Tag Archive | evidence based care

Benefits of Active Birth

From Janet Balaskas’ classic book, Active Birth:

“When birth is active–

  • There is less need for drugs.
  • Discomfort and pain are less.
  • The uterus functions better, so artificial stimulants are not usually necessary.
  • Labors are shorter.
  • The supply of oxygen to the baby is improved.
  • There is less need for forceps or vacuum extraction.
  • The secretion of hormones that regulate the whole process is not disrupted.”

Make sure to talk to your care provider about your plan for an active birth. You may have to introduce your attendant to the concept and be assertive about your right to have an active, normal birth.

Will I need an episiotomy?

The short answer is no, you do not “need” an episiotomy. Women rarely (if EVER) actually “need” an episiotomy. An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening as the baby’s head is being born. This procedure is rarely necessary and you should ask your care provider how often they perform episiotomies. A good answer is, “almost never” or “I’ve done 3 or 4 in my career.” Answers that are NOT good and that should encourage you to question further are, “only if you need it” or, “many first time moms need one” or, “a clean cut is easier to repair than a nasty, jagged tear!” or, “don’t worry about it. I’ll make the decision when the time comes.” These are not good answers, because there has no study has ever shown any benefit to routine use of episiotomy! There is no scientific evidence supporting the practice.

A commonly used analogy to explain why a cut is NOT better than a tear is to imagine a piece of fabric–when you try to tear it, it resists. But, when you make a small cut in the top of the fabric and then then try to tear it, it easily rips all the way down. The same is true of your skin! (and your muscles–an episiotomy cuts through your muscle as well as your skin. Many naturally occurring tears are very small and occur only on the surface of your skin).

Here is some more explanation from an issue of Midwifery Today e-news issue number 8:23:

“Ironically, one of the biggest contributors to perineal tearing is episiotomy, which has long been heralded as the great preventer of tearing. One recent study, which only assessed the effects of episiotomy on third and fourth degree tearing, found a definite correlation between episiotomy and tearing. The risk of severe tearing was found to be nearly four times higher with episiotomy than without. Another study involving thousands of women found that the number one risk factor for perineal tearing was episiotomy.”

Though it often is presented as a choice–i.e. “would you rather tear or be cut?” I offer that there is a third option….Neither! A perineal wound is NOT an inevitable part of giving birth (even with your first baby). Though it is not abnormal to tear, it is also perfectly possible to not tear or need stitches. One way to work with your body to avoid tearing is to give birth on your hands and knees, kneeling, or squatting. Another way is to stop pushing when you feel a burning sensation or “ring of fire” and let the baby’s head naturally ease out. Your uterus will push the baby out without sustained, breath holding, high exertion pushing from you–you can rest and let your uterus do the work! When you are doing forceful or directed pushing you are more likely to tear than if you follow your own body’s pushing urges and signals. Some people also advocate perineal massage prior to birth to help the tissues stretch. While it does not hurt to become more familiar with this part of your body and how your muscles feel when they are relaxed or tense, perineal massage has not been shown to have very much effect on your chance of tearing during birth.

What about fetal monitoring?

Another area in which common practice or hospital policy often diverges from evidence based pratice. Women in hospitals commonly experience electronic fetal monitoring as a matter of course, particularly an “admission strip” on the baby and then at least 15 minutes of monitoring throughout labor. ACOG itself has recommended that routine continuous fetal monitoring be dropped from the standard of care for low-risk pregnant women and instead recommends intermittent fetal heart tone listening (which can be done with a hand held doppler instead of a fetal monitoring belt). Still, at least 85% of women giving birth in the US have electronic fetal monitoring even thought their practitioners own trade union (ACOG) does not specifically recommend it. Additionally, “electronic fetal monitoring without access to fetal scalp sampling” is on A Guide to Effective Care in Pregnancy and Childbirth table of forms of care likely to be ineffective or harmful. This exhaustive research summary of evidence based care practices for pregnant women also nots that there is insufficient data to support or to disprove the use of short periods of electronic fetal monitoring upon admission to the hospital.

Continuous electronic fetal monitoring with scalp sampling vs. intermittent ascultation (listening) during labor is included on the table of tradeoffs between benefits and harm. the book suggests that women and caregivers weigh the effects of those practices according to circumstances, priorities, and preferences  (this is the same table under which epidural analgesia is classified).

What About Routine Suctioning?

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.”