Why medical induction should not be used routinely to deliver babies
by Tanya Mchale
Babies come in their own time, and their own time is often between 38 and 42 weeks.
But not always.
Last month I attended a birth with the baby being born at 35 and 4/7 weeks and it weighed over 8 lbs. There was confirmation that the mother’s dates were correct by the mother and the attending neonatalogist who evaluated the baby. Clearly that baby did not need an additional 4 weeks in utero to reach a stage of maturity where it could handle life outside the uterus.
Conversely, some babies will need more time in utero, and that additional time will often bypass the 41 week marker and sometimes even the 42 week marker.
The medical world has gotten used to scheduling inductions at 41 weeks, one week after the due date. But if the mother’s cervix has not yet started making cervical change, her likelihood of having a failed induction followed by a c-section goes up substantially.
In a study published in the Journal of Maternal-Fetal and Neonatal Medicine on January 2, 2014, perinatal outcomes were compared for a group of women who were induced at 41 weeks vs. a group of women who were allowed to go to 42.1 weeks (two weeks past the due date). First, it’s important to note that there was no difference in outcomes for the babies where the mothers were allowed to go to 42 weeks. Other sources have cited that babies do poorly the longer the mothers are allowed to stay pregnant, but this study contradicts those previous reports. Secondly, the study noted that of the women who were still pregnant between 41 to 42 weeks, 74% of women went into labor spontaneously prior to 42.1 weeks, when all remaining women in the study were induced.
What I glean from that study is that babies will frequently begin their journey out on their own, if given adequate time, and they frequently will do so without harm to themselves. This flies in the face in what is often practiced in obstetrics today, which is to just schedule a mother for induction at or before 41 weeks.
We can either believe that nature often makes mistakes, and therefore we must act preemptively before the baby harms itself, or we can believe that the baby and the mother’s body have a biological imprint for normal delivery that initiates in it’s own best timing. What is your leaning?
Why we need to continue to challenge the obstetric status quo in 2012
by Tanya Mchale
Having just watched Ironed Jaw Angels, a 2004 film based on Alice Paul’s and others work to get Woodrow Wilson and Congress to pass the right to vote for women in 1920, I bring new appreciation for the women of Illinois who have been fighting to give certified professional midwives (CPMs) a legal entity within this state. Who are CPMs and how are they different from certified nurse midwives (CNMs)? Why do we need one more type of midwife in this state?
The answers to these questions underlie our most basic premises of what is the best way to bring forth our children into the world. In modern obstetric practice, we assume that the method in which the baby enters the world is not even a blip in the order of importance in relation to whether the baby’s immediate physical markers can be judged as normal. I am not dismissing the value of having a healthy child, but I do grow weary of the erroneous belief that the single marker of observed health is all there is to measure through the passage known as childbirth. Contrary to what our culture seems to value, however, childbirth is an event that leaves its mark not only on the one being born, but also on the mother and father that is born in that moment as well.
Should the parents of the baby be led to believe that the way the baby comes out is insignificant “as long as it’s healthy,” she and he will never understand the disparate emotions that may come from our common transitions to parenthood. How does that transition often occur here? The mother not feeling a single contraction before the baby is lifted from it’s warm home into a cold operating room where it is whisked off to a warmer and learns it’s first lesson of human contact with strangers who offer the baby dispassionate observation. The parents may hide their disappointment and sadness as they compensate by minimizing the loss of an ideal start; in fact, that disappointment may never see the light of day if no one serves as an interpretive guide. But it may be just a beginning of a family pattern that minimizes the importance of presence, awe and honoring that can easily emerge in an undisturbed birth environment.
Certified professional midwives are midwives trained to deliver babies at home or in free standing birth centers. They learn through an apprenticeship model and arguably their board certifying exam that verifies their extensive knowledge of midwifery is deemed by many to be even more challenging than the American College of Nurse Midwives board exam. Certified nurse midwives’ (CNMs) primarily practice in hospitals. Those CNMs that practice home birth have to be creative and persistent in finding a renegade OB/GYN who will back them and work with them collaboratively. Very few CNMs in the state of Illinois practice this way due to its inherent challenges.
Although home birth is not for everyone, one value of having a certified professional midwife oversee the process is that this is the one practitioner who exists that has seen more normal births than abnormal births. If, on one end of the spectrum, the purpose of obstetric training is to observe and manage as much pathology as possible, the purpose of a CPMs role is to safeguard and trust the unique unfolding of a family in their own environment. Of course, health screening and low risk factors must be part of the criteria for such an event to take place at home. Many pregnant women would meet this criteria. And many do not choose this path because their culture distorts the beliefs of what is possible for the passage to parenthood.
If the standard obstetric beliefs prevail that there should only be one controlled environment to give birth, that of the hospital L&D unit, we will lose our ability to see that birth can thrive in a quiet undisturbed environment. Certified professional midwives are permitted in approximately 28 states, but in the state of Illinois the Home Birth Safety Act bill has yet to pass into law after several years of being in committee and in one session passing the Senate but not the House. Without the ability to have viable options for the pregnant woman in this state, we risk creating a strong fabric of belief in the need for interventions while giving birth. Are we wise enough to understand the value of diversity of options, one which preserves the process that effectively spawned mammalian birth upon this planet for more than a million years? If our wisdom is to reign in this field, we will challenge the status quo of this first benchmark of life.
What you may want to know about the hospital where you plan to give birth
Tanya Mchale published on February 10, 2011 at 11:01AM
childbirth, hospital birth, where to give birth
About 99% of American women will give birth in a hospital. What do you want to know about the place you give birth?
Understand your hospital’s philosophy about birth: Most obstetric departments are run by conventional OB/GYN’s that will do what they have been trained to do. They are not necessarily patient-centric in their approach. Mitigating factors that show that they have more of your needs in your mind include:
- Midwives that practice at the hospital AND are owned by the midwife group themselves. A hospital that may want the good PR but does not want to have to change their philosophy may hire a midwife group that practices under the obstetrician governed policies and procedures. If the midwives are owned by the hospital or by a doctor’s group, they are not necessarily practicing with a midwifery, family centered approach.
- A variety of non-pharmacological labor support measures that actually get used. If you ask about laboring in water, birth balls, and alternative birthing center rooms and you are given a sheepish “yes” or “maybe” as an answer, there is a good chance that these things don’t actually get used very often. Many hospitals want to say they offer these things to capture that demographic or look like they are interested in options, but when it comes down to it, it can be very difficult to access.
- IBCLC’s that see ALL of their postpartum patients. An IBCLC is a board-certified lactation consultant. She is someone who has put in between 2,000 to 4,000 clinical hours of breastfeeding assistance and sat for a lengthy extensive board-certifying exam to earn that title. Some hospitals, such as one very popular Chicago based hospital, have fired their IBCLC’s and replaced them with “lactation specialists,” a similar sounding title to lactation consultant, but the meaning of that title is VERY different. A lactation specialist may have gotten her training through a one-week class, and is not required to put in a specified number of clinical hours prior to using that title.
Ask moms from your community where they delivered and what they liked and did not like about it: People have differing values about what they consider a “good” birth. A woman who wants a c-section on demand may rave about her hospital’s ability to accommodate this request and their wonderful anesthesia department, AND she has different criteria than those who want a non-interventive labor and birth. Define what is ideal for you and your family, and then inquire around with your own criteria in mind.
Remember that large popular hospitals may not be better places to give birth than smaller community hospitals.
Larger hospitals are more likely to have physician-training programs called residency programs. Residents learn on your body, and are often in charge of your care in your primary care provider’s absence. Attending physicians (those that are done with residency) often use the residents to provide the majority of bedside care while you are admitted. I do not recommend hospitals that have residency programs as being good places to deliver for those reasons. Check with your health care provider as to whether the hospital they deliver at has OB and pediatric residents. If they do, expect to see more of them during your stay than your regular doctor. The worst month to deliver in as far as new residents is early July: a new group starts and they are advised to participate in care as much as they can. If it is busy, they many not be adequately supervised by older residents. The only time I saw a physician almost cause the umbilical cord to tear off the placenta was on July 1st, when a resident was attending a birth and left by herself caring for a newly delivered woman. Also remember that attending MD’s are not usually given the option to be with their clients and not use the hospitals’ residents. They are busy seeing patients in their office and doing surgeries, among other things.
Lastly, listen to your gut when you chose a hospital. If you have nagging worries, don’t downplay those thoughts. See what options best meet your criteria to assist you in having a happy beginning to your child’s life.
One chronic mistake we all make with laboring women is that we assume she is functioning from the neocortex. The neocortex is where logical thinking occurs. Yes, women can and do function from this part of their brains during labor. But labor and birth function most naturally when the limbic system (read: old, mammalian brain) is dominant during labor. A quiet, darkened room supports limbic system function. So does positive statements of interpretation of her bodily functions. When these statements are combined with slow pacing and rhythmic intonation, we are then utilizing hypnosis to support a woman through labor.
But direct questioning only serves to awaken her logical thinking and take her out of her limbic system. Unfortunately our hospital system seems to be largely unaware of that when they are dealing with a laboring woman; they increase the dysfunction of the labor pattern by direct questioning. So what do laboring women need to hear?
* You can allow these very strong sensations.
* Your body knows how to labor.
* Every uterine surge is bringing you closer to your baby.
* Your contraction is like a wave that you are riding.
* Allow your slow, deep breath to relax you.
* You are safe, your baby is safe.
* Your baby knows how to find it’s way out.
These statements can support a laboring woman through her entire labor and birth, without awakening her neocortex. How would birth be altered if all laboring women were offered a quiet dark room and nothing but positive interpretation of contractions? Imagine how the c-section rate could fall and the rate of natural birth could soar under these circumstances!
The second stage of labor is when the mother’s cervix has completely receded over the baby’s head and the mother begins expulsive efforts to release her baby. I have noticed that even when mothers have no cognitive instruction on this phase, when the forehead of the baby puts pressure on the posterior vaginal wall, most mothers begin to bear down with contractions spontaneously to release the baby.
Over the years there has been different styles of obstetric management of this stage. At the beginning of industrialized childbirth, in the 1930’s women were anesthetized with “twilight sleep,” a combination drug that included scopolamine. The result was that women could not respond to direct instructions during labor. Many babies born during these years were actually pulled from their mothers with “high” forceps (which strongly increased the risk of brain damage). Under the influence of this drug, women were in a haze that helped them to forget the actual content of labor. In addition to instrument delivery, leather restraints were also introduced to the labor and delivery unit to restrain women on the tables where they gave birth.
After that Draconian period past, the use of epidural anesthesia began to increase especially from the 1970’s forward. Epidurals reduce the ability to feel the natural urge to bear down, and the duration of the pushing phase is typically longer than an unmedicated labor because of the diminishment of natural feeling.
As an alternative pain management technique, small numbers of women have used hypnosis for the past fifty years. In the past 10 years in the US, a couple of authors of books who advocate the use of hypnosis for birth have dominated this field. One brand of hypnosis preparation is strongly against pushing during the second stage. In this methodology, women are advised to labor down gently. When the bearing-down urge presents itself, women are encouraged to inhale, exhale, and add a gentle pressure to the end of a bearing down effort.
While this sounds good in print, my vast experience with birthing women does not lead me to believe that this method works for many women. The only time women have a natural release of adrenalin in labor is when they enter the second stage. This makes sense; their bodies are about to push out a baby that is an average of 7 ½ pounds; they need increased adrenalin (read: energy, blood flow, focus) for this stage to accomplish this task. Releasing a baby is a giant act of physical exertion followed by the bliss of ecstasy brought on by labor hormones and the fantastic experience of meeting one’s offspring.
As a teacher of hypnosis for birth, I have heard expressions of frustration from many obstetricians and midwives about patients who attended other hypnosis prep classes where they were instructed not to push. These providers say that when women try to follow the method of gently bearing down at the end of an expulsive effort, some do this for hours without any progress toward birth and then they have to start strong expulsive efforts.
There is one important shift that should be made in the focus of this discussion: what does the mother’s body tell her to do? Does she feel an undeniable urge to push as the baby’s head comes lower? The obvious answer to me is for the mother to listen to her body, not anyone else’s methodology. I feel at times methodology can be arrogant, as there is an assumption that the method, rather than the mother, reigns.
1) One of the best ways to move through labor is to learn tools that will teach you how to allow very strong sensations (contractions) without creating resistance to those sensations.
2) If you are in early labor, go to work. It will distract you and keep you busy. (Don’t announce this to your coworkers however or your workday will be very short).
3) The time to go to the hospital is when the car is 100 feet away and she can’t figure out how to get to the car because the contractions are coming every 2-3 minutes and are so strong that she has to drape her body on yours and let go for the full contraction.
4) Install the car seat AFTER the baby arrives. The pregnant one needs the backseat so she can be on her hands and knees while you drive her to the hospital.
5) It is lovely to arrive at the hospital in a relatively calm state of mind & body at 9 centimeters dilated.
6) Don’t try to control others: your partner, your nurses, your doctors: it’s the biggest WASTE OF TIME. Spend more time developing your ability to cultivate happiness REGARDLESS of what others do.
7) Treat the baby like it is fully aware of your emotions—it is!
If you’d like to learn more eye-popping tips for labor, check the schedule for the next Hypnosis for Childbirth class starting soon.
One of the givens about United States culture is that we are swimming in commodities. Clothes, food, digital cameras, HDTV’s, cell phones, books, DVD’s, furniture: the list is endless. A commodity culture breeds a desire for finding the best deal. We love hunting for bargains and bragging about how little we paid for it.
So it gets confusing when we step out of commodities and step into services. We often want to bring our commodity sensibilities with us when we purchase a service. But it doesn’t really help us to look for cheap services. A cheap attorney? A cheap contractor? There can be serious repercussions for cutting corners in the service sector.
Purchasing a service, in part, is about purchasing expertise. It also means that you, the buyer, are committed. You don’t hire a contractor to re-do your kitchen when you are thinking about remodeling. You hire the contractor when you have committed to changing your home. Once you sign, you are going to experience the inconvenience of living through the remodeling. But all the while you know you are willing to live with inconvenience to get the results: a home that resonates with who you are and added value to an important investment.
In my field there is often confusion about the value of paying for monitrice care. Because I offer services in the field of health care many people have tried to determine whether or not to sign on for services based on whether their health insurance will pay for it. The reasoning goes that health care expenses should be covered by their health insurance, so why should I have to pay for something related to health out of pocket?
The short answer is because you are committed to having the best transition to parenthood possible. When you ask people what the best days of their life has been, most will state that their wedding day and days their children were born will trump all. We expect to spend money for our wedding (now an average of $20,000 without engagement ring or honeymoon) because we want to honor the commitment that we made in the best way we can. Interesting though that we often think that what ever health insurance covers is good enough for bringing our children into the world. If we had to pay out of pocket for our births, we would be paying around $15,000 for an average vaginal delivery. If we had to do that, I think most of us would be very picky about what kind of health care provider we would honor with our money. We would expect to be listened to, to be as empowered as the health care provider is, and to have a fantastic experience for ourselves and for our baby. We might interview several providers before we committed to the one we entrust to deliver our baby. But health insurance creates a type of insularity, a reason for not even questioning what the value of a good birth is. It prompts us to move right past the value of the birth and start investing our excitement and love for our baby into more commodities.
A good birth is more than a happy day: it can be the basis of strong connectivity to our children. A hormonal pattern of an undisturbed birth offers us weeks of easier parenting because of our high levels of beta-endorphins that contribute to bonding and well-being associated with the baby. A bad birth experience is often swept under the rug. Many women hide their shame, anger and sadness because they are told to just focus on the baby. But their feelings fester, chipping away at their self-esteem and level of connection to their children.
What would it be worth to you to have a guide through the maze of pregnancy and birth? What would be the value of investing a small amount in the beginning of your child’s life? What would it mean to you to make sure that no matter what kind of delivery you had, you would have an expert at your side that was concerned with your & the baby’s emotional experience? More than anything you invest in, this could have more significance to your family than all the commodities we could fit in our homes.Article originally appeared on Birth Transformation (http://www.centerbirthingtransformation.com/).
By the time a baby is in the last weeks of pregnancy, it is likely to have put it’s head down in the uterus, a position we refer to as vertex. About 3-5% of babies remain head up at term, and for those babies, in most locations, caesarian is the only mode of delivery available.
With caesarian birth, there is greater risk to both the mother and the baby. The mother, who would normally lose a little more than a cup of blood during a vaginal birth would be expected to lose at least a liter of blood during a surgical birth. When that mother goes home with a surgical scar on her abdomen, she is recovering from major abdominal surgery in addition to suddenly learning to care for a newborn. The baby born by c-section is more likely to spend time in the newborn intensive care unit from increased risk of prematurity and not having it’s lungs stimulated, as it does through a normal vaginal birth. In short, a caesarean creates increased health risks and makes recovery from birth much longer than in a normal delivery. Therefore we should do all we can to avoid unnecessary c-sections.
If you do some research on how to help breech babies to turn, almost all interventions will focus on how to physically get the baby to turn. This is as true for medical interventions as it is for alternative interventions. In obstetrics, external cephalic version is offered to women to physically manipulate the baby out of its breech position. Every alternative, from placing cold peas on the top of the uterus to get the baby to turn, to the chiropractic manuever called Webster technique which helps to relax uterine ligaments, to the Chinese medicine technique called moxibustion, which stimulates the Bladder 67 meridian, are all focused on physically repositioning the baby.
The one thing that I feel is missing from helping babies to turn head down is the psychological reasons for why the baby may be malpositioned in the first place.
As a pregnancy coach and hypnotherapist, I have worked with many women who have not connected the psychological picture with the baby’s position. In order to understand how this can work, you must first know what has been discovered about baby’s consciousness, even in-utero consciousness. Our culture makes a wide spread presumption that babies do not have as much awareness as an older child or an adult. In fact, after babies are born, we often justify why we can do things to babies by saying, “Well, the baby doesn’t know any better,” or “the baby will never remember the pain of this injection.”
In fact, APPPAH (Association of Pre- and Perinatal Psychology and Health), an organization that focuses on the awareness of babies and pre-nates, has been gathering research for over 30 years on how babies exist on two levels. According to their research, babies exist both as mammalian offspring that start out as pre-verbal human beings with little reasoning ability; and as sentient, conscious individuals who can understand their parent’s and other’s emotions toward them.
Utilizing this understanding in a clinical setting, I see many mothers who have not made the connection between the fear or stress they are experiencing and the baby’s position. If a baby is getting messages that birth is not safe, or life outside the womb is going to be difficult or some variation on these messages, babies often feel their mom’s emotions and refuse to put their heads down until the message changes. Fortunately there are tools from energy psychology that help to quickly alleviate the negative emotions. Once the dominant emotional pattern changes, then the baby can spontaneously turn with some help from hypnotic tools that create a strong picture for the baby to put it’s head in it’s mom’s lower uterine segment.
If your baby is breech, do consider what emotional messages the baby might be receiving. Start by playing “If the baby had full awareness of how I feel about birth, or having it, or raising it, what would the baby be feeling about coming out?” Consider consulting a professional hypnotherapist who can guide you through this process. This may be the one missing link to helping your baby into a head down position.
You have to move beyond fear by taking small daily actions toward your goal. Otherwise you may find yourself sending your copies of “Pushed” and “The Business of Being Born” straight off to Amazon for resale without ever looking back.
First, recognize your fears. They often sound like this: “For this baby, we’ll just give birth with the ob/gyn I’ve had since college. I don’t want to go looking around for a new health care provider at this point.” Or: “Of course I don’t really want an epidural, but I’ll just wait till I am in labor to see how bad it actually is.” Or: “I am going to hire a doula, and that way she’ll make up for my doctor’s conventional views and the unaccommodating hospital I am delivering at.”
What all of those statements have in common is a lack of commitment to shaping your experience of birthing your baby. The theme here is, “Now that I understand how technology based medicine may influence my birth, what is the smallest step I could take toward not having intervention and not upsetting the apple cart at the same time?
When you embrace natural childbirth, you need to embrace a daily practice of abdominal breathing, prenatal yoga, superior nutrition and many other tools that help you to get out of the way of yourself for this transformative event. You are now taking on the equivalent of wedding planning or marathon training. It is deeply worth the time because you can only start this baby’s life ONCE. You also need a strong support system composed of friends who have done what you are about to do, and a coach whom you can trust to guide you through it.
Don’t hide after you awaken; it will just create problems for you and your baby later. Begin by taking one step toward the outcome you are now seeking.
You have to admire nature.
When I planted the seeds in 40 Dixie cups last March, it was more to create some hope that the snow would finally melt one day and these tiny seeds may grow into one inch tiny vines with two true leaves. When they did, it was juicy in its gratification. 40 little living things, how affirming is that!
By early May I was tired of them occupying a ¼ of my dining room table. All had sprouted, some had died from a little neglect, but most were persistently present. So on the occasional warm sunny day, the Dixie cups went on field trips to the back yard. Then like teenagers pushing boundaries, they had the occasional night out on their own. They survived. More nights on their own, and finally the big transition, out of their pink and tan Polk-a-dotted homes and into the ground.
It was a cold spring in Chicago. By early June the nights often were still in the 40’s. It rained a lot, blew a lot, and stayed cold. Fireworks in rain and fleece jackets. Many overcast days. But the former Dixie cup occupants first looked sad and then decided to thrive anyway. As one would expect, first the radishes, lettuce, carrots took over the kitchen. Now, there are about 50 tomatoes ripening and I am tying bows on 15 giant zucchinis to give to everyone I can find who will take one. Tomorrow there will be more, and I will be trying to find yet another use for zucchini.
The point is, this incredible show from so tiny you can’t even see it with your bare eye to fear for the gardener who has to find her way through the mass of plants that have taken over her back yard is routine. Nature just finds a way to thrive.
Are we humans so different than the veggies and flowers? What would pregnancy and birth be like if we just relaxed and assumed that in spite of our vulnerable start, we are going to thrive anyway?
The first thing to know about the health care system, when it comes to birth, is that the system was not created for you. That is, you the pregnant woman, the laboring woman, you the new mom and you the baby.
It was created to perpetuate a use for itself, and you are its accessory.
There is a lie in obstetric care that is so pervasive that no one even stops to consider it. The lie is that birth is not safe, and that it would go terribly wrong without the help of modern technology. This lie is helped along every time a woman interacts with modern health care and comes out clinging to the belief that without her c-section she and/or her baby would not be alive if it wasn’t for the doctors that saved them.
Tell that to the 175 million years of placental mammals that came before us. If birth is dangerous, how is it that we so successfully managed to populate the Earth? Of the estimated 50 billion inhabitants that have populated the Earth, only a fraction have had access to the technology that we use to now deliver babies. That’s a lot of successful unassisted reproduction!
Sadly only 100 years into the introduction of technology on the birth scene, we have forgotten about our previous astonishing reproductive successes. Right now, stories about difficult labors abound in our culture. The concept that vaginal birth has any value for the baby or mother is shrinking, while justification for surgical birth is expanding. Let’s take a look at why birth is not going so well under our current tyranny of belief that babies can’t pass safely from their mother’s bodies without a cadre of machinery and people who think they know a lot about the process.
Our C-section rate just surpassed 33% in the US. The primary provider of health care for pregnant women is the obstetrician. We know that OB’s deliver 88% of our babies, but who is the OB?
The newly graduated OB, more often than not, is a 31-year-old woman who just spent the past four years of her life training in her specialty…a surgical subspecialty called obstetrics and gynecology. In fact, chances are that she chose this specialty for its opportunity to wield a scalpel. Is it surprising then that 33% of our babies are cut out of their mothers?
The obstetrician has one little piece of technology that gets more women in the operating room than ever before. That technology is called an electronic fetal monitor, and it is the device that almost all American women are hooked up to as soon as they are admitted to the hospital.
A fetal monitor is supposed to tell us whether the baby is doing “okay,” that is, whether it is maintaining a normal heart rate during labor. But what often happens is that as the baby rotates through its mother’s pelvis, its heart rate will normally drop from time to time. When it does, and when it is recorded on the monitor, the onus is now on the doctor to get the baby out as soon as possible.
This constant observation of the baby through labor gets more babies surgically removed than have ever existed in history, without improving their health one iota. This fact is according to the Cochrane database of systems, a group of researchers from Oxford, UK, who produce some of the best-randomized controls in the world. In their last evaluation of continuous fetal monitoring, they collected 10 trials with a total of 58,000 women and found that in babies close to their due date, babies that were constantly monitored resulted in a 40% increase in C-sections for their mothers without any health benefit to the babies.
In spite of the research, we persist in our actions and our beliefs that we need technology to make birth safe. We don’t really want to look at the research…it doesn’t fit our story about why we are giving birth the way we are. If it worked well, what would we do with all the bells and whistles?