The Way We Give Birth, Part I

Currently, on my L&D rotation, I’m watching some of the best of medical obstetrics. Patients are actively managed throughout labor; OB’s break their water, start pitocin, consult anesthesia for epidurals, examine their cervixes every 2 hours, monitor the baby and contractions, and deliver the baby, repairing any lacerations that occurred along the way. I’ve seen a vacuum extraction and at least two forceps deliveries, as well as a cesarean delivery. We routinely induce labor in up to four patients per day, placing cervical ripening agents to make an unchanged cervix respond.

We deliver babies in head to toe sterile blue gowns, sometimes with face shields and booties. We drape the mother in sterile blankets, break the bed down, put her feet in stirrups, and place a plastic bag under her bottom to catch the mess. After the baby is born, we stand to deliver the placenta into a plastic bucket and repair any lacerations while the pediatricians examine and wipe down the baby. Often, mom is holding conversations with family members while we are trying to repair her perineum. Fortunately, most (all?) of these women have had epidurals, so they can’t really feel us stitching. Eventually, baby comes back to mom, we finish stitching, and someone wipes all the mess off, dries her off, puts the bed back together, and covers her back up.

It’s an entirely medical, sterile process, until mom starts to push. When she grabs her thighs, puts her chin down, and really pushes, I’m reminded of what an ancient process this really is. Then, I start to ask questions. How much of our “active management of labor” is really meddling with a natural process? How much are we really helping? Do we help more than we hinder, or vice versa?

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Most of my mothers labor flat on their backs. Gravity isn’t allowed to assist them; at best, their bed is tilted slightly above horizontal. The bed is often raised 3+ feet off the ground, to make the angle better for the OB. So why can’t we change the angle for the mother? Women for centuries gave birth standing in a squat—it seems the least we could do is give these ladies some gravitational force.

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I have not yet attended a labor without an epidural. I have nothing against epidurals; I’m seriously considering one when I have babies. I’ve seen many mothers say “Wow, I could really push—I wasn’t tired at all!” I also have not seen any latching problems that I could say were directly related to the epidural; I would venture to say that we do not encourage immediate breast-feeding enough, which probably has a large impact. The babies I’ve seen have all been quite alert. (I know I haven’t seen all that much; I’m only commenting on my experience.)

My only problem with our use of epidurals is that everyone has one. We have talked several women into epidurals who really didn’t want one. Sometimes, it’s medically indicated, but often it is not. I’ve seen several moms who really didn’t seem to need one, at least not early. Also, epidurals can cause complications (like everything else), and I'm not sure how well we really counsel patients as to the risks and benefits. But, I've never really seen a mom say "Man, I really wish I hadn't gotten that epidural," so maybe it's all worth it.

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As I briefly mentioned above, we do not seem to encourage immediate breast-feeding. Even in moms who say they wish to breastfeed, no one has returned a baby (after weights and Apgars) and suggested that she attempt to feed. It’s not a huge deal, I guess, but it seems logical that many breast-feeding problems may be avoided, or at least caught sooner, the sooner one starts to breast-feed.

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Almost every mother I’ve watched has had her labor “augmented” with pitocin. It’s an automatic reflex for the residents and attendings. “Start her on pit—I want to get her delivered before 5 so I can go to my meeting” is not an uncommon sentiment. Ladies on pit contract harder, so they have more pain, so they all have epidurals. Then, sometimes pit induces uterine hyperstimulation and fetal bradycardia, so they’re given terbutaline. I remember on internal medicine that someone told me you should try not to give a medicine to treat a side effect of another medicine, unless for some reason the medicine is absolutely necessary. Is all this pit necessary?

I guess I wouldn’t find it so problematic if the women were saying “I want pit—let’s hurry this up.” Instead, it’s usually the OB’s who are saying “let’s hurry this up.” There’s very little choice involved on the part of the mothers; I’d venture to say that most of them don’t realize they HAVE a choice.

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I guess my biggest problem is the attitude of the obstetricians. Most of the residents are fairly passionate; they enjoy delivering babies. When they’re on L&D, they have no other responsibilities—no clinic, no meetings. The attendings, however, are super, super busy. They’re lucky to make it to the deliveries of their patients, and they’re usually impatient. They come in when she’s pushing and they leave after the lacerations are repaired. The majority don’t seem too excited to be there; they’re usually in a hurry to leave.

I’m sure that childbirth can lose its excitement after a while. I understand that. It’s more the impatience that bothers me, this attitude that we should induce this lady or increase the pit in order to suit OUR schedules, not hers. I would venture a guess that the real problem, though, is simply the extreme busy-ness of the attendings. If they were less busy, there might be more time to come in and deliver, or they might be able to enjoy it more.

My grandmother told me once that she thought her OB had given her pain medication to delay the birth of my father so that he could go home. I actually don’t doubt her story, or at least that it happens.

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Is there an alternative to all this? There is: the midwife. In my next post, I’ll address what little I know about alternatives to medical birth (which, I'm sure, is not much, as I have not seen a single midwife or doula in my time in L&D).