Part I: Common Medical Procedures & Interventions by Mary Ceallaigh
Introduction
This is basic information from common obstetric & midwifery texts and typical hospital statistics as reported in major periodicals. Additional, excellent informed choice analysis on the medical management of healthy women's labor and its impact on childbirth can be found in Birth as an American Rite of Passage by Robbie Davis-Floyd, Ph.D, The Thinking Woman's Guide To Childbirth by medical writer Henci Goer, Our Bodies, Ourselves by the Boston Women's Health Collective, and Episiotomy and the Second Stage of Labor edited by Sheila Kitzinger.
The #1 cause of hospitalization in the United States is childbirth: though birth is not a disease. In fact, unmedicated, supported birth can actually be an experience of optimal health physiology with many long-term benefits for mother, child, family, and society. It is often surprising for American women when we learn that formal, well-documented studies have shown that for healthy women attended by a skilled caregiver, homebirth is not only just 'as safe' as hospital birth, (it may be even safer, when the sequelae/side-effects from various medical procedures are factored in).
Most American obstetric practices are done in the name of compassionate care and ostensibly, to manage maternal-child health, but the U.S. ranks only 27th on the list of nations in the WHO's Report of Nations: Infant Mortality Rates. Our NICUs are busy and full with neonates who are separated from their mothers as both a medical philosophy and hospital administration fiscal objective to reduce staffing costs, despite sound scientific evidence that maternal skin-to-skin newborn care for procedures as well as kangaroo care by staff creates better outcomes for families.
9 out of 10 otherwise healthy American women entrust ourselves to medical management of the intimate birth process, perhaps in many cases, because of lack of: informed-choice information, prenatal empowerment, perceived financial options, and personalized labor support. This is in stark contrast to, for example, an 80% non-medical homebirth/birth center rate in modern, sophisticated Denmark.
Institutional birth setting medical practices typically increase fear and adrenaline in the laboring woman's neurological functioning, subsequently lowering pain-coping thresholds and simultaneously increasing the likelihood of medication interventions. Included in this is the early hospitalization of all women whose waters naturally rupture before labor begins or in very early labor (about a third of healthy pregnant women). Likewise, if a woman has unresolved deep- seated fears and she feels unsupported or unsafe in the home or birth center environment, planned or transported institutional birth may be her best option at the time.
Typically, first time birthing women (primaparas) who are not aware of variations in hospitals and medical birthing practices, are also not aware that we have options, including the option to postpone and/or refuse certain protocols.
1 in 4 otherwise healthy American women are undergoing major surgery (cesarean) to have their child extracted. Giving birth physiologically and in a freestanding manner is indeed even rare in some social circles. Cesarean surgery, though very welcome and humane in rare complications in healthy women, and modern breech birth protocol limitations, does bring with it a 12 times greater risk of death, significantly interrupted early bonding with the baby, and severe postpartum incapacitation. Post-cesarean female sexual dysfunction, particularly when a woman did not experience emotional support in labor, is another marked issue in women's heath.
There has also been a recent revival in operative delivery techniques in the U.S., using metal forceps and/or vacuum pumps to extract babies as a technique to avoid cesarean surgery due to dysfunctional second stage labor sequelae from epidural immobilization of the mother. However, extractive techniques have their own violent repercussions on the maternal tissues, long-term pelvic floor health issues, and, adding to the already stressful impact on the baby, severe nervous system shock and trauma through sustained traction, and bruising or hematomas.
Due to these many maternal-child health issues inherent in modern obstetrics, some well-known obstetrical spokesmen are now promoting "scheduled, non-labor cesarean surgery" as the new, humane response to labor dysfunctions in the medical environment. The alternative of instead humanizing hospital labor wards to facilitate healthy women by encouraging home laboring with doulas, installing en-suite birth pools in hospital rooms, providing more active labor support, and creating freestanding birth centers at hospitals is not an option that interests conventional obstetrics and profit-focused hospital administrator.s
The estimated "clinical" Postpartum Depression rate in the United States is 40% if not higher, as it is greatly under-reported. Prescription antidepressant usage by mothers of babies and young children is considered common in 2005. It is not difficult to correlate unsupported, negative birth experiences and physiological disruption with later neuroendocrine issues in mothers. However, being that our cultural tendency is to entrust the expertise of the medical professional we choose (or is chosen for us), as a whole, women are commonly unwilling or too overwhelmed when it comes to connecting the dots between dissociative birth practices and a dissociative postpartum.
Though anti-depressants may provide a very needed bridge back to sanity, let us not underestimate the power of woman (even after having had one or two dissociative or negative birth experiences) to create optimal preconception balance, an aware pregnancy, and supported spontaneous birth physiology. This is what sets the stage for a joyful postpartum immersion of skin-to-skin bonding, pleasurable nursing, and supported domestic retreat. In this context, the normal hormonal shifts ('the baby blues')that occur around the day 4-7 postpartum do not linger and postpartum wellness is the trajectory rather than depression.
The benefits and empowerment of nursing/breastfeeding, though strongly encouraged by the World Health Organization, are often experienced as physiologically challenging and psychologically less fulfilling and much less pleasurable for women who have had endocrine disruptions during medical birth (pitocin and anesthesia affect the pituitary-hypothalmic milk production orchestrations that go on during labor). Even so, Nature is a generous mother, and the support of a postpartum doula can help a woman help herself integrate her particular birth experience and access more relaxation and flow with her little one, often with increase in milk production and breastfeeding happiness.
For men who are becoming fathers in the medical birth room, as committed partners, unspoken stresses/issues of their very own can occur through witnessing the graphic and often unpleasant looking group interventions - upon that which they privately helped conceive. Once the "domino effect" of medical interventions upon an otherwise healthy mother-baby begins, men likewise may unconsciously feel inadequate long-term in their role with their lover - in a key time when a man's own re-orientation of himself as a provider and a father is occurring. All the ways a woman brings awareness to her fertility and birthing likewise expand her partner's capacity to connect to his own role and to the woman and baby, from deep within himself.
Some Common Medical Birth Procedures:
Of first-time birthing women (Primaparas) who have vaginal births in most American hospitals, nearly 90% have their vulva cut (episiotomy) with substantial risk of further 4th degree lacerations that continue to the rectum. This surgery obviously has severely uncomfortable side effects for women the first 2-3 postpartum weeks as well as higher risk of infection and, for some women, emotional and sexual response issues having to do with feeling violated. Episiotomy, or female genital cutting, is the most commonly practiced surgery in the United States.
Episiotomy prevention techniques to facilitate tissue elasticity often rely on unmedicated, free- moving labor; immersion in warm water; deep relaxation and emotional wellbeing of the laboring woman; breathing, into the perineum & pelvic floor; perineal massage; private orgasm/clitoral massage during unmedicated labor; hot compresses; squatting position (or any other loose tailbone postion like hands & knees) during second stage labor, perineal support, and ancient visualization techniques.
Laboring while Immobilized in a Hospital Bed
Purpose: To cater to the misconception that both staff (and women themselves may have) that women are safer in bed, as depicted in western culture imagery found in movies and TV shows. It provides a more convenient field of operation for care provider during the second and third stage (expulsion of baby and placenta), but is most inconvenient for maternal tissues. Many obstetricians and nurse- midwives are not trained in supporting a variety of birthing positions, especially those that are low on the floor (supported squat, birth stool). This is merely a matter of practitioner convenience and common practice.
Benefits: None. Women feel more empowered, more themselves, when they can walk, sway, and take various positions around the hospital room or home. Moving intuitively on the feet also induces a relaxation response in the brain.
Risks: Encourages fetal malpresentation; decrease in normal intensity of contractions resulting in a lengthening of labor; limits the mother’s ability to make herself comfortable; creates insecurity in the laboring woman; increases chances of instrumental delivery and surgery due to fetal malpresentation; creates a drop in maternal blood pressure which results in poor oxygen supply to the baby. Laboring supine (flat-on-the-back) is the absolute WORST possible position for a laboring woman.
Alternatives: Remaining active with a wide range of positions and movements throughout established labor... laboring in a more upright position, allowing gravity to help increase the strength of contractions and dilate the cervix more efficiently. This encourages optimal fetal positioning (birthing is a partnership between a mother's pelvic movements and the baby's movements.
Other interventions that may be required: Pharmacological augmentation; a desire for pain medication due to “back labor” often associated with an OP (occiput posterior) baby; increased fear and anxiety due to being incapacitated to a bed, with subsequent increase in pain perception; instrumental delivery or cesarean due to fetal malpresentation
Continuous Electrical Fetal Monitoring (EFM)
In the United States, EFM (electronic fetal monitor) use for healthy women who bring their childbearing to the hospital environment is often, though unnecessarily, continuous in routine hospital admissions. Therefore even laboring women who would prefer to have an unmedicated birth are immobilized and subject to increased discomfort and lower pain tolerance which creates more tension, fear, and pain. This can be actively addressed, however, with the help of a doula or empathic nurse to disconnect the EFM cords after the minimal reading time (10-15 minutes per hour in most states). Wireless EFMs are now being introduced into some hospitals, however, though beneficial for mobility continuous ultrasound exposure for large numbers of babies during labor is another issue altogether.
Purpose: Monitors fetal heart rate and maternal contraction pattern, indicates how the baby’s heart reacts to contractions, and how long, strong and close together the contractions occur; they also provide a permanent record for hospital litigation concerns. Can be done both externally with sensors belted to the mothers belly and internally with an electrode attached to the baby’s scalp.
Benefits: Theoretically, allows one nurse to monitor several patients at one glance of the screen; useful if intermittent monitoring indicates a possible problem. Provides hospitals with potential litigation defense material.
Risks: Very high “false positive” rate (indications of fetal distress when there isn’t any) thus resulting in unnecessary intervention, including surgical delivery; variabilty of staff interpretation of EFMs, over- dependence upon at-a-distance monitoring; the signal is often lost when the baby moves or the mother adjusts her position; ultrasound impacts the arterial red blood cells in the baby's circulation, with unknown subtle influences, from an eastern perspective; internal monitoring is invasive and introduces the risk of infection;
Alternatives: Intermittent monitoring with a Doppler ultrasound device for several checks over a 15 minute period every hour; continuous telemetry (wireless) monitoring; non-ultrasound fetoscope (available through some midwives for homebirths).
Other interventions that may be required: Artificial Rupture of Membranes, (AROM) is required with internal monitoring; cesarean surgery due to “false positives.”
Routine IVs
Purpose: To replace oral intake of fluids; also provides easy access for medication, which is expected to be administered.
Benefits: Keeps the mother hydrated
Risks: Inhibits mobility - makes the woman dependent both physically and psychologically; fluid overload, which can lead to fluid in both the mother’s lungs (pulmonary edema) and the baby’s lungs (neonatal trachnea); painful inflammation at the site (also a risk with 'saline lock' device); leakage from the punctured blood vessel resulting in painful bruising (also a risk with saline lock); increase of maternal and fetal blood sugar levels to diabetic levels (hyperglycemia) when fluids contain glucose (referred to as “dextrose IVs”)
Alternatives: Fluids (and foods, if possible) by mouth during labor; saline lock
Other interventions that may be required: Treatment for problems caused by fluid overload, infection at IV site and hyperglycemic conditions in mother and baby
Artificial Rupture of Membranes (AROM) or Amniotomy
Purpose: To induce or augment labor (removing the cushion of fluid and allowing the baby’s head to press directly against the cervix will theoretically aid in opening it) and check for meconium staining of the fluid (an indication of fetal distress two thirds of the time); it is also necessary to rupture membranes to place an internal monitor (an electrode attached to the baby’s scalp) when indicated.
Benefits: Shortens labor by 1-2 hours and may reduce the use of Pitocin (synthetic oxytocin)
Risks: Cord prolapse, fetal heart rate abnormalities due to lack of fluid (when done early in labor), maternal infection,
Alternatives: Conserve membranes and allow labor to progress with maximum cushioning of the baby's head; less invasive methods of stimulating labor, such as the woman going back home, prostaglandins via sexual intercourse (semen's potent prostaglandins are ten times more efficient when absorbed through the gut via oral sex, for the zealous committed couple) walking, active nipple stimulation in privacy by the laboring woman and/or her lover (though breast pumps effectively stimulate nipples, they are stressful, noisy, psychologically undermining, and unnatural), acupressure, relaxation and visualization if augmentation is indeed necessary; waiting for labor to occur spontaneously.
Other interventions that may be required: Amnioinfusion (replacing fluid via catheter); pharmacological induction or augmentation in cases of prolonged rupture of membranes; cesarean for cord prolapse.
Labor Induction and Augmentation with Pitocin
Western obstetric management, in contrast to the midwifery model of care, often includes labor induction to suit practitioner schedules or to initiate labor after the 40th week. This involves continuous electronic monitoring.
Purpose: To “jump start” a stalled labor or initiate labor before it has begun
Benefits: Usually effective in inducing or augmenting labor; can be stopped if adverse reactions occur
Risks: Restriction of movement due to IV & EFM; dramatically more painful labor because of overriding the body's endorphin production mechanism; uterine hyperstimulation (contractions that do not stop) which can result in fetal distress; increases risk of uterine rupture in VBACs due to tectanic contractions; may increase postpartum blood loss and incidence of newborn jaundice; increases risk of cesarean due.
Alternatives: Less invasive methods of stimulating labor, such as going back home, walking, nipple stimulation, prostaglandins via semen, acupressure, relaxation and visualization if augmentation is indeed necessary; waiting for labor to occur spontaneously.
Other interventions that may be required: An IV will be necessary; an internal monitor due may be necessary, thus requiring AROM; due to a higher intensity of contractions, the mother may be more inclined to request pain medication; cesarean for fetal distress.
IV Medication (Narcotics or Analgesics into IV fluids)
Purpose: To dull or “take the edge off” the pain of labor
Benefits: Do not require a needle in your back - no risk of spinal perfusion, does not require continuous EFM or a catheter; quick relief (there will be little delay in receiving it after you request it), do not slow labor or interfere with the second stage.
Risks: Nausea; a drop in maternal blood pressure; maternal glandular system stress; Interference with maternal endocrine pre-lactation orchestrations; respiratory depression in mother which may result in fetal distress due to inadequate oxygenation; alteration of the maternal-child syncopation, unity, and depth of bonding upon birth; significant stress upon the newborn's endocrine system; interference with newborn behaviors, including suckling reflex; neonatal respiratory distress.
Alternatives: An environment that is more comforting, familiar and conducive to relaxation; a care provider with a less interventive approach to childbirth; a doula (statistically proven to reduce the use of pharmacological pain relief); hydrotherapy; massage; acupressure; guided relaxation; visualization; patterned breathing techniques; movement and changing position often; vocalization; TENS (transelectronic nerve stimulation).
Other interventions that may be required : Anti-nausea medication; rescue measures and possible resuscitation in cases of neonatal respiratory distress
Epidural Anesthesia (get informed: to see a very detailed photo essay of the actual epidural procedure by award- winning photographer Patti Ramos, click here)
Purpose: To eliminate the maternal bodily sensations of labor contractions and pain by creating a temporary mind-body split (dissociation or induced psychosis)through the administration of cocaine derivatives (bupivicaiane/marcaine) and sometimes additional opiods. Being that the baby still continues to be fully present to all labor sensations, the maternal absence/anesthesia greatly reduces if not severs the mother-baby unified field of consciousness - it takes great determination on the part of the numbed mother to stay mentally, spiritually, and emotionally connected to the baby's experience, however, such an intention of connection can be maintained via keeping loving hands on belly, and allowing no distractions to interfere with your awareness that the baby is feeling each and every contraction, in a very profound, life-changing way.
Benefits: Usually eliminates the sensation of pain, allowing the mother to relax and sleep in active labor; MAY encourage progress of a “stalled” labor in a distressed mother by promoting relaxation; allows a mother to remain awake and alert during a cesarean
Risks: Tends to slow labor; risk of infection at injection site; increases the risk of instrumental delivery and cesarean; episiotomy due to tissue swelling; risks postpartum include maternal fever, temporary urinary incontinence, nerve injury, hematoma, spinal headache and a considerable drop in blood pressure - thus decreasing awareness and pleasure in bonding; increases the risk of much more serious complication including maternal convulsions, respiratory paralysis and cardiac arrest, and permanent spinal injury; unknown effects on newborn, both short and long term, from exposure to the drug which was definitively proven by Mt. Sinai Medical Center to enter the fetal bloodstream. Unknown longterm effects on the species, as sustained maternal dissociation during labor was unprecedented in human history until this past century.
Alternatives: An environment that is more comforting, familiar and conducive to relaxation; immersion in warm water/ a birth pool; a care provider with a less interventive approach to childbirth; a doula; massage; acupressure; guided relaxation; visualization; deep abdominal breathing techniques; movement and changing position often; vocalization; TENS (transelectronic nerve stimulation). Other interventions that may be required: Pharmacological augmentation if labors slows; WILL require electronic fetal monitoring, precautionary IV and possibly a bladder catheter (consider the risks associated with these procedures and the intervention “domino effect”); instrumental extraction of the baby with a vacuum or forceps, or cesarean.
"Purple Pushing" or Forceful Pushing
Purpose: To expedite the second stage of labor/the expulsive stage; to provide women who are medicated and unable to feel “the urge” instruction on when to push. To continue management of a physically numbed woman on anesthesia. Also a variation of this is used by some medical midwives who were not trained in full 2nd stage facilitation.
Benefits: To provide those who are medicated and unable to feel “the urge” instruction on when to push. To actively manage those who are not medicated in accordance to what is convenience or protocol of the care provider- rather than facilitate a woman "breathing her baby out."
Risks: Contributes to maternal exhaustion; greatly increased likelihood of tearing; greatly increased risk of "diastasis recti" abdominal muscle damage which is difficult to restore; compromises fetal oxygen supply.
Alternatives: Upright tailbone-free birthing position or laying on left side with right leg completely supported by a doula; spontaneous bearing down; pant, breathe, or grunt or moan your baby out; "Breathing the baby out" passive 2nd stage; Birthing the baby's head in the squatting or support squat position (speeds delivery via gravity, increases the pelvic outlet by 1.5 cm and increases intra-abdominal space, with tremendous oxygenation & glandular benefits, by 30%).
Other interventions that may be required : Instrumental delivery or cesarean due to maternal exhaustion.
