Doula Paula Cleary writes a Guest Blog for Birth You In Love
“I wish I’d have known these things before giving birth!”
It is amazing how many times I hear this statement from women who have given birth – sometimes many times.
And when I think about it, I feel angry for those women, who sometimes look back and feel they were tricked and hoodwinked into procedures on the basis that to not do them would harm their baby and put them at risk. Although the language can be subtle, mothers are very sensitive and vulnerable at this time and want to make sure their baby is safe.
When I was gathering birth stories for my birthplace matters campaign, I wept several times as I kept reading similar stories from mothers over and over again – expressing regret at being so trusting that recommendations were based on common sense and backed by evidence. Particularly upsetting were the stories where a mother ended up needing a possibly preventable and in fact, unnecessary Caesarean.
The thing is, most first time mums (I was just the same) will agree to just about anything a hospital advises (because they’re the experts, right?) especially when the word ‘risk’ is mentioned repeatedly. It seems reckless not to go along with seemingly completely sensible recommendations, only realizing later that perhaps some of what they were told was not strictly true, or based on poor evidence. And who can blame them? No woman or her partner wants to risk her child in any way at all! But how can so many practices which are KNOWN to be unhelpful in birth continue to be so integral to our birth culture? How and why do such ridiculous practices as giving birth on our backs persist, even though we know it doesn’t help women or babies? And what can women do to avoid the pitfalls of agreeing to things based on questionable or unproven assumptions?
1. Vaginal examinations do not always give an accurate measure of progress in labour
There is a lot of debate in midwifery circles about how useful / safe / necessary / accurate vaginal examinations are in accessing cervical dilation and progress during labour.
According to the AIMS book ‘Am I Allowed?’:
“A VE (vaginal examination) is a snapshot in time, and it is common for the cervix to open up or close down, and it may be that the stress of the examination itself causes the cervix to close down. It can also reduce a woman’s confidence in giving birth, particularly if, for example, after an examination the woman is told that she is ‘only’ x centimetres dilated or ‘has a long way to go yet”.
What often isn’t told to mothers is that there is actually an increased risk of infection each time a vaginal examination is performed (something midwives have never admitted to me at any time when VE’s were presented to me), and the person doing the performing may affect how relaxed or safe the woman feels. Often the language used is so breezy ‘I’m just going to have a little feel’… that it can seem like a woman has no choice but to say yes, and that to not have one would leave everyone mystified as to baby’s progress or position.
Besides the fact you may get an entirely inaccurate picture based on a VE, it can put women up against the clock and there will be pressure during labour to progress according to ‘The Friedman curve’ which is the progress chart of a fictitious person who does not have your exact body or your exact baby. Variety is women’s dilation is absolutely normal and not necessarily indicative of any problem – just that women’s bodies all dilate differently.
Some women can be 3-4 cm dilated for weeks without going into proper labour, and others can open up in a matter of hours. Even if someone tells you otherwise – dilation is not an exact science.
If you refuse VE’s (which is absolutely your right if you wish) your dilation can instead be assessed in other ways. One way is for midwives to pay attention to the purple line that grows up the crease of your bum starting from the anus and going upwards to the top dimple of your bum crack, which is handy huh?
Skilled midwives should also be able to tell how dilated a woman is by feeling by how warm her legs are. (Providing she is on dry land and not in the birth pool and she does not have a temperature). This method is called Mexican Hot Legs. If the leg is warm but only the feet and ankles are cold, a woman’s cervix is generally about 3cm dilated, if she is cold up to a little higher up the leg to mid-calf area, around 5cm, and if the entire leg up to her knees is cold she will be fully dilated and ready to push very soon. The reason for this is that blood flow gradually decreases to the extremities as labour progresses because it is needed higher up in the body.
Simply looking at women closely and reading her breathing and behaviour, the pitch of her voice, and how she is moving around should also be clue enough to any skilled midwife as to how far a woman is dilating.
With these simple, non-invasive methods, you have to wonder why midwives feel the need to perform VE’s so routinely and frequently, given their unreliability and the increased risks of infection.
If you prefer to be monitored and measured in other ways, just say no to VE’s.
2. Synthetic induction can be a fast-track to other interventions and more harmful than we are sometimes led to believe
NICE quality standard Qs60 Published April 2014
’Induction of labour has an impact on birth experience and the health of women and their babies, and so needs to be clinically justified. It may be less efficient and is usually more painful than spontaneous labour. Epidural analgesia and assisted delivery are more likely to be needed if labour has been induced’
Simply being 40 weeks, or what is known as Term + (insert number of days of your hospitals routine policy for induction) without any other medical indications is not a sound reason to induce on its own – yet it remains the number one reason women are induced!
Synthetic oxytocin has a completely different effect on the woman’s body and whilst effective in some specific situations, can cause a number of problems during labour for both mother and baby. When the benefits are played up and the risks are played down but are presented to a mother who by now has usually had enough of being pregnant and starting to doubt her body, induction can seem like a no-brainer.
What often isn’t explained to mothers is that because syntocinon-induced contractions come harder, faster and closer together than naturally released oxytocin contractions, and can feel like they are coming almost on top of each other, the baby’s ability to replenish blood and oxygen in-between contractions can be compromised and so you are more likely to get distressed heart activity from babies in induced labours with more ‘spikes’ and ‘dips’ in the heartrate showing on the monitors.
The conversation that then follows can end up quite quickly along the lines of:
“Baby is distressed… we need to think about getting baby out” which causes a cycle of panic to ensue. Mother’s breathing becomes more out of control and because she is in so much pain from these unnaturally strong contractions, she will produce large amounts of adrenaline (the fight-or-flight hormone) which are not useful at all in early labour and in fact prevent the cervix from opening, so she may have by now quite reasonably asked for an epidural…. but again, women are not always told ALL the facts about this.
3. Epidurals can seriously sabotage a vaginal birth
World Health Organization, Care in Normal Birth: A Practical Guide.1996
“Epidural analgesia is one of the most striking examples of the medicalization of normal birth, transforming a physiological event into a medical procedure.”
It is not surprising that women ask for an epidural following an artificially started labour, particularly synto-induced labour which can feel like it has come on like a steam train without any let-up. It is a welcome break from those hard and fast near relentless pains. But it can come with serious drawbacks, which aren’t always explained properly to women.
Firstly, now the labouring woman is now no longer mobile in the lower half of her body, she is likely to be sitting or lying back in a bed. This means there is now a problematic amount of compression on her coccyx which both narrows the birth outlet, whilst at the same time making it harder for oxygen and blood to flow to the baby. If she had the use of her legs, she would be able to manoeuvre herself on all fours for example, opening up her back which in turn widens the pelvic outlet allowing baby to pass through more easily and especially for the shoulders to be born with less stress and compression on them. So not being able to feel your legs can actually lengthen labour and make it worse!
With an epidural in place, the stretch receptors of a woman’s lower vagina, which would normally signal to the brain to release more oxytocin, are numb. And this is a bit of a problem.
Biological oxytocin is a really really important hormone in regulating the contractions so they are productive and regular, and is essential in signalling for the body to start milk production, birth the placenta, and provide all the right conditions to promote and stimulate the other hormones needed for optimal, immediate mother-baby bonding. Without oxytocin present in the right amounts, its’ best buddy prolactin is also compromised. Prolactin is responsible for the ‘tiger mother’ instincts and is released in the old primal parts of the brain where oxytocin and beta-endorphins are made – the hypothalamus and pituitary gland. Beta endorphins activate the brains reward system, so they are really crucial to the ecstatic feelings needed in a normal physiological birth. If you inhibit oxytocin, you inhibit the other hormones too.
The reason is that when these hormones are not being signalled for or requested properly by way of a cervix-brain-cervix ‘conversation’ up and down the spine – it causes confusion to the body and so it misses out on giving you that ‘high’ that is usually produced during intense physical activity like sex, or intensive sports, which flood the body and help it to perform things outside the normal range of activity.
At full dilation, if catecholomines (noradrenaline hormones) are not released because of the signal disruption caused by the epidural, the spontaneous foetal ejection reflex cannot easily occur – and is only possible with the powerful adrenaline surge which gives the body the energy kick it needs for the glorious finale. So then we are starting to need a bit of help, and at this stage a ventouse or forceps and ultimately, caesarean, are looking more likely.
Cutting off the conversation between the lower half of your body and the brain is not a good idea.
4. Valsalva, otherwise called ‘purple pushing’ on your back is one of the hardest ways to give birth
Valsalva pushing is also known as ‘purple pushing’. What this means is holding the breath and forcibly pushing your baby out of the vagina using all your strength. It’s pretty typical in most UK hospitals (and in the movies) in spite of all the evidence pointing to this being the least helpful position for both babies and mothers.
As well as narrowing the pelvic outlet making it harder for the baby to turn in the birth canal and be born without assistance, it puts an incredible amount of pressure on the tailbone, causing birth to be more painful.
In a personal communication to Beverley Beech (Chair of AIMS UK), Professor Roberto Calyedro Barcia, President of the International Federation of Obstetricians and Gynaecologists wrote:
“There is only one position worse than lying on your back for the birth, it is hanging by your heels from a chandelier”.
(pg 67, Am I allowed? AIMS publication)
The Royal College of Midwives website (March 2016) confidently declares:
“Gravity is our greatest aid in giving birth, but for historical and cultural reasons (now obsolete) in this society we make women give birth on their backs. We need to help women understand and practice alternative positions antenatally, feel free to be mobile and try different positions during labour and birth.”
It really isn’t a secret that being in upright rather than in reclining positions during labour improves air, blood and hormonal circulation around your body, and in turn, to the baby. Gravity can help the baby get into an optimal position for birth. Moving around also assists the baby’s head as it turns and makes its exit from the mother.
Unless there are some very particular circumstances that require you to have repeated vaginal examinations, any induction (syntocinon or otherwise), epidural or giving birth on your back, think twice and educate yourself about your options. Going along with these just because it’s policy may not be wise. If you find yourself in any of these situations where it really is, individually for you, a medically necessary course of action, then of course there are ways to support and soften the negative effects.
But before you agree to ANY procedure… remember the maxim at the heart of medical care ‘Nil nocere’ (First do no harm) and always ask:
Is this really necessary?
What is the evidence that my baby will be in genuine trouble if I decline xyz?
What are the full range of alternatives?
What is the evidence for this suggested course of action?
Is this standard policy or an individualised recommendation?
What happens if I do nothing?
What happens if we wait… half an hour… an hour…. a few hours…. another day… a few days…
If your birth team are not supporting your wishes for a physiological birth and you feel they are simply scaring you rather than offering you evidence-based information, even after a talk with a Supervisor of Midwives, it may be time to consider whether that team will help you or hinder you to have a physiological birth.
You would be surprised how many hospitals are ignoring the evidence about what facilitates normal birth and blundering along doing all the things that are known to inhibit it, even in some hospitals declaring themselves ‘activebirth friendly’ and dedicated to promoting ‘normality’- (Like having very bright lights for example, making women lie on a bed for their whole labour, bursting into a room while a woman is labouring, and non-specific generic time limits which set very low thresholds for the dreaded ‘Failure to Progress’ diagnosis)
Don’t be afraid to ask for a second, third and fourth opinion, to ask if something can be done differently, or to ultimately say ‘No’ simply because you have a niggling feeling that something is not right for you. Our instincts are not mumbo-jumbo unreliable nonsense but a powerful source of knowledge based on subtle communication with the baby on many levels. It is safe to trust your feelings, once you have established they are more than a fleeting worry, and with a sensible, vigilant, but not indiscriminately paranoid attitude, there are many ways of knowing, listening and supporting ourselves to have a physiologically optimal birth.
Further reading: A wealth of articles which discuss various aspects of physiological birth and some of the problems with hormonal interference can be found on each of these websites:
Sara Wickham – http://www.sarawickham.com/articles/
Dr. Sarah Buckley – http://sarahbuckley.com/articles
Dr. Rachel Reed – http://midwifethinking.com/ Michel Odent – http://www.wombecology.com/?pg=inlabour