politics of birth

I just found an interesting article that looks at how we view birth and how we view who should be the decision maker in birth.  I found this paragraph in particular interesting, because I just was having a conversion with a friend who was not "allowed" to push on her hands and knees.  Which, I of course, thought was ridiculous.

"The politics and power relationships of the labor and birth process may be seen to revolve around the word "allow." To allow is to make possible through a specific action or lack of action, or to consent to or give permission.1 The concept of allowance gives the power to the healthcare provider, whether physician, midwife, or nurse and makes the laboring woman dependent upon this allowance. Allowance removes some aspects of choice and consent from the woman and makes her dependent upon the actions and beliefs of the healthcare provider. To define the services one offers to pregnant women using the phrases "I allow" or "I don't allow" transfers all control to the provider. To "allow" ambulation during labor is to give a tacit approval and to not "allow" a trial of labor after a previous cesarean birth (TOLAC) is to imply that TOLAC is dangerous and imprudent. To "allow" an action implies an authoritarian relationship, similar to a parent and gives political power to the healthcare provider. The concept of allowance signifies that the healthcare provider is the expert, that the provider knows what is best without discussion and that the provider will always make the best decision for the woman. This language extends to nursing also; nurses are "allowed" to perform some procedures in hospitals and not in others. More respectful language would imply mutual consent between the parties in the discussion, or political cooperation and compromise.

Compare the statement "midwives are allowed to attend TOLAC and vaginal birth after cesarean" with the statement "midwives are qualified to attend TOLAC and vaginal birth after cesarean." Similarly, compare the statement "laboring women are allowed to ambulate during labor" with the statement "laboring women are encouraged to ambulate during labor." The emphasis moves from permission to active voice."

I would love to be a fly on the wall of physicians offices and see how they offer alternative choices to women. Do they "allow" women to move, or do they encourage it?  What if a doctor doesn't agree to a different type of care, like delayed cord cutting, how do they respond to that?

As I thought about these questions, the words permit, allow, offer, and provide all began popping up in my head.  All of these words entail a power structure that is pretty inherent in our medical system.  We, the patients, are allowed or permitted or have certain choices.  This seems wrong to me.  The doctor/care provider is not our parent.  They are not here to teach us right or wrong.  I think they should be here to provide us with choices.  To offer us their expertise and opinions, but at the end of the day, we are the ones that make the choice based on what we feel is best, no matter what the doctor feel is best.

Unfortunately, our system is very steeped in this hierarchal manner.  I would love to hear others ideas on how to help change that.  I think the increase in homebirths is definitely a sign that more women are wanting a different relationship with their care providers.  As well as the increase interest in alternative medicine.  Women are looking for ways to gain that control back in their lives.

Electronic fetal monitoring

"Joseph Campbell, the comparative mythologist noted that cultures which are the most subject to the variable forces of nature, such as seafaring peoples, have the most rituals, in order to exert some sense of control over the uncontrollable. The obstetrical community must fit that model, insisting on specific rituals of care, even in the absence of absolute evidence of their efficacy, in order to gain a sense of control and mastery of the birthing process. The fetal heart rate tracing is poured over like tea leaves or cast bones, and the doctor becomes the shaman.

This belief system has been preached to future physicians and obstetricians, who passed it along to their students until the whole culture of childbirth medicine became steeped in a religious-like belief in the power of the fetal monitor, labor curves, ultrasound measurements and the like. This belief is similarly conveyed to patients who are assured that if their pregnancy was managed according to the protocols developed by trusted researchers, their babies would be delivered without fail and without harm.

Reality, however, has proven otherwise. Despite close and continuous monitoring in labor by the best trained and most capable staff and doctors, babies still die suddenly, or are born with unexpected asphyxia, or unanticipated illness. Families feel bewildered and betrayed and seek explanation and often recourse. If the latest technology was employed, then certainly human error must have been the cause."

This quote comes from the science and sensibility blog. And it was oh so timely. I just taught in a college class about the birth process. During this presentation, I spoke about electronic fetal monitoring(efm) and how that is not necessarily the best option during birth. My opinions on this has come from research and also my own experiences.

First off, the efm was implemented without any prove that it was effective in preventing fetal death or complications. Since that time, it has actually been shown to have no benefits of intermittent monitoring(where the heart rate is listened to every 15-30 min). The only thing that I can think of that is beneficial is that it allows the nurse to be out of the room more often, and that is more beneficial to the nurse and hospital, not the patient.

Second, it is much easier for a woman to labor, both physically and mentally, without being tied down to a monitor. For some women, the heart rate is picked up fine while they are moving around, but for most movement caused distortion in the heart rate. This makes that reading invalid or picks up the wrong rate rate which throws everyone into a frenzy.

Yet, the efm has become sort of a religious ritual. Many doctors gasp at the thought of not using one. It certainly does allow them to think that they are in control of a force that is very uncontrollable.

Really the question should not be why wouldn't we use the efm, but why would we? I don't think anyone could truly give me a good answer.

Woman centered care

As I've been thinking more about why I appreciated my birth centered births, I realized that it had a lot to do with how the care was centered around me, not the staff. So, I've thought about what that means and what might improve that for hospitals...so here's my modest thoughts on that issue.

1)Options. Women need to given information on the options and choices available to them before they even enter the hospital, and it should be provided to them by their chosen providers. It is unfair to expect women to have to go out and find their own information, especially if they don't even know that there are options. For instance, intermittent monitoring is a option for women...do they know that? Most don't. A hep-lock or no iv at all is an option for women who don't have an epidural at the time. Even if they plan on getting one eventually, they should at least have that option to begin with. If you are able to move, why not take full advantage of that. But it should be something that is discussed before they arrive at the hospital.

2) Informed consent for procedures. This should also be given before a woman arrives at the hospital.

3) Admissions. We've got to fix this for laboring women. For those who are induced or come in for a scheduled c-section, it is not a big deal. For a woman in labor, though, having to answer the questions is difficult. It's not impossible, but to really be centered around a woman and her care, we should find away to get the information we need without distracting a woman from her task. At the birth center I went to, this was not even done, because they had my records on hand with them from my pre-natal appointments.

5) If procedures are needing to be done(like iv, breaking the water, admissions questions), other personnel should be on hand to simply provide labor support or emotional support.

6) Interventions should be minimized unless requested or needed.

7) Please take that BP cuff off between blood pressures(unless the mother would rather it stay on).

8) We need to take a look at how we do c-sections. Why not allow the support person in earlier? Why do we have to tie down a woman's arms? Why not allow her to see the baby right after it is taken out? Why not let the mom and baby stay together as long as the baby is ok? More emotional support is needed during the mothers stay at the hospital.

9) Nurses need be trained in labor support. I use these skills even with those who have epidurals. For instance, did you know that the uncomfortable pressure at the end of labor can be helped by sitting up in bed? Or if the epidural only works on one side, you can use counter pressure to alleviate some of that pain. Wet washcloths are great for moms who are pushing for a long time. These are things that nurses aren't taught. And of course, this knowledge would be a huge benefit to those who are choosing not to get an epidural.

10) The room layout should be made with a laboring woman in mind, as well as the nurse and doctor. The beds should be made for the convenience of the laboring woman, not the doctor.

Nursing Birth

I just wanted to highlight a new link I have under other links. While I have intentionally tried to steer away from discussing the medicalization of birth, this is a great blog that discusses that if anyone is interested. My main purpose for writing is to bring meaning to birth and motherhood, but I do feel that there are other important points to be discussed. Nursing Birth is written by an L&D nurse and I have found that many of her experiences have mirrored my own. Thus the inclusion. If any of my readers want to steer away from the controversies of birth, then this link is not one I would look at. If on the other hand you are curious, take a look. It has great research and is well thought out.