Perspectives on Normal Birth.
By Ronnie Falcao.
I recently returned from a three-month internship at one of the birthing
centres that doubles as a training centre for direct-entry midwives.
I had already studied a basic course in midwifery academics and apprenticed
briefly as a labor coach and midwife assistant, but it had become
clear that hands-on experience would come very slowly as an apprentice.
The requirements for both national certification as a Certified Professional
Midwife and licensure in California include at least 20 births where
I act as primary attendant under supervision, and it might take several
years to get that experience in a standard homebirth apprenticeship.
Because I'm nearly 40 years old and didn't want to add an extra couple
of years to my training time, I gathered information about various
intensive midwifery training programs and finally selected one that
was likely to offer the kind of experience I needed. Although there
were sacrifices in terms of tuition money, rigorous conditions and
three months spent away from home, I expected to get a lot of experience,
including 20 catches.
Fortunately, my sacrifices were amply rewarded with an amazing amount
of valuable education and experience, including a new perspective
on how outrageously unnecessary Caesarean rates of 20-30% are. During
my time at the birthing centre, there were 116 laboring women who
came into the centre. Of those, only three were transported - one
for pitocin augmentation, one for possible fetal distress, and one
for suspected CPD. Only this last case ended in a Caesarean delivery.
Although most babies were routinely suctioned, a small percentage
needed oxygen or more serious resuscitation. So, during those three
months, of the 116 women who came to the centre, only 1 labor ended
with a Caesarean. That's a Caesarean rate of less than 1%. Or a 3%
combined transport/Caesarean rate.
I've given a lot of thought as to why this might be so low. Certainly
it was not because of the population. If anything, it was a population
at risk - many of the clientele struggled to afford the low birth
fees and had limited ability to purchase recommended supplements,
although they did manage to grow healthy babies nonetheless. There
were a number of women with characteristics of android or platypelloid
pelves, not ideally suited to giving birth. A lot of the "young women"
were really girls, many younger than 18. And, as in any population,
there were women with family situations or past traumas that made
giving birth a trying emotional ordeal.
Some women were not entirely trusting of natural childbirth and were
apprehensive about our lack of drugs to dull the sensations. Some
had had unsatisfactory previous birth experiences - they came with
episiotomy scars, and a few even came with Caesarean scars. So, yes,
there were VBACs and borderline cases of PIH or polyhydramnios, and
there were lots of first-time moms; there was even one planned breech
birth. A lot of women were "induced" with castor oil after 41 weeks
so that their care wouldn't have to be transferred out of the birth
centre at 42 weeks, which nobody wanted.
Hardly an ideal clientele. And yet, a Caesarean rate of less than
1%.
How was this possible? How could it be that this birthing centre
had such a tremendous success rate, and all without any drugs for
pain relief? How could they do this with no electronic fetal monitoring
and no pitocin IVs? Well, that's probably half the answer right there.
Recent studies have shown that active management (i.e. pitocin augmentation)
and continuous electronic fetal monitoring do not improve outcomes
for moms and babies; in fact, they only seem to increase the Caesarean
rate. So maybe the "shortcomings" of an out-of-hospital birth were
a great part of the secret to success.
But still not enough.
Perhaps it was the built-in doula system. Although most laboring
women did not have continuous labor support from birthing centre staff,
they were individually observed each 15 minutes or so when the responsible
intern checked the baby's heart rate. Each of these visits was an
opportunity to observe the mother's condition, her progress, her response
to contractions. We did a lot of the standard doula work - recommending
changes in position, making sure they're eating and drinking enough
to keep up their strength, suggesting a shower when they got to some
of the transition points. And sometimes, for a mom without family
to support her, we did stay with her continuously if she was having
a hard time.
But mostly it was family staying with them.
So, could it have been the labor support that made the difference?
Maybe, but the doula studies only show a 50% reduction in cesareans,
not anything so dramatic as down to 1%.
So, I kept thinking. What was different about the situation at the
birthing centre? What was the single ingredient there that you don't
get anywhere else.
And then it came to me. These women were getting the kind of care
that money cannot buy. Each of these laboring women had a dedicated
caregiver who had or knew how to access the necessary expertise to
do whatever it took to help each woman have a vaginal delivery; and
that caregiver desperately wanted this labor to end in a vaginal delivery.
I'd like to be able to say that our dedication to the desired result
was because of our unrelenting support of natural childbirth, our
dedication to the clients, etc. But, in reality, operating on severe
sleep deprivation, working every day of the week, 75 hours/week, sometimes
with clients we had never met before, our motivation was not entirely
pure. We needed that birth to be a normal, spontaneous vaginal delivery
because nothing else would count as a catch for theintern. And we
needed that birth to be as easy as possible for the mom so she would
progress well and give birth on our shift, or else it would count
as a catch for some other intern.
Averaging out the tuition money and time I spent at the birthing
centre, each baby that I caught cost me over $100 and half a week
away from home. These were not opportunities that I was going to let
slip easily from my grasp, and certainly not to end in a Caesarean.
Really and truly, I wasn't thinking about all the economics of this.
I only knew that I had waited for nine long months for the opportunity
to catch babies, and I desperately wanted to catch as many as possible.
I worried when I didn't seem to be catching as many as other interns.
I was willing to stay for hours after my shift ended if it meant an
opportunity to catch a baby that looked like it might come soon, as
was permitted by policy. Even though I would then also be required
to provide another couple of hours of postpartum care, I was eager
to work a 16-hour shift if it meant more experience - another catch.
So, basically, the laboring woman was in the care of someone who
happened to have an unusually strong commonality of interest - an
efficient, easy vaginal delivery.
It didn't always work out that way - there were first-time moms who
needed one-on-one labor support for the better part of my twelve-hour
shift and then didn't deliver until six hours into the next shift.
I feel very lucky to have been at a place where I could still share
in her triumph, as we had the opportunity to observe every birth,
even when not on our shift. (No, please, don't ask when we slept;
it makes my body wince to think about it.)
But mostly my intense focus on keeping this woman's labor "easy"
and efficient was rewarded. I learned how to keep an eagle eye on
heart rate - to notice the first little beginnings of a troublesome
pattern and to keep trying things until we figured out what was causing
it, almost always the woman's position. Sometimes we saw early decels
that made me a little nervous, but then we knew the baby was at the
spines and it might be a rough road through. No problem. I learned
a lot about taking advantage of the relative relationship between
the baby's head and the mom's pelvis. I knew that it was almost certain
that this baby could fit through this pelvis - it was just a matter
of figuring out how.
And mostly it just took a lot of time, patience and hard work. There
were some marvellous teachers there, and I saw babies birthed in just
about every position in between upright and a full squat. And I learned
how to reshape a pelvis by applying pressure to this bone or that
bone at the critical moment to help the head get through.
I learned the beauty of real midwifery, being with the woman, advising
but not controlling. I saw some amazing examples of women knowing
exactly what her body needed to do to get this baby out. Sometimes
I would suggest a particular change of position, and she would start
to assume that position but somehow end up in another position that
I could never have imagined. Then, fifteen minutes later, she was
ready to push the baby out. I learned a profound respect for instinct.
I learned to take pleasure and pride in minimizing the interventions
- trying to help the mom deliver nice and slowly, assuming the baby's
heart rate wasn't at all worrisome. The slower the better - the baby
was better oxygenated at birth, and the moms didn't tear. The rate
of tears that needed suturing was about 15% while I was there, even
with small mothers and big babies. I saw nine- and ten-pounds babies
born with no tears.
So, will I be able to duplicate this level of success in my own midwifery
practice? Sad to say, probably not. I'll probably need to transfer
care earlier for women with borderline conditions, mostly due to legal
restrictions. I personally won't do breeches until I have a lot more
experience, but I do know an excellent homebirth midwife who is more
than qualified to attend breech or twin births. And I'll probably
never feel the same passion about really, really wanting the woman
to deliver under my care. This is probably a good thing and will keep
me from making decisions that might not be appropriate for a homebirth,
even where they were appropriate for the birthing centre, where there
were lots of experienced hands around.
However, I will strive with every ounce of ingenuity to see that
I match the overall statistics. I will hope to be able to say that
of all the women who entered my care, less than 1% had cesareans,
even though my transport rate may be more like 10%.
I hear myself say this and I hear the voices of doubt saying, "But
even Marsden Wagner says that Caesarean rates less than 5% tip the
balance towards losing moms and babies unnecessarily."
But I know that this is only the case where you're getting care that
money can buy. That's the type of care that isn't passionate about
preparing each and every mom mentally and physically for a vaginal
birth. That's the type of care that doesn't even believe in the concept
of "setting a mom up for success" through prenatal education, visualization
and appropriate herbs. That's the type of care that knows they "can
always do a Caesarean". That's the type of care that doesn't give
you much information on "how to turn a breech baby" other than to
schedule an external version, knowing they can do a Caesarean if things
go wrong or it doesn't work. That's the type of care that thinks it's
"easier" to have a mom with an epidural than a mom who's up and about,
changing position, eating and drinking to meet her needs. That's the
type of care that ignores those early warning signals of a funky heart
rate and ends up doing an "emergency" Caesarean for a situation that
could have been prevented, but only by the kind of care that money
cannot buy.
I feel confident in saying that if any individual woman offered a
skilled caregiver a million dollars if she had a vaginal birth, that
woman would have a vaginal birth 99% of the time. Why? Because then
it would be economically feasible to spend an hour with her at each
prenatal and address issues of presentation and position at every
appointment. Then it would make economic sense to anticipate the physical/social/emotional/psychological
issues that might become a problem for this particular woman, and
to advise strategies for coping with them. Then it would make a lot
of sense to facilitate the woman's going into labor at the first favourable
opportunity; this is easily done through herbs and relaxation/visualization,
but rarely done. Then it would make infinite sense to visit the woman
early in labor to make sure the baby's position is favourable, before
it's too late to change it easily. Then it would be extremely cost
effective to hire the best help necessary to provide non-pharmacological
support during labor - massage, chiropractics, hypnotherapy, a birthing
tub, a TENS unit, all in her own home, where she can labor most easily
and effectively. Then it would obviously make sense to attend the
woman full-time once she's in active labor, to make sure that everything
continues to go well. Then there would be no rush to hurry the pushing
phase, or the crowning, or the cutting of the cord, the bathing/separation
of the baby.
In short, it would be a completely different experience. Unfortunately,
an experience that reasonable sums of money cannot buy.
But sometimes that which cannot be had for money can be had for love.
Love of the triumph of the human spirit in each birth, love of the
strength of women as they labor to bring forth life, love of facilitating
the easiest, gentlest, quietest birth possible. Love of life and love
itself.
So, if you want to improve your odds of having a normal, spontaneous
vaginal delivery and a triumphant birth experience, I recommend selecting
a caregiver who does it for the love of the work above all else.
This article was originally published in the November, 1996, issue
of The Clarion (Vol. 11, No. 3), the journal of the International
Caesarean Awareness Network (ICAN).
Ronnie Falcão, LM, MS, is a homebirth midwife, licensed in
California. She also practices as a labor coach and prenatal hypnotherapist,
based in Mountain View, near San Jose, CA, USA. E-mail can be sent
to falcao@best.com
|