Interventions

Our “birth plan” is extremely short.  It basically says “we prefer to minimize interventions.”  This is kind of ironic considering the number of interventions we submitted to in order to get knocked up in the first place.  But our interest in minimizing interventions is not because we think childbirth has to be “natural” but because there are so many secondary risks that the interventions themselves can pose… and it seems like the US obstetrical system seems to be optimized to minimize the “risk of a lawsuit because we didn’t do anything when we could have,” rather than the actual risk to the baby.

Today I had an appointment with the midwife, which I had been dreading all weekend.  Our practice has multiple midwives, so you see different people every time you go.  Today’s appointment was with the super interventionist midwife, she of the “you have a DE baby, so we will be more likely to do a c-section” fame.  I knew she was going to get on my case about being post-dates (5 days and counting).

At the last appointment, she told me she would want to “sweep my membranes” at this appointment.  Sweeping the membranes is a very, very common procedure where they use a finger to separate the bottom of the amniotic sac from the uterus; it is supposed to trigger labor.  This weekend, I went on-line and did some research into sweeping the membranes to see if I should consent.  Here is what I found out.

First, there is no scientific research that shows that sweeping the membranes as a routine procedure actually makes any difference in how quickly labor comes.  Second, there are a few risks to the procedure, including that your bag of waters could break (in which case they have to induce you if you don’t go into labor within a day), and that they may introduce bacteria from your vagina into your uterus and thus increasing your chance of infection.  The procedure is often very painful and it is not uncommon to have bleeding afterwards.   All in all, it didn’t really sound like the benefits were worth the risks.

I took Mr. Nishkanu along with me to the appointment because I was pretty sure that the midwife was not going to be receptive to me turning down this procedure and I thought I could use some help fighting off the tidal wave of doom and gloom she likes to spread.  First, we had our non-stress test.  Baby passed with flying colors, not only doing all the right things with its heart accelerations but also kicking 15 times during the 15 minute test, at one point kicking the contraction monitor so hard you could see it bump off of my belly.   Hooray!  Everything is great, no need to worry… right?

We then went to the midwife’s office where the Big Fight ensued.  I was so glad that I brought Mr. Nishkanu because the midwife pulled out all the guilt stops.   The thing was, a lot of what she said just didn’t seem logical.  For example, she told me this was my last chance to avoid an induction, since it was practice policy to induce at 41 weeks (which I know it isn’t, since I talked to all the other midwives about it).  When we asked about risks and benefits of the procedure, she only talked about benefits and did not discuss risks.   She said it was very dangerous to be post-dates, that the placenta starts degrading… although she admitted that according to the test my placenta was in great shape.  But, she said, they prefer to induce before there is a problem… leading me to wonder, why did she bother doing a non-stress test, if her plan was to induce if there is a problem, and also to induce if there is no problem?

She also assumed that the reason I did not want to have my membranes swept was because I was “afraid to go into labor,” so she started trying to talk me into having courage to face the inevitable.  One thing I can tell you, lady, is that after 5 years of infertility treatment and 8 IVF cycles, I am not afraid of labor.  The hell in my past is much greater than the suffering in my future, even if the raw pain of the latter is much greater.  After all I have been through to have this baby, labor is just a minor bump in the road.  And actually, although I know this might be a bit weird and I might regret saying this in retrospect, I am kind of looking forward to the athletic challenge.

Fortunately Mr. Nishkanu had taken over the conversation at this point.  He is good at not getting upset by this stuff.  Finally he got the midwife to the point where she said “if you really insist on not sweeping the membranes, then the only option is for you to come in in a few days for more tests.”  Mr. Nishkanu said, “that sounds good, we’ll do that.”  Fortunately, our next appointment is with a different midwife.   If she continues the “must get this baby out now (despite no evidence of problems)” bandwagon we’ll listen; as is, I feel like this particular midwife has an induction ax to grind.

The whole thing made me think again about the difference between RE practices and ob-gyn ones.  The REs I have been to are compulsive about collecting statistics about most of their procedures.   If you say, “what difference will it make if we do assisted hatching?” they can tell you what the numbers, on average, for their practice are (of course, this may not apply to your case, but that’s another story).   In fact, this is one of the things that I think kept Mr. Nishkanu on the DE wagon rather than going to adoption… adoption agencies don’t hand out statistics, they work more with relationships and emotions, things Mr. Nishkanu does not derive as much comfort from.  But ob-gyn practices seem to do much of their practice because “this is how we’ve always done it.”  The national evidence-based standards for induction from the American Council of Ob-Gyns is to not induce until 42 weeks unless there is an indication of a problem.  But many, many practices across the US start haranguing people to be induced much earlier than that… “just in case.”

Part of the difference, I guess, is that REs are trying to stay on the cutting edge.  They acquire patients by having better stats than the competition, and in order to keep the stats up, they have to keep innovating.  They keep pushing to see if they can get the numbers better.  Ob-gyns are in a different position, their methods are established and they get more patients than they need even if they don’t do anything better (for example, in our town, there are two ob-gyn practices; one has twice the c-section rate of the other yet neither hurts for patients).

But, Mr. Nishkanu pointed out, another issue is the question of bad outcomes.   Ob-gyn practices are optimized to avoid the worst outcome, not to optimize the average outcome.   The risk of waiting may be small, but over the patient population our clinic sees, eventually they will see the bad outcome.  And the bad outcome can be really, really bad.

Now,  the fact is that REs have bad outcomes which are just as bad as ob-gyns… after all, they are causing the pregnancies that the ob-gyns eventually handle.  If their patients have multiple pregnancies, there are very real, serious risks for the babies that come out of the treatment.  If we look at higher order multiples, these are very high risks.  But… REs generally don’t actually see the bad outcomes.  The perinatologist is the one left holding the bag when the babies don’t make it home, or have serious disabilities.

OK, time to go back to thinking positive.  The baby is doing acrobatic leaps and bounds tonight, so the good news is: happy and healthy, nothing bad has happened so far!

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3 Comments »

  1. Rachel said

    Sweeping the wha…? That sounds absolutely barbaric to me. Have not heard a peep about any such thing from my OB and frankly, I’d refuse it too. I’m with you, let Mother Nature take her course.

    I’m pretty sure I’m older than you and if my OB is okay to let me go to 41.5 weeks without intervention, you’d think they would leave you alone. Sheesh!

    Good thinking on bringing the Mister and I hope the next midwife is a little more humane.

    Nazi Midwives, who knew!

    Hang in there, girl, you and baby are doing great!

  2. […] to do something called a ‘membrane sweep’ and I refused, having just read about it on Nishkanu’s blog this morning. It sounded painful and awful. However, driving away, I wished I’d had her do it. Why? […]

  3. Ana said

    Wow, membrane sweep? Doesn’t sound fun to me.
    Your post spurred me to ask at my appt today about the general protocol with post-dates. I was told they don’t even start asking until 10 days post-due date (41 1/2?) and then only if the patient desires or the non-stress-test shows anything concerning. Surprised, given its a huge medical center-associated hospital practice, with high c-section rates. But happy to know.
    Hang in there.

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