Black and blue cohosh have been used by midwives for generations, alone or in combination with each other.  Traditionally, blue cohosh was intended to stimulate contractions, while black cohosh was to have a regulating effect on the contractions. 

Blue cohosh has recently been in the news because of alleged links with complications during labor.  It has been associated with neonatal tachycardia, increased risk of meconium, and neonatal congestive heart failure.

Blue cohosh contains substances which are similar in action to nicotine, and thought to be responsible for increasing blood pressure, stimulating intestinal activity (thus causing increased meconium risk), and increasing respirations.  It also has a substance which acts on the uterus to stimulate contractions, but also acts as a coronary vasoconstrictor, which can increase heart rate and also affect blood pressure.

So how do we explain the many reports from women and midwives who have              used these herbs successfully, without seeming adverse effects?  How do we explain the fact that most women who have c-sections don’t have complications but we still need to be cautious about overuse of c-section as a method of delivery? Or the fact that pitocin induction can lead to problems with mother and baby due to water intoxication, but often has a good outcome? 

If we start focusing on our own experience as evidence, rather than the broad base of evidence available, we run into the same problem that modern obstetrics runs into–that of dismissing evidence of problems, because if “usually doesn’t happen”.  

I am not opposed to the use of herbs in healthcare.  The problem with many herbal formulas is that they have not been rigorously tested.  What is the strength of the black and blue cohosh tea?  Does each cup contain the same amount of herb, or does it vary?  Just because something is herbal does not mean it is safe.  There is a huge misconception among many who seek natural birth that if a product is “natural”, it is safe. 

I believe that any time we start interfering with the body’s natural proess of preparing for labor, trying to urge the body to speed up the normal process, we are asking for problems.  There are definitely times when a woman has her back against the wall, as in the reader’s comment, where her OBs were not going to allow her to VBAC if she went overdue.   This is where modern obstetrics is failing American women.  A woman should not have to choose between taking potentially unsafe herbs or being threatened with surgery. 

So what if you are in a position where you feel you have no choice but to try to stimulate labor?  There are alternatives to chemical (hospital) induction:

• Breast/nipple stimulation.  Using a breast pump, pump until you feel a contraction, then stop.  When the contraction is comletelygone, begin the pump again.  Repeat this process to achieve a maximum of three contractions in a ten minute period.  Baby’s heart rate should be monitored during this process by an individual experienced in interpretation of fetal heart rate.
• Cervical balloon catheter.  This works just like a urinary catheter, expect that the balloons are inflated just above and below the cervix, putting gentle pressure against the cervix.  This will often thin the cervix enough that labor can begin on its own.  While this must be done by a health care provider, following a period of monitoring the fetal heart tones, the woman can go home overnight, and have the catheter remove3d int he morning.   
• If herbs are used, they should be used in as precise a formula as possible, so that dosage is consistent.  They should be administered by an experienced herbalist, and fetal heart tones should be monitored carefully throughout.
• Consider seriously whether the lesser risk might be inw aiting for labor stto begin on its own.  If this entails waiting beyond 42 weeks, the baby can be monitored by non-stress tests and a biophysical profile, which will often reassure medical professionals that pregnancy can safely continue.

We all need to think carefully about our commitment to normal birth.  If we don’t want medical intervention in the process, why are we eager to use herbal intervention, assuming that it poses no risks?  Any intervention with the normal process is still an intervention.

Black Cohosh information:  http://ods.od.nih.gov/factsheets/blackcohosh.asp

Blue Cohosh information: 

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She Walked Out!

“My first pregnancy 9 years ago was a multiple pregnancy which automatically put me in the high risk category. I didn’t see anything high risk about it until I started looking for an OB. I live in Central Texas and at 22 years old, had little knowledge of birth or the stigma that has grown up around natural birthing. I just knew that I DID NOT want to have surgery if I could avoid it. Imagine my shock when physician after physician told me that they would not even let me attempt a vaginal birth because I was carrying twins. I can’t remember how many times I heard the words “automatic section” while pregnant with my boys.

Finally, I found a new-to-town doctor who was more than willing to let me attempt a vaginal birth. His only request was that I have an epidural and birth in the operating room just in case a c-section became unavoidable. I decided that I could deal with the epidural. Dr. Brian Becker of <a href= http://wacowomenshealth.com/> Waco Center for Women’s Health</a> was easy going and had no trouble talking me about any test or procedure.

I was diagnosed with Intracranial Hypertension during my pregnancy after months of severe headaches and finally a lumbar puncture to relieve the pressure on my brain. My neurologist prescribed Diamox to help with the spinal fluid pressure and as he handed me the script, he told me that he had never given this medication to a pregnant woman before because it had caused birth defects in animals during drug trials. I immediately burst into tears and told him that I would not take the medication. He was very gruff and said that if I did not take it, I could lose my vision. I remember leaving his office in a daze and as I walked through the medical complex, I ran into a staff member of Dr. Becker’s office. The office was closed, but she immediately took me inside to talk to Dr. Becker. He sat with me and calmed me down while he explained that Diamox was actually a Class C drug that was really no different than the pain medications that I had been taking to help with the headaches. Now, this was after hours and this doctor was sitting there holding my hand while I bawled like a child! I look back now and am just in awe.

I started having regular contractions on a Saturday night and went to the hospital. Unfortunately, Dr. Becker was not on call. The on call doctor kept me overnight and on Sunday morning told me that he was going to prep me for the O.R. I told him that my doctor had told me that my boys were both head down and that we had planned to at least attempt a vaginal birth. Now, I’ve come to see this doctor in my head as an evil little old doctor with large spectacles wringing his hands and telling me that he only delivered twins by c-section. If I’m honest with myself, I see an older gentleman with gray hair in a white coat. I told him that if that was the case, he would not be delivering my babies and I walked out. I had never done anything like that in my life and was instantly terrified. What if I had just killed my babies because I was afraid (and being completely honest now, I was terrified!) of having a surgery that millions of women have every year? I remember calling Dr. Becker’s office very early the next morning and being completely comforted by him and his staff. I had expected anger and shame! But they told me that I had done the right thing! And since my contractions were no longer regular, they would just see me on Thursday when I had already had an appointment scheduled.

I made my regularly scheduled 38 week check up that Thursday. My water broke at 4 a.m. Friday morning and labor started about 6 hours later. Dr. Becker met me at the hospital and told me that he was supposed to leave at noon that day but would stay with me as long as he could. I gave birth vaginally to twin A @ 1:45 that afternoon. Twin B followed a short 22 minutes later vaginally. I had to have one stitch and was able to hold my babies right after they were born. It was the most beautiful day ever! Both of my boys were extremely healthy and weighed in at 5 lbs 4 oz and 6 lbs 4 oz respectively. We got to go home Sunday morning.

Because of Dr. Becker, I knew that I could birth babies naturally. So when I got pregnant again 8 years later, I had a completely natural labor in a hospital with a doula in attendance. I don’t know if he meets your qualifications but since the birth of my twins, he has become involved in the only practice in this area that has a CNM on staff. He is highly regarded by the homebirth midwife I met with and by my doula, both of whom recommended him for my most recent child. (I was unable to use him with my next pregnancy due to insurance restrictions.) But I will never forget the man who taught me that birth was a natural occurrence in a woman’s life. In my mind, he is extremely qualified and I would recommend him in a heartbeat to any new mom who needs a physician she can trust.

I think this story is extraordinary for the compassionate care of this doctor, and the efforts he took to support normal birth, but what is particularly outstanding to me is that the woman telling the story had the courage to get up and walk out of the hospital when her gut told her she wasn’t going to get the care she deserved if she stayed.  This is what it’s going to take, ladies, for modern obstetrics in America to change.  As the saying goes, “Vote with your feet”.  Don’t be afraid to get up and walk out of the doctor’s office or the hospital, in order to get the care you need.

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There are 4 reasons I have heard physicians and other health care providers give for not wanting their patients to research their health care:

1. They do not have the time to review all the articles patients bring them. While this may appear to be a valid argument on the surface, I believe that having my patients research their own care saves me time. I couldn’t possibly research every problem that each of my patients presents with, but it takes only moments to review an abstract (a summary of a research study and its findings) and determine if it merits further reading.

2. They believe their patients have neither the background nor the education to properly evaluate a research study. While it does take training and experience to be able to evaluate a study for its merit, this is not a skill limited to those who go to medical skill. There are many anecdotes of ordinary people who discovered extraordinary things by educating themselves through study and research. In addition, there are many reliable websites which target the layperson and present scientific information in an easily readable format.

3. They believe the average patient is unable to discern between reliable websites and those which present opinion as fact. This is condescending to the patient. While I have had patients occasionally present me with “research” which had no evidence to back it up, it takes five minutes to discuss what we are looking for in terms of a reliable website. In addition, not everything that has no evidence to support it is necessarily harmful.

4. They resent the fact that someone without a medical degree would attempt to make suggestions about his/her medical care. This attitude is more prevalent than it should be. Healthcare providers should encourage their patients to read evidence-based research, not shut them down when they’ve been “reading too much”. I can’t possibly keep up with all the literature being published each month, and I appreciate when my patients bring something new to my attention. Despite the fact that I have more education than most of my patients, I view the two of us as a team.  I am never too smart or too educated to learn something from a patient.

There are several ways to ensure that the information you are finding is evidence-based. I’d like to stress again that simply because something has not been studied, and has no evidence to back it up, does not mean it is without merit. It does mean that we do not know for scientific fact that it is safe and of benefit.

When we are looking for evidence-based science, we look for articles which appear in peer-reviewed journals. This means that other professionals in the field are reviewing the article for flaws, bias, and other inconsistencies. As we know now, being published in a peer-reviewed journal does not guarantee that a study is valid (see the posts on the Wax study), but it is the best criteria we presently have. Generally, websites that have the .edu or .gov ending of their URL are more reliable sources of information.

If you’d like to learn more about reading research, two good sites to begin are Science and Sensibility, which often analyzes research studies; and Understanding Research, a terrific site written by doula and health educator Andrea Lythgoe.

If learning to evaluate research is not up your alley, never fear. There are numerous websites written for the layperson, which effectively evaluate and summarize research in understandable language. Although the Cochrane Database is written for professionals, its summaries are understandable by the layperson. The Childbirth Connection is another great source of evidence-based information, with Dr. Enkin’s classic book, A Guide To Effective Care in Pregnancy and Childbirth, available in its entirety online. Lamaze International’s Healthy Birth Practices provides a succinct summary of evidence regarding the benefit of several practices that support normal birth.

There are other websites, too numerous to mention, that also provide valuable information. Many, like mine, are simply written by midwives, doulas, childbirth educators, or others who want to get the word out about evidence-based practices for normal birth.

The bottom line is that any physician who is going to be patronizing to a patient who is trying to take an active part in her care need only look back a few years to recall the practices physicians have insisted on in the past, which are now known to be harmful to the patient. A good dose of humility would serve all us healthcare providers well.  Thoughtful consideration of a patient’s research and reading is simply a part of good medicine.

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During the interview, we discussed advanced maternal age (AMA) and how modern obstetrics views women of AMA as ticking time bombs. Karen puts it this way: 

“Are you worried about your biological clock? Are you currently pregnant and over 35? What is the real deal with the magic number “35″? What real risks do you need to consider if you want to have a baby later in life? We’re going to explore the opinions, the research and the nuance of what is sometimes called “geriatric pregnancy” and hear what women really need to know about their health and the risks that may increase with aging.”

I invite you all to listen in to our discussion.  A Labor of Love airs at 10 a.m. Pacific Time, Monday, August 30, 2010.  If you can’t listen at 10 a.m., the interview, along with many of Karen’s past programs, is archived for listening at your convenience.

Another project I am working on is developing a registry of midwives and physicians who support normal birth.  I receive many requests from readers for referrals to providers who will help them have the birth they desire.  Do you have a midwife or a midwife-minded physician that you’d like to see included in the registry?  Please send contact information and any other information you can include, such as location of practice, home/hospital/birth center, do they assist with VBAC, breech, twins, etc?  I am also looking for names of physicians who enjoy working with women who want to take an active part in their care, particularly ones who will help with higher-risk births while keeping interventions limited to those which are necessary for safety.   Do you know of a physician who will work with moms to allow more options during c-section, such as holding the baby rather than sending it to the nursery?  Send your recommendations to: birthsenseblog@gmail.com

I am looking for empowered birth stories to include on this blog site.  Do you have a story, video, or photos that can encourage other pregnant women?  Please send it to birthsenseblog@gmail.com

Finally, I am asking readers to send in suggestions for topics they would like to see addressed on the Birth Sense blog.  You can send your topic ideas to: birthsenseblog@gmail.com

I’ll be back again tomorrow with a blog post that answers this reader’s question:

How valid is an internet based education when educating oneself for pregnancy and birth? There are obviously some great resources out there for women. Some, like Cochrane, seem to be targeted to the healthcare provider but more utilized by patients. I wonder why DRs sometimes seem not to keep up to date when its so easy to do now. I do a good bit of research on the internet when it comes to my health and that of my family only to be looked down on at times by medical professionals for having gone to the effort. At times they assume that I’ve only done internet research when I’ve actually gone to the library and read actual books. (and btw… what’s so bad about internet research anyway? yes there’s bad advice out there but there’s bad advice everywhere. why not trust the client to sort it out or help with sorting process rather than discourage them from ever starting?) How can we get the resect we deserve from DRs when they don’t fully understand the research process we go through as healthcare recipients?

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Obstetrician (at the end of a 5-minute visit): I’ll need you to come back in four weeks, and you’ll have your glucose test at that visit.
Client: I would prefer not to have that test done. I don’t have any of the risk factors.
Obstetrician: It’s required for everyone. It’s just routine. It’s really important for the health of your baby.
Client: But I’m caucasian, with no family or personal history of diabetes, average weight, my baby is measuring normal size, and I’m under the age of 25. From what I studied on the internet, that means I don’t need to be screened.
Obstetrician: Well, don’t believe everything you read on the internet. I require all my patients to have this test. Wouldn’t you feel terrible if you refused the test and something happened to your baby?
Client: I don’t think not having the glucose test puts me at high risk of something happening to my baby. I’ve researched this, and believe the evidence shows that based on the fact I don’t have risk factors, I don’t need the test unless my baby appears to be growing too quickly.
Obstetrician: Yes, and just where did you go to medical school? Do you think that what you read on the internet makes you more qualified than I am after 12 years of training?

The “just where did you go to medical school?” question is one I’ve often heard employed by physicians who are frustrated with a client who is questioning a suggested plan of care. This is also used as an argument for the superiority of obstetricians over midwives. This comparison makes about as much sense as asking the question,
“Who is the superior workman, a plumber or a house painter?” Your answer would likely be, “It depends on the job you need done”.

In the same way, whether a midwife or an obstetrician is the superior provider for attending birth depends on the job you need done. If you have a complete placenta previa and will need a c-section, an obstetrician would definitely be the better choice for the job. As a certified nurse-midwife (CNM), I frequently assist with c-sections. I have done this long enough that I could perform a c-section myself if necessary. It’s a fairly simple surgery. What I could not do, however, would be to manage complications. Sometimes excessive bleeding occurs during c-sections. One must be very knowledgeable in pelvic anatomy, suturing, and how to quickly stop bleeding. This is why obstetricians must have four years of residency and practice in surgery after surgery. This is where they shine.

Normal birth is where midwives shine. When I was a novice midwife, I did not have the experience of watching hundreds of women give birth normally. Now that I am a midwife with many years of births under my belt, I have seen normal birth thousands of times. I can often just sense when things aren’t going right, based on years of watching women give birth without intervention. I know what a normal labor and birth looks like.

Many obstetricians have never sat with a woman from the beginning to the end of her labor. Many have never observed how a woman behaves in labor when she is not confined to a bed or instructed how to behave. Thus, they often are not familiar with what a normal birth looks like.

I highly respect the skill of obstetricians. In no way do I pretend that my six years of education to become a nurse-midwife compares with an obstetrician’s twelve years of education to become an OB. But I do believe that midwives’ education and experience in normal birth makes them the superior birth attendant for low-risk pregnancies.

Marsden Wagner, MD, is a highly respected perinatologist and epidemiologist. He put it this way:
The United States and Canada are the only countries in the world where highly trained surgeons called obstetricians attend the majority of normal births. The American obstetrician is to be pitied. He or she is trying to be all things to all women—primary maternity care provider for normal, healthy pregnant and birthing women, specialist in complications of pregnancy and birth, specialist in women’s diseases and highly skilled surgeon. No other doctor anywhere in the realm of health care tries to maintain competency at all these levels and in so many areas because it is totally unreasonable to expect this from one human being. Can an obstetrician do a six-hour “pelvic clean out” gynecological surgical procedure on a woman with extensive cancer, then rush to his or her office and do the best job of quietly and patiently counseling a pregnant woman about her sex life? Not likely.