Women's Bodies, Women's Wisdom (105 page)

Developing persistent pulmonary hypertension, a life-threatening condition (more than four times as likely)
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In addition, researchers have found that C-section babies have an increased risk later in life for allergies, asthma, type 1 diabetes, testicular cancer, and childhood leukemia.
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For more information, see the CIMS website at
www.motherfriendly.org
.

Episiotomy

Another procedure that should be abandoned is episiotomy. It is estimated that one-third of all women who deliver vaginally in the United States (more than 1 million women per year) undergo episiotomy, the surgical cutting of the tissue between the vagina and rectum. Nationally, 70 to 80 percent of first-time mothers delivering vaginally in the United States undergo this procedure.
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Women who have an episiotomy are fifty times
more
likely to suffer from severe lacerations than those who don’t.
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The reason for this is that episiotomy cuts frequently extend farther into the vaginal tissues during the delivery. This surgical cut of the perineum can result in excessive blood loss, painful scarring, and unnecessary postpartum pain.
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The woman’s discomfort may affect her bonding with and nursing of the infant.

Studies have shown that whether a woman giving birth has an episiotomy is most dependent upon whether she is attended by a doctor or by a midwife. Midwives are taught how to do normal, noninterventional deliveries. Doctors naturally
do
more—that’s what they’ve been trained to do. Letting a woman push her baby out slowly, gently, and without interference is a rare experience in some hospitals. A retrospective analysis of 2,041 operative vaginal births (meaning that forceps or vacuum extractors were used) in San Francisco showed that the rate of fourth-degree tears (tears extending into the rectum) declined from 12.2 percent to 5.4 percent during a ten-year period as the rate of episiotomy at the hospital fell from 93.4 percent to 35.7 percent.
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While the rate of vaginal lacerations increased, these are trivial and very easy to repair in comparison with the damage done by episiotomies. They are also far less painful.

A highly publicized review has finally laid this matter to rest (I hope). In an exhaustive review of every article published in the medical literature from 1950 to 2004, the authors found that none of the benefits previously ascribed to routine episiotomy did exist. “In fact,” the study reported, “outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision.”
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A Word About Pelvic Floor Dysfunction

Ever since the late 1990s, the potential for pelvic floor dysfunction from natural birth has been used to justify cesarean delivery, especially when there is no other indication. In fact, the American College of Obstetricians and Gynecologists released a statement in October 2003 indicating that although physicians are under no obligation to initiate discussions about elective C-section, a physician is justified in performing the surgery if he or she believes that C-section delivery promotes the overall health and well-being of the mother and baby better than vagi nal birth. And the potential protection of the pelvic floor through C-section (which I call vaginal bypass surgery) is one of the justifications.

This statement received wide criticism from many organizations, including the International Cesarean Awareness Network, the College of Midwives, Doulas of North America, Attachment Parenting International, and the American College of Nurse-Midwives. The Society of Obstetricians and Gynaecologists of Canada stated in two press releases, in March 2004, that vaginal birth remains the preferred approach and the safest option for most women because it carries fewer of the complications in pregnancy and subsequent pregnancies than C-section.

A thorough review of the medical literature on mode of delivery and pelvic floor dysfunction published in 2006 pointed out the difficulties of comparing modes of delivery because of the varying skill levels of practitioners and also the varying conditions under which birth takes place. For example, vaginal births involving forceps deliveries by un skilled practitioners or vacuum extraction, or the use of episiotomy, are far more apt to be associated with pelvic floor problems than births that don’t involve these modalities. The authors state, for example, that “gentle birth in nonlithotomy position, [lithotomy position is flat on the back with knees bent and legs spread apart] without urgent directed pushing and without the routine use of episiotomy, will tend to protect the pelvic floor and the perineum and reduce strain on the very structures that we are reviewing, thereby improving outcomes and reducing dif ferences between vaginal birth and C-section where they exist.”
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Regardless of the statistics, it is clear that the female pelvic floor is designed to give birth without complications in most women and is perfectly capable of doing so in a supportive environment. I was on a panel with the famous midwife Ina May Gaskin at the Annual Meeting of the Association for Pre-and Perinatal Psychology and Health in 2005. Ina May, whose “Sphincter Law” I mentioned earlier, suggested that it’s nearly impossible for a woman to birth normally if she is out of touch with her pelvic floor, including her bowel function—a com mon situation in many women who are terrified of losing control during birth. She jokingly suggested that women might want to follow a horse around so they could see how well the anal sphincter of a horse expands to allow discharge of waste matter and then instantly returns to normal size. The female cervix is also a sphincter that is capable of dilating very nicely under optimal conditions but is heavily influenced by how safe and supported a woman feels in birth. The same thing is true of the pelvic floor. A comprehensive website designed to help women prevent pelvic floor problems at birth is available at
www.childbirthconnection.org/article.asp?ck=10206
.

Anesthesia

Modern anesthesia is a godsend in many instances, but in labor it is used far too often. This culture believes that if a little is good, more must be better. So there are now obstetrical services in which almost every pregnant woman, long before she goes into labor, is sold on the virtues of epidurals— the “Cadillac” of obstetrical anesthesia. The seed is often planted during hospital-sponsored childbirth classes: “You don’t need to feel a thing.” Anesthesia is offered as a panacea to many. I’ve heard women say, “I want that epidural catheter put in during my last two weeks of pregnancy!” One remarked, “I’m making sure I get that ‘happy dural’!” But the risks include arrest of the first and second stages of labor, fever, increased forceps use, pelvic floor damage, and fe tal distress, with a subsequent increase in cesarean section rates.
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In a 1996 study of 1,733 women having their first babies, the ce sarean rate for those who received epidural analgesia was 17 percent, compared with 4 percent in those who did not receive this type of anesthesia—a fourfold increase.
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In a study published in 2005, researchers found epidurals were strongly associated with the more problematic fetal occiput posterior position (the baby’s head facing up at delivery, instead of the more ideal position of head down, facing the mother’s back), which the researchers suggested might explain the higher rate of C-sections in women who have epidurals.
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The reason for this is that when the epidural numbs the sensory nerves to the pelvic floor, it also affects their motor function. Thus the pelvic floor muscles don’t function properly to get the baby in the right position. It’s kind of like trying to eat soup after you’ve had a dental procedure that used novocaine! Despite these studies, there continues to be debate on the pros and cons of epidurals. (How the anesthesia is given, by whom, and when during the course of labor are among the factors that can affect outcome.) But the association of epidurals with C-section accords with my own experience working in a large hospital delivery unit.

In another study of 1,657 women having their first babies, 14.5 percent of those who received epidural anesthesia experienced fever, compared with only 1 percent of the women who did not receive an epidural. Because of these fevers, infants born to the women in the epidural groups were over four times more likely to be evaluated for infection and about four times more likely to be treated with antibi otics than babies born to women who didn’t receive an epidural.
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Yet of the 356 newborns in the epidural group who were evaluated for sepsis, only 3 actually had it. Epidurals put women at higher risk for fever regardless of the infant’s size or the length of labor, two factors also felt to be associated with increased risk of infection. The cascade of adverse consequences of having your baby worked up for an infection include having your baby taken away from you and taken to the neonatal intensive care unit; more pain for the baby, because blood needs to be drawn and IVs started; the risks of antibiotics, which kill all the friendly, normal bacteria in the baby’s body, thus increasing the risk of infection from antibiotic-resistant strains of bacteria found in hospitals; increased anxiety for both mother and baby; and possible adverse effects on the establishment of successful breast-feeding. Since this sepsis workup takes place right after you’ve had your baby, it can significantly affect the important bonding period that nature intended following birth.

Supine Position

Women who deliver in a physiologically normal position, such as standing or squatting, are much less apt to have perineal tears and are more apt to have normal, nonsurgical second stages of labor. Many women also feel most comfortable laboring on their hands and knees. In fact, lying supine while pushing out the baby is a position that is actually unfavorable for birth because this position favors excessive pressure of the delivering baby into the posterior vagina, and it
decreases
the diam eter of the pelvic outlet—a setup for vaginal tears. (Ever try to move your bowels while lying flat on your back?) This position, known as the lithotomy position, was apparently popularized by Louis XIV in France, who was a voyeur and wanted to watch the births of women in his court without their knowledge of his presence. In the lithotomy position, with her skirts hiked up, the laboring woman couldn’t see who was watching. This position caught on because it was associated with the upper classes and therefore was imitated. It also made things easier for the birth attendant.

Probably another reason it caught on was the popularization of obstetrical forceps. Forceps were originally developed in 1630 by Peter Chamberlen, a male midwife who came from a family of male midwives. These tools remained a Chamberlen “family secret” until they were released to the medical profession in 1728.
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Training in the use of this instrument was given only to men (usually physicians and surgeons), and they were originally used when all else failed and the woman had been trying to push the baby out for hours. The lithotomy position was the one in which the exhausted woman could rest while forceps were applied. It also allowed the obstetrician maximal control over the process of forceps delivery.

During the second stage of labor, women who squat instead of lie supine increase the size of the vaginal outlet naturally, because this position distributes pressure equally throughout the entire vaginal circum ference and helps bring the baby’s head down. In the squatting position the anterior/posterior diameter of the bony pelvis (front to back) is in creased by a half centimeter or more.
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The squatting position also keeps the pregnant uterus off the major pelvic blood vessels leading to the heart. The blood supply from the mother to the baby is therefore improved, resulting in increased safety for both. (I’ve seen countless ba bies go into fetal distress in the delivery room simply because of the mother’s position, flat on her back.) Women who are encouraged to touch their perineum and the baby’s head get connected up very quickly with their birthing babies and deliver much more easily. In general, it’s not advisable for a mother to overexert herself during the second stage of labor. Pushing the baby out slowly and gently is associated with far less pelvic trauma.

Bottom line: When birth technology is truly needed, it is lifesaving and miraculous. When a physician is in the operating room transfusing a woman whose placenta simply won’t separate from the uterus and who is losing blood quickly, she knows that one hundred years ago her patient would have died. In the vast majority of cases, however, more “high-touch” and less “high-tech” would do the job.