The Way We Give Birth, Part III

Last week on L&D, a crusty old doctor (which my school seems to keep in large supply) sat us students down for a little chat.

"You ladies all want scheduled inductions these days. In private practice, around 90% of childbirths are induced, and that's a good thing. We induce in the daytime, when the hospital's full, so it's safer. We have cervical ripening agents for an unfavorable cervix. If you want to induce your baby on a particular day, why not? I'll check the cervix--if it's too unfavorable, I won't do it, but if a patient comes in at term and her cervix has changed, I'll go ahead and schedule her induction. And if we schedule labor, especially during the day, I can attend more labors. I probably attend over 90% of my patients' deliveries.

"Did you know childbirth is the only type of pain that a doctor is allowed to withhold pain medication for? It's true. For any other pain as intense, a doctor would be committing malpractice to withhold pain medication. That whole 'natural childbirth' thing? Nonsense. All that Lamaaze crap--it doesn't work. I'm so glad that fad is over. Childbirth hurts! Epidurals are good!

"I don't see why labor is different from any other medical condition. We control our blood pressure, we control our cholesterol--now we control childbirth the same way."

I thought it was interesting to hear these viewpoints, as the other student and I had spent a good part of our time on L&D discussing alternatives to medical birth. Both of us had felt somewhat alienated by the medicalization of the whole process, but neither of us had really heard a justification for the medical attitudes. I was especially surprised to hear him admit that OB's schedule deliveries for their own convenience--he not only admitted it, he reveled in it. If you're going to be a medical OB, it's not a bad idea to be like this guy. Be passionate.

Nevertheless, I couldn't help but be turned off by his little speech (which went on for probably half an hour--I've abbreviated a good deal). He simply assumed that all patients would agree with this mindset, and he basically brushed aside any concerns--I know what's best, honey.

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I'm turned off by the prevailing mindset in medical obstetrics, but I'll admit to being frightened of going totally the other direction. I've seen several stat c-sections where things were going fine and then BAM! prolonged decelerations of fetal heart rate, or cord prolapse, or shoulder dystocia, etc.

The reason we don't all give birth at home in comfort is that we've all heard a horror story from our mom, our aunt, our grandmother about the "bad old days". Despite the fact that our maternal and baby mortality rate is high for an industrialized nation, it's still better than it used to be. In the 1930's, up to 1 in 150 mothers died as a result of pregnancy. Now, fewer than 1 on 10,000 mothers die. We've come a long way.

I think one problem is that we don't really distinguish between low and high risk pregnancies. Sure, we talk about the difference between the two, but at my hospital, we strap them all to a continuous fetal heart monitor. Therefore, the difference is blurred for me; in looking back, it's hard to tell which pregnancies were high and which were low risk because they were all treated the same until fetal distress ensued. Thus, it's hard for me to remember which ladies were higher risk prior to delivery and then had trouble with delivery, as opposed to ladies who had no indication of trouble and then ended up with an unexpected complication.

Atul Gawande's new book, Better, has a whole chapter devoted to the history of obstetrics, the development of the forceps, and the rise of the current medical aura. He attributes a lot of it to the need to "standardize" OB. Only a highly skilled doctor may successfully use the forceps; almost any obstetrician can use a vacuum, or perform a cesarean section. In the right hands, forceps are as safe or safer than c-section; in the wrong hands, they are quite dangerous. In the interest of saving all babies, no matter the skill of the doctor, birth has become more standardized. It's an interesting viewpoint.

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At the end of all this rambling, I've reached some temporary conclusions about the way I want to labor. Home birth scares me, because of my innate fear of something going wrong emergently, STAT, that requires medical intervention. Fully medical birth is distasteful to me. I think if I were to have a baby tomorrow, I'd probably try to find a doula to assist me in labor at a hospital. I'd like to try to do without the epidural, or at least put it off for a while. If my labor is progressing well, I'd like to avoid pitocin and artificial rupture of membranes. I'd like to get up, walk around, use a birthing ball, use the restroom without help, etc.

However, out of cowardice, I'm hedging my bets. Instead of fully trusting my birth to a midwife, at home, I'm trying to have my cake and eat it too. I'm also leaving myself plenty of room to eventually change my mind in either way as I get more information--hence "Part III" instead of "Conclusion". And, like the lady in Better, who ended up having a c-section after extremely protracted labor and arrested descent, I'll get over it if I can't have everything I want, so long as I'm home with my baby eventually.

No, I'm not pregnant. No, I'm not planning on becoming pregnant any time soon.