Legal bkgrnd ~ physician supervision, physiological CB practice vs. obstetrics, ACOG ruling ethical to perform medically unnecessary Cesarean surgery

by faithgibson on April 27, 2006

in Physician Supervision Issues, Practice Issues - Safety & Cost

Tags: physician supervision, physiological CB practice vs. obstetrics, ACOG ruling ethical to perform medically unnecessary Cesarean surgery, Ob-GynNews

There is much disagreement about the appropriate relationship between physicians and midwives. At the core of the question about the modern role of midwifery is yet another question — what is the right relationship between “modern” medicine and “modern” childbearing? Has the obstetrical knowledge of the 20th century fundamentally changed the nature of childbirth (which is a natural biological act) the same way medical science fundamentally changed the course of human illness, disease, deformity and accidental injury (all forms of pathology)?

This controversy has nothing to do with the appropriate use of obstetrical medicine to treat the 30% of pregnant women who develop complications, about which there is a widespread agreement. Rather the question concerns using these same forms of medical interventions routinely or “prophylactically” (the ‘pre-emptive strike’) on the 70% of healthy women with normal pregnancies.

In addition to society’s general lack of confidence in the normal biology of childbearing, there is even greater anxiety about place-of-birth, which includes an automatic rejection of Planned Home Birth (PHB). The most familiar perspective about midwifery and PHB assumes that licensed midwives are practicing some aspect of obstetrical medicine without an obstetrical education or appropriate access to the emergency medical services that we assume are instantly available in hospitals – a professional staff, drugs and surgery, etc.

Were that grim perspective true, childbirth services in a domiciliary setting would indeed be a risky undertaking. This would result in a greatly increased perinatal and maternal mortality and morbidity, which would be reflected birth and death certificates, and research which contrasts PHB with Hospital-Based Obstetrics (HBO). In fact, the consensus of the scientific literature reveals the exact opposite – its supports PHB under the care a professional attendant. The principles of physiology, which underpin the midwifery model, do not belong to midwives but to human biology, to be used widely for the benefit of society. They can be used by all types of birth attendants, including physicians, and in all birth setting. While rare in the US, physiological management is the foremost standard of care for homes, hospitals and birth centers around the world.

Over the course of the 20th century, there has been a devastating loss of ‘institutional memory’ by the medical profession. Beginning in 1910, physicians have moved farther and farther away from the principles of physiological management which were traditionally used to provide care to healthy women. As a nursing student in the early 1960s, the form of childbirth practiced in our hospital was already redefined as a surgical procedure. Women gave birth under general anesthesia with the routine assistance episiotomy and outlet forceps. However, as a student nurse in 1961, just prior to court-ordered desegregation in the South, I got to closely observe and directly participate in two entirely different, racially segregated systems — side by side, in the same hospital, at the same time, with the same staff and the same type of patients. These two management styles and the outcomes for each were different as day and night, but not in the way you might expect. More was not better.

However, as a student nurse in 1961, just prior to court-ordered desegregation in the South, I got to closely observe and directly participate in two entirely different, racially segregated systems — side by side, in the same hospital, at the same time, with the same staff and the same type of patients. These two management styles and the outcomes for each were different as day and night, but not in the way you might expect. More was not better.

Orange Memorial Hospital (now Orlando Regional) in Orlando, Florida provided a naturally-occurring, one-of-a-kind scientific study, contrasting the two styles of maternity care – a profoundly interventionist model, characterized as “knock’em out, drag’em out” obstetrics, versus a lazier-fair system that resulted in, ipso facto, classic physiologically-managed maternity care of the type routinely provided by midwives like myself. It all depended on whether the laboring woman was black or white.

White mothers were admitted to the whites-only 5th floor L&D unit, where they were isolated from their family, immobilized in bed, heavily narcotized, given general anesthesia, a “generous” episiotomy was routinely performed, outlet forceps used to “lift” the baby out. Their babies routinely required resuscitation (about 5% could not be revived). This was followed by the manual removal of the placenta and lots and lots of sutures and what our OB doctors liked to call “the husband stitch”. Then these still anesthetized new moms were rolled by stretcher to a recovery room where they retched and gagged their way back to consciousness over the course of several hours.

The only upbeat note in this bleak description is that obstetricians of that day were still expected to manage breech or twin deliveries vaginally, which they did skillfully and, given the amount of drugs that we had given to these mothers, with remarkably good outcomes.

Black mothers were denied access to the white labor rooms in our racially segregated hospital and as a consequence, ‘denied’ all these lovely, potentially injurious interventions. Racially-motivated institutional neglect (luckily) meant our black moms had physiologically managed labors and deliveries and much better outcomes than the ‘other’ cohort. In 1961, our black moms were not drugged or restricted to bed, no anesthesia was offered or used, no episiotomy, no forceps, no manual removal of the placenta, no stitches and no babies that were too undrugged to breathe on their own. I’ve always considered this to be a bit of poetic justice.

As a staff nurse working in the labor and delivery room for the next 10 years, I also participated in the integration of our obstetrical system in the early 1970s. Unfortunately, court-ordered “equal treatment” had unintended consequences, in that we just imposed injurious interventions on both our black and while moms.

Since the medical malpractice crisis of 1976, physiological principles of childbirth have been virtually eliminated from the medical school curriculum. Today, the greatest realistic danger for healthy women who are well-fed, well-housed, well-educated, and well-cared for during pregnancy, is over-treatment and the cascade of complications associated with routine interventions such as induction or augmentation of labor, narcotic pain medications, anesthesia, episiotomy, forceps, vacuum extraction, Cesarean surgery or manual removal of the placenta.

The medicalization of normal labor triggers a chain of inevitability that starts with the ‘domino-effect’. This is a string of unintended consequences consistently triggered by routine interventions. It makes childbirth progressively more complex, even if it does not result in complications. Unfortunately, for a significant number of labors, the mounting complexities eventually make injurious interventions a necessity.

In far too many instances, this progresses to serious complications that are iatrogenic in origin. However, we are all being lead to believe that the injuries to mothers or babies associated with aggressive and routine use of obstetrical interventions are the result of the ‘defective’ biology of childbearing. This seems to be a modern day version of Freud’s claim that “biology is destiny”, at least when it comes to gender. Mothers and/or normal birth gets blamed, instead of questioning the over-use of interventions which actually triggered the cascade of complications that resulted in the final adverse event.

The childbearing pelvis – that is, the internal bones that the baby must pass through — normally creates a hollow space shaped like a lower-case letter “j”. Most people erroneously think of the birth canal as a straight chute (lower-case ‘l’), going straight down thru the lower half of the mother’s body. In other words, if the mother was lying down and you were watching from the side, her baby would pass through the pelvis and out of her body the same way a train comes out of a tunnel – a straight cylindrical object passing thru a straight cylindrical container.

But this is not anatomically correct. Imagine instead that you are looking at an upright pregnant woman from the side as she labors and gives birth while still in an upright posture. If you had x-ray vision, you would see that the long stem of the ‘j’ tracks with the mother’s lower spine and the curved foot of the letter bends forward to track with the lower half of the birth canal.

What this means is the pelvic outlet — last 1/3 of the journey – bends at a 60-degree angle (technically known as the Curve of Carus), which requires that the baby to go around a corner and emerge into the world going forward (into its mother’s arms!) instead of down (where in the ancient world it would be hard to reach by the mother and might be injured as it fell to the floor). Not doubt this “frontal delivery” is an important survival characteristic, as for 99.99% of human history predates hospital obstetrics, which meant it was the mother herself who was responsible for catching her own baby.

 

Were you to look down into the pelvis from the top, you would notice that the big triangle-shaped bone of the lower spine — the sacrum and coccyx — encroach forward into the pelvic outlet about an inch or so. In this regard, the pelvis is like a hollow bowl with smooth walls on three sides but the fourth side is bent in, making it impossible for anything that is the same size and shape as its circumference to pass through.

However, in the second stage of labor, after the baby is squeezed out of the uterus thru the cervix and starts its trek down into the birth canal, you would see something remarkable happen. In pregnancy, the sacrum and coccyx are able to move somewhat and are actually pressed back out of the way by the baby’s head as it descends lower and gets closer and closer to being born. The hormones of pregnancy also make the cartilage that holds the two sides of the pubic bone together become very elastic. Thus the pelvis can stretch and become wider side-to-side, which can give the baby an extra 1-2 centimeters of room to negotiate its passage into the world.

Of course, this nifty trick ONLY works if the mother is standing, squatting or is in some other position that makes ‘right use’ of gravity and allows her sacrum to move back out of the way (similar to the way a pet door is pressed open by the dog or cat as it passes through). However, if the mother is bearing her own weight on her lower back, such as lying down with her legs held up in stirrups, the sacrum cannot move out of the way, and sometimes the trap door gets stuck in the closed position. When a woman tries to give birth lying down, not only must gravity be defined in order to push the baby uphill and around a corner, but she must do this with the doorway partially blocked, reducing the aperture of the pelvis by as much as a third.

If the baby is small or the mother’s pelvis is big, the forces of labor and extra effort on her part can overcome this impediment. However, for a mother who lying down, the baby will still have to be pushed uphill and will emerge in an upward angle (towards the ceiling). This is obviously a lot harder and may require the use of forceps or vacuum if the mother has had anesthesia. Unfortunately, if the reverse is true (a relatively big baby and/or small pelvis) the baby can get stuck – the ‘obstructed labor’ of Old World fame but with a New World reason. In modern life, this would require a forceps delivery or a Cesarean.

In the ancient world or for women in poor countries without access to obstetrical services, cephlo-pelvic dystocia (CPD) eventually results in the death of the baby and may cause the mother to develop a fistula between her bladder or rectum or other debilitating forms of incontinence due to obstructed labor or associated with the use of episiotomy and forceps. It should be noted however, that CPD caused by positioning the mother on her back or other “wrong uses of gravity” in modern societies and the damage it may cause to the baby or the mother’s pelvic floor, are iatrogenic in origin and therefore preventable complications.

This out-of-control situation has the US tittering on the brink of a precipice in the 21st century, with a 50% Cesarean section rate predicted by the obstetrical profession. Some vocal obstetricians are promoting Cesarean section as the new, 21st century standard of care for all childbirth. Obstetricians consider this to be good lawyer ‘insurance’—that is, a hedge against malpractice litigation, the idea being that you can’t sue a doctor who did a C-section before the mother was even in labor.

In 2000 Dr. Ben Harer, who was president of ACOG at the time, appeared on the Good Morning American show, promoting the idea that vaginal birth was dangerous to mothers and babies and the operative risks of C-section were minimal and actually “no greater” the normal birth over the long run. This statement is not supported by facts.

However, in 2003 ACOG’s ethics committee ruled that it was ‘ethical’ for obstetricians to perform medically unnecessary Cesareans, claiming that no good data was available to determine the relative safety of normal birth versus Cesarean section. After this decision was announced by ACOG,

After this decision was announced by ACOG, Dr. Harer was interview by the Washington Post. In an article, Dr. Harer fully supported the idea that it was ethical for obstetricians to perform medically-unnecessary Cesarean surgery, saying:

“I think it’s a step to where we’re going. And my guess is that as increasing evidence comes out, it will probably become a more accepted procedure… Before this statement, it was gray area. This clarifies it and gives it some permissibility.”

The Post went on to report that Dr. Harer had “triggered a furor when he was president of the organization by arguing that women should have the option of a Caesarean.”

National Institute of Health (NIH) (2006) public conference on the ‘maternal request’ Cesarean

March 27-29th of this year (2006), the National Institute of Health (NIH) held a public conference on the ‘maternal request’ Cesarean. Many consumers and midwives attended. Interestingly, the conference officials released a draft report at

Interestingly, the conference officials released a draft report of its finding at 5 pm on the dot on the last day. There was no way they would possibly have integrated input of those who attended and compiled this report while the conference was underway. As a result, we must assume the contents of the NIH report on was compiled prior to the event.

In spite of massive evidence to the contrary, the NIH report concluded that there was no evidence that delivery by electively-planned Cesarean was any more risky than planned vaginal birth.

This reflects two highly disturbing things – first a biased interpretation of the scientific literature that favors the obstetrical profession at the expense of the patient/consumer and the fact that a century of ever-increasing medicalization of normal childbirth (exacerbated by the 1976 malpractice crisis) has succeeded in protecting doctors from litigation by making vaginal birth every bit as risky as major abdominal surgery. And the ugly stepsister of this situation is a uniform lack of any true informed consent on the part of patients who dutifully follow this disturbing advice.

Headline  on NIH’s report: “Elective Cesarean: Honor Her Choice”.

On April 15th, 2006 Ob.Gyn.News (Volume 41, Issue 8) summed up the NIH’s report with a headline that read: “Elective Cesarean: Honor Her Choice”. Here’s the little slip twist cup and lip conveniently ignored by ACOG and NIH.

Unique ‘route of delivery’ risks of cesarean includes 33 well-known complications (including a 13-fold increase in emergency hysterectomies) compared to only 4 specific ‘route of delivery ‘ risks for normal vaginal birth [Maternity Center Association of NYC’s systemic review “What every pregnant woman needs to know about Cesarean Section” at www.maternityWise,org].

Childbearing women who are delivered by Cesarean section are two to four times more likely to die from the intra-operative, post-operative, delayed or downstream complications of Cesarean surgery than from normal vaginal birth (including the most complicated vaginal delivery). More than a dozen operative and post-op complications for the mother are associated with Cesarean surgery, including maternal death, maternal brain damage, anesthetic accidents, drug reactions, infection, accidental surgical injury, hemorrhage, emergency hysterectomy, blood clots in the lungs, the need to be admitted to ICU, the need to be on life support and inability to breastfeed.

Potentially-lethal complications and protracted difficulties extend into the postpartum, post-cesarean reproduction, post-cesarean pregnancies and post-cesarean labors. Reproduction complications include secondary infertility, miscarriage and tubal pregnancy necessitating the surgical removal of a fallopian tube. Downstream complications in future pregnancies include placental abruption, placenta previa, placenta percreta, uterine rupture, and maternal death or permanent neurologically impairment.

Risks to babies include accidental premature delivery, surgical injury during the C-section, respiratory distress, increased rates of admission to NICU, chronic lung disease and increased rates of both childhood and adult asthma. Risks to babies in subsequent pregnancies include placenta abruption/stillbirth, death or permanent neurological disability (due to uterine rupture).

But don’t worry, tort law protects the obstetrician who performed the original (and often unnecessary) C-section from liability for any of these “post-OR” complications. Unless s/he accidentally stapled the patient’s ureter shut or some other egregious lack of surgical skill, the physician has purchased a life time of protection for him or herself by electing to perform a Cesarean section.

The information described above is easily accessible from reliable scientific sources readily available to the average obstetrician. Relative to non-urgent and medically unnecessary Cesarean section, this body of knowledge constitutes true informed consent. I quote the California Medical Association’s Document # 0415Informed Consent, Jan 2001: “..a physician must disclose all information which is ‘material to the patient’s decision of whether to proceed” (that is) “that information which the physician knows or should know and would be regarded as significant by a reasonable person in the patient’s position when deciding to accept or reject the recommended procedure. ….. This includes the risks, complications, expected benefits of the proposed treatment (including likelihood of success) and any alternative to the procedure, including the alternative of no treatment and the relative risks and benefits of not having the procedure.”

The ‘Other’ Way

Everybody in society, even those who would never use a midwife or plan a home birth, would benefit from preserving and promoting physiological management. In a perfect system, medical educators would again learn and teach the principles of physiological management to medical students. Practicing physicians would utilize physiological management as the standard of care for healthy childbearing women. Hospital labor & delivery units would be primarily staffed by professional midwives working in tandem with obstetricians.

This would dramatically reduce rate of injurious medical interventions and the cost of maternity care while increasing good outcomes and satisfaction of families served. Should the US ever suffer a catastrophic event such as dirty bomb, avian pandemic or effects regional storms such as Katrina, it will be very helpful to have a system of physiologically-based maternity care that does not have to depend on “surgery-intensive” methods for normal childbirth in healthy women.

By making maternity care in all settings equally safe and equally satisfactory, families would not be forced to submit to forms of care that are not appropriate for their needs. This would also permit American women to use a physiological form of care referred to in Holland as the “relocated home birth”. A ‘relocated home birth’ is a planned birth delivery, in which Dutch midwives accompany their patients to the hospital after active labor has begun. The professional midwife continues to personally provide physiologically-based care in a “low tech” homey environment. Should obstetrical services become necessary, they have immediate access to them. Surely ACOG’s most enlightened response to PHB would be appropriate changes in planned hospital birth, so that it better addressed the needs and desires of healthy women with normal pregnancies who do not wish to use drugs to accelerate labor or pain relief or anesthesia for delivery.

Community Midwives ~ Do More With Less?

Let me begin by addressing the question of how community midwives, who are not trained in obstetrics and do not have recourse to the use of drugs, instruments or surgery in domiciliary setting, can possibly have ‘good outcomes’ that equal or exceed hospital-based obstetrics (HBO). It does seem to defy logic, when you consider that current intervention rates for healthy women (according to the CDC) include12% forceps /vacuum extractions, 23% inductions, 29% C-sections and a 33% episiotomy rate. People see all these complications in hospital births, and based on that, they think anyone would be crazy not to be in a hospital, given what seems to them to be a very strong likelihood of something going horribly wrong.

Logically, this perceived level of complexity would argue that a minimum of 50% of women choosing PHB would suffer severely as a result of unmet medical or surgical needs, since LMs are not legally permitted to practice medicine or surgery. These mothers would either require intrapartum transfers (resulting in a 50% hospitalization rate for PHB clients) OR uncorrected intrapartum pathologies would result in preventable deaths or disabilities more than half the time. I can assure you that midwives are not burying dead bodies in anyone’s backyard. To cover up such a crime, we would also have to ‘dispense’ with all the rest of the family, the relatives, neighbors and anyone else who knew about the planned home birth. Obviously, there must be some more likely explanation.

The ‘other’ explanation is that PHB actually is as safe (or safer) than HBO. The consensus of the scientific literature consistently identifies perinatal mortality rate to be virtually identical for both groups (approximately 2 per 1,000 for both PHB and HBO), with a dramatically reduced rate of obstetrical interventions — three to ten times less for the PHB cohort. The most recent study contrasting home with

The most recent study contrasting home with hospital was published in the British Medical Journal (June 2005). For the PHB cohort, it identified a perinatal rate of 2 per 1,000 and a Cesarean rate was under 4 percent for women who began labor at home. The C-section rate for the HOB cohort was 24 percent.

It must be kept in mind that mortality and morbidity statistics are always attributed to the practice of midwifery, even if the patient was transferred to a physician or hospital or if the baby died some weeks later from SIDS or hospital-acquired infection.

A study published in 2002 also attributed unfavorable outcomes to PHB even if the woman risked out for PHB during last weeks pregnancy and was referred to a physician or if she delivered prematurely or precipitously before the midwife arrived.

So rest assured, the bias in statistical outcomes is significantly weighted in favor of obstetricians and HBO.

Physiological Process Explained

A little background about the midwifery model of care will help to explain how midwives do more with less and do it safely.

Midwifery as an organized body of knowledge preceded the modern discipline of medicine by more than 5,000 years. Midwifery principles recognized as effective and still valid in the 21st century were found among ancient Egyptian hieroglyphics dating back to 3,000 BC. The early discipline of midwifery was empirically-based and organized around meeting the practical needs of laboring women, which are primarily psychological, emotional, and social.

For healthy women in safe surroundings, childbirth was generally successful for both mother and baby. We know this is true because the human species has survived (and in fact thrived!) into the 21st century. Anyone alive today is a direct genetic descendant of women who were successful at giving birth vaginally, without the need for drugs, forceps or cesarean surgery.

Midwifery is neither a practice of medicine or nursing but a separate discipline arising in response to the spontaneous biology of childbirth and the physical, psychological and social needs of childbearing women and their babies. This includes the ability to recognize and respond appropriately to complications. In contemporary times, the discipline of midwifery is both art and science. The art and science of modern midwifery is based on physiological management in combination with the best use of modern science. Today, these principles of physiological management are the scientific backbone or evidence-based model of maternity care used worldwide by midwives.

Medical dictionaries define ‘physiological’ as..in accord with, or characteristic of the normal functioning of a living organism”.

This form of care is actually protective for both mothers and babies, lowering the rate of medical interventions. It also rates highest for maternal satisfaction. Nationally certified direct-entry midwives, using a physiologic process for PHB and timely transfers to HBO when indicated, reduced the episiotomy / operative delivery rate from approximately 72% to approximately 5%, with an identical or even slightly improved perinatal mortality rate. Physiologically-based midwifery care is efficacious — that is, both safe and cost effective.

Midwifery and obstetrics are at opposite ends of a continuum, spanning the most simple to the extremely complex. Their respective expertise overlaps in the middle of the spectrum but is not identical. Both benefit from the abilities of the other. The midwifery model of physiologic care has been repeatedly proven to provide the most appropriate caregivers for healthy women experiencing normal pregnancies.

But midwifery is more than an absence of obstetrical interventions. It is a positive model with specific methods for successfully addressing the most common problems that concern childbearing women and normal birth. The spontaneous nature of childbirth is best compared to a slow-motion sneeze – an internally triggered and coordinated process that has been fine-tuned by eons of biological evolution.

The art of midwifery depends on ‘patience with nature’, the right use of gravity, and a commitment not to disturb the natural process. It is a high-touch, low-tech, minimal-intervention model that includes continuity of care, the full-time presence of the caregiver through out active labor, one-on-one social and emotional support and non-drug methods of pain relief such as walking, one-on-one support, therapeutic touch and access to deep water tubs. Obstetrical intervention is reserved for complications and women who request medical help or anesthesia. This functional form of care for normal childbirth is supported by a consensus of the worldwide scientific literature.

Scientific Methods of Midwifery Revealed

The general principles of physiological management are divided into two basic strategies – a major and minor cord, so to speak. The primarily methods address the normal, supportive care of a laboring woman. It employs attitudes and behaviors such as a calm presence and the appropriate use of gravity. However, at some point in time, many labors contain variations or deviations from the average or straight forward trajectory of progress. So the second set of physiological strategies deals with physiologically-sound methods that permit a birth attendant (physician or midwife), to forward the action without initially having to employ medical or surgical interventions.

This is the place in the story that the lay public and medical community goes south – as neither can’t imagine that childbirth can be kept in the ‘normal’ category without the use of powerful drugs and medical devices. But midwifery is a distinct discipline with a unique knowledge base and set of skills that are not normally taught in medical school. Physiological principles are one end of the spectrum, while a through understanding of modern science of pelvic architecture, the biology of uterine activity and the principles of fetal monitoring is at the other end.

A uniquely modern skills learned by licensed midwives is a reliable method for monitoring fetal well-being without having to depend on continuous electronic fetal monitors. This technique, known as ‘intermittent auscultation’ (IA), uses criteria arrived at by medical science from 30 years of experience with EFM. IA is scientifically documented to be equally effective as EFM for low and moderate risk labors.

Using only a fetascope or doptone and wrist watch or clock with a sweep second hand and counting in a continuous series of five-second samplings over 60 seconds (12 or more sampling) immediately following a uterine contraction, it is possible to collect the same four crucial elements of information printed out so prettily on an EFM tracing.

These are the presence of a normal baseline (110-150), reassuring variability (5-25 bpm), intermittent accelerations (an amplitude of 15 bpm for a minimum of 15 seconds) and documenting the absence of pathological decelerations (a drop of 15+bpm over a period of 30seconds). An addition advantage of intermittent auscultation is that it does not suffer from one of the common technological glitches that bedevil EFM – the doubling of abnormally low heart rates and halving abnormally high numbers.

This kind of integrated knowledge permits midwives to monitor the well being of the baby while successfully addressing problems such as lack of progress which, if prolonged, can waste the mother and baby’s biological reserves, the type of painful labor that can retard progress or wear down the mother’s spirits, nausea that can result in labor delaying dehydration, lack of fetal decent during second stage which can result in fetal distress or the need for operative delivery and the reduction of perineal trauma.

Lack of Adequate Progress.

I’ll start with an all too frequent accompaniment of labor – a lack of adequate progress.

In the medical model this is routinely treated by starting an IV and administering Pitocin to ‘enhance’ or accelerate the uterine contraction pattern. This must be accompanied by EFM to continuously monitor the fetus, since some women are unexpectedly sensitive to Pitocin and can have tetonic contractions lasting from 2 to 10 minutes. This can result in such profound fetal distress as to necessitate a “crash” C-section. In order to manage this well-known complication of artificially stimulated labors, EFM is mandatory for any woman receiving Pitocin for labor stimulation. The combination of IV tubing and electronic fetal monitor leads effectively tethers the mother to the bed, making the strategies of physiological management virtually impossible t o use.

This can result in such profound fetal distress as to necessitate a “crash” C-section. In order to manage this well-known complication of artificially stimulated labors, EFM is mandatory for any woman receiving Pitocin for labor stimulation. The combination of IV tubing and electronic fetal monitor leads effectively tethers the mother to the bed, making the strategies of physiological management virtually impossible t o use.

This is particularly important when it comes to managing the normal pain of active labor, as the mother cannot easily change positions, nor can she walk around or get in the shower or a deep water tub. Once Pitocin-accelerated contraction become long, strong and close together, narcotics and/or epidural anesthesia usually becomes mandatory.

Unfortunately, pain-relieving drugs and anesthetics often slow down labor significantly, requiring the rate of Pitocin infusion to be repeatedly increased. The negative synergy of these drugs, each of which amplifies the unwanted side effects of the other, combined with the mother’s unfortunate immobility, often results in fetal distress or an inability to get the baby down far enough into the pelvis to permit the safe use of vacuum or forceps to assist a vaginal delivery. In those cases, a Cesarean will become necessary. For instance, the CS rate is 35% for first-time mothers who are induced before their cervix is ready for labor (.i.e., Bishop score of <6).

Unfortunately, pain-relieving drugs and anesthetics often slow down labor significantly, requiring the rate of Pitocin infusion to be repeatedly increased. The negative synergy of these drugs, each of which amplifies the unwanted side effects of the other, combined with the mother’s unfortunate immobility, often results in fetal distress or an inability to get the baby down far enough into the pelvis to permit the safe use of vacuum or forceps to assist a vaginal delivery. In those cases, a Cesarean will become necessary. For instance, the CS rate is 35% for first-time mothers who are induced before their cervix is ready for labor (.i.e., Bishop score of <6).

Now let’s look at this from the perspective of the licensed midwife providing care in a domiciliary setting and using the principle of physiological management. Knowledge of physiology teach that the right use of gravity stimulates labor, helps to dilate the cervix and helps the baby descend through the bony pelvis. Encouraging the mother to be upright and mobile not only helps labor process normally but also diminishes the mother’s perception of pain, perhaps by stimulating beta-endorphins, providing the comfort and distraction of movement and a greater sense of control.

Since the parents are in their own home, they are not affected by that subtle institutional sense of urgency reminiscent of a taxi waiting at the curb with the meter running. In the comfort and privacy of one’s own home, it’s more OK for the mother-to-be to take her time.

Assuming that fetal heart tones and other intrapartum parameters continue to be “reassuring”, the midwife providing care in a mother’s own home can encourage her to go for lengthy walks. The midwife may also suggest that the mother rest in her own bed or relax in the bathtub. This works very well for some mothers, letting them doze off for an hour or two.

After resting, other strategies for stimulating labor can be tried out one at a time. This includes upright and mobile position for the mother, walking, swaying or squatting, standing in the shower, nipple stimulation, acupuncture pressure points, a foot massage and conversations to determine if the mother is struggling with such a high level of fear or anxiety that it is retarding the progress of labor.

Last, certainly not least, is the ‘secret weapon’, what midwives refer to as the “H” word – the possibility of a hospital transfer. This is a conversation directed by the midwife, in which the mother is told the basic facts, such as:

“the last 2 (3, 4, 5, etc) hours, your contractions have not gotten any longer or stronger. They continue to be only 30 seconds long, so there is no change in your cervical dilatation over (X # of hours).”

The second half of that conversation asks the mother to decide:

“You and your baby are OK right now but how much longer are you willing to have painful uterine contraction without making any progress? One, two or three more hours?”

Then the mother and midwife must decide mutually what criteria will be used to determine “adequate progress” in the agreed upon time frame – for example: “at least one more centimeter of cervical dilation” or “uterine contractions at least 5 minutes or less and lasting for 55-65 seconds or longer” when she is rechecked in 2 hours.

This is a very useful exercise for the mother. It gives her a chance to determine for herself if she is really dedicated to making it work at home or would b e better served by going to the hospital. Sometimes she genuinely needs something that can only come from hospital-based obstetrics. I have many times seen laboring women who could not progress with the reassurance or feeling of safety. They just can’t surrender themselves with the total abandonment necessary until they are in the hospital. Mothers who have been 3 centimeters for 7 hours suddenly dilate to 7 during the20-minutee drive to the hospital and presto, change-o, they are pushing and delivered in another hour. Labor is often a zigzag course with plateaus along the way.

What ever it takes, a midwife’ job is to make it work for the mother and baby.

It is remarkable how often one or more of these tactics will forward the action and the mother will go on to have a progressive labor and give birth normally at home to a healthy baby. I’ve also had moms decide they just “couldn’t do it” and wanted to go to the hospital so to get ‘something for pain’. While everybody was packing up midwifery equipment and getting ready to leave for the hospital, the mother was calmly laying their, feeling at peace with her decision. Then suddenly she started to have spontaneous urges to push and sure enough, the baby was born shortly thereafter, at home. The only downside of this is the extra gray hairs that midwife acquires from packing up and then having to race to the car to bring it all back in.

Honestly though, we don’t mind.

Labor Pain

My next topic is labor pain, without which no labor progresses. As an aside, I have long believed that the painful nature of labor was proof that God’s gender is male, because only a guy would think up such a stupid system. Women would have the baby delivered by FedX at 10am Saturday morning, after the mother had a full night’s sleep. The baby would of course be cleaned up pretty and dressed in a cute outfit, with a sweet little bow in her hair. Personally, I’m going to complain big time about this when I get to Heaven.

Ok, now for reality. Labor hurts. Yes, I know that for a fact, as I’ve had three unmedicated labors and spontaneous vaginal births. Almost changed my mind each time. However, I think normal labor is best characterized by Winston Churchill’s comment about our democratic form of government – not a very good system, just better than any of the other alternatives. The obstetrical issue with labor pain is that every possible permutation of allopathic interventions has been tried –drugs or anesthesia – and each has such potentially grim consequences

Unfortunately, drugs lead to MORE drugs. As an L&D nurse in the early 1960s, narcotics given during labor and general anesthesia was the universal way to manage labor pain. Unfortunately, a seasoned OB doctor that I worked with informed me that death from anesthesia-related complications was the 3rd leading cause of maternal mortality in 1960. So we are inevitably lead back to square one – non-drug methods of coping with labor, one contraction at a time. Unmedicated labors are safer and far less likely to trigger the familiar cascade of unintended consequences that can lead to operative delivery.

The problem for modern obstetricians is that his hands are tied. The modern hospital environment presents the modern laboring woman with few options for physiological management and a built-in series of small “bumps” that constantly risk derailing the natural process. Once the mother is sitting on the side of the bed in the labor room, the only reliable strategy for pain management in the institutional environment is either repeated injections of narcotics or epidural anesthesia. Both have a really negative effect on the progress of labor, especially if given too early.

Labor is a ‘subtle’ system, sharing the same endogenous hormones and the same delicate mind-body connection that is more familiar to us in regard to human sexuality. During labor, exogenous sources of hormones or narcotics have the same effect that a 1/16th of an inch bump in the surface of a pool table has on the path of a cue ball. The ball, which was directly lined up to fall in the corner pocket, hits that little bump and goes just a little off track. However for every inch it travels, that error in direction is magnified until the original 1/16th of an inch bump has changed the trajectory so much that the ball hits the bumper 10 inches off target.

Teaching moms before labor

So what do midwives do to deal with the difficult reality of labor pains? One part of the answer is that we talk about it and teach coping strategies ahead of time. This may include some form of “breathing technique” but of equal or greater importance is teaching a way to think about the experience of pain, to help demystify pain, to recognize the difference between the pain of injury and the “normal” pain of labor, which is pain with a purpose, pain that accomplishes something of value. This simple stance invites women to make peace with the idea of labor pain. Fearing and fighting pain always and only makes it more difficult.

It is possible to develop common sense strategies to deal with transient pain. Acceptance is one of them. I once watch a little gaggle of teenage boys deal with transient pain in a remarkably effective way. They were kicking a ball around on the street in front of my house when one of the boys got a minor but painful injury. In unison the rest of the kids chanted a line that must have been the advice of their football coach about how to handle pain. It was: Don’t sit down, don’t stop, don’t give up — just walk it out, repeated over and over again, until the kid was OK and able to play ball again.

Another bedrock of midwifery management is to discuss the possible value of tolerating the noxious sensations of labor. When drugs and anesthesia are presented to women as the preferred response to labor pain, it communicates the idea that the hard work and often painful nature of childbearing has no redeeming value, serves no purpose for mothers or society. This can be viewed as an unconscious form of sexism, which perceives childbearing women as biologically or psychologically unable to cope. In an era of reality TV shows, with women contestants running marathons, climbing mountains, swimming with sharks and eating big, slimy disgusting bugs, it wonders me that women can be convinced to have a scheduled C-section, because childbirth is just ‘too hard’.

In so many other areas of an adult woman’s life — sports, schooling, professional, political or artistic achievements — we honor her hard work, respect the determination it takes, we provide effective and sympathetic support for the painful aspects of her efforts and celebrate it as a victory when she succeeds. But for childbirth, we don’t value or respect the hard work of labor or provide the circumstances for its success. In fact, we do just the opposite — we tell women they are crazy to even try a natural birth and sabotage the mother’s best efforts by asking every 20 minutes if she’s “ready for her epidural yet”.

I once watched a televised Olympic marathon, in which one of the women runners was weaving back and forth and staggering just 20 feet from the finish line. However, she was still on her own two feet and still making some forward progress. The voice of the announcer explained to the viewing audience that were someone to go out to “help” her, it would disqualify her from the event and the entire 25 and 9/10th miles she had already run would be negated. Pity, which can be a laudable characteristic, would none the less have stolen an incredibly important personal victory from her.

I think of this analogy when medical personal suggest epidural anesthesia to a laboring woman who is already 8 or 9 centimeters or even completely dilated. The mother is afraid that she won’t be able to handle the birth. Yes, she has pain but the deal breaker is the fear. Instead of offering reassurance, encouragement and confidence that she can do it, pointing out that she has already accomplished the lion’s share of the work – 23 ½ miles of the 26 mile marathon — they adopt a ‘value-neutral’ attitude and just call for the anesthesiologist.

I know from experience with many women under these circumstances that they often believe they simply didn’t have what it took. I also see a similar phenomenon when doctors want to “help the mother out” by using vacuum extraction to deliver the baby and shorten 2nd stage by 10 or 15 minutes. The mother will be inappropriately grateful to the doctor, believing that without this help she wouldn’t have been able to do it or her body just wasn’t ‘built’ to give birth. This attitude is sometimes passed on to her daughters as the idea that women in their family have genetically defective pelvises.

An effective pieces of advice to the mother and her ‘coach’ is to “do” labor a half hour at a time. This forestalls the feeling of being overwhelmed. Most people can put up with most things for 30 minutes. So we reassess at the end of every half hour to see if the techniques and coping skills were working for her, and if not, to try something new.

A good midwifery strategy for managing the experience of pain is to let laboring women now that if they can get to 5 or 6 or so centimeter of dilation, they will have experienced the “it” that labor is. Labor at 7, 8 or 9 centimeters is more of the same, it isn’t a geometrical progression in which the strong sensation of 8 or 9 centimeter are twice as painful as they were at 4 or 5 centimeters. If they can get to 5, chances are good that they can get to 10.

Another aspect of this type of patient education and preparation is to know that “hitting the wall” is a very normal experience, one that often indicates that she is just about to break thru to the pushing phase (first time mom) or about to give birth (second or subsequent baby). This provides some psychological comfort in that experience, replacing fear and overwhelm with the encouraging knowledge that the labor is coming to an end and baby is about to be born.

Managing Labor Pain, one contraction at a time

First, mother laboring at home get up and move about freely in a place that is familiar to her and affords her psychological privacy. Both movement and psychological privacy are important. If you’ve ever hit your thumb with a hammer you’ll be familiar with the need shake your hand while moving rapidly around the room and yelling “OWWW!”. Contemplate for a moment what it would be like if you were forced to hold REAL STILL and NOT MOVE! Horrible thought. So freely moving about is a good start.

End of draft version — will eventually be posted by topic instead of one long mixed-topic document

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