Continuation of my commentary on the New Yorker article ~ Part 2 – corrected and republished on 10-26-2006
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I’m a part-time scholar in the history and politics of midwifery and obstetrics. One of my areas of expertise in obstetrical history is the period from 1820 to 1935. I have a considerable library of classic obstetrical textbooks and archival copies of the original documents from this period. Information from those documents disproves many of the crucial facts about obstetrical history as presented by Dr. Gawande.
Unfortunately for all of us, the facts used by Dr Gawande are either wrong or used in a misleading manner. His tactics were scare-tactics, a strategy that discourages public debate or any individual questioning of the practices and policies institutionalized by the American
Dr Gawande is factually incorrect to conclude that:
- each and every childbearing woman through out the history of the human species has been just seconds from disaster at all times
- only the ‘obstetrical package’ stands between the modern mother-to-be and catastrophe
- if women wind up with an unwanted C-section, the Cesarean hasn’t anything to do with the style of obstetrical management –Mother Nature is just a bitch
- as long as the baby is healthy, it really doesn’t matter that its born by major abdominal surgery or that you can’t breastfeed it
This makes the obstetrical package like a planned plane crash -- all that counts is that you can walk away from the wreckage with all your limbs intact. That is really a sad, if not actually perverted, vision of the best we can do for the 70% of healthy mothers giving birth in the 21st century.
Missing the Point – effective strategies for labor
But aside from the substitutive criticism, there was a particular place in the article that I thought was the most striking example of having missed the point. I wondered if I was the only one who saw that connection. Since a midwifery client of mine told me she had just read the New Yorker article, I ask her what she saw as most representative of a fundamental misunderstanding. She blurted out “when her husband went to sleep while she (the physician-mother-to-be) was having strong painful contractions, leaving her in pain in the middle of the night all by herself”.
I had the same reaction – the obstetrical ‘package’ was unable to provide care to the mother at this most critical junction -- its not part of the ‘package deal’. Obstetricians don't attend labors and they certainly don't make house calls or send other knowledgeable professionals in their stead. Then, with either hubris or arrogance, the obstetrical profession uses the negative consequences of that built in failure (or as they say in Silicon Valley -- it’s not a bug – it’s a feature!) as an example of why ascending levels of obstetrical intervention, including the most extreme of those interventions -- Cesarean section -- are always warranted.
Of course, the narrative of this mother in labor has nothing to do with the official merits of the either the article or the obstetrical package. However, it was used by the author to exemplify how, despite the ‘best of circumstances’, mothers or babies will, with great frequency, need to be ‘rescued’ by C-section.
But lets fact it -- if a pregnant physician (with all the ability to control events that we ascribe to physicians) who didn’t want any interventions and wished to have a natural birth with fairies in a forest bower has, instead, the ‘book’ thrown at her, up to and including an unplanned C-section, then Freud must have been right all along – female biology is destiny (a desperately defective one) -- and obstetrics is our only salvation from the cruel fate of Mother Nature.
It not my intention to dishonor the birth experience of Elizabeth Rourke, the young mother/physician described in the article. Should she ever read this blog, I apologize for making public comments about so important and private a matter. Actually I believe that any C-section that has already taken place was ‘necessary’ -- at that time, with those particular individuals and under those specific circumstances, it was the necessary thing. As with all “water under the bridge” situations, we learn from it (doctors included) and move on.
So I want to re-contextualize my comments as addressing the general circumstance that Elizabeth Rourke’s situation was to exemplify, but not
Physiological Management ~ not the absence of medical interventions
In that regard, I have to mention that physiological management is not simply the absence of medical interventions. Being at home alone in the middle of the night with no physical, psychological or social support services, no way to access how you are doing, no witnesses to your pain and your valiant efforts to cope, is neither ‘natural’ or normal. When a mother experiences labor as unending unendurable pain, her mind and her body start working against each other and she will not be able to make progress unless or until she receives appropriate social and emotion support or effective drugs.
Functionally speaking, what makes a bodily process “physiological”, rather than simply biological, is the interplay between the psychological and emotional state of the individual and the targeted body organ – think erection (or the let-down reflex for breast milk) and you’ll have no trouble getting the picture. The big problem with the industrialization of childbirth is that the current ‘obstetrical package’ offers no specific training, experience or skills in physiological management – i.e, the mind-body events of labor and childbirth.
This means that modern interventionist obstetrics has little more to offer healthy women with normal pregnancies than kidney dialysis has to contribute to those with healthy kidneys. The contemporary problem with obstetrics for a healthy population is that obstetrics is all about the obstetrician, not the mother or the physiological process. Also missing from obstetrics is active concern for the social and economic consequence of policies that promote the routine use of the expensive, pre-emptive strike and its many complications -- immediate, delayed and downstream. It’s the ‘gift’ that keeps on giving.
For the professional practitioner of normal birth, physiological management is not a passive state. In fact, it is just the opposite – it is an activity and a rather arduous and intellectually-discerning one at that. It is a ‘contact’ sport that uses continuous physical proximity, physical touch and intimacy skills, more than a tad of mothering and an occasional Dutch Uncle- football coach “only you can push your baby out normally, so open your eyes and look at me, focus your energy and just push a little bit more” pep talk. You have to love your mothers like they were your daughters, love being a birth attendant, pray fervently and then work wholeheartedly like your prayers meant nothing at all.
When the mother is having serious trouble coping or is not progressing in labor, it requires the full-time presence of the primary care provider (physician, midwife or labor attendant) through out the remainder of the labor. This includes the latent and early 1st stage if that is where the problem first showed up. It is important to build into everyone’s expectations – mother, father, midwife, family, etc – an acknowledgment that most contemporary women experience 4 to 48 hours of a “warm-up” phase. This is an irregular labor pattern of varying lengths and strengths – too much labor to be ‘normal’ but not enough to expect progressive change.
Warm-up Labor ~ Why it’s OK and How to Cope
However, prodromal labor should not be thought of as an inherently dysfunctional state. In many instances, a long prodromal phase seems to prepare the mother for a briskly active labor and straightforward birth. It is a period with important contributions in the social, psychological and biological realms. The mother gets to make the mental changeover from just being pregnant to “moving day” for the baby – being in labor. She gets to ‘practice’ her coping techniques, while the father and other family get involved and focused on the mother, as they should.
While I don’t have facilities to do endocrine research, I do have a hypothesis generated by close observations over a long time – the prodromal and latent phases of labor seem to trigger the mother’s biology to start building up the necessary hormones of labor – oxytocin to progress labor, beta endorphins to make the pain of labor tolerable and adrenal hormones to help the mother push during 2nd stage and prepare the baby for independent respirations at birth.
From that standpoint, the physiological contribution of the warm-up phase is equally, if not more, important than the social and psychological contributions. I am convinced that the biological evolution of normal labor and birth, as a successful and straightforward event, actually benefits from and is programmed for this “warm up the mother / build up the hormones” phase.
Natural Birth in the Natural World
I have carefully interviewed women from non-industrialized cultures (
In agricultural societies, the on-going demands of family or farm take precedence over early labor until such as time as the uterine contraction pattern is overwhelming --so long, so strong and so close together (3-4 minutes apart and a minute long) that the mother can’t do anything else. Then she must fully attend to giving birth, which tends to occur in less than 6 hours from this point. This is the only part of that long period that is officially acknowledged as “labor”. The biological gift of this is a mother who usually gives birth when she and her unborn baby are physically strong, well nourished and well hydrated, which is ideal.
Initially, the most effective coping style for the early end of warm-up labor is called distraction. The mother and rest of family are encouraged to go on with their normal life during waking hours as a strategy to distract her from the early crampy and often anxiety-provoking aspects of her experience. During the night time, the coping strategy of “distraction”' means turning off the lights and resting in bed, even though she will be awakened regularly by contractions.
If she can’t tolerate laying down during a contraction (most women find lying on their back while in labor to be intolerably painful), then midwives and other labor attendants suggest that she prop her self up in a comfy chair and doze between contractions, while incorporating the next style of coping during each contraction – paying attention and using her labor breath.
One that I find to work well is a pattern of 6 to 10 breaths in a one minute period, in which the mother takes a little short inhalation each time (2-3 seconds), followed by a slow, steady relaxed exhalation (6-10 seconds). Physiologically speaking, each exhalation is similar to letting the air slowly out of an inflated balloon or singing a long musical note. According to my
Being in Control – Not a Characteristic of Labor or Birth
I frequently provide care to older, highly educated 1st time mothers, who lead incredibly busy and stressful lives. In particular, these women seem to seem to actually benefit from a longer a warm-up phase. The sleep deprivation naturally associated with it seems helpful to women who have a hard time giving up control.
For the female of the species, labor and sex are typically a “you’re-not-in-control” experience. Both benefit from ‘surrendering’ oneself to the biology of the moment and riding (as opposed to fighting) the waves of sensation. For most (but not all) women, as they get farther and farther out on the sleep derivation scale, the psychic stiffness slowly ebbs away. They get too tired to fight, soften slowly and eventually surrender. Some may have 60 hours of warm-up, 8 hours of latent labor and as few as two hours of active labor.
Alas, for some, sleep deprivation only makes everything worse. These moms will need an epidural before they can function again and labor progress.
However I remember one client who fit the general description of a high stress life, who went from 5 centimeters of cervical dilatation to delivery in 43 minutes. This was after 74 hours of “yes/no, maybe-baby-day, maybe-not” labor. Her first contraction was 3 am Wednesday morning. Early active labor set in at 11 pm Friday night. Saturday morning at 4:48 am her water broke and she was 5 cms. At 5:31 am – exactly 43 minutes later -- the 8 pound baby was born. I’ve seen a lot of deliveries, but a photo-finish birth like hers still stands out in my mind. Spontaneous biology, yes – bring it on!
Industrial Responses to Human Physiology – not a good fit
For the rest of the childbearing population, the prodromal phase is where industrialized childbirth prematurely hospitalizes women. This is especially a problem for 1st time mothers. Their care providers don’t make house calls, the mother can’t tell what is happening to her and she can't cope at home all alone. Hospitalization and the obstetrical package is the only help and only hope available to her. For a large percentage of contemporary women, the warm-up/prodromal phase is where the trolley goes off the track, triggering the cascade of unwanted obstetrical interventions and ultimately ending in an operative delivery 24 to 48 hours before the baby would have naturally have arrived.
This phase often includes painful, close together but brief contractions that make it difficult to sleep normally, so obviously that is a big factor. Midwives make daily (or twice daily) house calls during this period of time and remain at the mother’s home when appropriate. There are strategies to help women get thru this period – dozing in the bathtub is a favorite – and I always use the example of being sleepy on a transatlantic flight. You can’t lie down and you can’t stay awake, but you really want to go to
The prodromal phase is particularly hard if the mother starts labor already at the skinny end of sleep deprivation. This was obviously the case described in the New Yorker article, as the mother-to-be was a resident at Mass General. According to Dr Gawande, she worked up to the day she went into labor. Considering the long hours required of medical residents, one can assume that she was suffering from massive and chronic sleep deprivation. She readily admitted that it was extreme sleep deprivation -- more than the pain of labor -- that triggered her grudging request for an epidural. Mind you, this was coupled with the fact that few other options were offered by the hospital staff or available in the hospital environment.
The obstetrical package doesn’t routinely offer active support for the physiologic process. Instead it depends on the sequential use of various interventions. The contemporary obstetrical package as provide to healthy women consists of:
1. Admission to a labor room bed - 99%
2. Continuous electronic fetal monitoring - 93%
3. Administration of intravenous fluids - 86%
4. Being confined to the bed during labor - 71%
5. Giving birth on your back - 74%
6. Artificial rupture of membranes - 67%
7. Labors induced or artificially accelerated - 63%
8. Epidural anesthesia - 63%
9. Gloved hand inserted into the uterus after birth - 58%
10. Bladder catheterizations – 52%
11. Episiotomies - 35 %
12. Cesarean section - 29 %
13. Instrumental delivery forceps or vacuum (12 %)
(*Listening to Mothers Survey- 2002, except C-section rate taken from 2005 stats)
An astounding 76% of healthy women with normal pregnancies (70 % of all pregnancies) who are having babies in the system of industrialized childbirth will experience some form of operative procedure, if you just count the rate of episiotomies, forceps and Cesarean section. Artificial rupture of membranes and manual exploration of the uterus after delivery are both technically surgical procedures for billing purposes, but I did not included them in these statistics.
As for Elizabeth Rourke’s choice to not to have effective labor support at home, I can appreciate that neither she nor any other mother wants to “be paired with someone who might be annoying”. However, that’s another of the many good reasons for having a practitioner relationship with a midwife as the designated labor attendant. You start out by working with the midwife during the prenatal period. If she turns out to be annoying, you find a different one long before you are in labor.
Elements of Success for normally progressive labor
As for what a skilled and experienced labor attendant does for a mother with a painful non-progressive labor, it starts with strategies for calming her by first addressing and defusing the anxiety and fear. Vaginal exams, while kept to a minimum, are necessary to get a bench mark, judge progress, inform management decisions and keep everybody attached to reality. They are also necessary to get the mother to the hospital at the right time - not too soon, not to late, but just right (6 cms).
In the mean time, the midwife must provide effective non-drug methods to manage the mother’s pain and reduce it to a tolerable level. This usually includes touch relaxation and/or walking around, being upright and mobile, making right use of gravity, having access to a hot shower or warm, deep-water tub, etc, and lots of encouragement. I tell the mother to think of this as “doing labor a half-hour at a time”. It helps everyone to keep focused on the moment and away from the “what ifs” - what if something is wrong, what if this goes on all night, what if I can’t take it any more, what if I loose it – this list never ends well.
When the going get tough, it means that someone -- midwife, husband or family friend -- must breathe with her through each and every contraction. Face-to-face, one-on-one support by an experienced midwife or labor attendant and the continuing presence of an encouraging husband is the functional norm under these circumstances.
Contrast the dynamics of that description with being alone in a dark & empty house at 2:30 AM after being in labor all day, husband sleeping soundly in the other room, as one is gripped by the 500th labor pain, no end in sight, no help, no hope. Midwives call this the “Kill me now” phenomenon. By that point women will agree to anything, no matter how much it diverges from their plan or violates their body.
For women who are overwhelmed by their current stage of labor, the process of labor support is highly reminiscent of talking someone who is afraid of heights down from the tallest branch of a swaying tree. It is an art form, an all-encompassing activity like writing, where every word, every minute matters. It is also vital that the husband /father/ partner repeat to her frequently and ardently (if not passionately!) that he knows she “can do it”, that he is confident in her and her ability to cope, that he is there to help her, that he believe she has what it takes to give birth to their baby and that whatever happens, they’ll deal with it together, etc.
Husbands & Fathers -- the Secret Weapon Against Discouragement
I cannot emphasis enough how important it is for men to overcome the idea that they “can’t know what its like” and therefore have no “right” to say anything definitive or take a stand on the general desirability of a normal biological process (as contrasted with blasting caps, salad tongs or a toilet plunger to pull the baby out).
Fathers also can’t permit themselves to give in to the idea that their wife’s experience of labor is the rightful role of the obstetrician. It’s not -- he or she won’t be there until the very end. If, by chance, they come before the baby is on the perineum, well, lets fact it -- doctors still don’t ‘do’ labor. Last but not least, husbands must divest themselves of the idea that the ‘proper’ role for the husband is to defer to the obstetrical ‘wisdom’ of the system – the “hey, I’m not gonna tell the doctor how to do his business” or that “how can I (a non-physician) tell if something’s wrong? I’ll just stay way back and watch”.
No, no, no, no! To the mother, the husband is the most important person in the room. If he gives away his natural power, her “rock of
Childbirth is about making functional families, so let’s help all the family members to be empowered at this crucial time. Bonding is not just for mothers and babies; it’s also between husbands and their wives and sometime between mothers and daughters or between the mother and her sister or other family member. Fathers and families are going to live with the mother and baby for a life time – the staff is going home after 8 hours and will never see any of you again. In a few years the
Athletic Coping -- Not Usually an Effective Coping style
While every woman’s process for coping with labor is unique, ‘coping’ styles that are highly energetic, even athletic, do not work, physiologically-speaking. I’m describing a labor with lots of rapid striding about the room, dramatically writhing and moaning with every contraction, desperately grasping the hand (or other body parts) of those nearby, perhaps attempting to bite themselves or others -- the word ‘panic’ should give you the picture. This is the psychological equivalent of a trickle bleed -- it places an absolute duty on the birth attendant to respond effectively.
Just as the constant loss of a small amount of blood multiplied by many hours is a devastating form of hemorrhage, so is the leaking away of the mother’s physical and psychological resources (her spirit), while the labor-retarding, pain-enhancing effects of fight or flight hormones are constantly being secreted into her blood stream and sabotaging her progress. The responsible practitioner cannot stand by and permit the mother’s labor to self-destruct like this. If the birth attendant (midwife or physician) cannot satisfactorily return the mother to a state of calm and achieve a progressive labor pattern in a reasonable time through the above listed methods, then analgesic drugs or epidural anesthesia will be just as necessary as oxytocin would be for a postpartum hemorrhage.
The good news is that timely use of these medical interventions can reduce the likelihood that operative delivery will be needed.
The High Price of Labor without Physiological Labor Support
For women without access to physiologically-sound methods to support and advance labor (even if the mother herself rejected the help of a labor attendant), the risk of a painful but non-progressive labor, persistent posterior fetal position and operative delivery is disproportionately high. Obstetricians won’t tell you this but mothers know.
The author of a new book on childbirth, written from the perspective of a new mother, was interviewed today (10/24/06) by Terry Gross on NRP. Tiny Cassidy researched and wrote “Birth- a History of How We Were Born” after an experience similar to the one facing Elizabeth Rourke. Ms Cassidy described needing active and effective labor support for a long slow and painful labor with a posterior baby. What she received however was the standard medical care, the obstetrical package if you will, in which a busy nurse repeatedly stock her head in the door and asked kept asking if she was “ready for her epidural yet”. Under these circumstances, a mother, who was in pain and exasperated, will eventually say yes. In far too many cases, the posterior baby gets stuck in an undeliverable position. Like
Gender Politics
However, that kind of dysfunctional labor is not the destiny of our gender. No – it’s a social deficiently in our maternity care system, an educational failure in teaching the public about normal birth and the elements for success and a policy failure at the highest levels of government. It is not the mother’s personal fault, it is ours, collectively, as a society.
We are a society that does not provide the elements for successful childbirth. To a great extent, this is because we do not value the mother’s experience of normal labor and spontaneous birth. Instead, a woman’s interest in normal birth is dismissed as either naive or selfishly hedonistic. I still haven’t figured out why doctors consider not having narcotics drugs or anesthesia (and their associated risks) to be a selfish or hedonistic act on the mother’s part – personally I consider it a very brave thing to do.
But in the industrialized model of birth, the medical-industrial complex values efficiency and reliability more than any aspect of the mother’s experience. The obstetrical package is constructed to get the job done in the least amount of time, with the largest number of billable units and no uncompensated services, nothing that doesn’t have a billing code. There is no billing code for physiological management. Time spent with the mother, ‘merely’ providing a supportive presence, represents uncompensated services.
An example of how much this colors our entire relationship to ‘modern’ birth can be seen in how we talk about it. We don’t even speak of the mother delivering her baby. We say the doctor delivered her baby. The mother’s role is first to be passive, then to be appropriately appreciative. Over the course of the 20th century, women have permitted childbirth to be ‘industrialized’, with little more that an occasional whimper of protest. As a result, we let normal birth become the property of the obstetrical profession. They have chosen to industrialize it, borrowing ideas like ‘standardization’ and assembly line thinking from manufacturing and the agri-business – all in pursuit of the obstetrical ‘product’, defined here in the 21st century as the unborn and the “wellborn” infant (Williams Obstetrics, 1970 edition).
Prior to the baby being the identified ‘product’, the obstetrical package was geared towards providing the mother with a pain-free labor that she would not even remember, and then being ‘knocked out’ for the birth. The very earlier version of the obstetrical package was configured in the desperate hope of simply preventing maternal deaths from ‘childbed fever’ -- an all too common complication of laboring and giving birth in the bio-hazardous environment of a hospital before the discovery of antibiotics.
Ever since it was originally conceived, the design of obstetrical package has depended on an unequal ‘division of labor’ – that is, the professional activities associated with caring for women under obstetrical management. Continuity of care (such as provided by midwives sand old country doctors) was replaced by the ‘hand-off’, in which the unfinished ‘product’ (the mother in labor) is handed from one low or mid-level medical personnel to another. This is accompanied by move, conveyor belt style (via hospital gurney) to different wards, each with a separate staff of nurses -- labor room, delivery room, recovery room (mom), nursery (baby), hospital room. Each hospital employee has just small or brief part in the overall process. The laboring woman is provided ‘pre-op’ care by the labor room nurse until she is readied for her ‘op’ – the surgical procedure of vaginal delivery or cesarean section. Then the obstetrician is called and comes in to receive the finished product, which is pushed into his hands by the mother or pulled out with forceps, vacuum or Cesarean section – it doesn’t matter too much to an obstetrical surgeon which it is, except that the CS is often faster and easier to control.
Then the parents thanks the obstetrician, who turns the ‘post-operative’ care of mother and new baby over to the two different hospital assembly lines – one for the mother and one for the baby. They will wind though the system for many hours, eventually be reunited. After a few days, the mother will be put in a wheel chair, the baby placed in her arms and they will both be deposited at the back door of the ER door, ready for dad to bring the car around and take them home – the happy product of the American obstetrical package. In the six to 12 8-hour shifts that she was a patient on the
On the “shop floor” of Industrial Childbirth
The industrialized childbirth means our fate as healthy childbearing women is decided by the market forces, in combination with obstetrician preference. Sometimes this is just the personal preferences of the doctor on duty and other times it reflects policies and protocols handed down from on high – hospital administrators, insurance companies, ACOG practice policies, etc. For the last decade, the hot new thinking of the policy makers has been the idea of eliminating the messy, unpredictable, time-consuming, miserable hours, often unprofitable business of normal birth.
To that end, a significant minority of American obstetricians have developed a personal preference for performing Cesareans. These same obstetricians are working hard to convince all the rest of us, including the lay public, medical profession in general, insurance companies and the government, that C-section should be welcomed as the new standard for the 21st century.
The only question left was how to make the idea of operative obstetrics into a functional reality. Since June 2000 there has been a steady stream of public relations and propaganda campaigns of various sorts. In 2000, Dr Ben Harer, then president of ACOG, appeared on Good Morning American with Diane Sawyer and introduce the American public to the incredible idea of Cesarean as safe and better than vaginal birth. Mark Twain once remarked that “Only fiction must be credible”.
The talents of Dr Gawande are just the most recent of these incredible efforts. THE SCORE is the first time that an extensive and comprehensive article (8600 words) has been published in a magazine with such an outstanding reputation and wide circulation. Its placement in the New Yorker is a real coup. In addition, Dr Gawande does a masterful job of laying the necessary foundation for the total industrialization of childbirth. Unintentionally or otherwise, he covered all the bases, leaving the average reader with a feeling of certainty – the idea that childbirth is one less thing to worry about. Now there is a new ‘medical miracle’ – the scheduled Cesarean at 39 weeks, how lucky for us all.
Unfortunately, Dr Gawande’s writing talents have been used to spin the notion of birth as an industrial function of obstetrics into a high wall that distracts us and blocks out our view of normal childbirth. This acerbates the loss of critical institutional memory; it hides dangerous practices and policies; it agues against public discourse; it stands fore square against any critical review; it foils any attempt to correct individual excess; it diminishes the chance that the obstetrically-defined policies that currently define our national maternity care system will be debated, reviewed and rehabilitated.
Too bad, because in another decade, there will be no one left who remembers childbirth “BC” - Before Cesarean.
Personally, I’d like to see the New Yorker magazine offer equal time and a ‘rematch’ –opportunity for a robust public discourse consistent with the New Yorker’s singular reputation in the literary world and a real service to childbearing families and to the rest of society who, directly or indirectly, picks up the tab.
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