Part 2: Approaches to Maternity Care

Ok this is a long one! But all important and I tried to be as pithy while still informing as I could. This round of birthing blogging is going to follow up with the rest of the information regarding the two models of maternity care. In the last post I covered the basics of the medical model and midwifery model of care for women and babies.  With this post I’m going to offer the specific interventions that are often used in the medical model of prenatal and birthing care.

Disclaimer: I feel I need to always offer a disclaimer with this!  I am in no way bashing any of these interventions. My intention here is to offer information about them so you’re prepared and informed so you can give real informed consent. Often times these interventions may be offered at a time when there isn’t adequate time to give all of the information, chew on it, and make a decision you feel confident in. Sometimes they are offered without full disclosure about the whole picture.  I want to shine the light on these, so you can decide what fits for you and your care. When we file all of this down to the bare bones, it’s your body and your child. Your family. Your medical provider doesn’t have to deal with the long term story of any of this, so ultimately the decision should be yours, and one of the saddest things to me is when women are left feeling like they missed something. So, I’m going to cover these following tools that are used: Ultrasound, Chorionic Villus Sampling, Amniocentesis, Gestational Diabetes screening, Beta Strep screening, and Prenatal Rhogam. Keep in mind that these tools are widespread and utilized differently everywhere. There are probably areas of the country and certain practitioners where they are all standard and others where they may not be utilized heavily or at all.

** Ultrasound **
Very popular and not fully regulated in the US. There is an idea that the use of ultrasound makes pregnancy and birth safer for everyone. This isn’t fully true, as several studies have evaluated the effectiveness of routine ultrasound and nothing has shown that it improves maternal and infant health. Ultrasound when used as medically indicated and necessary is a different story as is the case with all interventions. The problem we run into is that these tools often become second nature and routinely used with everyone. When it’s not fully indicated or needed and has negative effects, that’s the unfortunate part.

Purpose:
 ultrasound can be used to diagnose if the fetus is alive, the age of the fetus, how many babies there are (this can sometimes be mistaken), the location of the placenta, the position of the baby, the sex of the baby (this is often be mistaken by ultrasound) and how the baby is growing.

Considerations:
routine ultrasound is often utilized frequently in the medical model. It’s a good idea to consider how the ultrasound will enhance the pregnancy before agreeing to have them out of being compliant or following the trend. Having an early look may not always be reassuring, nor does it prepare you for what’s coming. If your provider requests an ultrasound, it may be helpful to ask them what information they are hoping to get from it before you agree. If you don’t want an ultrasound, but they want certain information, you could try other routes to getting the information (Example: the desire for a due date, you can use records about the conception of the baby). In either case, you should state your preference about the ultrasound and see if your provider listens to you and works with you. If they don’t, you may want to consider how this person is going to show up for you when the birth comes.

*** Practitioners can get a lot of information simply using their hands, like they had to before ultrasound was brought into the picture. Ultrasound is sometimes used to measure the woman’s pelvic dimensions. This is simply not necessary! It’s a poor use of technology. The woman’s pelvis can be seen as an art, like Ina May Gaskin thinks of it, or it can be seen as a science with an exact system. This judgment can be better made by hand than by machine. Some women get told that their pelvis is “inadequate” or too small to bear a child based no their ultrasound or X-ray. Excuse my frankness, that is a crock of shit. It’s so unfortunate that women are given these messages about their body.

Numbers: In one case study of 25 women, except for 2, all of the women whom were told this message about “your pelvis is inadequate” ended up successfully giving birth vaginally. This study was performed by midwives whom did not find ultrasound or X-ray necessary or helpful. There is something to be said about the intuitive sense of how big the pelvis is and if it can accommodate the head of the baby (it usually can!)  One other thing to remember is the pelvic dimensions actually change according to the position you assume, so the dimensions you get from lying down on your back may not be appropriate for when you’re birthing and you’re on your hands and knees, squat, in the tub, etc.  The female pelvis is not fixed in shape and size, it is composed of bones that are connected with ligaments. The hormones that loosen the ligaments during birth allow for more flexibility in the pelvis.

Something to try:  There’s an exercise you can do to get in touch with the power of your pelvis. Stand or kneel with one hand on your pubic bone in front and the other on your tailbone. Notice how far apart your hands are. Lean back as far as possible (careful not to hurt yourself), and notice how far apart your hands become. Next, lean forward until your torso is parallel to the ground. Most people (including me) are surprised by how much their hands move with this. There is usually a noticeable increase in the distance between their pubic bone and tailbone. This is a direct example of why monkeys lean forward during birth…it gives a lot of space and space never hurt a birth.

** Chorionic Villus Sampling (CVS) **
This is a test for chromosomal abnormalities such as Down Syndrome. It’s done before the fetus is 12 weeks old. The main advantage is that it can be done early in pregnancy vs amniocentesis (below) which is done later. Women whom have already had a child with an abnormality or women who are over 35 (which is more and more likely these days) may be offered this test routinely. There is a risk of miscarriage with this test. The rate of pregnancy loss after a CVS test was about 4%. Rarely, this test can cause damage to the arms, legs, fingers, and toes of the embryo.

Consideration: if you know you would not have an abortion if the test indicated you may have a child with some kind of abnormality, you should decline the test as it may only make the pregnancy more stressful. If you’re unsure, then there are risks and benefits to be weighed and carefully considered. Statistics should be considered and some soul searching about what you are prepared for based on any possible outcome of the test. This procedure is invasive in its nature as it samples the tissue of the placenta (you can imagine what a sampling of the internal tissue of the placenta would take, not comfortable by any means).

** Amniocentesis **
This is another test that can reveal conditions and disorders (similar to CVS). It involves a sample of the amniotic fluid which is taken through a long needle while the doctor uses an ultrasound to lessen the chance of accidentally hitting the fetus with the needle. This can reveal the gender of the baby like the CVS test. It can also check for other defects such as spina bifida and anencephaly.

Numbers: This has become a standard test for women over 35 in the medical model. This number was chosen because the likelihood of having a baby with an abnormal condition is the same or greater than the risk that the test would injure the fetus or cause a miscarriage. Not the best odds. There is about a 1.5 risk of damage or miscarriage following this test. This test is offered to younger women as well after lawsuits happened where parents who had a child with Down Syndrome sued doctors who had not informed them about the availability of this test. This test is done 15-18 weeks into pregnancy and occasionally the test has to be performed more than once.

Considerations: some people will find the test reassuring and others will wish they have been warned about the period of waiting after the test. By that time, the baby’s movements can be felt and this can often produce an emotional conflict. In the words of Barbara Katz Rothman (sociologist), this test “asks women to accept their pregnancies and their babies, to take care of the babies within them, and also be willing to abort them.”  With this test, a woman has to consider the possibility of having a child with a disorder or having a miscarriage caused by the test. It can be healthy to remember that this test never cured anything.

A note about disorders and abnormalities:
 I’m not sure what “abnormal” even means these days. There are some people in this world whom have children with different capabilities than the masses and love them all the same. And there are some people whom may not deal with that difference as well. I don’t enjoy writing “abnormality” and “disorder”. I use them because it speaks to what the whole of the culture understands. But I also invite you to think about the fact that bringing a child into the world with love is a powerful thing, whether they fit into the majority or the minority group. My personal opinion is that our culture has gotten a little obsessed with knowing every possible thing, when we are really all in a big unknown and we will never ever fully know what’s going to happen.

** Maternal Serum Alpha-fetoprotein Screening **
This isn’t a test for diagnoses, but a screening. This is routinely offered to women at 16 weeks within the medical model. This test doesn’t tell you if the baby is ok. It’s a blood test that tells you the possibly chance (not an answer one way or the other) of the baby having certain abnormalities, but it cannot tell you whether your baby has a condition. This screening indicates that there could “possibly be a problem”, and then the provider may offer an amniocentesis test or an ultrasound. About 5% of these initial screenings produce an abnormal result even when the fetus is completely healthy. This high percentage of mistakes is partially due to a miscalculation of the gestational age or the presence of twins.

Consideration:
 when this screening was first introduced, the FDA allowed it for usage only in research settings. Due to pressure from physicians and labs, the FDA withdrew this regulation. The American College of Obstetrics advised its member to offer the test to all women as part of a liability alert. This alert was for the benefit of the professional and to prevent a lawsuit. Notice the brushing over the consideration of the woman. The test is marketed to be “reassuring” to the woman, but most women find it to be the opposite. The results of this screening may be quickly analyzed but then the follow up amniocentesis involves weeks of waiting. This procedure has been questioned because it subjects many women to test and anxiety when so few of them will have problems. One thing is definite: if you are already having an amniocentesis, you do not need this screening.

** Gestational Diabetes screening **
You’ll likely be offered this screening if your provider works within the medical model. This is not a disease! It’s a higher level of blood sugar than average during pregnancy and is determined by a glucose tolerance test. Gestational Diabetes goes away after the baby is born. Many doctors recommend this test for all pregnant women and it’s performed between 24-28 weeks. The test is not very reliable. 50% of women will have a different result in a second test than the first test if they are retested. There is no real treatment that improves the outcome for the woman or the baby. The anxiety that is often produced with this test may not be worth the information gained from it. Sometimes if the test is positive, if your provider is very conservative, you may be encouraged to go through with further expensive tests and treatments with no proven benefit.

Consideration:
 There is a routine urine test with a pee stick at prenatal visits. There is also something available called a glucometer to help identify if a woman can benefit from a dietary change if the blood sugar levels vary widely. It’s a finger stick that measures the sugar level in a drop of blood. These can be used when the following symptoms are noticed at 28 weeks or after: fast weight gain, feeling funny / dizzy after meals, constant thirst, sugar cravings, family history of diabetes, previous large baby. You can get a reading 30 minutes after breakfast and another one an hour later. Women whom have high variable readings may be eating something they don’t tolerate well during pregnancy, like sugar and white flour. For the short term, the best response is to get light exercise and eliminate white pasta, flour, sugar, and other starchy foods that are causing the symptoms. Sometimes the simple answer is the way to go, and we seem to be making things more and more complicated as we become “advanced”.

** Screening for Beta Strep **
We think of bacteria as a disease causing agent, but there are many varieties that live in our bodies and cause us no harm at all. One common variety (Group B streptococcus, beta strep) has significance for pregnant women. The normal bacteria in a woman’s vagina sometimes includes this variation. About 1 in every 5 has this living in her vagina. There is a difference between this variation living in us (many of us have this) and being infected / sick. Usually the presence of this variation causes no symptoms. An occasional urinary tract infection and much more rarely, an infection of the placenta could cause premature rupture of the membranes and a premature labor.

Consideration: Some women whom have this variation in their vaginas will birth a baby whom will have it living in them as well. This does not mean all of these babies will become ill! In fact, 98% or more do not become infected. When the infection does occur, it is serious and it is fatal in 10% of cases. That’s scary, and it’s also important to remember only 2 in 1000 babies will be infected. The problem is there is no accurate way to know which two babies it will be. There are some situations that may be associated with a higher risk than usual (you can find those online, they include things like premature birth).

The response: There are some prevention strategies that have been developed to cover this issue. One is to test all pregnancy women and then treat those whom carry the variation with antibiotics. The problem is that this approach didn’t work, it did not reduce the number of babies who became ill. This means that all women will receive antibiotics and most of them will have babies whom are not at risk. And some babies who really do need treatment are then missed. The overuse of antibiotics is well known to contribute to bacteria development that are resistant to treatment. This could cause a yeast infection, thrush, and diarrhea in mothers and babies. One organization estimated that if all women whom had this variation were given penicillin, there would be 10 maternal deaths per year from a severe allergic reaction. For all the risks stated above, know that you have every right to deny this test and antibiotics! You can slightly decrease the risk of your baby being infected by declining as many interventions as possible (example: when a vaginal exam is done to measure dilation, every single time it introduces bacteria into the vagina no matter what, especially if your water has already broken. Vaginal exams are often done way too prematurely and often). You can also have everyone wash their hands frequently before touching the baby during the newborn period.

** Prenatal Rhogam **
This is about blood type. During pregnancy you (and if possible the baby’s father) should find out if you are Rh negative or Rh positive. If you’re Rh positive or if both you and the father are Rh negative, you can disregard this whole section. But if you are Rh negative and the baby’s father is positive, Rh incompatibility complications could be a possibility with each pregnancy if you have more children. Having Rh negative blood is not a problem but there are negative consequences if the blood of an Rh negative person is mixed with Rh positive. When an Rh negative woman carries an Rh positive baby, there is usually no mixing of their blood during pregnancy. However, sometimes during pregnancy a small amount of the baby’s blood gets into the mother’s bloodstream. If this happens the baby’s blood is recognized as foreign and the mothers blood produces antibodies to fight off the foreigner. The blood of the mother is said to be sensitized if this occurs. Procedures such as amniocentesis, external version, and episiotomy increase the chance of this. This mixing of blood is rare in the first pregnancy unless there’s been a previous abortion or miscarriage. But if the antibodies are present in the mothers bloodstream there may be an increased risk in future pregnancies because the antibodies can cross the membrane of the placenta and attach the proteins in the baby’s blood. The results could range from mild jaundice to acute hemolytic disease which is sometimes fatal to the baby.

Treatment:
 injections of a manufactured blood product called Rhogam are sometimes given to Rh negative mothers with Rh positive babies after birth or after any traumatic event during pregnancy if the mixture of blood may have taken place. This is an effective procedure to prevent the formation of the antibodies that could present a danger to future babies. Since Rhogam has been developed there has been a great reduction in the number of babies lost to severe hemolytic disease.

Risks:
 despite the overall benefits of Rhogam, some women have reservations due to the long list of side effects: inflammation, malaise, chills, fever, body rash and rarely anaphylaxis. Some Rhogam products use a mercury-based preservative which can cause be toxic to a fetus. The concern of blood-borne infections is always relevant. In the early days of this drug, there were illnesses contracted that are now screened for, but there is always the chance of an unknown virus being transferred through blood.

Consideration:
 If your blood type is Rh negative and you use the medical model, you will likely be urged to accept a Rhogam injection at 28-34 weeks regardless of the blood type of your baby. The rationale for this is that it’s the best way to prevent a “silent” sensitization. The unknown with this routine prescription is that many babies who are Rh negative like their mothers will be exposed to the drug and there is no long term study of the effect of this product in babies. Less conservative midwives advise their clients to decline Rhogam unless there has been a traumatizing event. Women should be given the information about the risks and benefits of Rhogam, along with the risks of the sensitization that can occur, and then she should choose whether to accept or decline so they feel they have full control over the situation. Giving Rhogam to a baby after birth is much less controversial than at 28 weeks of pregnancy. 90% of Rh negative women giving birth to an Rh positive baby will not need the prenatal Rhogam because there has been no mixing of the blood. Unfortunately there’s no sure proof way to determine whether you’re among those who will become sensitized. This decision is not easy to make. There are multiple things to reflect on. If the woman has no plans for a future pregnancy, she will probably decline the Rhogam. Women whom have religious convictions about blood products will not accept it. Women who have medical intervention at birth are more likely to be sensitized than those who have not. Some women choose a test to find out whether fetal cells have entered their bloodstream. If the test is negative, they may decide the chance of sensitization after birth of an Rh positive baby is low enough to refuse it. However, those tests are not always accurate.

Woo! That was a lot, I know. The motivation for these posts is not to produce fear or anxiety. I know it can feel overwhelming. But it helps in the long run to know all of this. Good job sticking with it. I encourage you to come back to it, consider different pieces at different times.

Informed consent: The home run for these posts are to beat the point into the ground that the MOST important point with all of this is informed consent. Before you agree to any treatment or procedure or intervention, you should be given every single piece of information to help you make a decision. The information from your provider could always be a bit biased. You may want to seek second opinions or additional resources. The degree of consent during labor is tricky and I’ll cover this more in another post about interventions that sometimes occur during labor and delivery. The last thing anyone in labor is going to do is read and be rational, but you can do this research before the birth happens. Wherever you’re going to give birth, take the steps before the labor process to find out what the procedures are, inform yourself about what you will and will not accept.

Implied consent: Implied consent to procedures is bullshit. It’s lazy. Some organizations operate on the assumption that you give implied consent “if you did not actively object to a procedure by refusing, firing a provider, or discharging yourself against medical advice.”  Some hospitals have begun asking women to sign a statement that they do not wish to be informed about the potential risks of drugs they are asked to take.  WHAT?!  Where are we living?!  I cannot express enough my extreme disapproval of those modes of thinking and approach to the care of a woman and her baby.  (And of course, if there is an emergency and a surgeon has to make a decision in a split second to save a life, those are the hard situations that there’s never the “right” answer to). But for the most part, the reality is even if there are challenges or trauma during a birth, every woman feels better about the situation if she is informed and feels she had a say in what happens.

In my next post I will finally begin to cover the labor process and the interventions that are often utilized during birth. Thank you for your presence, with love, Alicia

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About Alicia Patterson

Alicia Patterson is a Psychotherapist / Dance Movement Therapist, Birth Doula, Energy Worker, Dance and Yoga Facilitator in the Boulder / Denver area.
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