106 in "Does Dr. Know best? Often,but not always. So take responsibility for the quality of your healthcare.")

The article continues, "Plus medicine is full of controversy and conflicting theories."

Nowhere is this so damaging as it is in the birth of a baby. First, the use of drugs in birth is clearly shown by research and logic to be bad maternal care. Second, Doctors and midwives are now battling over who is more scientific and who provides the safest births. Women who chose midwives do so in large part to avoid the pressure to use drugs in birth (and other reasons not discussed here.) Midwives practice the physiological belief that a woman's body is built to give birth, that pain is manageable and even empowering, and that the natural processes are best for mother and baby. The physiological model of childbirth is rooted in biology and physiology, ironically the foundation for medicine. For most pregnant women, the midwifery model of care is safest.

Dr. Mayer Eisenstein, MD, JD, MPH, medical doctor of Homefirst in Chicago, IL, now the largest physician- and midwife-attended homebirth practice in the nation says that, “homebirth is safer than hospital birth for those 90 percent of mothers who are low risk. The problem is that obstetricians treat all women as high risk.”

This tendency to see every pregnancy as a potential high risk is reported to contribute to the c-section rate being close to 30% in the United States, an all time high. The Consortium for the Evidence-based practice of Obstetrics in California, US, states, "The primary purpose of maternity care is to preserve the health of already healthy mothers and babies." (www.sciencebasedbirth.com).

Low to moderate risk women are best cared for by midwives who work in partnership with physicians in the event that something happens during labor and birth. The best care -- a blending of modern technology and ancient wisdom best happens only when physicians and midwives work together as respected partners. The current battle between midwives and doctors leaves midwives practicing alone and sometimes, dangerously, in order to provide the services women want. In the event of the need to go to the hospital, both the birthing woman and her midwife are often treated poorly. It is the baby who is being hurt the most by the social debate that keeps maternal health caregivers at odds.

Ina May Gaskin, credited with bringing midwifery back to the states is the founder of The Farm. She reports less than a 2% cesarean rate and other stellar statistics over 30 years (http://www.inamay.com/statistics.php.) I have met Dr. Eisenstein and I trained with Ina May and her midwives. As a young resident, Dr. Eistenstein trained with a female homebirth physician forty years ago and his children were born at home. His staff of nurses, CNM, and Family Practice physicians have mobile units that attend only homebirth. Ina May was closely associated with a physician who both trained her and backed the Farm midwives for many years. Whole Health Family Practice and Birth Center is the only birth center in Missouri. Family Practice physicians and direct entry midwives both attend either homebirth or birth center births. This model of family physicans and midwives working together seems to work well to practice scientific integrity in birth. They have better maternal and infant outcomes for low and moderate risk woman than do surgically trained obstetricians. They tend to have high cesarean rates. Imagine? Obstetric residents typically never witness what many believe is a "normal birth."

Critical in the Physician-Midwife Team is that the model honors healthy women and the physiological process of birth, they do not use drugs in their practices and they instead support waterbirth, and they create a relationship with the woman so that they know her as a person. Women who choose the non-drug method do so to be in control of her body and responsible for her choices. She knows that drugs harm the birthing brain. Thomas Verney, MD author of "The Secret Life of the Unborn Child" and co-founder of the Association for Pre and Perinatal Psychology and Health suggests a third professional on the team. A trained prenatal and birth counselor (more about that in a future entry.)

This model of physician-midwife team is under high attack from the obstetric community. Currently, the use of drugs in birth is widely accepted by both women and physicians, although the evidence shows it leads to many complications and issues for women and baby (see long list of resources at the end.) A major US television news report recently stated that most drugs used in obstetrics are NOT approved for obstetric use (that would include not approved for the BABY!) The drugs are FDA approved for other uses and a physician can use them for anything. It is called “off-label” use. These drugs are used on pregnant, laboring and birthing women and babies without trials to show they are safe. For example, Cytotec, a drug approved for ulcers, but contraindicated in pregnancy because it causes miscarriage, is used for inducing. It is said to be the cause of uterine rupture in first pregnancy and vaginal birth after cesarean.

Epidural was shown unsafe (in obstetric medical literature) for women and babies by 1992 (see list of research below). Now fifteen years later epidural is seen as "natural" birth by birthing women and their partners, and is promoted as safe by medical caregivers. Recent research compares the different kinds of narcotics and other drugs in the epidural cocktail to determine which is least damaging. How is this good science? Seems like Epidural’s run will be longer than seventeen years.

Dr. Mayer Eisenstein, says that "Obstetrics, which is really a combined philosophy, business, and religion, does not have science as its base," and,

"Obstetricians practice much more philosophy than science. Pregnant women are tested, medicated, and operated on to excess every day by this profession in an unethical and dangerous way. This unscientific medicine is dangerous to us as a nation. Our maternal and infant mortality rate is unacceptable for a society as sophisticated as ours. We produce more premature infants than any other country with our interventionist technology and then praise ourselves for saving some of their lives."

I am an advocate for a system that expects and supports the partnership of midwives and physicans. The most alarming is the widely accepted practice now demanded by both women and doctors is inducing THE BABY’s labor and the use Epidural Anesthesia. It now considered normal and sometimes even called “natural.” It is currently a consumer driven trend that is unsafe and unchecked by medical professionals whose own research journals shows it is unsafe.

Think about what's being done to women and babies in history and right now. Is it evidence-based and safe? Historically, the drugs used on laboring and birthing women and babies have NEVER been shown to be safe. Drugs and interventions are stopped ONLY AFTER years of harm and death to women and babies. Think about that – historically, women and babies have been NON- informed and NON- consenting subjects in one long experiment.
In the fifteen years since it's been known to be dangerous for women and babies, epidural has become so routine that 80% of births involve epidural anesthesia. During the same time frame, there has been an epidemic of new "unexplained" disorders (autism, asthma, colic, ear infections, depression, etc) and other never-before seen rates of childhood disorders. BUT NO ONE in medicine, psychology, or even addiction studies is looking at the effects of NARCOTICS on the birthing brain.

This, even though we know that babies laboring and born with epidural have heart and breathing issues. And, NONE of the NARCOTICS used in epidural have been shown to be SAFE for the birthing brain. NOW, research looks at the different narcotics in order to use the least problematic ones. WOMEN AND BABIES are one long research project and it is wrong!

There is also no acknowledgement, no concern or observation by doctors of the high number of women with back problems, depression, headache, limb weakness, new allergies and illnesses, Women present these symptoms to a doctor but she or he is NOT likely to even consider the epidural as the problem. Doctors know the possible effects of epidural -- they are mandated to disclose it, but when they see the presentation of it repeatedly -- in babies, children, and women -- they don't see it. When presented with the scientific information, doctors and pregnant women will deny it. WHAT is that about???

Source: http://www.fensende.com/Users/swnymph/Epidural.html

Maternal complications of epidurals include:

[Uitvlugt, A. "Managing complications of Epidural Analgesia" International Anesthesia Clin. 1990;28(1):11-16]

· Maternal hypotension(5 studies). This reduces uteroplacental blood supply and can cause fetal distress. (8 studies)
· Convulsions (4 studies)
· Respiratory paralysis (3 studies).
· Cardiac Arrest (6 studies)
· Allergic Shock (2 studies)
· Maternal nerve injury due to needle injury, poor positioning, forceps injury, infection, hematoma, or subarachnoid injection of chloroprocaine. The last three usually cause permanent injury. (9 studies)
· Spinal headache (3 studies)
· Increased maternal core temperature. (2 studies)
· Temporary urinary incontinence. (1 study)
· Long-term backache (weeks to years), headache, migranes, numbness, or tingling. (2 studies)

Serious complications occur despite proper procedure and precautions. The epinephrine test dose can cause complications. (12 studies)

Epidural anesthetics "get" to the baby. (5 studies)

Epidurals do not protect the fetus from distress. In fact, they cause abnormal fetal heart rate, sometimes severe, which may occur with or independant of maternal blood pressure (11% - 43% depending on the study and type of medication used - the 43% was found with Bupivacaine, the most common drug for epidural.) (15 studies)

Stavrou C, et al. "Prolonged fetal bradycardia during epidural analgesia" S Afr Med J 1990;77:66-68

Epidurals may cause neonatal jaundice. (2 studies) [Clark, DA & Landaw, SA. "Bupivacaine alters red blood cell ... jaundice associated with maternal anesthesia" Pediatr. Res. 1985; 19(4):341-343]

Epidurals may cause adverse neonatal behavioral and physical effects. (these are both direct effects and indirect effects from the increased rate of labor complications and interventions.) The importance of this is debated. (4 studies)

Epidural anesthesia may relieve hypertension, but hypertensive women are at particular risk of epidural-induced hypotension, which reduces placental blood supply. (2 studies)

Epidurals substantially increase the incidence of oxytocin augmentation, instrumental delivery, and bladder catheterization. (21 studies cited)

Saunders, NJ, et al. "Oxytocin infusion ... primiparous women using epidural..." BMJ 1989;299:1423-1426

Diro, M. and Beydoun, S. "Segmental epidural analgesia in labor: a matched control study". J Nat Med Assoc 1985;78(1):569-573.

Chestnut, DH, et al. "The influence of continuous epidural bupivacaine analgesia on the second stage of labor and method of delivery in nulliparous women". Anesthesiology 1987;66:774-780.

Kaminski, HM, Stafl, A, and Aiman, J. "The effect of epidural analgesia on the frequency of instrumental obstetric delivery". Obstet Gynecol 1987;69(5):770-773.

Philipsen, T and Jensen, NH. "Epidural block or parenteral pethidine as analgesic in labour; a randomized study concerning progress in labour and instrumental deliveries". Eur J Obstet Gynecol Reprod Biol 1989;30:27:33.

Gribble, RK and Meier, PR. "Effect of epidural analgesia on the primary cesarean rate". Obstet Gynecol 1991;78(2):231-234.

Thorpe, JA et al. "Epidural analgesia and cesarean section for dystocia: risk factors in nulliparas". Am J Perinatol 1991;8(6):402-410.

Thorpe, JA et al. "The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial".

Am J Obstet Gynecol 1993;169(4):851-858. Nel, JT. "Clinical effects of epidural block during labor. A prospective study". S Afr Med J 1985;68(6):371-374.

Yancy, MK et al. "Maternal and neonatal effects of outlet forceps delivery compared with spontaneous vaginal delivery in term pregnancies". Obstet Gynecol 1991;78(4):646-650.

Stavrou, C, Hofmeyer, GJ, and Boezaart, AP. "Prolonged fetal bradycardia during epidural analgesia". S Afr Med J 1990;77:66-68.

Eddleston, JM, et al. "Comparison of the maternal and fetal effects associated with intermittent or continuous infusion of extradural analgesia". Br J Anaesth 1992;69:154-158.

Bogod, DG, Rosen, M, and Rees, GAD. "Extradural infusion of 0.125% bupivacaine at 10 Ml H-1 to women during labour". Br J Anaesth 1987;59(3):325-330.

Smedstad, KG and Morison, DH. "A comparative study of continuous and intermittent epidural analgesia for labour and delivery".

Can J Anaesth 1988;35(3):234-241. Chestnut, DH et al. "Continuous infusion epidural analgesia during labor: A randomized, double-blind comparison of 0.0625% bupivacaine/0.0002% fentanyl versus 0.125% bupivacaine". Anesthesiol 1988;68:754-759.

In first-time mothers, epidurals substantially increase the cesarean rate for dystocia. This effect may depend on management. (12 studies cited)

Thorpe, JA et al. "The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial".

Am J Obstet Gynecol 1993;169(4):851-858. Diro, M. and Beydoun, S. "Segmental epidural analgesia in labor: a matched control study".

J Nat Med Assoc 1985;78(1):569-573. Chestnut, DH, et al. "The influence of continuous epidural bupivacaine analgesia on the second stage of labor and method of delivery in nulliparous women". Anesthesiology 1987;66:774-780.

Thorpe, JA et al. "The effect of continous epidural analgesia on cesarean section for dystocia in nulliparous women". Am J Obstet Gynecol 1989;161(3):670-675.

Philipsen, T and Jensen, NH. "Epidural block or parenteral pethidine as analgesic in labour; a randomized study concerning progress in labour and instrumental deliveries". Eur J Obstet Gynecol Reprod Biol 1989;30:27:33.

Gribble, RK and Meier, PR. "Effect of epidural analgesia on the primary cesarean rate". Obstet Gynecol 1991;78(2):231-234.

Thorpe, JA et al. "Epidural analgesia and cesarean section for dystocia: risk factors in nulliparas". Am J Perinatol 1991;8(6):402-410.

Abboud, TK et al. "Continuous infusion epidural analgesia in parturients receiving bupivacaine, chloroprocaine, or lidocaine - maternal, fetal, and neonatal effects". Anesth Analg 1984;63:421-428.

Stavrou C, et al. "Prolonged fetal bradycardia during epidural analgesia". S Afr Med J 1990;77:66-68.

Smedstad, KG and Morison, DH. "A comparative study of continuous and intermittent epidural analgesia for labour and delivery". Can J Anaesth 1988;35(3):234-241.

Epidurals decrease the probability that a posterior or transverse baby will rotate. Oxytocin does not help. (7 studies)

Saunders, NJ, et al. "Oxytocin infusion during second stage of labour in primiparous women using epidural analgesia: a randomised double blind placebo controlled trial". BMJ 1989;299:1423-1426.

Thorpe, JA et al. "Epidural analgesia and cesarean section for dystocia: risk factors in nulliparas". Am J Perinatol 1991;8(6):402-410.

Kaminski, HM, Stafl, A, and Aiman, J. "The effect of epidural analgesia on the frequency of instrumental obstetric delivery". Obstet Gynecol 1987;69(5): 770-773.

Thorpe, JA et al. "The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial". Am J Obstet Gynecol 1993;169(4):851-858.

Having an epidural at 5cm dilation or more eliminates both excess posterior/transverse and excess cesarean for dystocia. (2 studies)

Thorpe, JA et al. "Epidural analgesia and cesarean section for dystocia: risk factors in nulliparas". Am J Perinatol 1991;8(6):402-410. Thorpe, JA et al. "The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial". Am J Obstet Gynecol 1993;169(4):851-858.

Epidurals may not relieve any pain or may not relieve all pain. (3 studies)
Thorpe, JA et al. "The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial". Am J Obstet Gynecol 1993;169(4):851-858.

Eddleston, JM et al. "Comparison of the maternal and fetal effects associated with intermittent or continuous infusion of extradural analgesia". Br J Anaesth 1992;69:154-158.

Crawford, JS. "Some maternal complications of epidural analgesia for labour". Anesthesia 1985;40(12):1219-1225.

Innovations in procedure - lower dosages, continuous infusion, adding a narcotic - have not decreased epidural related problems. (13 studies)

Naulty, JS. "Continuous infusions of local anesthetics and narcotics for epidural analgesia in the management of labor". (this is a literature review) Int. Anes. Clin. 1990;28(1):17-24.

Diro, M. and Beydoun, S. "Segmental epidural analgesia in labor: a matched control study". J Nat Med Assoc 1985;78(1):569-573.

Chestnut, DH, et al. "The influence of continuous epidural bupivacaine analgesia on the second stage of labor and method of delivery in nulliparous women". Anesthesiology 1987;66:774-780.

Thorpe, JA et al. "The effect of continous epidural analgesia on cesarean section for dystocia in nulliparous women". Am J Obstet Gynecol 1989;161(3):670-675.

Thorpe, JA et al. "Epidural analgesia and cesarean section for dystocia: risk factors in nulliparas". Am J Perinatol 1991;8(6):402-410.

Thorpe, JA et al. "The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial". Am J Obstet Gynecol 1993;169(4):851-858.

Abboud, TK et al. "Continuous infusion epidural analgesia in parturients receiving bupivacaine, chloroprocaine, or lidocaine - maternal, fetal, and neonatal effects". Anesth Analg 1984;63:421-428.

Eddleston, JM, et al. "Comparison of the maternal and fetal effects associated with intermittent or continuous infusion of extradural analgesia". Br J Anaesth 1992;69:154-158.

Bogod, DG, Rosen, M, and Rees, GAD. "Extradural infusion of 0.125% bupivacaine at 10 Ml H-1 to women during labour". Br J Anaesth 1987;59(3):325-330.

Smedstad, KG and Morison, DH. "A comparative study of continuous and intermittent epidural analgesia for labour and delivery". Can J Anaesth 1988;35(3):234-241.

Chestnut, DH et al. "Continuous infusion epidural analgesia during labor: A randomized, double-blind comparison of 0.0625% bupivacaine/0.0002% fentanyl versus 0.125% bupivacaine". Anesthesiol 1988;68:754-759.

McLean, BY, Rottman, RL, and Kotelko, DM. "Failure of multiple test doses and techniques to detect intravascular migration of an epidural catheter". Anesth Analg 1992;74(3):454-456.

Delaying pushing until the head has descended to the perineum increases the chances of spontaneous birth. (a time delay of 1 hour is not really delaying - it needs to be a positional not timed thing...)

Evidence is divided as to whether letting the epidural wear off before pushing increases spontaneous delivery. (4 studies)