By Gill Boden and Nadine Edwards
Administering synthetic or artificial oxytocin during childbirth may be the most common labour inter vention in the world. If it is, then it is crucially important to know about any unintended harmful effects. A study published in 2011 by Kurth and Haussmann strongly suggests a link between increases in the use of pitocin (an artificial oxytocin, known as syntocinon in the UK) around the time of birth and subsequent childhood attention deficit hyperactivity disorder (ADHD). The authors looked at the birth records of 172 children aged between three and 25 and considered obstetric complications, family incidence of ADHD and gender. They found that perinatal pitocin exposure was a strong predictor of ADHD diagnosis which occurred in 67% of those children exposed to pitocin and in 35.6% of those who were not. This work was done as part of a PhD.
The sample is not representative and the proportion of ADHD in this sample is above what you might expect to come across in a general population, but the finding is so clear that further research is needed. There are already concerns about correlations between pitocin use and autism (see www.sarawickham.com/research-updates/inductionaugmentation- and-autism/), as well as an increase in postnatal bleeding, so in my view we must press for more research to clarify these relationships, but in the meantime far more caution should be exercised before using this powerful drug.
In February 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine issued a joint consensus statement, Obstetric Care Consensus Statement: Safe Prevention of the Primary Cesarean Delivery.
What the consensus says
By 2011 one in three women had caesarean sections in the US, but 'the rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused.' Evidence of potential short-term and long-term harms from the overuse of caesareans is cited, particularly for women and babies in subsequent pregnancies, due to increased placental problems.
As in the UK, wide variations in caesarean rates are documented - between states (23% to 40%) and between hospitals (7.1% to 69.9% overall, and 2.4% to 36.5% for women deemed 'low risk').
Main reasons for women having caesareans included: first baby, slow labour, concerns about fetal heart rate tracings, fetal malpresentation, twins or more and suspected large baby.
The statement looks at these and other issues, and makes recommendations for practice which could decrease the caesarean section rate. For example:
The statement concludes by acknowledging that changing obstetric culture and practice is remarkably difficult and numbers of suggestions are made for change, including controversial tort reform.
This consensus statement has been described as a 'game changer' (www.scienceandsensibility.org/?p=7958) and would certainly be a departure from usual current practice in the US. It is important because it acknowledges both the short and long-term risks of caesarean sections for mothers and babies, and sets out the known evidence (and rates this evidence) with a view to reducing the numbers of first caesareans. Some of the main recommendations are to allow more time for labour and birth, to wait longer before diagnosing 'failed induction', to expand normality, and to retain or improve clinician training and skills (such as rotating the baby's head manually when it is posterior or to the side during the second stage of labour, offering operative vaginal deliveries as a safe alternative to caesarean section, and offering external cephalic versions to women with breech babies near or at term). It also accepts that continuous support is beneficial for women and reduces the need for interventions.
Of course, this statement remains within a medical framework, using medical language, and describes a largely medicalised philosophy and practices. A consensus for reducing the numbers of caesareans might look rather different if it were based on midwifery knowledge and informed by what we know about the physiology of birth and the benefits of continuous support from a trusted midwife. This could include, for example, taking a much more individualised approach to induction, generally avoiding arbitrary time limits (rather than just extending them), encouraging healthy women to birth in community settings, providing environments that least disturb the woman in labour and encouraging women to move as they want during labour and birth, thus reducing stress and the likelihood of fetal distress which could reduce the need for the recommended medical procedure of amnioinfusion for some instances of fetal heart rate decelerations.
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