Labor is not a Toothache!

From curvewire.com: Kim Kardashian Wants C-Section Posted by Johnny Robish on April 10, 2013 - 10:18pm..... “Kim Kardashian Wants C-Section: It’s being reported that pregnant Kim Kardashian wants to give birth by C-section as soon she’s 8-months pregnant because she wants her life back. And since Kanye is a musician, I would assume it’ll most likely be a “Middle-C” section.” ..... I was at a dinner party last night in celebration of the recent homebirth of twins in Santa Barbara, CA. During a lovely evening we discussed a lot of topics and the subject of Ms. Kardashian’s choice came up. This blog is not about bashing her obvious narcissism but her choice did produce a dialogue about labor pain. I have given this subject a lot of thought during my metamorphosis from hospital based to home based practitioner. Since epidurals and narcotics are not available at home we rely on other methods to deal with pain. Movement, water, hypnosis, massage and strong support are beneficial and work well for many laboring women. The key is that these things help cope with the pain but don’t remove it. To understand why coping but not eliminating pain is important we need to ask ourselves why labor is painful in the first place. I mean, if we believe in evolution why wouldn’t the pain of labor evolve away since natural selection usually eliminates those things that are detrimental to the survival of the species. There is, of course, the biblical Garden of Eden explanation but let me put that aside for the moment. Just suppose labor pain is not detrimental but is beneficial. I give credit to my colleague, Aleks Evangelidi, LM, for her insight in this regard........ Anyone who has ever had a toothache or a kidney stone will argue there is no benefit to the pain other than to let us know something is wrong. Painkillers are a godsend in these circumstances. But labor is not a toothache and it is time to look at the pain of labor in a different light. All mammals have labor and all mammals have labor pains. The onset of labor contractions usually build slowly but eventually become quite painful lasting 40-60 seconds followed by 2-3 minutes of relief. The mammalian body responds to this pain by releasing its own narcotics and neurotransmitters that nature designed just for that purpose. Endorphins and enkephalins are the body’s natural opiates. Oxytocin release produces warmth and attachment responses and adrenaline helps the body cope with stress and possibly spaces out the next contraction allowing time for rest and recovery. And don't forget Cortisol, which orchestrates all sorts of needed stress responses including blood sugar modulation. It really is a beautiful cocktail that nature has designed just for this purpose............ When a laboring woman is not allowed to cope with pain as nature designed it is easily understood why hospital epidural rates approach 90%. Having to stay flat in bed so continuous fetal monitoring (CFM) can occur does not allow for the natural desire and ability of mammals to move about in labor to diminish discomfort and use their own pain stimulated cocktail. And so, modern obstetrics encourages epidural use to eliminate pain and modern women think this is a good choice because to them: Labor Pain = Toothache........ It gets back to the saying about the long habit of not thinking something wrong gives it the appearance of being right. Nature is pretty smart. And a toothache does not have a baby inside but a pregnant woman does. And when a woman undergoes the stress of labor so does her baby. Her body’s response to pain releases that cyclical cocktail and those substances certainly cross the placenta. And just maybe all those neurotransmitters and hormones that help mom deal with the pain and stress of labor help her baby cope as well. For after 9 months of sitting comfortably in the womb suddenly everything that baby has ever known is changing. Labor has to be stressful and even painful for the baby and the suddenness of delivery by c-section even more so. Mom’s natural opiates, oxytocin and adrenaline clearly serve a purpose in assisting her baby in this transition. Denying the baby these substances through the commonplace use of epidurals or scheduled c-sections is counter to nature’s design. Babies are little sponges absorbing every experience and forging new and sometimes permanent neural pathways that will be used in the future. Altering labor has to mean altering this process as well. I was never taught this way of thinking in residency and in my 31 years as a physician I have never seen this discussed in a grand rounds or an academic journal and yet it is so common sensical. Modern medicine needs a bit of humbling and as we are beginning to discover when you mess with Mother Nature you inevitably get something not intended........... The process of labor is painful for a reason and that reason just may be how it benefits the baby’s transition to extra-uterine life. Women are too often told that the pain of labor need not be endured. And while modern anesthesia is also a godsend and epidurals have a place in some labors, obstetricians need to rethink their unconcerned attitude towards its ubiquitous use. Especially in those cases where they scoff at the woman with a birth plan that states an avoidance of pain medicine. Allowing laboring women the freedom to move about and use other pain coping mechanisms might just be doing future generations a favor. Once again it boils down to informed consent. If Ms. Kardashian still wants her unnecessary c-section so she can have her life back after reading this blog then that is her choice and should be respected. I am willing to bet she has never been taught about or thought of birth in this way. Dr. F

Cesarean Section & Newborn Immunity

With the proliferation of unnatural birth by cesarean section in the United States it is only to be expected that new data on the consequences of this intervention will be forthcoming. We have now had about 30 or more years of rising “elective” cesarean section rates in the U.S. which gives us a good petri dish from which to see good scientific evidence of its effects. One of the negative effects seems to be the rise in respiratory ailments in neonates and children. In a recent review by Cho and Norman, (Cho CE , Norman M. Cesarean section and development of the immune system in the offspring . Am J Obstet Gynecol. 2013;208:249–254), they conclude: “Recent epidemiological studies provide evidence that elective cesarean section (CS) is associated with aberrant short-term immune responses in the newborn infant, and a greater risk of developing immune diseases such as asthma, allergies, type 1 diabetes, and celiac disease. However, it is still unknown whether CS causes a long-term effect on the immune system of the offspring that contributes to compromised immune health.” They conclude that more emphasis should be placed on discussion and counseling amongst professionals and childbearing women. In the same issue of the AJOG is a corresponding article by Romero and Korzeniewski from Wayne State University that discusses the likely causation of Cho’s findings. http://www.ajog.org/article/S0002-9378(12)02261-2/abstract?elsca1=etoc&elsca2=email&elsca3=0002-9378_201304_208_4&elsca4=obstetrics_and_gynecology I strongly suggest reading the full article as it goes into depth explaining the importance of microbial exposure at birth and its correlation to the newborn’s immune response. They cite a sentinel work by Hugo Lagercrantz and Theodore Slotkin that emphasized the importance and adaptive value of intrapartum stress in their seminal article “The ‘Stress’ of Being Born.” In it, “The authors described 4 main transitions that occur at birth: (1) emergence from an aquatic environment where oxygen is acquired through the placenta to a dry environment in which respiratory exchange occurs through the lungs, (2) change from a warm environment in which the fetus has a temperature that is 1 degree higher than the mother on average to a cooler environment at room temperature, (3) moving from a continuous supply of nutrients through the placenta to intermittent feeding in the neonatal period, and (4) going from a sterile bacterial environment to the establishment of the neonatal microbiome (eg, skin, respiratory tract, gut). Lagercrantz and Slotkin's views have gained relevance with time and are now buttressed by a considerable body of work suggesting that the microbiome plays an important role in the developing immune system.” It would seem the body of evidence is beginning to weigh heavily that there are consequences to the route of birth. For those of us that support vaginal birth options this comes as no surprise. Nature does have common sense sometimes. The ethics of informed consent should imply that obstetricians include this information when counseling patients on the RISKS and benefits of an elective cesarean section. One final article in the same edition of the AJOG takes a different tack. Authors Lynch and Iams state: “we fear that their (Cho, et al) limited review of a very complex literature leads the reader to a naïve conclusion: that the cesarean procedure itself might be bad for infants and children.” http://www.ajog.org/article/S0002-9378(12)02262-4/abstract?elsca1=etoc&elsca2=email&elsca3=0002-9378_201304_208_4&elsca4=obstetrics_and_gynecology They take a critical look at the methodology and cannot agree with Cho’s conclusions. It seems they think that prematurity and its effects on the immune system may play a role in skewing the data and that cesarean section cannot be isolated as having a direct role in causation. While I applaud the AJOG for publishing all three of these articles and bringing the problem of a rising cesarean section rate into the limelight, I cannot ignore the contradiction to when the Wax paper was published. If you recall, the Wax paper criticized the safety of home birthing and was immediately adopted as gospel by ACOG and critics of home birth. There was no such corresponding critique of its methodology in the same issue of the Green Journal despite a myriad of cited authors who found great flaws in his methodology and conclusions. Maybe I am overly sensitive but it seems clear that these two articles, one critical of elective cesarean section and one critical of home birthing, are being responded to in different fashions, both of which seem to favor and support the expediency of the current medical model of obstetrics. I mean, here you have compelling data of the risk of surgical birth on newborns and whether or not scientists and researchers believe it fully isn’t it worthy of informing mothers of this research and letting them decide? A peaceful Easter to you. Dr. F

Cholestasis & The Rule of Threes!

One of the oddities and urban legends haunting the halls of medical schools and centers of learning is the theory that bad things often come in sets of three. It may be years before you see an ectopic pregnancy and suddenly you have three. Months go by and suddenly you have three clients in a week who have abnormal Pap smears. Some of us go a long time without having a set of twins in our practice and, then, there are three in one month. No explanation, probably coincidence, but perplexing all the same. The rule of threes has struck again! This past month in my practice I have three women, two of them with twins, who developed cholestasis of pregnancy. Cholestasis of pregnancy usually manifests itself in the third trimester of pregnancy with the symptom of intense itching usually on the belly. Cholestasis of Pregnancy Here is a reference to a relatively simple explanation of this disorder which has an incidence of about 1-2/1000 pregnancies. I thought I would use this blog to illuminate some of the research and thought for my colleagues and me. It is rarely predictable and the major theory is that high levels of certain pregnancy hormones slow or block the flow of bile from the gallbladder. This backup then causes some of the bile salts to be absorbed in the bloodstream and eventually deposited in the skin. Diagnosis is usually suspected by the symptom of a rashless itching and confirmed by laboratory testing. Treatment is discussed in the links I have provided and supplemental Vitamin K has been suggested for the mother while pregnant and nursing and for the baby after birth. There are numerous case reports in the literature of bad fetal outcomes from this disorder, and while not the norm, these have led to the suggestion that the treatment for cholestasis of pregnancy at term is delivery. (Not by cesarean section unless for other indications). Here are a few suggested links: Ursodeoxycholic acid in the treatment of cholestasis of pregnancy: a randomized, double-blind study controlled with placebo. http://www.ncbi.nlm.nih.gov/pubmed/18006244? http://www.ncbi.nlm.nih.gov/pubmed/16449148? http://www.ncbi.nlm.nih.gov/pubmed/19155945? In my practice, so far 2 of the 3 women have been delivered. One set of twins with elevated liver tests was fortunate to have Dr. Wu in Glendale induce her and have a vaginal birth of her vertex/vertex twins. Another was breech and, sadly, had no option of induction so had a primary cesarean section. The third client with twins is still holding on with stable labs, well informed consent and hopes of her home vaginal birth. I hope none of you ever experience this rare problem but am of the philosophy that being well informed is a good thing. Dr. F

Trusting Nature....Again

Just as she had hoped for she began having regular contractions every 15-20 minutes on the evening of her assigned due date. This couple had a history of several recent pregnancy losses and was so happy expecting their first baby. But like most parents in our fear based society they were frightened of what they had read about birth and especially about hospital birthing. Also, mom worked in a health care facility and what she experienced made her wary of western medicine. Mom has a phobia for hospitals and for needles and so sought out the option of home birthing. They had been referred to me by a midwife colleague in her first pregnancy which had ended in a miscarriage. We had spent much time together over the past two years and the trust necessary for a successful birth was the result. As part of our many conversations we discussed the midwifery approach to pregnancy and birth as well as the medical model and the care that resulted was a hybrid of both. My experience with both models of care gave her the confidence to overcome some mental and physical obstacles. She had to take medication through the first trimester because of her previous miscarriages. In the medical model she would have been labeled “high risk”. But once the milestone was passed and her medication stopped she was as normal as any other mother. Many physicians would have continued to carry the high risk label with all the subsequent fear and over-testing that comes with such a label. There is no doubt in my mind that doing so would have written a much different story of her labor and birth. Add to that the positive group B Strep carrier state and frightening stories of babies gone awry that so often accompanies that scenario and a perfect storm for interventions would be brewing. Through the night her contractions increased in intensity and came every 4-5 minutes. We spoke just after midnight and again at 3:30AM and just after dawn. I cancelled my day in the office as she lived about 50 miles from there and waited. After sunrise and as the morning passed her contractions spaced out. I have become acutely aware of the power of the higher brain over the primitive brain. My lectures about the mammalian nature of birth make the understanding of distractions and the effect on labor so obvious and clear. This family is highly educated and as mentioned tends to think too much on the “what ifs” and so I was not surprised that as the day wore on labor malingered with her contractions coming every 7-20 minutes all day long. My midwife and I stopped over about 7:00PM to take some vital signs and give reassurance and suggestions for comfort, rest and patience. It was likely that if she was not given these things that she would be up another full night and eventually become exhausted. We put her to bed after a warm shower and some fluids and suggested that she not try to walk her baby out. She was able to get some rest and sleep through the night and awoke on the third day still with regular but infrequent contractions and a bit of bloody show. I went to work this time at my much closer office feeling a bit foolish for missing the previous day. But understanding labor and predicting its course is not a fruitful activity. Trusting it, however, has proven reliable. Gradually, her contractions picked up in intensity and frequency to the point where the next phone call just after 7:00PM came from her husband. For those of us practicing the home birth model the call from the husband is a sure sign of things progressing. Mom is now too inwardly focused to make the call. The birth team arrived at 8PM to loud noises and concerned looks from Grandma and relief from dad. A quick assessment showed all to be as it should be and a requested exam was 7 cm. and still intact. I started an IV which drew loud protests. Reminded of her needle phobia I used a little lidocaine first. 2 grams of Ampicillin were administered and we prepared our equipment while mom walked, paced, sat on the toilet, knelt on all fours supported by her man. Around 10PM her membranes spontaneously ruptured and just before 11PM the incredible urge to push could not be resisted. A gentle exam showed baby to be at +2 station with no cervix left. In less than an hour they were holding their baby in their own bed with emotions of relief and exuberance and joy! Having seen birth in hospitals and birth at homes there is no comparison. To call them by the same name, “birth”, does not do justice to the differences. Just over 48 hours had passed from the time of the first regular contraction. I was confident that labor would progress here in its own time. If not, nothing would have been lost with conscientious observation and eventual transfer of care. I have little doubt that my hospital based colleagues would never have allowed nature to follow its own path. The first morning she would be told to go to the hospital. Here she would have gone through the usual litany of tests, consents, interruptions and indignities. Labor cannot function well in that setting. Her contractions spacing out would have precipitated an IV, CFM and either Pitocin augmentation or AROM, likely the former considering the group B strep status. Unable to move or shower would have meant an epidural and eventual AROM likely with fetal scalp electrode and, of course, NPO. If she made it to complete she would have likely been too numb to push effectively leading to a longer second stage and possible operative vaginal birth and laceration or episiotomy. Who does not believe she had at least a 40% chance of a c/section? There is little if any room in the hospital model for patience and trust in the wisdom of the natural labor process. Now, at home, holding her baby for the first time, no lacerations, placenta out, and husband next to her with her own mother looking on there was this amazing smile on her face. A face that earlier had the look of determination mixed with panic that so often appears in transition. Never separated from her baby and a realization of what she had accomplished, her life and that of her child’s will never be the same. The stories they will tell and the admiration husband will have for wife are so different than they might have been had not the process of labor been respected. My experience and wisdom for understanding the variances of the birth process did not come from books or residency training. It is not something I or any obstetrician can glean from watching hospital birthing. There is too much hustle and bustle and timetables and interruptions and fear in that setting to learn to trust birth. I am so fortunate that my journey has taken this path and that I allowed myself to be open to learning. I and the women I care for are grateful to the midwives and visionaries who have taught me well.

Birth Center Outcomes

Few words needed from me. Read Tara Elrod's Blog at taraelrod.blogspot.com and find the full article at http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full This is a huge study in both it's numbers and for support of the benefits of the freestanding birthing center option. Always nice when good evidence based medicine supports what we all know to be true. The authors, 2 midwives and a physician from Yale University conclude: This study demonstrates the safety of the midwifery-led birth center model of collaborative care as well as continued low obstetric intervention rates, similar to previous studies of birth center care. These findings are particularly remarkable in an era characterized by increases in obstetric intervention and cesarean birth nationwide.

Stage 2 Consequences

Much of what passes for legislation these days seems to be feelings based and reactionary. With litte time given to debate or deep thought. As long as it feels good there is no concern whether once implemented it will actually do good. The Affordable Care Act (Obmacare) is the penultimate example of stopping at stage 1 thinking. As Nancy Pelosi so famously said, "You will have to pass the bill to find out what is in it!" Well, think on this! I recently read an opinion piece in the Wall Street Journal titled, "The Doctor's Office as Union Shop" by Dr. David Leffell, a practicing physician and the former CEO of the Yale Medical Group and a professor at the Yale School of Medicine. As you know me by now, I am a critical reader of opinion pieces and pretty much anything that passes as mainstream news these days. It is hard to know what to believe. I could not find any fault, however, in Dr. Leffell’s arguments about what is likely to happen to doctors in the wake of the government takeover of health care thus reducing the once proud sole proprietor into nothing more than a salaried service worker. If you have followed my blog for some time you will find that I am not a fan of the poorly named “Affordable Care Act” for a myriad of reasons. One of which has been the inevitable discouragement of the ambitious and brightest from undertaking the years of commitment and expense it takes to become a physician. Those young men and women who prefer to be shepherds of their destinies and not sheep will look to other opportunities. What will remain are dedicated workers who will prefer defined hours, a better lifestyle and the security of a set salary. While this is not a bad thing in and of itself it is like the proverbial finding of half a worm in an apple. For their employer will no longer be “the self” but will be the government or some big faceless corporate entity dependent on government rules and regulations that define treatment protocols and regulate reimbursement. Dr. Leffell says, “The truth is that physicians are now becoming service workers. They are well-educated and expensive to train, and their decisions have substantial significance in the lives of others. But doctors essentially provide a service, one that cannot be outsourced to India or China……When doctors occupy a service niche like the chambermaid in Las Vegas or the school teacher in Chicago, the expectations and compensation of the physician-worker will be defined in ways that may make the benefits of collective bargaining appear very attractive…… If doctors unionize, that raises an immediate question about their right to strike—the key lever in collective bargaining. That's a question for another day. For now, it's enough to contemplate what will occur when the practice of medicine becomes detached from its past as a profession—when doctors may in time come to see themselves not solely as healers but as workers, units of labor, in a system that is committed to delivering care to the greatest number.” It is inevitable then, as government inserts itself into the equation, that choice for consumers will decline and services will be rationed. Cost containment will fall heavily on doctors and hospitals. With no relief from threats of malpractice lawsuits and pressure to adhere to artificially set performance standards piled on top of less financial reward we will inevitably see rising job dissatisfaction. And although the expectations of Americans will be that they should get the same quality of care for less money in reality that is not possible. All the micromanaging and theories about efficiency do not take into account what happens in the real world. No longer individual professionals but now salaried workers, likely disgruntled salaried workers, what is to keep physicians from unionizing? Leaders of the dwindling private sector organized labor movement will drool at the prospect of a whole new profession to appeal to. As Dr. Leffell’s concludes: As has happened in other countries that have charted the course we are now on, a new reason for lack of access may at times be: "Office closed, doctors on strike." Dr. F

Power Point Debut

Today the gracious members of the Orange County DASC hosted a gathering and invited me to come and share my thoughts on home birth and a recent opinion piece in the AJOG which took a strong stance against it. It was an educational experience for all of us and I really appreciated the attention and feedback. I talked about logic and ethics and how this opinion article skewed its ethical arguments, applied faulty logic and created straw man arguments in an attempt to vilify home birth and those who support it. We tend to be a headline reading society and rarely have the time or expertise to truly analyze the content in a critical manner. Doing so here led me to the surprising conclusion that ethicists are not always ethical and the editors of the AJOG ought to not blindly accept shameful submissions from well credentialed authors without vetting the data. I would be happy to share or debate my take on this with any inquiring minds. Happy New year! Lets make it a safe and honest one. Dr. F