Wednesday, September 1, 2010

lactic acidosis associated with ftp and subsequent surgical birth

A few days ago, this link made the rounds of the birthy-minded folks on Facebook. Researchers have published a series of studies (here's a better description of it, including references to the researchers involved and their studies) which linked levels of lactic acid in amniotic fluid with long labour and caesarean sections resulting from failure to progress. The conclusion they reached was that pitocin augmentation was ineffective for women in whom their amniotic fluid contained heightened levels of lactic acid. Lactic acid is produced by fatigued muscles, and a researcher was quoted as saying that an already fatigued uterus being supplemented with pitocin was akin to asking a marathon runner to run an extra 10 000 metres after crossing the finish line.

I was a party to a number of discussions on it. Some commenters argued - as do the researchers - that this represents an improvement in maternity and partum care. Now women who are destined for long, painful labours without the likelihood of a successful vaginal birth at the end can avoid the hours of trial and have the inevitable caesarean section sooner, avoiding the exhaustion and trauma of a long labour.

But others saw this differently. Will this publication be used as yet another excuse by injudicious obstetricians to encourage mothers - particularly first time mothers, as noted in the article - into prophylactic caesarean surgery? And will practitioners suspecting lactic acidosis be willing to wait for the spontaneous rupture of membranes in order to check the amniotic fluid for lactic acid levels, or will they more readily turn to amniotomy? We know that amniotomy does not greatly shorten labour, and that it is linked to an increase in the rate of caesarean section, so to even unintentionally encourage the use of amniotomy would serve to only exacerbate matters.

We can go further with this, though. Shouldn't we look at why mothers may be experiencing lactic acidosis and find ways of avoiding it? Could it be that the way labour and birth are approached is leading to uterine fatigue? None of the studies referenced in the article appear to examine any external influence which could be contributing to acidosis. Could immobility and chemical pain management be associated with fatigue to the uterine muscles? Is there evidence that acidosis predates the beginning of labour, in which case, can we be caring for our bodies during late pregnancy in such a way that lactic acid build up may be avoided? And what about the iatrogenic norms in regards to defining labour as "long"? Hospitals are notoriously clock-oriented in their approach to labour, and far more liberal with the application of the diagnosis "failure to progress" than are home-based practitioners. How long did researchers "allow" (I hate using that word!) women to labour before declaring their labour unsuccessful and a caesarean necessary for failure to progress/failure to dilate/labour dystocia?

I'd love to believe that this study will be a good thing for mothers and babies, I really would, but frankly, I just don't see it that way. Too many important and fundamental questions are left unasked and unanswered. The outlook taken by researchers is predictably pathological, looking for what is wrong, rather than looking at what can be made right. I'm all for avoiding unnecessary suffering and trauma, but increasing prophylactic caesarean sections is not going to achieve that.

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