Friday, February 14, 2014

The machine that goes PING! Part I: EFM, IV, Cut!



Every woman whose ever given birth at a hospital looks around her at one point or another and asks herself the following questions: What the heck are all these machines for? And, what should I be doing?

Of course the answer is, "Nothing dear, your not qualified!"

But in case you are still wondering what the machine that goes PING is for, or if you expect to birth like the majority of women in the US at a hospital, you will likely experience one or more of the following PINGS during your birth ~ so you might want to learn a bit about them. (You know, just to become qualified to do something during your own birth!)

  • Continuous electronic fetal monitoring (EFM)(93 percent)
  • Restrictions on eating (87 percent)
  • IV fluids (86 percent)
  • Restrictions on drinking (66 percent)
  • Episiotomy (35 percent)
  • Epidural anesthesia (63 percent)
  • Artificially ruptured membranes (55 percent)
  • Artificial oxytocin augmentation (53 percent)
  • Cesarean surgery (24 percent)


(Declerq et al. 2013)

Continuous Electronic Fetal Monitoring (EFM):

This really is the machine that goes PING! You know the machine they hook you up to by wrapping stretchy cloth around the top and bottom of your belly to hold in place two little circles? Yep, that is the EFM machine. The EFM was designed to continuously monitor the baby’s heart rate in an effort to detect fetal distress and prevent injury. Sounds innocuous, yes? However, research shows that one of the unintended consequences of the routine use of continuous EFM is an increase in cesareans without any improved outcomes for babies. (Translation: harmful for mom, no benefit to baby.) (Goer et al. 2007)

The key words are: Routine and Continuous. The WHO and ACOG recommend intermittent monitoring with a Doppler or stethoscope during labor for low-risk healthy moms, every 30 minutes during active labor and every 15 minutes during pushing. (ACOG 2005) This also allows mom to be active and upright during labor which will help keep her comfortable and move things along. 

When is a good time for continuous monitoring? Research shows that there are benefits to continuous EFM if you are using Pitocin, have an epidural, your baby is experiencing changes in heart rate, or if your or your baby are not in good health. But if you are a healthy low-risk mom, research shows that you would benefit more if your doctor monitored you and your baby intermittently with a Doppler or stethoscope.

IV:

Many hospitals restrict normal eating and drinking, but then trying to keep mom nourished through an IV. Yes you read that correctly. The practice of restricting moms eating and drinking began when the majority of moms gave birth under anesthesia and the accompanying fear of aspiration. However, many studies have confirmed that that are no medical benefits to routinely restricting eating and drinking during labor. Instead it deprives a woman of energy when she needs it most. In addition, routinely hooking up moms to an IV during labor restricts movement, may adversely impact labor progression if mom becomes over-hydrated, and increases risk of low blood sugar in babies. (Enkin et al. 2000) The WHO and ACOG recommend fluids be offered to mom by mouth, and the routine use of IV fluids be eliminated. If you are a healthy low-risk mom ask your doctor about a hep-lock, an IV started in your hand/arm that is capped off so that it is in place and available but does not interfere with your movement and normal labor progression.

Episiotomy:

This word often makes women cringe. As it should. For those who don't know what an episiotomy is, it is an incision that a care provider makes to widen the birth canal (yeah- they cut down there!) This is a controversial procedure because research has provided no evidence that routine episiotomy reduces the risk of perineal injury, improves perineal healing, prevents birth injury to babies, or reduces the risk of future incontinence (these are all reasons cited by doctors for the routine use of episiotomies) (Goer et al 2007)(Hartmann et al 2005). Research does show that routine or liberal use of episiotomy is likely to be ineffective and harmful to mother (the list of risks to mom are too long for this article) (Klein et al 1994). The WHO also recommends eliminating routine or liberal episiotomy.

Of course there are times an episiotomy would be beneficial. For example, if a change of position or taking a break from pushing does not resolve signs of distress in your baby, or if your baby is very large or in an unusual position (again, first try changing your positions to see if it helps) an episiotomy might be necessary (i.e. in an emergency). 

If you want to avoid an episiotomy (who doesn't?), discuss your concerns with your doctor or midwife before hand and choose your care provider carefully, push in an upright position that lets your birth canal stretch gently as your baby descends, change positions often while you’re pushing, push spontaneously when you feel urges rather than directed, and remember your body knows how to give birth and be patient!

Look for The machine that go PING! Part II: Pit, Epidural, and Cesarean



_____________________________________


American College of Obstetricians and Gynecologists [ACOG]. (2005). ACOG practice bulletin #70: Intrapartum fetal heart rate monitoring. Obstetrics and Gynecology, 106(6), 1453–1460.

Declerq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to MothersIII: Pregnancy and Birth. New York: Childbirth Connection, May 2013

Enkin, M., Keirse, M., Neilson, J., Crowther, C., Duley, L., Hodnett, E., et al. (2000). A guide to effective care in pregnancy and childbirth. New York: Oxford University Press.

Goer, H., Leslie, M. S., & Romano, A. (2007). The Coalition for Improving Maternity Services: Evidence basis for the ten steps of mother-friendly care. Step 6: Does not routinely employ practices, procedures unsupported by scientific evidence. The Journal of Perinatal Education, 16(Suppl. 1), 32S– 64S.

Hartmann, K., Viswanathan, M., Palmieri, R., Gartlehner, G., Thorp, J., & Lohr, K. N. (2005). Outcomes of routine episiotomy: A systematic review. Journal of the American Medical Association, 293(17), 2141–2148.

Klein, M., Gauthier, R., Robbins, J., Kaczorowski, J., Jorgensen, S., Franco, E., et al. (1994). Relationship of episiotomy to perineal trauma and morbidity, sexual 

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