February 2009


One thing that has been on my mind lately, is the fear of childbirth (technical name, tocophobia).

Sometimes women are afraid of childbirth prior to having any children, and this is not really surprising — after all, the average woman will have seen few actual births, but only those portrayed in movies and on soap operas. Of course, those are all not just dramatized (fake) but are typically dramatic — water breaks and the woman has to get in the hospital this instant or the world will come to an end!! Or she’s stuck in the backside of nowhere in labor with just her husband (yes, I still remember when Jennifer had Abby on Days of Our Lives, and Jack was the only other person in the cabin, with serious snow outside), and everybody is panicking. Or labor is portrayed as the worst and most awful thing that it is possible to endure, until the magic epidural comes and makes everything all right. The other thing that is now available on TV, that I didn’t have as a child, are shows like “A Baby Story” which do portray actual births, but I notice that an inordinantly high number of those end in a C-section, or are otherwise highly interventive; and I’m not surprised that this leads to a fear of birth prior to the woman’s actually giving birth the first time. And this doesn’t even begin to touch on all the labor and birth horror stories that mothers for some reason feel so imperative to scare first-time pregnant women with.

Other women, however, have given birth before, and this experience has made them scared to have any more. Some women may choose never to have any more children at all (this happened to a friend of mine; her daughter is now about 8-9 years old). Or they may choose a C-section because they can accept pain from surgery and the attendant post-op pain (which may be manageable by narcotics), but they fear the lengthy but intermittent pain from labor. But there are other options.

After her first very painful birth, this woman was terrified to give birth again, but she chose to overcome her fears by using hypnosis to relax during labor. If you watch the video on that link, you’ll notice that they show a few clips from an online video of a woman using hypnosis during labor. That woman in the video was Independent Childbirth Educator Sheridan from EnjoyBirth blog whose painless childbirth using hypnosis (Hypnobabies) was what this Georgia mom saw that gave her the courage to try to give birth again. [I’ll clarify that although the news story referred to hypnosis during birth as “HypnoBirth,” that is a name for a particular type of childbirth hypnosis, and Hypnobabies is another, and it was this type that Sheridan used during birth, and what she teaches.]

The fear of childbirth is very real. And it’s understandable, considering all the negative images surrounding birth that we are bombarded by almost from our own births — and considering that most of us were born in less-than-ideal circumstances ourselves (my mom was under general anesthesia and given an episiotomy, and I assume I was dragged out of her womb by my head), perhaps it might be not too big of a stretch to say that we are surrounded with negative birth images from the time of our birth. But all too often, doctors are just willing to tell women who are afraid of childbirth, “Oh, don’t worry about a thing — if you don’t want to give birth, we can give you a C-section.” While I can accept that women should have the right to choose to give birth as they wish, I wish that doctors (and others) would give a little extra time to ask a woman why she’s afraid, and see if they can work through her fears, rather than just cutting her open unnecessarily. If her fear is irrational yet she holds onto it, fine, give her a C-section; but if she has a rational but misguided fear (for example, I heard recently of women who want a C-section because of a fear of their “vaginas exploding”), then get to the root of the fear! Instead of treating her like a little child who is afraid of getting her dress mussed by going outside, treat her like the rational woman she is, and give her true information to combat the

F-alse

E-ducation

A-ppearing

R-eal.

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Just a quick look at the birth outcomes for Independent Childbirth educator led birth classes led by Sheridan Ripley, Gretchen Vetter, Olivia Sporinsky, Molly Remer, Aimee Crane, Joni Nichols, Ruth Trode, Dale Bernucca, Brandy Segin, Helen Loucado, Sara Wallbaum and Dorene Vaughn.

PLANNED OUT OF HOSPITAL BIRTHS  (132)

Free Standing Birth Center = 45; Planned Home Birth = 55; Planned Unassisted Birth = 4; Unplanned Unassisted Birth = 3; Transfers = 25

Combined Spontaneous, Unmedicated, Unmanaged Vaginal Births = 107

Combined Transfer Medicated, Vaginal Births = 8

Combined Transfer Medicated, Cesarean Births = 2

Combined Transfer Unmedicated then OR for Cesarean = 13

Combined Transfer Unmedicated, Vaginal Births = 2

  C/S Rate for all OOH Births:  11.36%

  Transfer Rate for all OOH Births :  19%

  C/S Rate for Transfers of OOH Births:  60%

 

PLANNED HOSPITAL BIRTHS  (101)

OB Attended = 75; Family Physician Attended = 6; CNM Attended = 19; Other = 1

Combined Spontaneous, Unmedicated, Unmanaged Vaginal Births = 57

Combined Managed, Unmedicated, Vaginal births (i.e. AROM) = 6

Combined Managed (includes pitocin/induction only) Vaginal Births = 25**

Combined Managed Resulting in Cesarean Births = 11**

Combined Spontaneous, Unmedicated, Unmanaged Resulting in C/S = 2

   C/S Rate for all Planned Hospital Births: 12.88%

   C/S Rate for all Managed Hospital Births**:  26.19%

   Percentage of Hospital Births Managed**:  41.58%

 

We did not penalize hospitals by including cesareans from homebirth transfers in their statistics.  We did however include c/s for breech in their statistics because medical training trends have forced those cesareans by no longer training medical practitioners to catch breech babies.

Amber Marlowe anticipated an easy delivery when she went into labor on January 14, 2004. But after a routine ultrasound, doctors at Wilkes-Barre General Hospital, in Pennsylvania, decided that the baby–at what looked like 13 pounds–was too big to deliver vaginally and told her that she needed to have a cesarean. The mom-to-be, however, wasn’t convinced: After all, she’d given birth to her six previous kids the natural way, including other large babies. And monitoring showed that the fetus was in no apparent distress.

After she said no to surgery, doctors spent hours trying to change her mind. When that didn’t work, the hospital went to court, seeking an order to become her unborn baby’s legal guardian. A judge ruled that the doctors could perform a “medically necessary” c-section against the mom’s will, if she returned to that hospital. Meanwhile, she and her husband checked out against the doctors’ advice and went to another hospital, where she later gave birth vaginally to a healthy 11-pound girl. “When I found out about the court order, I couldn’t believe the hospital would do something like that. It was scary and very shocking,” says Marlowe. “All this just because I didn’t want a c-section.” ~ Could You Be Forced To Have A C-Section?, Lisa Collier Cool, Baby Talk Magazine

Although the c-section rate for planned out of hospital births appears to be the same as that for planned hospital births here is the difference:  the c-section rate for planned hospital births doubles when the labors are managed (ANY intervention is used).

The possibility of a cesarean section should be discussed with every patient as part of the patient’s birth plan, with contingent consent for a cesarean section obtained early in the woman’s pregnancy. The woman must sign the consent form herself; her husband should not be asked to sign it. At the time the cesarean section becomes necessary, the woman should be asked to resign the original consent form, indicating that the conditions for needing a cesarean section have now occurred. The fact that the mother may have had some pain-relieving drugs does not render her legally incompetent to acknowledge the need for the procedure. Her husband has no authority to sign the consent to her surgery unless she has given him this right in a power of attorney. If the mother is medically unable to consent because she is psychotic or comatose, the surgery may go forward based on the consent signed as part of the birth plan. – Excerpted from LSU’s Law Center Medical and Public Health Law Site

Practitioners presenting the information for acquiring a mother’s informed consent are not always comfortable with how to explain the procedure they want to do and why they want to do said procedure.

It isn’t always easy for birth practitioners to call their colleagues’ errors to public attention and in the process perhaps admit that they themselves crave a better quality of training.  

It is necessary to call attention to and demand spontaneous, normal, unmedicated, vaginal birth over an intact perineum be the gold standard for birth care.  We do so for the greater benefit to global maternity care.  Independent Childbirth educator members are at the forefront of making a difference.  When women are educated as to all of their birth care choices including planned out of hospital birth our combined c-section rate is 12.02%. The World Health Organization declares no region in the world should have a c-section rate greater than 10% to 15%; based on the cesarean rate for managed births we know our combined cesarean rate could be improved dramatically with increased use of better birth care practices by medically trained personnel.

*In our statistics there were 7 successful VBACs and 2 successful VBA2C; 2 VBACs became repeat CS for a successful VBAC rate of 81.82%.  There were 29 waterbirths.  There was one vaginal breech birth while 5 other breech presentations were automatic cesareans.  All 7 unassisted births were successful, healthy outcomes.  There were four sets of twin births, two with both vaginal but very managed labor, one scheduled c/s for breech at 31 weeks, one singleton born vaginally at term with sibling stillborn vaginally and it was known sibling had died inutero but mother chose to continue pregnancy for her other daughter’s health.  Learn more about gentle stillbirths and remembrance at Now I Lay Me Down To Sleep.

Professor Steer, BJOG editor in chief recommends …”doctors and midwives monitor how much water women drink during labor.” (Drinking Water During Labor Carries Risk)

Either the author of the above article or Professor Steer overlooked a couple of important nuances from Dr Vibeke Moen at the Sweden’s Karolinska Institute where the study he references was conducted.  He states hyponatraemia, an imbalance of electrolytes, is not uncommon following labor.  Not during labor, following labor.  That means something occurred during labor whose resultant effects are found in the immediate postpartum.

Let’s not allow the medical folks to obfuscate the hydration in labor issue.  Some real scenarios involving extreme labor:

“Scientific studies have looked at the best ways or most appropriate ways of replenishing the body with fluids under the extreme of conditions of heat and dehydration (Castellani et al, 1997, Marish et al, 2001, Kenefick et al, 2000). Castellani et al (1997) investigated athletes who were not acclimatised to temperatures of above 35oC, and submitted them to 2 bouts of exercise, which would be similar to that of a footballer in the midfield. In between they were rehydrated only once with either IV, oral ingestion or no fluid replacement after being dehydrated by 4% of body weight. It was found that there was no difference in performance between those that were rehydrated orally or by IV. They also found that oral and IV were equally effective as rehydration treatments. There was no difference between the treatments in regards to the way in which the bodies handled body temperature and fluid losses.

Marish et al (2001) found that oral hydration rather than IV rehydration resulted in athletes reporting less thirsty, feeling cooler and not as physically tired. Kenefick et al (2000), also found no added benefit of rehydrating the body using IV as opposed to oral hydration in mildly dehydrated individuals (persons had lost 4.5% of body weight as fluid loss) prior to competition. This group investigated the ability of the body to maintain body temperature and handle fluid losses. Casa et al (2000) found similar results to Castellani et al (1997), however also showed that the body and skin temperature was lower in those that orally rehydrated themselves as opposed to the use of IV.

In summary, all the studies reviewed showed no added benefit of using IV rehydration methods, as opposed to oral hydration in mildly dehydrated individuals before and during a match. There was no benefit in regards to sporting performance, body temperature and fluid control. In fact the benefits of oral hydration included persons feeling not as thirst [sic] and more comfortable in regards to feeling less exercise and heat stress (feeling tired and hot). Oral hydration if consumed in the required amounts is adequate to meet the needs of all footballers. IV rehydration should only be used under medical supervision and advice at times of severe dehydration, heat and exercise stress.” ~ Jeanette Fiedling, BSc, MHN; Oral vs. Intravenous (IV) Hydration

We admit a labor cannot be determined from the onset that it is going to last a specific amount of time, have a specific intensity, etc. is unlike a football match (American or otherwise) having set periods and a clock that winds down (or up).   Well, scratch that last comparison on the clock.  Another nuance here, dehydration is caused when the rate of fluid loss is greater than its intake of fluid.  Too much fluid intake can also cause the same symptoms of dehydration because either situation causes an imbalance of electrolytes, minerals as well as causing a change in body temperature.

As medical practitioners it is vital that they be well trained to know the clinical definition of dehydration.  As someone licensed to enact medical procedures upon our bodies it is vital to the consumer that the practitioner be attentive and act only when necessary.  It is very easy to alleviate mild dehydration, drink water.  Obstetricians are making a really huge leap here equating dehydration with hyponatraemia and it’s no surprise that they are doing so.

“One problem would seem to be that some clinicians experience difficulties in investigating the causes of hyponatraemia. It is here where the clinical biochemistry laboratory and chemical pathologist can play an important role in facilitating optimal patient care. Interestingly, Saeed and colleagues showed that rarely did patients with severe hyponatraemia have their urine osmolality or sodium checked.1 In such cases, it is difficult to see how the cause of the hyponatraemia could be clearly established. This of course is of fundamental importance, because the management of hyponatraemia should differ according to its aetiology.2–4 ”  ~ The Investigation and Management of Hyponatraemia; Journal of Clinical Pathology

Here’s another nuance from the study Professor Steer:

 “Women should not be encouraged to drink excessively during labour. Oral fluids, when permitted, should be recorded, and intravenous administration of hypotonic fluids should be avoided. When abundant drinking is unrecognised or intravenous fluid administration liberal, life-threatening hyponatraemia may develop. The possibility that hyponatraemia may influence uterine contractility merits further investigation.” (emphasis by Independent Childbirth)

Why the brouhaha over IVs in labor, really, docs?  Is it really that critical to you to win the argument over whether or not a woman consents to an IV?  Serious psychological turf issues here.  Think about it, what are the two first protocols a woman will need to make a decision about when arriving at the hospital in labor?  The vaginal exam and the IV.

Consenting to both, declining both or consenting to one and not the other, each scenario is the beginning of a scoreboard.  If she is allowed to ‘get her way’ from the start, all the other items an individual practitioner will decide are important may face a “no” from mom, too.  The latex gloves are off.  

“At one time, a myth became prevalent that drinking lots of water each day was a healthy habit.” ~ Professor Philip Steer

I had no idea that the belief in drinking lots of water each day is healthy is actually a myth.  How much is “lots?”  There are ounces, liters, but lots?  Okay, but when you have an IV in place Professor Steer, how can you tell if you really are thirsty?  You go on to cloud the issue for your colleagues,

“However, recent research shows clearly that in general, one can trust one’s natural body messages, and that we only need to drink more when we feel thirsty.”

According to you, are we laboring women capable of taking care of ourselves by laboring naturally and spontaneously so as to recognize thirst all by ourselves or aren’t we?

A word of wisdom for birth practitioners, the same one for mothers: don’t say no to everything.  Say no only when you mean no.  That way when it’s really important the “no” will truly stand for something and capture our attention.