Labor and Delivery Philosophies and Risks of Medical Intervention

Last time, I told you about the beginning of my decision to have a natural labor.

I struggle with how to blog about this, because while I want to share something I truly believe in, I also don’t want to come off as preachy or soap-boxy.  And if any of my posts about this topic are going to come off that way, it’s this one.  I mean absolutely no offense, and I apologize ahead of time if I do offend.  So I’ll reuse my disclaimer from last time:

This is a sensitive subject that a lot of people have passionate views on.  I love the passion and love the comments, even and especially the ones that don’t agree with me.  Always feel free to leave them in a respectful way.  I am excited about what I have learned and think it’s important to share because our culture presents a lot of mistruths about labor.  I am thankful for my friends who have pointed them out to me and hope to do the same for others. That being said, the decision on how to labor is incredibly personal and each woman has the right to make her own choices free of judgment.

Got that?

Good.

It’s important to understand that there are two different birthing models- the Medical Model and the Midwifery Model.  If you are pregnant, make sure to know which model your care provider practices.  If having a natural birth is important to you, it’s going to be much harder if your care provider operates under the Medical Model- and it’s not always obvious.  Some OBs subscribe more to the Midwifery Model than the Medical Model, and some midwives practice in hospitals that have restrictive rules that force them to practice more of the Medical Model.  So what’s the difference?

• Medical Model- Care providers that use this approach believe that labor is a medical condition that should be closely managed.  The birthing mother is a patient and there is little she can do to impact the process.  These care providers are highly skilled at handling severe complications, but may intervene early and unnecessarily in uncomplicated labors.
• Midwifery Model- Care providers that use this approach believe that an uncomplicated labor is a natural part of life and that intervention should only be used when necessary.  The birthing mother is an active participant in the labor and how she feels physically and emotionally can have significant impacts on the process.  These care providers have much lower rates of C-sections and foreceps/vacuum delivery (3% vs 30%!!), but if an unexpected severe complication occurs, these care providers may need to transfer care to a provider more skilled with surgery.

Let’s talk about midwives.  Many people in the general population of the US don’t understand what a midwife is- they think a midwife is a witch doctor or a wannabe OB.  In actuality, midwives are nurse practitioners that provide women with care, most commonly through the pre/postnatal period and through labor and delivery.  They do not operate, but are highly skilled at delivering healthy babies.  They have the same education and licensing requirements that any nurse practitioner does.  In many countries, midwives attend the majority of births; in the U.S. they attend less than 10%.   In Germany, a midwife is required to attend a birth, even if an OB is there!  For normal, healthy pregnancies, the safety statistics for a birth attended by a midwife are just as good or better as a birth attended by an OB.

When I decided to do a natural labor, it had nothing to do with wanting to be super woman.  It had everything to do with being an active participant in the delivery of the baby I had waited so long for, even if that meant I would have to go through more pain before meeting him.  Add in the risks and side effects of some of the interventions and my mind was made.

So what are some of the risks and side effects?

There are many forms of medical intervention, and sometimes they are necessary.  The potential benefits might far outweigh the potential risks; medical intervention is not necessarily a bad thing.  And just because something is a risk doesn’t mean it’s going to happen- it’s entirely possible to have an intervention and see only the good with none of the bad.  It’s important that women understand both the potential benefits and risks so that they can make an informed decision.  This is all told from my very unscientific brain, do your own research for more information.

Here are just a few of the forms of medical intervention:

• Induction.  There are many reasons for induction. Some are valid, some are not.  If you’re a few days past your due date, that’s not a great reason.  Due dates are estimates and are rarely correct, and unless the heart rate is significantly changed or there’s a drop in fluid level, there’s no need to hurry nature along.  However, if you’re a few weeks late, the placenta starts to break down and induction may be necessary.  If your labor has started but is not progressing quickly enough, that’s not a good reason.  Labor doesn’t look the same from woman to woman, and it’s normal for a labor to start and stop.  There shouldn’t be a time limit on labor.  Progress will almost always be made if the woman is relaxed and comfortable.  However, if you have an infection or if your water has broken and you’re not having contractions, induction may be necessary.  If you are induced, they give you a drug that makes your uterus contract.  These contractions are longer, stronger, and more painful than natural contractions.  When the uterus contracts, the baby is deprived of oxygen-rich blood.  That’s normal, and the baby can handle that through natural contractions, but sometimes induced contractions are so long and strong that the baby is deprived of blood for too long, which can send it into distress, which can lead to an emergency C-section.  In extreme cases, the contractions are so strong that the uterus ruptures, putting both mother and baby at risk.  Also, the drug that induces contractions prohibits your body from releasing oxytocin, which helps you deal with pain and promotes breastfeeding and bonding.

• Epidurals.  Epidurals are that happy needle that so many women want- the really long one that is inserted into the back that numbs your lower half.  Many women love epidurals because they allow them to have a pain-free birth, but they are not without risks.  Some of the risks are mild, like headache or itchy skin or sore/numb muscles lasting long after the birth.  Sometimes epidurals cause the mother’s blood pressure to drop or temperature to rise, which leads to more interventions.  Sometimes epidurals don’t work, or sometimes they work too well and the mother can’t feel to push.  Babies born with epidurals have a much higher likelihood of being delivered via C-section/foreceps/vacuum.  Research shows that epidurals lower the levels of oxytocin the mother releases, and in some cases prevents it from being released at all.  Some babies born with epidurals have a harder time breastfeeding.  The longer the mother receives the medicine, the more of it is passed on to the baby and the higher likelihood of experiencing side effects.  Given all this, my biggest concern with an epidural is the limited movement.  Since the mother cannot feel her lower half, she is confined to the bed.  There is a version called the walking epidural, but “walking” is used optimistically- the mother may be able to move around in bed and perhaps walk to the bathroom, but will not be strolling around the room.  Women have flexible pelvic bones.  Their pelvis is more open in some positions than others.  If a laboring woman can choose, she will almost always decide to deliver in a super glamorous position like a squat or on all fours- one where the pelvis is open wide and gravity helps the baby descend.  An epidural keeps the woman on her back, or at best reclined, where the pelvis is small.  At the time, the woman doesn’t feel the pain this causes, but it puts her at a higher risk for tearing and a longer recovery.

• Episiotomy.  It’s not uncommon for a woman to “tear” during labor- the skin between her vagina and her rectum rips.  Can you even read that without shivering in horror?  To be honest, that is my greatest fear about labor.  An episiotomy is when the doctor/midwife cuts that skin rather than letting it tear naturally.  Episiotomy rates are actually declining as the medical world is learning that they are not necessary.  If a woman is going to tear, she is going to tear- and episiotomies often make tearing worse.  For a demonstration, fold a sheet of paper in half and pull at both ends.  It’s possible to tear apart, but not especially easy.  On that same sheet of paper, start a little tear along the fold and tear again.  What happens?  The paper is torn in half.  Some care providers prefer to do episiotomies because it ensures the skin will tear in a straight line, making stitching it back up simple.  But that tear is often more severe and takes longer to heal than a natural tear would have been.

There is no doubt that medical interventions in labor are an advancement in medicine and have saved countless lives of mothers and babies.  I’m just not convinced that they are necessary for a typical, uncomplicated delivery- I think our bodies are smarter than that.  However, I also think that labor is the toughest thing a woman will ever experience and it’s extremely important to be prepared both physically and mentally.  Next time I’ll talk about ways to do that.