Sunday, August 26, 2007

My OB saved my life.

My OB saved my life. My OB almost killed me (and my children). This was all during the same pregnancy.

Katie's comment on my OB/Midwifery post got me thinking. I, too, can say an OB saved my life. Problem is, it was the OB who put me in danger in the first place.

First and foremost, I must say that OBs do have their place. They do save lives. Often, though, they create emergencies or make situations appear as though they are emergencies when they are not. Midwives are trained to calmly assess. OBs are trained to provide medical interventions to correct the problem or the perceived problem. Often times, there are circumstances that doctors consider high risk whereas a midwife does not. This isn't because midwives are blind, but rather because midwives are trained to recognize and treat challenges very early. They want to keep you in their care and the only way to do that is to keep you low risk. OBs typically don't have that focus on prevention because there's the idea that they can treat whatever comes along. Granted, there are situations where OBs can provide care that a midwife cannot. I'm not denying that. If a situation like that occurs, a midwife is trained to recognize it quickly so that the mother can either transfer to an OB's care or can be taken to the hospital. Midwifery is not opposed to obstetrics. They can actually work hand-in-hand if need be.

The Midwifery model of care includes preventing challenges (aka "complications"). They have diet guidelines to keep you healthy. They provide tests to check for problems (although these are typically far less invasive and far less often than the tests required with an OB). That way, they can help you come up with a treatment or, if necessary, refer you to an OB if one can better complete your care. That, however, seems to be fairly rare and in those cases, you may be able to continue seeing the midwives for some or all of your prenatal care. Midwives typically have access to standard medical treatments (medications, labs, etc), but many are also extensively informed on more natural alternatives which have been used and proven for centuries. You won't be denied a necessary prescription drug, but she may recommend either an alternative or a natural treatment that compliments the prescription. Although, typically, with midwifery, the final decision is yours.

The Obstetric model of care is that anything can be treated. You will be tested repeatedly during your pregnancy. Although, there is very little preventative medicine. If the problem continues, you may be given a prescription. If it persists, you may be given a number of different prescriptions and most likely more tests. If those don't help, there's bedrest. If that doesn't help, there's always induction. If that fails, there's always a c-section for mom. If it's too soon, well, there's the NICU for the baby.

For those women who truly have a higher risk (and the OB model of care considers many patients to be "High risk" even when a midwife might not consider them so), OBs are fabulous. Please don't think I'm taking issue with women who are truly high risk and who seek an OB's care.

I will leave you once again with this fabulous quotation:

"Midwives see birth as a miracle, and only intervene if there's trouble. Obstetricians see birth as trouble, and if they don't intervene, it's a miracle." Gentle Birth Choices.

Aug 30th edit: I have edited portions of this post as a result of recent on-going discussions/information.


19 comments:

Katie said...

I'm not trashing midwifery at all...I am asking this. My daughter is laying completely sideways. How long do we wait for her to move into position? What if she never does? Do I put my foot down with the OB and insists we wait an wait until she moves?

I'm a bonafied wimp. I could not do what Pixie did. i could not have a homebirth. I don't do well with pain.

If I were having a boy, I would not circumsize him (that I have found alot of value in with all the conversations we have had in the pas), but I wonder this: am I uneducated even if I read everything here and still decide to have a hospital birth with my beloved OB...seriously I love this woman. She gives it to me straight. If I ask 1 million questions about induction and c-sections she won't BS me.

One bad OB does not an entire medical field of Dr.'s make.

Krissy said...

Knowing your history, I am *loving* the fact it's against the law in PA. Currently, there is a midwife in jail in PA for either homocide or manslaughter (I forget). Interestingly enough, the family doesn't want to press charges and is raising money for her defense, however the state is still trying to convict her.

I heart PA @@

Rose said...

First and foremost, Katie, please don't think my OB rants have been about you. Your comment inspired the last one and made me think, but I'm not aiming any accusations at you. I hope these entries aren't coming across that way.

I do want to say more in response to your last comment. One good OB does not negate the fact that the Obstetric model of care is more dangerous. I didn't come to this realization because I had a bad experience. I didn't realize just how bad my experience was until I compared the standards of care.

No, I don't hold it against you that you're planning a hospital birth. Homebirth certainly isn't for everyone. Even my very favorite midwife says that. It just worries me when people chose a hospital birth because I know the risks for complications increase. I don't for a minute think you haven't done the research. I just worry because I don't know what your outcome will be. If you don't want a homebirth, then I don't want you at home because that's not the ideal place for you. I want you somewhere where you're comfortable and safe. I want that for all moms. I just think many (not necessarily saying you) don't realize the difference in care. They think they'll be safer in a hospital when that's usually not the case. I was one of those women. Many women don't even consider a homebirth, but if they actually did the research and met with midwives (again, NOT saying you), they would likely find many of their fears to be unfounded.

As far as positioning, some babies turn during labor. Most babies turn by 37 weeks. There are ways for health care providers to manually manipulating them to help them move. There are positions you can try (You would have cracked up if you saw hugely pregnant me hanging upside down on the bed trying to get the girls to flip. I looked like one of those people upside down on those torture wheels where they throw knives). And, in the end, if you find yourself in labor and she's not in a position that allows for her to engage, no one could say a bad word about it. Remember, I would not have physically been able to have my son if not for c-sections. The thing is, though, that situations like that are pretty rare. In most cases, babies turn on their own and in a number of those rare ones who don't, they can do so with a little encouragement. Chances are she will move, but if she doesn't, I'm grateful for the surgical option.

In the end, what it comes down to is that I want you (and all moms) to be safe. Research has shown that for the majority of moms, that's with a midwife in an out of hospital setting. I'm not saying that's the case with your situation.

I know that any mom who uses obstetric care and delivers in a hospital has an increased risk of specific medical interventions. I have seen the research on the risks of some of those interventions. I live in fear of the risks of some of the interventions that were performed on me. I don't want that for you. Most moms who are subjected to them (again, not saying you) can avoid them and it kills me that so many moms are forced to face those risks.

Giselle said...

katie:

I took a hypnobirthing class with my last baby and there was a visualization we did with the babies while looking at a picture of a baby in utero in perfect occiput anterior presentation. We would focus on our own baby, put our hands on the baby and either think or say out loud exactly how we wanted the baby to move. "Head down, butt in the air, back to Mommy's belly, belly to Mommy's back, cross your arms across your chest, tuck your chin to your chest." I am not kidding you, by the end of the pregnancy, I was able to feel the kid flip into position before I finished the first sentence of the meditation. Arthur was head down from week 34 to week 37 when he freaked me out because he flipped transverse and stayed that way for three days. Then one night he just turned back head down during our nightly meditation. It might not work for you, but it's definitely low cost and non-invasive.

Katie said...

I want to apologize for my first comment. I jumped to conclusions and got all hormonally thinking. It happens when you are pregnant. Ya know???? I realize you want me to be safe, but considering my condition the risk for blood clots (I have a friend who lost her baby due to a blood clot in her placenta), at this moment I feel pretty safe with a hospital birth, Not to mention, we know a couple of nurses at the hospital we are delivering at and believe me...they will have our best interests at heart.

I know she will turn...I'm just sensitive because everyone is on me about how "tiny" I am. So my thought is....great someone is going to criticize me of I get induced and then have a c/s.

Again I'm on hyper sensitive overdrive these last few weeks. Rest assured, we've made a list of questions to ask in regards to being induced and C-sections.

So please excuse my previous emotional outburst (thank God this wasn't posted last week when I was freaking out about not being a good mom LOL)

Pixie LaRouge said...

Katie, if anyone understands pregnant hormones... LOL

As far as being a wimp goes, anyone who knows me will tell you I am a giant pussy. I cannot handle pain. I don't like being uncomfortable, even. I don't sleep in socks for fear of a wrinkle near my toes. Seriously! (alright, stop laughing at me right this minute! I am aware that I'm a freak, but I'm comfortable with my freakiness LOL)

Want to know the weird thing about child birth? With the proper training and mindset, I SLEPT THROUGH IT! Really! pesimst and I had a HUGE fight early in my pregnancy when I said I wanted to try hypnobirthing. He thought it sounded like so much bunk. I was desperate, because I am so afraid of pain. When he told me he didn't think it would be worth the money for the class, I pointed out that my pain control options were seriously limited, and I was terrified (then I wanted to throw something at him for being a jerk, and, as I was in the bathtub, all I had was a handful of water. But that's another story).

I took the class. I practiced. I did the visualizations. I was calm. I was ready.

And then, just before the midwife got here, I was a wreck! It hurt. I needed to pee, but couldn't because the baby's head was so low. I *knew* I couldn't make it. I wanted to go to the hospital and get drugs.

And then I got a grip on my breathing (with help from the montrice). I relaxed. I calmed down. She got me on the bed to check my progress, and I never got up again. I just laid there and slept.

I wish I had known that kind of peace was possible with my first pregnancy! Labor wasn't hard. Delivery wasn't hard (there was one moment of pain that lasted a few seconds as he was crowning, then I knew I was done and felt no more discomfort AT ALL).

So don't let anyone convince you birth = pain. It's not guaranteed; it's mostly about mindset. Fear makes us tense up, relaxation keeps things, well, relaxed!

As far as hospital vs. homebirth, though: I think women should make educated decisions and birth where they're comfortable. For me, I wanted a birth center birth, but that's not an option around here. So I went with a homebirth so I would have certain things that were important to me. It was my right choice (emphasis on MY).

I hope your birth is YOUR perfect birth. Run your fingers up your belly and picture her spine stretching under them. I know it sounds corny, but talk to her and tell her how you want her to lie. And, no matter what, have a great birth and celebrate the new life that's joining yours! :)

Anonymous said...

I saw a homebirth midwife and ate the Brewer diet in my first pregnancy, and got preeclampsia anyway. My midwife missed it altogether because she always took the lowest of the readings at every appointment, and scheduled my next appointment two weeks later. By the time that rolled around, my baby had been out of the womb and in the NICU for a week, and my pressures were still 180/110 on meds.

My OB saved my life.

I think the reason people extol the Brewer diet is that most women don't get preeclampsia in their second pregnancies. There's no research to support it either, as Brewer didn't publish his data and no subsequent studies have ever confirmed his proposed mechanism. These days they think it's an immune system conflict between the mother, and the foreign placenta.

Rose said...

First and foremost, Anon, it doesn't sound like your midwife followed the midwifery model of care. That calls for a huge emphasis on prevention. It doesn't sound like your midwife did that. I'm so sorry you had to go through that. Our providers, no matter who or where they are, should listen to us and our bodies. I'm so sorry your midwife didn't do what she should have.

Research has shown that pre-eclampsia can be directly related to poor diet/lack of supplements (if not in the food than in pill form).

I haven't been able to find any direct links specifically to the Brewer's Diet for preventing pre-e, but I've found list after list indicating that diet most likely plays a roll. It's interesting that many articles mention specific properties of diet which actually fit much of the Brewer's Diet (here's one example from IVillage: http://parenting.ivillage.com/pregnancy/pcomplications/0,,4b0,00.html)

My midwives actually don't use the Brewer's diet. You'll notice in my post that I mentioned that diet "or an approved version thereof." The version they prefer calls for less protein. Still, that and the Brewer's diet are well-rounded and call for complex carbs so as not to spike the blood sugar excessively (often causing morning sickness which can then lead to other problems).

Think about it, those with high blood pressure are told to avoid sodium because it effects their blood pressure. So why would it make sense to tell someone that has pregnancy-induced high bp that diet isn't a factor?

FTR, I WAS high risk for Pre-e during my second pregnancy. I did see a backup OB who classified me as "high risk." I have a family history of it in addition to developing it myself. Although, yes, I know there are some who say it is not genetic and the cause is unknown. Interestingly, since some claim it's not genetic, I find it odd that my "genetic tendency" towards pre-e was one of the reasons my OB performed an emergency c-section without attempting any other interventions. And yes, I was specifically told that was a big reason they were performing surgery rather than putting me on bedrest.

During my first pregnancy, I ate a diet very high in fast foods (aka high in sodium/sugar). My OB not only had no problem with that, she urged me to eat more high fat/high sugar snacks so that I could put on more weight.

Yes, some people have negative experiences with a midwife just as some have negative experiences with an OB. Statistically, though, you are more likely to have problems in a hospital than with a homebirth midwife. You are more likely to have a good outcome with fewer interventions in an out of hospital birth setting with a midwife.

Rose said...

I mentioned sodium in my last comment, so I wanted to point out that my midwives told me to salt my food to taste while pregnant. I know our need for sodium increases as our blood volume does. I hope that wasn't confusing. I was, however, told that foods naturally higher in sodium were fine, but those that were processed and artificially high in sodium were to be avoided.

My sister, however, who developed pre-e (Toxemia at the time) and 30 years later, still has high bp as a result, she has dietary restrictions which means she can have no table salt at all. Even with fast food, she has to ask for it unsalted.

Anonymous said...

The current Cochrane Review on this subject found no change in preeclampsia rates when women were advised to increase their protein and calorie intake, and no change in preeclampsia rates when women were advised to a high-protein diet. It did, however, find an increase in SGA births in the high-protein diet group. It concludes: "Dietary advice appears effective in increasing pregnant women's energy and protein intakes but is unlikely to confer major benefits on infant or maternal health."

Here's a link to the abstract: http://www.update-software.com/abstracts/AB000032.htm

In addition, you may be aware of the results of two recent large studies: one examined supplementation with the antioxidants C and E, which found that they did not reduce risk, and the other examined supplementation with calcium, and found that it did not reduce risk of occurrence of preeclampsia, but did reduce the frequency of severe outcomes like eclampsia.

Here's a link to the Pubmed abstract:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=16641396&query_hl=5&itool=pubmed_docsum

Another recent large study published in the American Journal of Obstetrics and Gynecology analyzed almost 30 nutritional factors and found no relation between intake and the development of the hypertensive diseases of pregnancy.

Here's a link to the Pubmed abstract:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=11262466&query_hl=7&itool=pubmed_DocSum

The current model for the development of these diseases implicates immune system involvement during initial placental implantation which results in a poorly implanted placenta with inadequately remodeled spiral arteries, and the release of two proteins (sFlt-1, a VEGF antagonist, and sEng, which improves the invasive capability of trophoblastic cells by compromising the maternal immune system) by the placenta.

Here are links to the publicly available paper on this from the Journal of Clinical Investication:
http://www.jci.org/cgi/content/full/111/5/649

and a Pumbed abstract of a Nature Medicine article:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=16751767&query_hl=10&itool=pubmed_docsum

In addition, an article appeared in the New Yorker last year discussing this research further:
http://www.newyorker.com/fact/content/articles/060724fa_fact

I would be very interested to hear of any recent peer-reviewed research showing a link between nutrition and hypertensive outcomes, and would welcome any information supporting such a link.

Rose said...

Anon,
I'm very interested to read through those articles you provided, but none of the links are complete. I suspect Blogger is cutting them off.

Would you mind using one of the sites to shorten the URL and post them again?

Anonymous said...

Sure.

http://tinyurl.com/ytdmjq
http://tinyurl.com/yvruh4
http://tinyurl.com/2yvyjo
http://tinyurl.com/2849ov
http://tinyurl.com/2haxkt
http://tinyurl.com/2cehq7

I don't understand why the "fact" that preeclampsia is related to diet is still in common currency. As far as I can tell, it's just not true, and has been known to be not true for some time. When I ask people for substantive evidence, I get anecdotes, and they just don't count. I never seem to get peer-reviewed research.

My midwife wanted me to keep a diet log, so I did. It was flawless. She couldn't say that I'd screwed up by not following the diet perfectly. But you know that lots and lots of her clients weren't that careful, and didn't get preeclampsia, either.

Rose said...

I've read through the New Yorker article, but I need to read more before I comment on them.

I want to ask, though, do you believe diet is never a factor? Do you believe it plays a roll at all? Do you believe there are any cases of pre-e that could be avoided with a change of diet?

I think it's interesting that I've read pre-e survivor boards where some moms object to the idea of the Brewer's diet because it would suggest that a mom who developed pre-e did something wrong.

I'll need to read the rest of the research before I comment on it, but I will when I do.

Anonymous said...

I have seen no peer-reviewed evidence to suggest that diet, per se, is a factor.

I'd love to see any peer-reviewed evidence suggesting that it is, because then I'd have a better shot at avoiding preelampsia next time.

Rose said...

Okay, and I'm back. Sorry for the delay in my response. I don't post on Shabbat and then with the holiday and all, I haven't been around much. On top of that, I wanted to take some time to do/read the research before I responded.

First and foremost, I must say that I always hope people will have open minds when information is presented. And so, that's how I tried to see this information on pre-e. To be honest, I will say it deeply affected me. I do not want to believe it, but there seems to be an abundance of information. And so, I'm willing to admit that I no longer believe pre-e is as black and white as I once thought.

That being said, I'd like to post thes links:

From the American Journal of Epidemiology

"...the study does show further evidence that nutrition is relevant for the prevention of preeclampsia"

Here's another article on the same study:
http://www.emaxhealth.com/88/6771.html

Here's another study:
Rosemary Theroux RNC, PhD (2007)
Preventing Pre-eclampsia: Do Multivitamins Work?
Nursing for Women's Health 11 (1), 77–79.
doi:10.1111/j.1751-486X.2007.00121.x


Granted, those are about multi-vitamins, but that would fall under the 'nutrition" headline.

This is from 2005, so may not be new enough to be considered relevant (especially given the current data is so new):

"Conclusions: Increased urinary excretion of isoprostane and decreased antioxidant production is an imbalance that is consistent with oxidative stress, and it precedes clinical recognition of preeclampsia. The maternal diet is an underlying factor that provides an environment for free radical generation."


This would most likely not be considered recent as it's from 2001, but here's information on a study in Norway:

"High intake of energy, sucrose, and polyunsaturated fatty acids is associated with increased risk of preeclampsia."


Financially, it doesn't make much sense to fund studies on diet. A pharmaceutical company does not serve to benefit in any way if diet is found to play a roll. I wonder if that's not a factor in why we don't see many studies that specifically examine the role of diet.

It's interesting that in the recent supplement studies (Vitamins C, E and calcium), supplements weren't started until the 13th or 15th week of pregnancy (depending on the study). As you pointed out, there is research that indicates the building blocks for pre-e are set when the placenta attaches. So I wonder if supplementing sooner/implementing a diet change sooner would help create a different environment in the uterus around that time.


I will say that I realize now that pre-eclampsia is far more complicated than I realized. Those links you posted were both fascinating and heart-breaking. I now believe that diet may not play such a huge role for many women (I still believe diet is incredibly important, but I'm beginning to think it may not always be as directly related to pre-e as I once believed. I still believe it's extremely important, but I believe there are other factors at play. It seems to me, that for some pregnant women, diet may be less influential in developing pre-e than in others.

Although, I've had some suggest there may be a link between the new research you posted and the nutritional recommendations.

I'm quoting someone here (for the sake of anonymity, I don't want to give names, but at the same time, I don't want to take credit for her information):
"The (new research) doesn't necessarily dispute Dr. Brewer's work. It very well may be that with a constricted blood volume caused by malnutrition, women are more prone to autoimmune reactions to their fetus... "

The woman who noted that also pointed out that Dr. Brewer's diet (and others that are similar) does not rely solely on increased protein. It's the combination of protein, complex carbs, vitamins and minerals, etc. that form a well-rounded diet for proper nutrition.

Anon, thank you for posting the links you did. I don't want to spout misinformation. I don't want to mislead anyone. You'll notice that I removed the references to pre-e in this blog entry. I do still believe that diet plays an important role, but I now believe there may be more to it. I don't want to portray it as something black and white when I realize now that it may not be.

I do still believe midwifery care is far safer and can prevent a number of complications for many women, but I won't use that specific example since I now recognize it is more complex than I once realized.

Anonymous said...

Thank you for reconsidering your position. I too am in favor of zero intervention in low-risk pregnancies, because the evidence supports that.

The data on multivitamins shows a small drop, in women of normal BMI only. It does not reduce rates substantially, though; a lot of women get preeclampsia even when they start pregnancies at a normal weight and taking multivitamins.

Aspirin, taken as a blood thinner, reduces rates about 10%. But a lot of women taking aspirin get preeclampsia.

Women with preeclampsia are thought to be hungrier, which makes them eat more calories. Probably it has something to do with signals sent from the placenta, which is "aware" that it's not implanted well.

Research is currently being conducted into earlier vitamin C and E supplementation. The fact that the women on them in the previous study got sicker, quicker, is thought to possibly suggest that they *did* improve placentation. This, however, upregulated the maternal immune system response. Rates of preeclampsia were unchanged, but the hypertension was more severe in the supplement group.

What broke my dependence on diet as a solution was this question: why did a woman of normal weight, taking a multivitamin, and eating the Brewer diet get it, if malnutrition causes the autoimmune reactions?

I would love to see midwives run a controlled study on this. I know there is nutrition funding available through the NICHD.

Rose said...

The information about pre-eclamptic women eating more fascinates me.

See, an interesting anecdotal note (and I realize an anecdote does not a study make) is that, among the people in my life who survived pre-e (myself included) we tended to actually be LESS hungry earlier in the pregnancy.

A number of us were nauseated to the point where we didn't eat, but with very little actual vomiting. And for most people I know who experienced that with pre-e, it continued past the 12 week mark.

I was beginning to wonder how/if that played a role. It seems from my experience that those of us who were later diagnosed with pre-e were more likely to suffer the extrema nausea with little to no vomiting.

With my second pregnancy, I had more vomiting and the symptoms were initially worse, but I saw a direct result with diet. When I didn't eat enough protein, I got sicker. I carried protein bars in my bag (had to be careful about the sugar content, though) and could actually stop the nausea pretty quickly by eating some. If I kept a consistent amount of protein in my diet, though, I found I could avoid the nausea all-together. And sure enough, on more than one occasion, when I ate a high carb meal, I vomited. Rather than staying sick through 3/4 of my pregnancy like I did the first time, I was able to control that with diet the second time around.

I've been assuming that my nausea would have been less severe during the first pregnancy if I had a better diet, but with the information you provided, I can no longer say that definitely would have happened.

And I completely agree about a midwifery study into diet. I've been thinking the same thing myself. I know some wonderful midwives/midwifery students who tell me anecdotes about the role of diet. I wish they would create a controlled study so we could really examine the results.

Again, Anon, thanks so much for the information. And thank you for being willing to have an open discussion. This really is fascinating intellectually and very important to me given my history.

I haven't checked in with any pre-e survivors in a long time and this recently prompted me to do so. It really gave me a better appreciation for the strength of these women. I sometimes get caught up in the "Oh woe is me," mindset when I remember what we went through, but I have to remember that in some ways, we are very lucky. It's very rare when I look back on pre-e and think happy thoughts. It was the most horrible thing that ever happened to me, but I realize I'm not the only one. Making myself familiar with other women's stories reminded me that I'm quite lucky/blessed. I can't let myself forget that. It also reminds me to celebrate the strength of other survivors as well.

I try not to reflect too much on my battle with pre-e (I'll discuss it, but won't let myself tap into those emotions), but this discussion has made me do that more and that has lead me to give thanks for where we are today and to give thanks that other women are willing to pull through.

So, again, thank you.

Anonymous said...

You know, pregnancy nausea is also thought to be driven by the placenta. I think the argument is that you're being made nauseous by the placenta to keep the fetus from being exposed to toxins.

I've met women with a history of preeclampsia who were horribly nauseous even on Zofran, and women who were horribly nauseous and delivered 10 pound babies, and women who were never nauseous and developed preeclampsia. Somewhere out there is a woman who never develops either. Lucky woman.

Anonymous said...

Thought you might like to see another new study into diet:
http://tinyurl.com/2bfg4u

Short version: the only dietary variable that seemed to possibly have an effect was omega-3 consumption, and that didn't rise to the level of statistical significance...