Part 3: Approaches to Birthing

*** We’ve finally made it!  ***
This is the post where I’m going to get into the nitty gritty details of the interventions that are often used during childbirth. I hope I’ve built enough ground and framework with previous posts so that you have something for this information to rest on. If you’re visiting this blog for the first time, I really encourage you to go back to some previous posts and do some grounding reading. This information below can feel jarring if you’re coming in at this point in the game. And if you really only have time for this one, then get something refreshing or warming to drink, make sure you feel stable in your body, and put your seatbelt on!  Someone once said that reading information about birthing can be more challenging than actually doing it. I can understand that…there’s something about reading these words and the way you think about it and the way it makes your body feel, that can be more intense than you expect. So, take a breather, step away, come back later if you need to. I’m going to cover the beginnings of labor, the generics of induction by natural support and medical intervention (starting labor), things that seem “small” but to consider, Electronic Fetal Monitoring, and the big medical interventions.

Going Into Labor: One of the most helpful things I learned that can get skipped over: just because you begin labor, it does not mean you need to rush to the hospital! A lot of women do a majority of their birthing at home, and this can help reduce the number of interventions. Once you step into a hospital, sometimes they have time limits. Once you’re on that “24 hour since labor began” time clock that many hospitals follow, all kinds of things can happen to try to speed up your labor, and those kinds of things are not always helpful. (Disclaimer again: sometimes they are helpful and even necessary, we will cover that).

Labor Starts & Stops: Labor can start and stop 2-3 times before you get into a rhythm. This is why it’s helpful to see how it goes before rushing in. Sometimes by the time a mama gets to the hospital and goes through the admittance process, her labor then stops. If you’re in early labor and it’s not intense, take a warm bath, take a nap, and rest. This can conserve energy for the birthing process and prevent the stalling once you get to the hospital. You could even make progress in your labor as you take a snooze. Keep in mind the hospital generally can stall / slow a labor due to the environment. Basically, you want to be in your normal daily routine and know that a pattern of start / stop (even 4-5 times) is completely normal and there’s no risk to the baby if the water has not broken. If the water has broken, labor usually progresses more quickly and you want to get to the hospital or center quicker.

Induction: the artificial induction of labor is something a lot of women are facing these days. There are legitimate reasons for induction including cancer, hypertension, diabetes, kidney disease, small-for-dates baby, and decrease in the amniotic fluid or an intrauterine death followed by a long wait to begin labor. When the risks posed by waiting for the natural process to kick in are higher than any posed by an induction, we always want to keep the safety of the baby and mother in mind first. However, many studies agree that fewer than 10% of women require induction for a medical reason. As women and doctors get more crowded with their time and schedule, non medical inductions have increased and is apparently still rising. Unfortunately, mothers and families are not always informed of the risks associated with induction.

Induction and the baby: The main reason for induction is that it reduces the number of complications for babies. The problem with this is that the induction can compromise the baby. One study showed a cesarean is more likely to be performed with an induced labor vs a spontaneous one. The distress to the baby is simply higher. Fetal distress can lead to a higher amount of meconium (the baby’s bowel material). When meconium is passed, it is a problem and often changes the labor and can pose high risk for the baby.

Induction and the mother: Labor involves a very complex play of hormones. Induction changes the normal pattern of hormones and disrupts the natural physiological pattern of the birthing process. This can cause other problems which leads to a need for other interventions. An induced labor is very different than a spontaneous one. Women tend to have harsher, stronger, more intense and painful contractions with chemically induced labor. One whom may cope well with natural labor often finds she needs pain medication to bear the intensity of an induced one.

One thought about the number of weeks: There isn’t enough research that there should be a specific week of pregnancy to give birth. Women can give birth after 42 weeks with no problems. A few days on either side of 42 weeks could be good too. Induction used to be risky, and there needed to be justification to do it. Then the pendulum swung to the other end where inductions were happening consistently at 39 or 40 weeks, just in case. We’ve now landed at 42 weeks being a kind of hard line. What if women were allowed to go to 43 weeks and not pushed? There are almost always clear warning symptoms of a baby is in distress from staying in the womb too long. Why the big rush?

*** Before we go into the medical interventions, here are non-medical methods to support the beginning of labor ***

– Castor Oil: Tribal cultures have used castor oil to induce labor forever. If taken orally, it acts as a laxative and the stimulation of the digestive tract often starts labor. No one knows why it works so well, but nearly 9 out of 11 thousand women used it to begin labor with no adverse reaction. Using a castor-oil induction at breakfast after a full nights sleep can be a support. One tablespoon of oil added to breakfast or mixed with fruit juice to make it easier to taste can help. If needed, take one more tablespoon one hour after the first.

– Breast stimulation: Nipple stimulation causes the release of oxytocin into the bloodstream of the mother. This oxytocin stimulates contractions of the uterine muscles. For cultural taboo reasons, some hospitals do this by means of a pump or a TENS unit. Stimulation by hands or mouth (often more comfortable in a home birth or birth center environment) never causes uterine rupture. It’s just more natural and comfortable and pleasurable than some synthetic version that doesn’t flow with the woman’s body. Stimulation of the breasts can be stopped. Chemicals cannot be taken back. Unless your partner is a poor lover, you may want to consider these methods before hopping on the chemical train.

– Sexual Intercourse:  Yahoo! Isn’t it great that this can be encouraged? Key word encouraged. It’s unfortunate that there are rumors that this is harmful. Lovemaking and pregnancy go together, there has been no association of lovemaking during pregnancy and a poor outcome for mother or baby. In fact, semen is the most concentrated source of prostaglandins (the substance named above that companies have made synthetics of to induce or speed along labor…no brainer). Pleasurable intercourse during the last weeks of pregnancy can help the woman’s body go into smooth labor. Women who are sexually active during pregnancy were more likely than those who were not to go into labor around 40 weeks. And the prostaglandins in semen have never been associated with uterine rupture, fetal distress, painful or intense contractions. Women who have had a miscarriage or premature birth or whom may have a chance of miscarriage should avoid sexual stimulation and arousal until their babies are ready to be born.

*** Things to Consider Refusing ***
You have the right to refuse interventions or offerings! You definitely have the right to ask for more information before agreeing.

– Enema: At one time this was considered necessary upon admission. Now it’s less common. They do not shorten labor or reduce infections. You may poop a little bit as the baby’s head emerges. Its easily cleaned and ok!  And, sometimes an enema can help a slow labor get going.

– Pubic Shave:  You do not need to be shaved to give birth. It was introduced as an infection prevention, but studies later found the rate of infection was actually higher in women who have been shaved. Most places have abandoned the practice. Many of us know how uncomfortable it is. Don’t go there if you don’t have / want to.

– Fast: Many people wonder if they can eat or drink during labor. A lot of hospitals place restrictions on this and some maintain a strict policy of nothing by mouth. The fear is that if a woman needs a cesarean birth and goes under anesthesia, she could vomit and inhale the food into her lungs while unconscious. Keeping a woman hydrated with electrolytes and a steady urge to urinate is healthy. A woman who urinates regularly and has a reason to walk to the toilet can help further the descent of the baby. When women become hungry after long hours of labor, they often become less effective. IV fluids may satisfy a fluid requirement, but it does not prevent the woman from getting weak. A starving woman may not have the endurance for labor. They require nourishment to keep up their stamina.

Electronic Fetal Monitoring: This has become routine in many hospitals, due to the thought that it would make things safer for the baby. This machine has not been associated with lowering any infant mortality. Research has been done that listening to the baby through a fetoscope is just as good at detecting a baby who is in trouble. For the mother, listening every once in awhile is way less painful and less likely to interfere with the labor than continuous electronic fetal monitoring (EFM).

When the uterus contracts, blood flow cannot go through the placenta as easily as usual, which means the baby gets less oxygen. Babies normally tolerate these quite well. Generally, contractions don’t last long enough to cause damage from being deprived of oxygen. If a baby is oxygen-deprived, the pattern of the heartbeat will usually change and this means the baby needs to be delivered quickly.

Alternative: the alternative is listening every 15-30 minutes with a handheld scope. This gives more human attention. One reason hospitals like EFM is that it cuts costs. The printout on paper gives the appearance that the woman is receiving continuous care, but the reality is the machine makes it possible for one person to “monitor” multiple laboring women at the same time.

The options of EFM: EFM is done in two ways. One is where receivers are held in place by belts around the mothers hips. The mother has to stay in place for this first option. The second is when an electrode is attached the baby’s head by a small needle stuck into the baby’s scalp which is kept in place until the baby is born. The electrode is attached to a wire that is introduced into the vagina and the signals of the baby’s heart are recorded on a printout. Research has shown that EFM used routinely can make doctors or midwives believe that something is wrong when everything is ok. A reading can be misinterpreted, an emergency cesarean can be ordered, and a perfectly healthy baby without any sign of distress is born. The mother then has to recover from major surgery that was a mistake. An unnecessary surgical delivery is less likely when the baby’s heart rate is monitored with a Doppler or a fetoscope intermittently. Even so, many hospitals require all mothers to have EFM beginning 20 minutes after admission and many others call for continuous EFM monitoring throughout labor.  There’s no good evidence that it should be mandatory.  It has not been proven to reduce infant deaths, nor has it reduced the incidence of cerebral palsy. 

Not to be forgotten:  One little mentioned part of the EFM act is that laboring women who are being monitored often feel the machine becomes the center of attention. When the provider enters the room and goes right to the machine, how does that feel to the woman who is the one doing this whole process? Sometimes family members become fascinated with the machine and forget the woman.

*** Common Medical Interventions ***
I’m going to cover the basics of the basics here. Please research these on your own and ask your provider about any and all of them.

– Breaking the Water: This can start the labor if the mother is not going into labor on her own. This method alone will initiate labor within 24 hours in 70-80% of women. The problem is the other percentage will experience an infection. The water can be broken by inserting a small hook like fixture and tearing the bag open. This can often produce more intense contractions quicker, and has a “there’s no going back” effect. Inserting anything external into the woman introduces more bacteria and thus increases the chance of infection. Breaking the water alone does not increase the danger of uterine rupture. However, this method puts a time limit on labor to start and conclude in most hospitals because of the higher risk of infection. Sometimes this can cause the umbilical cord to fall out of the cervix below the baby’s head which is a life threatening emergency for the baby and changes things very quickly.

– Prostaglandins: These are naturally occurring substances in the body which soften the cervix and the lower part of the uterus. Synthetic versions (such as gel, tampon, and a pill) have been created and are often used in combination with pitocin. Some women experience nausea, vomiting, and diarrhea with them. Even with precautions, there are risks of uterine rupture and multiple occurrences of this have caused doctors to change the way they use them.  There have been more adverse side effects from the Cytotec pill such as dead or brain-damaged babies, profuse bleeding, hysterectomies, and uterine rupture. Just to speed up labor…

– Pitocin: This is a synthetic version of oxytocin (a natural hormone that is released from the mother’s pituitary gland in small amounts during labor). It’s also the hormone of bonding / love / attachment / safety. Side note: people abuse substances to get hits of oxytocin…it feels like a warm hug and produces bonding between the mother and baby when it’s natural and real.  When pitocin is given intravenously from the synthetic version, the dose is far larger than that which is naturally secreted and its increased every few minutes until the desired contraction rate is reached. This can be extremely hard to tolerate for the mother, it can feel like too much too fast. Pitocin is more likely to end in a vacuum-extraction or a forceps delivery (the metal spoons) because fetal distress stems from contractions that are too strong. A baby is overwhelmed by the amount of pitocin. It’s uncomfortable and stressful for both parties (mother and baby). It doubles the chances of the baby being born in a poor condition because the intense contractions can interfere with the blood flow to the baby. There is also an increased chance of post partum hemorrhage. It can be used to strengthen contractions when a labor is moving slow. Some women undergo the usage of pitocin for 3-4 days without ever going into effective labor.

Risk: There is a higher incidence of uterine rupture in chemically induced labor than in spontaneous labor. Let’s all take that one in with a breath. Uterine Rupture. We’re talking about a uterus being torn here. In natural labor, the uterus will not contract so hard that it would destroy itself. In a chemically altered labor, sometimes the uterus may not be able to withstand the intensity. Am I the only one who cringes at the thought of someone trying to speed up a labor due to convenience and having it end in uterine rupture?

– Epidural Anesthesia: This is a local injection that is often utilized / offered. Not a lot of people know the full extent of the procedure. An epidural is numbing medicine that is injected into the woman’s spine and prevents the woman from feeling the lower body. This is done by a small device being inserted into the spine (an external piece is put into the spine) so that the medicine dosage can be regulated. The device is removed later. You may want to watch an epidural procedure before you get one. It’s not as simple as one small injection as one might expect. Women whom have epidurals too soon often don’t get to delivery vaginally because they lose stamina or feeling and are unable to push. Getting an epidural later in labor rather than earlier can help reduce the number of other interventions. Women whom have epidurals cannot get up and walk around after labor and delivery, because they can’t feel their legs or walk well. There is a longer recovery process, though the woman is awake the whole time and that has benefits. Epidurals can be like a detour for the rhythm. It can be hugely beneficial to labor for as long as possible, and then get the epidural. A lot of people might have a “what was the point of all of that if the epidural was going to be the end”, but trust that laboring naturally for awhile before an epidural can be really healthy.

– Vacuum / Forceps Delivery: These two tools are used when the mother is having trouble delivering but she is too far along for other interventions. Or perhaps there have been other interventions involved (such as pitocin and an epidural) and she’s gotten too tired, is unable to progress, the baby becomes distressed, or other complications occur. A forceps delivery can be beautiful and graceful when done well and it can be painful and harmful if not. It’s all about finesse and care, just like everything else. Except in this situation we happen to be dealing with the head of the baby and the vagina of the mother. Hopefully we know what it feels like to have our vagina cared for. And we probably also know what it’s like to have our bodies be abused and not cared for. This is not to be taken lightly.

– Episiotomy: This is where the perineum is surgically cut to make more room for the baby to come through. In my mind, this happens as a result of other things that happened in the labor process. It seems this intervention is used too often when perhaps a little more time and support could have gone a long way. An episiotomy can lead to infections, a high level of pain and increased discomfort for the mother. I’m going to include more on episiotomy in another post because it has become its own monster.

– Cesarean Birth: sometimes cesarean births save lives. Life of the mama, life of the baby. And, it’s a major surgery. The uterus is a tough, multi-layered muscle, and a lot has to happen to get to it. Every layer of superficial skin is cut, and the woman’s entire digestive system is moved and taken out so that the surgeon can get to the uterus. The uterus is then cut so that the baby can come out. The recovery process is long. It can sound simple when you read about it “there is an incision in the uterus so the baby is removed”, but when you REALLY think about it and feel into it…it doesn’t seem to simple / small. The amazing side of this is that there is a way for babies to come out of the mothers bodies if a vaginal birth is not available. And how beautiful is that. There are many ways to make recovery easier and more healthy, and there are many ways to produce healthy and strong bonding between the mother and the baby. For example, after the baby is born, there can still be skin to skin contact between the mother and the baby with the baby on the mother’s chest. This is not to be skipped! Ask for these things.

*** That covers it ***
For now. That was a lot, again. I hope this has provided some good guidance to add to your knowledge bank. I encourage you to go take a walk, breathe deeply, have a snack or a drink, and let this flow out of your mind and return to it when you need it. The point of all of this is so that you get to try out all of this in your mind. When we become too attached to anything, it may show up. If we know all of the possibilities and have our wits about us, we may have an easier time when things get intense. Having the information is good, and letting go of it and coming back to your body is also good. Until next time, with love, Alicia

About Alicia Patterson

Alicia Patterson is a Psychotherapist / Dance Movement Therapist, Birth Doula, Bodyworker / Energy Medicine Practitioner, Dance and Yoga Facilitator in the Boulder / Denver area.
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