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Thread: Episiotomy ?

  1. #16
    Join Date
    Nov 2013
    Posts
    221
    Quote Originally Posted by galatea View Post
    I have heard lots of moms say the same thing: "I will use a doctor with my first, and then a midwife with my second," but the problem with that reasoning is that the first one sets the tone for the rest, and it is in the first delivery that so many interventions can happen that might lead to a section and then it will be harder to have that second birth be more natural. The first birth is the most important, as in many communities, VBACs are not the standard of care. To give you an example, my first was induced because of very low fluid. It took 20 hours just to get to 3 cm, and then I got an epidural (not really sure why) and I fell asleep for two hours and woke up at 10 cm. Then it took 3 hours to push him out, but because I had a CNM, she was patient and let me do my work, despite the OB who was their attending specialist out in the hall pushing for a section. There were no disturbing signs with my baby; it was just taking a "long" time. It was only long by OB standards; I think it was pretty darn quick for being pretty numb and stuck on my back! In fact, my midwife covered the clock and kept encouraging me, and she was the only reason I did not have a section.

    My husband was also weird about midwives when we were pregnant the first time, so I bought this book (http://www.amazon.com/Thinking-Woman.../dp/0399525173), and he only needed to read the intro before he agreed to see a CNM. We had #1 and #2 in a hospital with a CNM and thus had all the safety of the hospital (quick surgery times, etc.) with the humane treatment of a midwife. I would highly recommend seeking out a CNM group and using them in a hospital.
    Thank you for this. I think it is what I need to hear right now. My husband has said he will support whatever choice I make from the beginning, but I so badly want him to feel comfortable and like me and the baby are in safe hands. Maybe I should stop thinking about my husband and just go with my gut. I looked into it and there are OB's on the delivery ward, so if there were to be a problem there wouldn't be a delay in receiving help.

    I believe what you're saying about the first birth setting precedence too. I honestly want to thank you for your posts, I really think that your words have been the push that I have needed to make the switch to a midwife.

  2. #18
    Quote Originally Posted by themamae View Post
    Thank you for this. I think it is what I need to hear right now. My husband has said he will support whatever choice I make from the beginning, but I so badly want him to feel comfortable and like me and the baby are in safe hands. Maybe I should stop thinking about my husband and just go with my gut. I looked into it and there are OB's on the delivery ward, so if there were to be a problem there wouldn't be a delay in receiving help.

    I believe what you're saying about the first birth setting precedence too. I honestly want to thank you for your posts, I really think that your words have been the push that I have needed to make the switch to a midwife.

    Good. I am really glad to hear that. I was worried that I had offended you. There are plenty of stats to show that hospital CNMs have just as healthy outcomes with lower costs and interventions. In many other developed countries, most women deliver with midwives, not doctors; doctors are only for high-risk moms.

  3. #20
    Join Date
    Sep 2012
    Location
    Los Angeles
    Posts
    4,518
    To answer your technical points:

    1) an epidural (or spinal, or Combined Spinal-Epidural) in the United States is essentially the only method of pharmacologic pain relief offered. In Europe it is common to offer shots of narcotic medication and/or nitrous oxide ("laughing gas," as at the dentist). This are not preferred here since narcotic pain medication is quickly absorbed, acts systemically, and is 100% passed onto the baby. If given too close to delivery the baby is essentially drugged and can have more respiratory distress than otherwise. Nitrous oxide caused psychological dissociation, where you the mother no longer are fully aware of your surrounding and the events taking place. Since it removes the mother as an active participant in her own labor, and of course potentially erases all of the wonderful memories of the birth and meeting the baby for the first time, it is extremely rarely used in the US. Epidural/spinal anesthesia, on the other hand, provides focused *local* pain relief with zero effects on the baby. The mother is psychologically aware, a full participant, and will remember the birth well.

    Ideally an epidural provides a sensory block rather than a motor one, but there is nearly always a degree of motor impairment. A person with an epidural will be unable to safely bear weight on their legs and as such, once it's placed, you will not be able to stand, walk or squat. You can lay to one side or another, curl your legs up to your chest, and lay supine, but that's it. However, pushing on your back is not the horror show you might think. IN addition to providing the optimal view for your birth attendant, who can safely assess baby's position, guide baby out of the birth canal, apply appropriate perineal pressure to prevent a precipitous birth & tearing... it is the position which requires the least amount of energy for you, the mother, to maintain. Childbirth takes a tremendous amount of energy (estimates average around 4000 calories burned for a labor & delivery). You will be expending a great deal of effort in the pushing stage. Having to maintain your own weight in addition to that (whether squatting, sitting, hands & knees, whatever) really can tire you out.

    2) In the US, around 80% of births are medicated. Frankly, the majority of women simply say "it's not so much that I *can't* do this unmedicated, it's that I don't *have* to." It is in NO way required that a woman be medicated for a hospital birth. A substantial number of women have unmedicated births in hospitals daily across the US, with OBs. However, the only caveat is that if things go south very fast, and you need an emergency c-section without an epidural already in place, you will have to be intubated and go under general anesthesia for the birth (thus being unconscious and missing the whole thing). If you simply need an urgent c-section, not an emergent one, then there will be time to place a spinal (not an epidural, which takes ~30min to achieve full effect, but a spinal, which acts immediately). The chance of needing a true emergency c-section is very slim, but it is non-zero.

    3) For low-risk women, seeing a Nurse-Midwife who is in practice with an obstetrics group and delivers in a hospital is the absolute best of all worlds. Midwives tend to have a smaller panel of patients, spend more time with their healthy patients, and many women find them more reassuring. Since they risk out to OBs both antenatally and during labor if significant complications arise, they take care of only healthy women and healthy babies. Their outcomes data are superb.

    4) C-section rate is both useful and not useful. In order to interpret it, you need to know what kind of patients she takes care of. If she sees many high-risk women and/or high-risk babies; if she practices in an urban setting where many patients have multiple comorbidities and poor primary care; if she's in an area with a high percentage of multiples due to ART, etc, her c-section rate will naturally be much higher. If you're in an area of the US where many women are obese, have gestational diabetes, and have macrosomic fetuses, her c-section rate will be higher. Even then, the only statistic that really matters is YOU. In your labor, if you experience any of the indications for section (obstructed labor, malpositioned/breech baby, fetal distress, disorders of placentation, etc) who cares if 15-40% of her other patients experienced the same thing or not? Conversely, if your labor is a breeze, your pelvic outlet is lovely, your baby's placenta continues to function, her cord doesn't get in the way, etc-- who cares? I think you might feel that if Doctor A sections 24%, but Doctor B sections 40%, it's apples and apples and you should go with Doctor A. Maybe so. But honestly the medical community has a *great* deal of difficulty in determining who has an "unnecessary" c-section. Unless you can pore over the charts, labor curves and fetal tracings of each of these patients, you can't ever really know.

    5) Episiotomies are not routinely indicated with vacuum deliveries, only if the baby is asynclitic or otherwise malpositioned.
    Blade, MD

    XY: AR
    XX: CVN

    Aquila * Chrysanthe * Emmanuelle * Endellion * Ione * Jacinda * Lysandra * Melisande * Myrra * Petra * Rosamond * Seraphine * Silvana * Theophane / Blaise * Cyprian * Darius * Evander * Giles * Laurence * Lionel * Malcolm * Marius * Peregrine * Rainier

    كنوز الصحراء الشرقية Hayat _ Qamar _ Sahar _ Maysan _ Iman / Altair _ Fahd _ Faraj _ Khalil _ Najid _ Rafiq _ Tariq

  4. #22
    Join Date
    Nov 2013
    Posts
    221
    Quote Originally Posted by blade View Post
    To answer your technical points:

    1) an epidural (or spinal, or Combined Spinal-Epidural) in the United States is essentially the only method of pharmacologic pain relief offered. In Europe it is common to offer shots of narcotic medication and/or nitrous oxide ("laughing gas," as at the dentist). This are not preferred here since narcotic pain medication is quickly absorbed, acts systemically, and is 100% passed onto the baby. If given too close to delivery the baby is essentially drugged and can have more respiratory distress than otherwise. Nitrous oxide caused psychological dissociation, where you the mother no longer are fully aware of your surrounding and the events taking place. Since it removes the mother as an active participant in her own labor, and of course potentially erases all of the wonderful memories of the birth and meeting the baby for the first time, it is extremely rarely used in the US. Epidural/spinal anesthesia, on the other hand, provides focused *local* pain relief with zero effects on the baby. The mother is psychologically aware, a full participant, and will remember the birth well.

    Ideally an epidural provides a sensory block rather than a motor one, but there is nearly always a degree of motor impairment. A person with an epidural will be unable to safely bear weight on their legs and as such, once it's placed, you will not be able to stand, walk or squat. You can lay to one side or another, curl your legs up to your chest, and lay supine, but that's it. However, pushing on your back is not the horror show you might think. IN addition to providing the optimal view for your birth attendant, who can safely assess baby's position, guide baby out of the birth canal, apply appropriate perineal pressure to prevent a precipitous birth & tearing... it is the position which requires the least amount of energy for you, the mother, to maintain. Childbirth takes a tremendous amount of energy (estimates average around 4000 calories burned for a labor & delivery). You will be expending a great deal of effort in the pushing stage. Having to maintain your own weight in addition to that (whether squatting, sitting, hands & knees, whatever) really can tire you out.

    2) In the US, around 80% of births are medicated. Frankly, the majority of women simply say "it's not so much that I *can't* do this unmedicated, it's that I don't *have* to." It is in NO way required that a woman be medicated for a hospital birth. A substantial number of women have unmedicated births in hospitals daily across the US, with OBs. However, the only caveat is that if things go south very fast, and you need an emergency c-section without an epidural already in place, you will have to be intubated and go under general anesthesia for the birth (thus being unconscious and missing the whole thing). If you simply need an urgent c-section, not an emergent one, then there will be time to place a spinal (not an epidural, which takes ~30min to achieve full effect, but a spinal, which acts immediately). The chance of needing a true emergency c-section is very slim, but it is non-zero.

    3) For low-risk women, seeing a Nurse-Midwife who is in practice with an obstetrics group and delivers in a hospital is the absolute best of all worlds. Midwives tend to have a smaller panel of patients, spend more time with their healthy patients, and many women find them more reassuring. Since they risk out to OBs both antenatally and during labor if significant complications arise, they take care of only healthy women and healthy babies. Their outcomes data are superb.

    4) C-section rate is both useful and not useful. In order to interpret it, you need to know what kind of patients she takes care of. If she sees many high-risk women and/or high-risk babies; if she practices in an urban setting where many patients have multiple comorbidities and poor primary care; if she's in an area with a high percentage of multiples due to ART, etc, her c-section rate will naturally be much higher. If you're in an area of the US where many women are obese, have gestational diabetes, and have macrosomic fetuses, her c-section rate will be higher. Even then, the only statistic that really matters is YOU. In your labor, if you experience any of the indications for section (obstructed labor, malpositioned/breech baby, fetal distress, disorders of placentation, etc) who cares if 15-40% of her other patients experienced the same thing or not? Conversely, if your labor is a breeze, your pelvic outlet is lovely, your baby's placenta continues to function, her cord doesn't get in the way, etc-- who cares? I think you might feel that if Doctor A sections 24%, but Doctor B sections 40%, it's apples and apples and you should go with Doctor A. Maybe so. But honestly the medical community has a *great* deal of difficulty in determining who has an "unnecessary" c-section. Unless you can pore over the charts, labor curves and fetal tracings of each of these patients, you can't ever really know.

    5) Episiotomies are not routinely indicated with vacuum deliveries, only if the baby is asynclitic or otherwise malpositioned.

    Thank you, Blade! Your posts are so informative. I am low risk, and the midwives work in a hospital with the obstetrics group. There will be OB on the labour ward in case of any emergency.

    I've arranged a "meet and greet" with the midwife team on monday and am hoping my husband will come away from it feeling reassured that they are professionals and not a bunch of hippies who are against interventions at all costs... he works in nuclear science so this whole process of childbirth is very scary to him, and he feels out of control. If it were up to him I think he would have a team of 20 surgeons delivering this baby.

    I have been told that there are 2 OBs in particular who work very closely with the midwives, so if my husband is still overly anxious after the meet and greet, we still have that option.

    Thanks again everyone! I'm on the right track and feeling great about labour. Only 11 more weeks to go!

  5. #24
    Join Date
    Sep 2012
    Location
    Los Angeles
    Posts
    4,518
    Great-- good luck. Seems like you're in a good place.
    Blade, MD

    XY: AR
    XX: CVN

    Aquila * Chrysanthe * Emmanuelle * Endellion * Ione * Jacinda * Lysandra * Melisande * Myrra * Petra * Rosamond * Seraphine * Silvana * Theophane / Blaise * Cyprian * Darius * Evander * Giles * Laurence * Lionel * Malcolm * Marius * Peregrine * Rainier

    كنوز الصحراء الشرقية Hayat _ Qamar _ Sahar _ Maysan _ Iman / Altair _ Fahd _ Faraj _ Khalil _ Najid _ Rafiq _ Tariq

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