Googling stuff on your smartphone can be a great way of quickly finding out interesting facts. However, it’s not a great method for finding out the risks and benefits of a procedure in the middle of labor. Even if you are planning to have a completely natural birth, it’s a really good idea to know about the different procedures you may have to make a decision about. So to get you started, here is a brief intro to procedures that most low-risk women probably won’t need during labor.
Labor and birth on back– Imagine you’re heading out on a long hike up a big mountain with a backpack filled with useful equipment like snacks, water, a first-aid kit and a rain jacket. The pack is definitely heavy, but manageable. Now imagine that someone adds several large stones to your filled backpack. Hiking that mountain is going to be a lot harder. That’s what labor and birth are like lying down. Midwives and natural birth oriented obstetricians like Dr. Michel Odent and the late Dr. Bradley have been big advocates of upright birth for a long time. Women birthing on their backs or in a semi-recumbent hospital bed position actually has nothing to do with safety or biology, but caught on among obstetricians in the United States during the 19th century because the position was more convenient for them to use forceps during the delivery. A little research that has been done has shown a decreased use of forceps and a decrease in severe tears in women who give birth in a squatting position. On the other hand, if you are more comfortable delivering in a lying down or semi-recumbent position, more power to you. (A great example is actually Cindy Crawford in her interview for More Business of Being Born).
Induction/augmentation– Here’s the thing, the pregnant woman’s body is designed to keep the baby in until the baby is ready to come out. Your baby and your uterus are on their own timetable that doesn’t necessarily coincide with a doctor’s. Also, a woman’s body releases catecholamines during labor if the woman feels threatened. This pauses labor so the woman can escape from the threat. So when we hear about “failure to progress”, “stalled labor” or other terminology, it may have more to do with the environment at the birthing place or an unrealistic timetable than something being “wrong” with the mother, the baby or the labor. Induction of labor increases the risk of c-section, premature birth, uterine rupture, infection, low heart rate, umbilical cord prolapse, and postpartum hemorrhage. Ideally, OB-GYN’s would take the advice of the late Dr. Bradley: “As my chief pointed out, ‘An obstetrician should have a big rear end and the good sense to sit calmly thereupon and let nature take its course.”
Cesarean- My husband is here today because his mother was able to have an emergency cesarean for placenta previa with his older sister. What I’m talking about here are unnecessary cesareans- which are actually a very real public health issue. As many of you have heard, almost one-third of all babies in the United States are delivered through Cesarean section. However, according to WHO, cesarean surgery is medically indicated in only about 10%-15% of deliveries. In fact, OB-GYN’s often perform cesareans simply because they don’t want to wait around for a mother to deliver vaginally and believe it to be a low-risk procedure. Some have tried to claim that cesarean birth is safer than vaginal birth, however research does not bear that out as certain types of serious birth injuries are the same for planned cesareans or vaginal births. Other scholars have tried saying that the WHO’s upper threshold of 10-15% cesarean rate should be increased to 20%, however, this does not account for the increased public health costs of cesareans, which include higher financial costs associated with Medicaid, less breastfeeding, much higher respiratory morbidity for infants and frequent injuries to mother’s internal organs resulting from cesarean surgery. For a full explanation of how high cesarean rates impact public health, see my paper posted in three parts starting here.
Amniotomy/ Stripping membranes– From the U.S. National Library of Medicine’s database here is the summary of research on amniotomy: “Evidence does not support routinely breaking the waters for women in normally progressing spontaneous labour or where labours have become prolonged.” There is really no hard evidence that it actually speeds up labor or strengthens contractions. But it can increase the risk of infection for the mother and baby.
Pain medication- Well, this is one of those touchy subjects. But technically most of us don’t need pain medication for labor. Believe me, when you’re having a painful labor it’s not fun. (You should have heard me a few weeks ago during my last labor. “It huuuuurrrrts!”) But having pain medication for a normal labor (spontaneous and without serious complications) won’t make the labor any safer. There are many mothers who report positive experiences with pain medication during labor. However, like any medication, parents need to be aware of the both the benefits and risks as well as the alternatives- and pain medications do have risks. According to the American Congress of Obstetricians and Gynecologists, pain medications in labor can cause side effects like nausea, feeling drowsy, or having trouble concentrating. They can affect the baby’s heart rate temporarily. It can be more difficult to detect fetal heart rate problems when these drugs are used. High doses of these drugs can cause the mother to have breathing problems and can also slow down the baby’s respiratory system, especially right after delivery. Other complications can include: Decrease in blood pressure which can slow the baby’s heartbeat, fever, headache, and soreness. Serious complications with epidurals are very rare but can include: anesthetic medication being injected into one of the veins in the epidural space causing dizziness, rapid heartbeat, a funny taste, or numbness around the mouth. There are a number of different approaches for managing pain in labor that don’t involve medication including water birth with a qualified attendant, hypnobirthing and changing positions.
Episiotomy- Once upon a time, doctors thought that performing an episiotomy (a surgical cut made to the perineum) would prevent extensive vaginal tearing and heal faster than a tear. Turns out neither of those is true. The Mayo Clinic says that there are certain circumstances when an episiotomy might be recommended such as when extensive vaginal tearing appears likely, the baby is in an abnormal position, the baby is large (fetal macrosomia), or the baby needs to be delivered quickly. However, getting out of the lithotomy position can be very helpful in preventing or minimizing tearing in many of these circumstances.
Continuous Electronic Fetal Monitoring- Maybe you’ve heard that continuous electric fetal monitoring prevents babies from dying or being brain damaged during birth- but that’s only been shown to be the case for high risk pregnancies with conditions like preeclampsia, type 1 diabetes, preterm birth and suspected intrauterine growth restriction
If you’re low-risk, continuous EFM doesn’t have any proven benefits and has a significant increase in the risk of cesarean and instrumental deliveries and maternal infection. In fact, the American Congress of Obstetricians and Gynecologists has stated that for low-risk pregnancies there are no proven benefits of EFM over intermittent ausculation. (Intermittent ausculation is the form of fetal monitoring used by midwives who attend home births. It involves using a Doppler fetal heart monitor to check the heart rate every few contractions. It allows midwives to easily check heart rate when the mother is in different positions and even underwater in a water labor/birth.) So why do doctors and nurses persist in using continuous EFM as a one-size fits all solution? Well… it is easier on the nurses, especially when there is central fetal monitoring where the readings from several EFM machines can be observed from the nurses’ station. Intermittent ausculation requires more individualized attention. Doctors are frequently worried about liability and the possibility of being sued for not using it, even though there isn’t any evidence backing up this belief either.
Forceps- Well, by now you should probably be seeing a pattern: certain practices like the lithotomy position or continuous EFM for low-risk women lead to more instrumental deliveries. So if you’re low-risk and stay off your back and have intermittent ausculation during labor, you’re much less likely to end up with a forceps delivery. Which is a good thing since forceps delivery carries an increased risk of uterine rupture, injury to the mother’s bowel and bladder and injury to the perineum. The baby is at an increased risk for temporary facial paralysis, skull fracture, seizures and hemorrhage in the skull. All that being said, forceps may pose less of a risk of seizures for babies than delivery with vacuum extractor or c-section.