From the wonderful women at Independent Childbirth comes the following quote:
“Women gain the best birth knowledge from other women who have chosen natural childbirth with supportive birth care. Women are intuitive and need not accept the negative images of labor that the media portrays.”
I recently read on the Passion for Birth blog that the Maternity Care Working Party in the UK has a new consensus statement called Making Normal Birth a Reality. It is difficult to arrive at a concise definition of normal birth (which I define as “physiological birth”). They describe it as a women whose labor “starts spontaneously, progresses spontaneously without drugs, and who give birth spontaneously.” There is a lot of room in each of these for some interventions (such as electronic fetal monitoring) that many activists would argue impede the progress of normal, physiological, naturally progressing birth. However, it is nice to see the emphasis on spontaneity and also to see what other countries are doing/saying about protecting and promoting normal birth.
Another instance in which hospital policy may not match the evidence is with regard to suctioning the baby’s nose and mouth immediately after birth. Some doctors may suction all babies routinely. Others have a policy to only suction if meconium (baby’s first bowel movement) is present.
However, the newest protocols from the American Academy of Pediatrics say not to suction while the baby is on the perineum at all–whether or not meconium is present. A fellow independent childbirth educator, Jeanne Anderson, was certified in neonatal resuscitation by the American Academy of Pediatrics this year and shared the following information about the AAP’s 2007 guidelines:
“Their latest research indicates that the baby will spit up the meconium on its own, and if it is one that will develop respiratory problems, they will happen regardless of perineal suctioning. The newest protocols are to birth the baby and only wipe any visible mucous from the mouth/nose with a towel as you are handing the baby to the mom and
visually evaluating him/her. If the baby needs more resuscitation it will show up as poor respiratory effort, lowered heart rate or poor color, which can then be addressed. Normal infants will only need help less than 10% of the time.”
Childbirth Connection also has an excellent handout titled Comfort in Labor. It is by Penny Simkin and it has TONS of great line drawings and covers a lot of labor support material in 14 pages. For partners looking for ideas of how to support women in labor, this is almost like a really quick doula training!
What is a doula?
A doula is a labor support professional trained to support birthing women physically and emotionally. She is a non-medical care provider who offers continuous one-on-one care during labor and birth.
The cesarean rate in the US continues to rise and in 2006, 31% of all mothers had cesareans. The World Health Organization suggests a 10-15% cesarean rate is the upper limit to “necessary” cesareans and most experts agree that the US cesarean rate has gotten out of hand. Considering that a pregnant woman has a 1 in 3 chance of having major surgery just upon walking in the door of a hospital, it is important to become educated about cesareans and cesarean prevention.
In September, Mothering magazine published an excellent article called Cesarean Birth in a Culture of Fear. In addition to being a thought provoking analysis of technological birth in the US and the ever-rising cesarean rate, it was also extremely well illustrated (including a remarkable computer created image of a woman in a “traditional US hospital setting” that gives me chills–she has 16 different “attachments” hooked up to her as she tries to focus and give birth to her baby). There is also a series of illustrations that very clearly demonstrate the step-by-step process of a cesarean in a way that we rarely see. Now, this useful article has been turned into a booklet and made available as a handout on the Childbirth Connection site!
A woman in labor is working harder and longer than she may ever have done before. Eating is important to maintain her energy, strength, stamina, and good health. Many women choose light, easily digested foods–whatever appeals to them most at the time. However, many hospitals and care providers have a policy in which laboring women can only have ice chips to “eat” during labor. Others permit water and sometimes clear liquids. This is an example of a situation in which common policy and routine is NOT in accordance with evidence based care.
A large recent study from the UK confirms what birth professionals have long felt to be true–that light eating during labor does NOT raise the risk of complications.
Policies denying women solid foods during labor are often explained with the reasoning that there is a risk of “aspiration pneumonia” if you eat during labor (and then end up having a cesarean under general anesthesia). The researcher, Dr. Liu, says that this problem “did not occur.” He also stated that the UK Department of Health’s records show only one case of aspiration in two million births (the risk of complications of cesarean is considerably higher than that and that doesn’t stop US doctors from having a 31% national rate of cesareans!).
Policies against eating during labor originated during the 1950’s and things have changed a good deal since then. As an ICAN representative stated, “This new study will allow doctors to rest assured that eating helps rather than hinders the birth experience.”
The excellent exhaustive research summary and review A Guide to Effective Care in Pregnancy & Childbirth (available for free download from Childbirth Connection), also supports light eating during labor, pointing out that not doing so leads to a risk of dehydration and/or ketosis. Withholding food or drink from women in labor is included in the Effective Care book’s table, “Forms of care unlikely to be beneficial.”
Simply put, evidence based care is care that is based on the best available evidence (research, studies, accurate, up-to-date published materials) and upon the individual woman’s unique situation. Any interventions are applied judiciously and with consideration of true medical indication and also the needs of the woman. Evidence based care is different than “routines” or “policies” which may or may not have a basis in evidence.
Citizens for Midwifery has an excellent fact sheet summarizing the evidence behind the Mother Friendly Childbirth Initiative’s 10 Steps.
In her excellent new book, Pushed, Jennifer Block shares the following about evidence based care:
“…The goal is to have a healthy baby. ‘This phrase is used over and over and over to shut down women’s requests,’ she [Erica Lyon] says. ‘The context needs to be that the goal is a healthy mom. Because mothers never make decisions without thinking about that healthy baby. And to suggest otherwise is insulting and degrading and disrespectful’…What’s best for women is best for babies. and what’s best for women and babies is minimally invasive births that are physically, emotionally, and socially supported. This is not the kind of experience that most women have. In the age of evidence based medicine, women need to know that standard American maternity care is not primarily driven by their health and well-being or by the health and well-being of their babies. Care is constrained and determined by liability and financial considerations, by a provider’s licensing regulations and malpractice insurer. The evidence often has nothing to do with it.” (emphasis mine)
In the next couple of posts I will address some specific examples of evidence based care.
Several months ago I previewed the new Business of Being Born film and one of the doctors interviewed said that made me really outraged. He said something to the effect of: “in three months you’re just going to be pushing a baby in a stroller, so what difference does it make how you gave birth?” What difference does it make?! Would anyone even THINK to say something like that to a marathon runner or Olympian–“in three months, you’ll just be pushing a baby in a stroller, who cares that you won a gold medal?”
Side note to this analogy: feeling good that you won a gold medal [gave birth in a triumphant and empowering way] does NOT invalidate or cause guilt in those who did not run the marathon, or had to quit early, or needed help finishing. There is no shame in not running, but there is also rightful PRIDE and “glory” in finishing the “race” you set out on.
Someday soon I will be developing this analogy into a real essay, so wait for that…
The Lamaze Institute for Normal Birth has a powerful series of research based care practice papers describing the six care practices that support normal birth. The papers were updated recently and are available on their website in both HTML and printer-friendly PDF formats. These care practices are of vital importance to the normal birth process. The papers are extensively researched and include many citations and are an excellent resource to share with your doctor or with curious (or doubtful) family members or friends. These care practices form an underlying basis for much of the information I present during classes and are practices that should underlie good care in any birth setting (though, sadly, all too often what women receive from their care providers is NOT evidence based and does not follow these care practices. I will write more about this later). Lamaze’s Care Practices are:
Care Practice #1: Labor Begins on Its Own
“Labor is a set of complex, interacting components. Alteration of the natural process can expose a woman and her baby to unneeded risks.”
Care Practice #2: Freedom of Movement Throughout Labor
“Free movement during labor allows a woman to manage contractions and assist the baby’s rotation and movement through the pelvis.”
Care Practice #3: Continuous Labor Support
“Current research supports the benefits of continuous emotional and physical support during labor.”
Care Practice #4: No Routine Interventions
“Supporting the natural, normal, physiologic process of birth requires clear medical indications prior to any medical intervention.”
Care Practice #5: Spontaneous Pushing in Upright or Gravity-Neutral Positions
“Allowing a woman to find positions of comfort and encouraging her to push in response to what she feels is beneficial to the birth process.”
Care Practice #6: No Separation of Mother and Baby, with Unlimited Opportunities to Breastfeed
“When a baby is kept with the mother, there are physiological benefits to both, including the facilitation of breastfeeding.”
My own short description of the care practices using more direct language would be:
1. Avoid induction.
2. Stay out of bed. Move around a lot!
3. Hire a doula.
4. Demand individualized care–no interventions that are “just because” or “hospital policy.”
5. Squat, kneel, or get on all fours to push.
6. Breastfeed your baby early and often! Keep your baby with you and do not let hospital staff separate you from your baby because of routines or policies.
Another concept I like from Birthing from Within is that of, “finding your question.” Really, it is your question in response to the question, “what is it I need to know to give birth?” This question was personally meaningful to me during each of my pregnancies. During my first pregnancy, my question was simply, “Can I do this?” I felt like birth was a “test” that I had to pass and that I needed to make sure to study for so I could “pass” it well! After giving birth, I realized that it hadn’t really been a test, but was instead really a rite of passage.
With my second pregnancy, I revisited the concept of finding my question and it was, “Can I mother another?” I finally answered this question for myself late one evening (while not in labor and resigned to being “pregnant forever”) and less than four hours after that I was holding my baby in my arms! 🙂
My personal experiences have led me to believe that finding your question can have important implications for your birth and it is an interesting concept to consider.
Talk Birth 