Sunday, October 24, 2010

A Watched Pot Never Has Its Baby

Having watched many labors that have been allowed to proceed on their own course, I can tell you this - there is no "normal," no "textbook." But yet, obstetrics revolves around the idea that there is, and anything outside of what they consider normal is a problem labor, which needs to be reigned in and forced to conform.

In the 1950s a physician named Dr. Emanuel Friedman studied labor progression and came up with a graphical analysis of how normal labor should proceed. His analysis found that woman with labors that followed a certain pattern were less likely to need intervention to deliver their baby safely. Fast forward 6 decades and the Friedman's Curve of Labor is still regarded as the standard by which the obstetric field decides what normal labor looks like. Women who "fall off the curve" are considered to be having abnormal labors and to need interventions. There are several problems with this. Dr. Friedman created his curve as a compilation of patterns that varied, not one single curve that all normal labor followed. And the (ir)rational with using the Friedman's Curve is basically: women who don't follow this pattern are more likely to need intervention, so we intervene to make them follow it. Most importantly, the Friedman's curve does not address or account for the way routines in the modern hospital birth system create abnormal laboring conditions as soon as a woman walks in the door. Routines that set women up for what we who believe in the natural process of birth term "the domino effect of intervention." The births I attended last week both ended up with a cascade of interventions. However, one of them was a striking example of another thing The Friedman Curve doesn't account for, and which obstetrics refuses to acknowledge: the effect emotional stress and lack of peace can have on labor progress.

My client, whom I'll call Jane, had her husband call me about 9:30 on Saturday night. She had been having contractions for about 5 hours, was working well through them, and wasn't ready to go to the hospital. I thanked him for the heads-up and mentioned they should watch for signs of late labor - extremely strong contractions that are less than 4 minutes apart, lasting over a minute, combined with a serious attitude in mom, and possibly chills, vomiting, and/or mild bleeding. Around 1am, she was experiencing all of that so they decided to go ahead and go to the hospital. When I arrived at labor and delivery, Jane and her husband were waiting to be taken back to triage to be assessed. I timed her contractions using a very handy app I have on my iPhone. They were 3 minutes apart, lasting over 60 seconds. She was handling them well but obviously needed to focus on them, blocking out the disturbance of people and noise around her. They took her to triage to assess whether she was actually in labor enough to stay (they used all their fancy equipment; I could tell just by watching her for 10 minutes).

In triage her contractions started to space out to about 5 minutes apart and lessen in intensity (this is not uncommon for when a woman changes locations during labor). But she was 4.5 cm so they blessed her with a room. The other changes with her body - I'll spare you the details - all indicated her labor was progressing well. I figured it would be 6-10 hours tops. Jane and her husband had prepared for an unmedicated labor and worked extremely well together to achieve a state of relaxation and calm within which Jane could focus on handling her discomfort and allowing her body to do what it needed to. The problem was that in the hospital setting, Jane was not allowed to have what she needed most: a calm environment free of distraction. More than almost any woman I have ever worked with, Jane's emotional state, and by way of that her labor, was profoundly affected by her environment. Let me paint a picture:

At home: Jane spent hours in a dim, quiet house, her husband talking softly to her and rubbing her back through contractions. They listened to relaxing music and slow-danced together in the living room. She moved around freely how she felt she needed to and ate a little bit of protein and sugar periodically to give her strength for the work her body was doing. Working with her body to have that baby was all that was on her mind. Quiet, peaceful, focused work.

At the hospital: Jane is hooked up to monitoring belts, one to record the baby's heartbeat, one to record her contractions. She must stay hooked up to them for 20 minutes of every hour. Moving around during this time is difficult because it can cause the bands to shift and stop collecting their important data. When that happens, the nurse comes in to lecture Jane about how she'll have to stay still for the monitoring period. She is told she can not have anything but clear fluids - broth, popcicles, apple juice... lots of sugar, no protein or complex carbs. (You wouldn't hike for 16 hours with only lollipops and water to fuel you, would you?) The nurses come in repeatedly to take her blood pressure, take her temperature, take her on and off the monitors, readjust the monitors, fiddle with things in the room, or just ask if she needs anything (isn't that what the call button is for?). They come in, flip the lights on, and start talking without checking to see if she's concentrating on a contraction. They leave the door open, sometimes even forgetting to close the curtain. The light and noise come in from the hallway. There is a nurse's station just outside of Jane's room and the laughing and chattering of hospital personnel floats in.

What we quickly discover is that each disturbance by the nurse, the doctor, or even loud talking from the hallway causes Jane's contractions to space out again. Once the room is quiet again, it takes her 10-15 minutes to get fully relaxed again and have her contractions return to their prior frequency. If we factor in only the fetal monitoring, every hour was about like this: monitors put on (5 minutes), monitoring causes decreased mobility and increased discomfort (20 minutes), monitors taken off (5 minutes), period of time it takes her to readjust and get back into a good labor pattern (10 minutes)... which leaves just 20 minutes an hour during which she is having strong, frequent contractions. With this contraction pattern, it is not surprising to me that it takes Jane 5 hours to dilate from 4.5cm to 5.5cm, then 4 more hours to dilate to 6.5cm. Jane and her husband try to explain to the nurse and doctor the effects the constant interruptions are having, but they aren't buying it. The conclusion of the doctor is that the labor is not progressing normally and they might have to intervene. After 6 hours at 6.5cm, the doctors do intervene, putting her on an IV drip of Pitocin.

Pitocin is a synthetic form of Oxytocin, the hormone responsible for causing contractions. I have too many issues with Pitocin to fully cover here; the main things to know are that Pitocin causes extremely difficult, abnormally strong contractions and is risky enough for mom and baby that hospitals require continuous fetal monitoring when a woman is on it. Since the problem with Jane's labor was not a lack of natural Oxytocin but rather her stress hormones counteracting the work of the Oxytocin, the Pitocin she was being given did not fix her labor pattern or help her dilate. After 5 more hours with no progress despite incremental increases in the amount of Pitocin they were giving her, the doctors were talking c-section and it was time for me to pull the last trick out of the bag for my clients. I knew that they wanted a natural birth and avoiding an epidural was extremely important to them. Jane had even worked through hours of very painful Pitocin contractions with that goal in mind. This is the hard part about my job - trying to convince a client that they need to give up an important aspect of their desired birthing experience. But here's what it came down to: Jane was not progressing because she was the proverbial watched pot. Her body was responding to interruptions, distractions, and stress by trying to shut down her labor process. At this point, exhaustion was starting to compound the problem. And she was facing a c-section. The only thing that might help Jane now was to set aside her initial plans and get the epidural. The pain relief would eliminate the need for her to work through each contraction. And without needing complete focus and lack of distraction to work through her contractions, the interruptions from the nurses became more irritations than barriers to progress. It would also allow her to sleep, which she desperately needed. As I suspected, after her epidural, Jane progressed relatively quickly to full dilation while sleeping. She delivered her baby about 27 hours after she entered the hospital.

What if Jane had planned a home birth instead? She would have stayed in her dim, quiet house, focused on nothing but having her baby, eating when she wanted to, moving around however she wanted to. A midwife would have periodically listened to her baby's heart rate with a hand-held doppler device or stethoscope and taken her blood pressure and temperature way less frequently than the hospital did. Jane's labor process and her needs would have been acknowledged and honored. But here's the thing... Jane didn't want a home birth. She felt much more comfortable with the idea of being in a hospital. Many women feel the same way, especially with a first baby. So my question is - why does the difference between having a baby at home and having it at the hospital have to be so night and day? Is it less safe to monitor the baby every two hours instead of every hour? Since she had no health issues or risk factors, did she need her blood pressure and temperature taken so often (laboring women aren't sick after all)? Can the nurses not be trained to go into a room quietly and respect the mother's desired atmosphere?

I can't tell you how many of my clients' doctors have told them that if they don't want all the routines and interventions they should stay home as long as possible. So... it's safe for a laboring woman to be at home where their temperature, blood pressure, contractions, and baby's heart rate aren't being monitored; where they don't have an IV; where they can still eat and drink if they feel like it... but when they get to the hospital, suddenly they are a tragedy waiting to happen. Makes no sense.

Jane was more fortunate than my other two clients this month. They both had c-sections which were the result of the domino effect of intervention. Sadly, this is the state of our hospital birth system. When I did my follow-up with Jane and her husband, they said that they were pretty sure they would have a home birth for the next one. That's a strike for the obstetric community. If they want women to be in the hospital where it is supposedly safer to have a baby, they are going to have to start addressing the issues that make women want to birth at home in the first place. Getting rid of all the unnecessary routines would be a good start. Then people like Jane could labor in relative peace, with emergency care nearby in the rare event something goes wrong. This is something I keep fighting for, and like all causes where the activists are up against a Goliath, it is an exhausting, emotional draining fight. But worth it.

No comments:

Post a Comment

I love your comments!