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.

how high do we set the bar?

A woman gave birth in Minnesota last night.  I'm sure she wasn't the only one, in fact, but I imagine she was the only one to do so live-streaming a video feed to the internet.  A massive number of viewers tuned in to watch her birth.  What began as a natural birth ended with an epidural, pitocin, and purple pushing in the lithotomy position.  There has been much discussion on facebook, and on a number of blogs, much of it analyzing, and some have said criticizing, the progress of the birth. I've weighed in on The Unnecessarean Facebook fan page and on Navelgazing Midwife's blog, but the discussion has compelled me to consider how we balance the expectations of birth with the reality of birth when that reality falls short of the bar we have set.

Very often we hear people say "As long as mother and baby are alive and healthy, that's all that matters" but such a phrase seems disingenuous and not terribly optimistic.  Shouldn't we expect more than mere survival and the avoidance of catastrophic events or wounds?  Why have we set the bar so low for birth in an era of relatively good health, good hygiene, access to nutritious food, and frequent medical miracles?  Isn't it reasonable to expect a great deal more than women are typically getting?  How can survival be enough?  And yet, how do we show the necessary care and compassion to those mothers whose births fall short of their own pre-birth expectations?  What do we say to our friends, our peers, our clients, when they are swept along in the tide of intervention despite a previous desire to avoid it?

How do we find the necessary balance?  What do we do?  What can we say?  I'd really welcome your thoughts, so please do comment.