The antidote to the routine medicalization of normal labor and overuse of induction of labor and elective Cesarean surgery

Today’s blog continues the commentary on the ABC article increasing maternal mortality (published March 4th, 2010, excerpts embedded in the March 8th Normal-Birth blog).

The only good reason for a risky medical or surgical procedure is a serious health problem that makes the potentially life-threatening complications of surgery less of a danger than the disease being treated. In the absence of a potentially life-threatening condition, potentially life-saving medical interventions are themselves life-threatening.

The lives of mothers and babies are depending on us to replace the well-meaning but ill-advised ‘pre-emptive’ use of technology and routine interventions with a genuinely evidence-based and cost-effective mother-baby-father-friendly model of maternity care.

There is no getting around these very grim facts: Cesarean surgery, as the route of delivery, is associated with 33 serious complications – a number 8 times greater that the risks of vaginal birth. Not only is the risk of maternal death 2 to 5 times greater during or after operative delivery, but for every post-Cesarean maternal death there are a 100 new mothers who suffer a serious complication, such as emergency hysterectomy, secondary infertility or stillbirth in a subsequent pregnancy.

To access the research, go to: www.motherfriendly.org/pdf/TheRisksofCesareanSectionFebruary2010.pdf

The only answer or antidote to routine medicalization, with its emphasis on elective procedures such as induction and scheduled Cesareans, is a return to the time-tested principles of physiological management. Medical dictionaries define “physiological” as: “…in accord with or characteristic of the normal functioning of a living organism”.

Physiologic care provides a reliable method for working with the normal process of biology and has long been used by those countries with the best maternal-infant outcomes. The scientific literature identifies physiological management for normal birth as the safest and most economical type of maternity care for a healthy woman with a normal pregnancy. It is the scientific or evidence-based standard of care.

Physiologic care during labor and birth is associated with the lowest rate of preventable maternal and perinatal mortality and is protective of the mother's pelvic floor. It has the best psychological outcomes and the highest rate of breastfed babies. Dependence on physiological principles results in the fewest number of medical interventions, lowest rates of anesthetic use, obstetrical complications, episiotomy, instrumental deliveries, Cesarean surgery, post-operative Cesarean complications and delayed or downstream complications of Cesareans in future pregnancies.

Physiological management takes into account the positive influence of gravity on the stimulation of labor, dilatation of the cervix and decent of the baby through the bony pelvis. Maternal mobility not only helps this normal process move along without the need to use artificial hormones to speed up labor, but also diminishes the mother’s perception of pain, perhaps by stimulating endorphins.

Effective labor support always addresses the mother’s pain, her fears and privacy needs so that labor can progress spontaneously, reducing or eliminating the need for medical interventions such as artificial hormones (Pitocin) to speed up labor, pain medication, anesthesia and operative delivery.

Healthy, mentally-competent women have a natural right to have control over the manner and circumstance of normal labor and birth. Just as we acknowledge a woman’s right to choose obstetrical intervention, epidural or an elective Cesarean, so women have an even more compelling right to choose normal care based on the principles of physiological management and the healthcare system has a matching responsibility to provide access to physiologic care. It is society twin obligation to provide maternity care based on ‘best practices’ as determined by the scientific evidence, as well as seeing that women desiring or requiring obstetrical interventions do so with informed consent that also fully reflects the scientific literature.

What we need now is to reboot our maternity care system so that all categories of birth attendants (obstetricians, family physicians and midwives) are taught the body of knowledge and specific skills for effectively addressing the physical and biological needs and emotional stresses that healthy women typically face during labor. In addition, hospitals must become truly “mother-friendly” by providing evidenced-based care in a low-tech environment that is appropriate to normal childbirth.

This model of normal childbirth includes continuity of care, the full-time presence of the primary birth attendant though out active labor and the supportive presence of family members or other companions chosen by the laboring women. It acknowledges the mother’s on-going need for social and emotional support and physical privacy, which includes control over her environment and the people present. This means that laboring women are free to move about and choose their own positions and activities.

The strategies of physiologically-based care include patience with nature, the right use of gravity and proven methods to help mothers cope with the pain and stress of labor, such as one-on-one support, therapeutic touch, movement and access to hot showers or deepwater tubs.

Women who walk and move about at will and make use of traditional coping strategies to keep pain within manageable levels usually have greatly reduced rate of drugs and other interventions. However, mother-friendly care also provides ‘no-fault, no-blame’ use of pain medication or epidural analgesia when other methods don’t provide the needed relief.

Patience, maternal mobility and the right use of gravity are also critically important during the pushing stage. Even mothers who’ve had epidural analgesia benefit by pushing and delivering on their side, so they are not bearing weight on their sacrum (reducing blood supply to the placenta and O2 to the baby) or fighting against gravity as they try to push an 8# baby uphill and around the normal 60-degree angle of the pelvic outlet (the Curve of Carus).

This science-based model of maternity care for normal childbirth protects and preserves maternal-fetal wellbeing, while providing access to appropriate obstetrical intervention for those women or babies with complications or if medical interventions are requested by the mother. This serves the needs of healthy families far better than our expensive and inflexible high-tech model, which costs two to ten times more than it needs to.

Billions of health care dollars can be saved every year by lowering the direct cost of maternity care and reducing post-operative, delayed and downstream complications associated with Cesarean surgery.

MaternityCare_2.0 is a big first step on our national path to a safe, effective, affordable, accessible healthcare system that we Americans can to proud of -- HealthCare_2.0

Come back tomorrow for the last installment of this 3-part series on the irrational enthusiasm of the “system” to unnecessarily medicalized and complicate normal birth and the deleterious consequences to maternal health and the economics of our national healthcare system.