Tuesday, February 14, 2006

The case for normal birth

My friend gave me her birth plan a few days ago. As I looked over it, I couldn't help but wonder why we have to "fight" so hard to give birth naturally, without medical intervention. Maternity care in this country is so backwards. Women can walk into a doctor's office and complain about being tired of being pregnant, and many OB's don't think twice about offering induction if the woman is within a couple of weeks of her estimated due date. Women can talk to their OB's about not really wanting to go through labor and vaginal birth at all, and many OB's won't think twice about going along with an elective cesarean. Yet when a woman comes along, asking to give birth naturally with minimal or no intervention, she is almost being chastised. Because you know, labor and birth are so unpredictable. And most women will ask for an epidural after all. And sure, you can plan all you want, but realize that childbirth is an emergency/catastrophy waiting to happen. It's such a backwards attitude. No, birth is not a catastrophy waiting to happen. In the majority of cases, if left alone, birth will happen just fine, without anyone meddling. In fact, birth probably goes better if nobody intervenes with the natural process that it is. It irritates me to no end that women wanting a natural birth without interventions are constantly questioned. Sometimes to the point of people implying that a woman is putting her baby's life at risk because she refuses a routine IV and continuous fetal monitoring! The fact of the matter is, none of the interventions routinely used by OB's actually improve maternal or fetal outcome. None of those routine interventions are backed by research. In fact, research shows that many of those interventions actually hurt the natural birth process. Just to name a few:
1. Not being allowed to eat or drink during labor - this is a totally outdated practice. It was introduced back when most c-sections were done under general anesthesia, and aspiration was a problem. Nowadays, almost no c-sections require general anesthesia anymore. And even when they do, techniques to administer anesthesia have advanced to the point where aspiration really isn't a problem anymore. Yet birthing women still get denied the food and drink they need to sustain the energey needed during their birthing time. Denying a laboring woman food and drink can lead to exhaustion, which can stall the birth process. At which point, thank goodness we're in the hospital, because the doctors have all these interventions available to "help" the woman. Never mind that had she been allowed to eat and drink, she wouldn't have gotten exhausted in the first place...
2. Administration of routine IV's. To "keep the woman hydrated". Yeah, well, if she was allowed to drink she likely would stay hydrated just fine. When refusing an IV, many hospitals will still push a heparin lock, "to keep a vein open just in case". Oh, it's uncomfortable? Well, too bad, you'll just have to live with it. It really makes no sense. When an accident victim is rushed to the ER, he didn't have a vein open "just in case he got in an accident". Really, where's the logic to this? If an emergency arises that requires access to a vein, there is generally plenty of time to insert an IV just fine.
3. Continuous fetal monitoring. Research has shown that this has no impact on maternal or fetal outcome (as far as mortality is concerned). The only thing it has been shown to do is increase the chance of a c-section. Intermittent monitoring has been shown to work just as well, with the added bonus of making mom more comfortable and decreasing her risk of getting a c-section. Yet strapped to bed we are, and chastised we are for putting our babies "at risk" should we ask not to be monitored continuously.
4. Confining the laboring woman to bed. Having a baby can be accompanied by pain, but it is more so if a woman is confined to bed. Allowing a woman to move around, walk, sway, sit on a birthing ball, or use the shower or birthing tub are all excellent ways to make the birthing time more comfortable, often with the added bonus of allowing the baby to descend faster (use of gravity and all). And still we are put to bed the minute we enter the hospital...
5. AROM. It has become standard practice for doctors to break the woman's water once she reaches a certain stage of dilation. Some doctors will rupture as early as 3 cm, though standard seems to be around 5 cm. Supposedly, this should "speed up" the labor. My midwife told me about a study she had read where it showed that on average, it shortens labor by half an hour. Big deal. The bag of waters plays an important role during labor. It provides a natural cushion, making contractions less intense for the woman and the baby. Leaving the bag of waters intact also allows the baby to move around more freely, letting baby move into optimal position for birthing. And it protects against cord prolapse. Rupturing the bag when the baby is still too high makes it more likely for the cord to prolapse, a rare but dangerous complication that often results in fetal death or a baby with brain damage. AROM makes it harder for the baby to move around and get into optimal position, often resulting in the need for forceps or vacuum delivery because the baby is in an odd position. AROM can also lead to fetal heart decels, as contractions become harder on the baby without the cushion and the cord gets compressed more. Again, doctor induced "complications" that would have never happened had the mother been left alone.
6. Episiotomy. Many doctors still feel that first time mothers "need" an episiotomy so there can be enough room for the baby to be born. Or that a "clean cut" is better than a natural tear. ???? Maybe doctors should learn how to support the perineum instead, reducing the chance of tearing. Even the ACOG has come out with a statement no longer recommending routine episiotomy. Yet women continue to be mutilated. Research has shown that routine episiotomy actually causes the very problems it was supposed to prevent (namely incontinence). And the standard answer a woman asking to be allowed to tear naturally rather than get a routine episiotomy gets is that "you just never know what happens, you may need an episiotomy to make more room for the baby". Or "I'll only cut if it looks like you're about to tear". Well, with an episiotomy, you have a 100% chance of perineal injury. With tearing it's something like 40%. Hm...
7. Pitocin augmentation. Often doctors will feel the need to "speed up" a woman's labor. According to the book, women are supposed to progress a centimeter per hour once they're in active labor. Not all women labor this way, and if it's too slow for the doctor, pitocin is ordered. Some women will also experience a break between full dilation and pushing. This break can sometimes last an hour or more, during which contractions may completely stop. This is normal, and generally not a reason for concern. Yet doctors feel the need to intervene, so pitocin is ordered. Pitocin is used so widely, but is not without risks. It can lead to uterine hyperstimulation, and fetal distress. Which is when the "thank goodness we're at the hospital" mentality comes into play...
8. Routine pitocin after the birth. If a baby wasn't separated from the mom soon after birth, but instead given the chance to suckle for howeverlong the baby wants, the mom's body would produce natural oxytocin to help expell the placenta and contract the uterus to clamp it down and keep from hemorrhaging. After a drug-free labor, newborns are generally awake and alert for several hours, and would nurse a lot if given the chance. But hospital policy has it that often, babies are separated from mom as soon as the cord is cut, to be assessed and weighed and measured, etc. Then given back to mom to "bond" for half an hour, and off to the nursery it is. All procedures that could easily be delayed for a couple of hours, and assessing can be done while the mother is holding the baby, no problem. Without the baby suckling, the mom's body doesn't produce as much oxytocin, and excessive bleeding is much more likely to happen.

Of course, there are some complications that can arise even in a completely normal, low-risk birth. This is when doctors are really needed, when modern medicine is able to save lifes. What I question is the routine use of interventions, when there is no indication that they are medically necessary. The notion that a mom wanting to "refuse" routine interventions is somehow putting her own and her baby's life at risk. The continued use of interventions even when research shows they are unecessary, and may actually cause harm. For references, "Obstetrics Myths versus Research Realities" and "The Thinking Woman's Guide to a Better Birth", both by Henci Goer, are excellent books to read. To see what normal birth is all about, "Ina May's Guide to Childbirth" by Ina May Gaskin is an excellent book. It shows that birth is a normal, natural process that is best left alone. In the majority of cases, it's not a medical emergency or catastrophy waiting to happen. Unfortunately, in our society, OB's are taught all of the details they need to know to spot problems. They are taught surgical skills. They are taught all the things that could possibly go wrong during pregnancy and birth. What they are not taught is the natural process, the natural evolution a woman goes through during pregnancy and birth. What doesn't happen is saving interventions for when they are truly necessary, but rather using them routinely. There is a great book about childbed fever in the 19th century. Thousands of women could have been spared an awful death if OB's had just washed their hands properly after examining one woman and before examining another. Yet OB's were ignorant, arrogant, whatever, and refused to follow this practice for a long time. Many things have changed since the 19th century, but what hasn't changed is the notion that women need to be saved from childbirth, and OB's have all the tools needed. Research clearly goes in favor of leaving a birthing mother to do her thing, yet doctors can't get past the notion that they need to intervene "to make sure everything goes well".

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