Avoiding the Cascade of Medical Interventions

By Cynthia Mosher

In our culture, there has been a tendency to turn pregnancy and childbirth into a medical experience. One intervention can lead to another in a cascading sequence of questionable procedures, many made necessary only because of a previous intervention.

We are indeed lucky to live in a time when medical aids to labor and delivery exist, but medical interventions such as labor induction, pain relief, and cesareans—measures that have saved many lives—have been overused.

It can be helpful to get familiar with many of the tests and interventions associated with childbirth in order to know when they are warranted and when they should be avoided.

Tests in Late Pregnancy
As you approach, or pass, your projected due date, your practitioner may suggest that you have one or more tests to assess the well-being of your baby, particularly if there is any reason to believe his health might be compromised.

One of the most common reasons practitioners worry about this is simply because of post maturity, which is when a baby remains in the womb past the time of his projected due date.

Truly post-mature babies can sometimes receive inadequate nourishment due to placental failure. Therefore, many doctors automatically give women one or more of these tests as soon as they reach their due date. This is particularly true for any women who have been designated high risk.

Here are some of the tests commonly given in late pregnancy:

• Fetal movement counting, or the kick test. This is a do-it-yourself test. You set aside a several-minute block of time at the same time each day. Your practitioner will instruct you to begin timing with the first movement you feel, recording how long it takes to feel ten movements. This test is only effective as a rough screening device and can not predict the likelihood of problems. This is because the test is extremely subjective—fetuses, like adults, are highly variable. You might choose a time to measure movements that coincides with a nice long nap, for example, resulting in very little movement.
• The non-stress test (NST). The NST will be conducted in your practitioner’s office, or in a hospital. You will sit in a chair, and an ultrasound transducer will be placed on your abdomen. You will be asked to signal every time you feel the baby move. The change in the baby’s heart rate as a result of these movements will be observed. This test often causes false alarms, where the baby seems to be nonreactive, as often as 75 percent of the time. One highly esteemed source of information, A Guide to Effective Care in Pregnancy and Childbirth, remarks, “One can only speculate as to why the [non-stress test] continues to be used in such an extensive way…and why the results from the only four randomized trials that have been published are so widely disregarded by many obstetricians.”
• Biophysical profile (BPP). This test combines the non-stress test with other evaluations of the fetus, all using the ultrasound to obtain results. Fetal movement, heart rate, breathing movements, muscle tone, and amniotic fluid levels are each assessed. The fetus is given a score from 0 to 2 for each element. A score of 8 or higher suggest the baby is doing well. A score of less than 6 is of concern. This test is more accurate when it detects either high- or low-range scores. Scores in the mid-range are less accurate. Studies testing the effectiveness of the BPP on women in high-risk categories did not show an improvement in birth outcomes.
• Contraction stress test (CST) or oxytocin-challenge test. During the CST, the baby is subjected to minor contractions in order to see how she reacts. This will help determine how the baby is doing in the womb, as well as how she may react to the real contractions of the upcoming labor. Because this test can bring on actual labor, it cannot be administered to women who have had preterm labor, placenta previa, multiple fetuses, or ruptured membranes. This test is normally conducted in a hospital. Ultrasound will be used to detect the baby’s heart rate. The mother will be given a small dose of pitocin. If the baby is doing well, her heart rate will not change significantly during contractions, and will return to normal quickly after each one. This test has a high incidence of false positives, where the results erroneously indicate that the baby is not doing well. It is not an accurate indicator of an acute emergency situation, where a baby should be delivered via C-section right away. However, it can effectively alert a practitioner to keep a closer eye on a baby during labor.

Although most of these tests do not have the potential to directly harm a baby (except for the CST which can bring labor on), the danger in using them lies in the rate of false positives. This can motivate practitioners to recommend emergency cesarean, unnecessarily subjecting the mother and baby to the dangers of major surgery. This is especially true if the test is given as a matter of routine, rather than because of a specific concern.

Since late pregnancy tests have such a poor track record of predicting trouble even in high-risk pregnancies, taking them may set up a woman for unnecessary worry at a time when she needs to rest, relax, and prepare for the birth ahead.

Labor Induction
A decision to begin labor at a given time, rather than leaving it to nature, is referred to as labor induction.