Women's Bodies, Women's Wisdom (106 page)

MOTHERING THE MOTHER:
A SOLUTION WHOSE TIME HAS COME

Labor support is centuries old, and it is intuitively obvious that those women who feel most supported in labor are apt to do the best. Marshall Klaus, M.D., and John Kennell, M.D., have proved in six controlled clinical trials that the presence of a female labor support person, known as a doula, shortens first-time labor by an average of two hours, decreases the chance of a cesarean section by 50 percent, decreases the need for pain medication and epidural anesthesia, helps the father or co-parent participate with confidence, and increases the success of breast-feeding. Dr. Kennell has shown that if doula labor sup port were routinely used, this simple step would save the health care system at least $2 billion a year in the costs of unnecessary C-sections, epidurals, and sepsis workups for newborns. He once quipped, “If a drug were to have this same effect, it would be unethical not to use it.”

Too often, when we think of labor support, we think of a labor coach— someone who specializes in knowing the right breathing techniques and so on. But a doula embodies women’s wisdom. She is a compassionate woman especially trained to give emotional support in labor by tuning in to the needs of the mother and mothering
her
. Doulas create an “emotional holding environment for the mother, encouraging her to allow her own body to tell her what may be best at various times during labor. . . . A successful doula,” write the authors of
Mothering the Mother,
“is giving of herself and is not afraid of love.”
⁸¹
A doula enters the space of a laboring woman and is highly responsive and aware of her needs, moods, changes, and unspoken feelings. She has no need to control or smother. Every pregnant woman should have the benefits of a doula. This person does not detract from the role of the baby’s father or co-parent, by the way. A doula enhances it and leaves him (or her) free to do the very important job of loving the mother.

HOW TO DECREASE YOUR RISK
FOR A CESAREAN SECTION

Though cesarean sections are sometimes necessary, many experts in the field feel that a rate of 15 percent plus or minus 5 percent is far more reasonable than the current overall rate of 33 percent.
⁸²
This means, of course, that many women are having cesareans that aren’t truly necessary. Because this surgery is so common, however, many women do not realize that cesarean section is major abdominal surgery fraught with potential complications, such as bleeding and infection. This surgery should be avoided unless absolutely necessary. Here’s how to decrease your chances of having a C-section.

1.
Check out your beliefs and your doctor’s. Do you believe vaginal birth is inherently distasteful and too dangerous or frightening for you to get through? Many women and their doctors actually operate under this belief, and it gets played out seamlessly in what happens in labor and delivery. A 1996 study published in the
Lancet
found that of 282 obstetricians surveyed, 31 percent of the women and 8 percent of the men (17 percent overall) said they would want a cesarean section if they or their wives were pregnant. Many said that they would choose the operation even in uncomplicated, low-risk pregnancies.
⁸³
Though I don’t know of a similar study from the United States, I’ve met many physicians who honestly believe that cesarean sections are the superior mode of delivery, and this belief is reflected in their personal C-section rates. Hospitals keep statistics on the C-section rates for individual doc tors, so a physician should be able to tell you his or her rate. (Of course, in a practice limited to high-risk obstetrics in a large medical center, the rate will be higher.)

2.
If you’ve had a prior C-section, consider having a normal vaginal delivery for your next birth. Though many women don’t know it, both the medical literature and the personal experience of countless obstetri cians (including me) who have performed vaginal births after cesarean for years show that the vast majority of women who’ve had a previous C-section can safely go through a normal labor and delivery. A recent study found that roughly 73 percent of women attempting VBAC were successful. The same study also reported that only one woman out of every two thousand who undergoes VBAC will have a sig nificant complication from uterine rupture.
⁸⁴
This makes VBAC far safer than a routine C-section. Yet according to a 2009 study, women who have given birth via C-section have a greater than 90 percent chance of having another C-section with their next pregnancy.
⁸⁵
If your doctor is not comfortable with the VBAC option, find someone who is.

3.
Choose your birthing place carefully. Plan to have your baby in a setting in which you know you’re most apt to feel safe and secure. More and more, studies are documenting that home births are safe for care fully selected and well-supported women. Family-centered maternity care centers offer many of the comforts of home with the safety net of a hospital. A growing number of hospitals and some freestanding birth centers now offer this kind of care, which is characterized by the following: the laboring woman, with her support person(s), labors and delivers in the same room; the labor and delivery nurse is the same throughout her stay; and the mother’s nurse is also the primary nurse for the baby, who rooms in with the mother. In short, in family-centered maternity care, the focus is on keeping mothers, babies, and families together in supportive and healthy ways. This is a vast improvement over the childbirth-as-major-operation approach that has been common since the 1950s; that approach requires a labor room, delivery room, and recovery room, all staffed by different nurses, and the baby is sent to a nursery, where yet another group of nurses takes over. This fragmented care, which was experienced by nearly all of our mothers, can be devastating to a laboring mother and her new baby, and it in creases the risk of intervention starting from the time a woman enters the hospital.

4.
Hire a doula to mother you during your labor and delivery. (See page 484.) Better yet, work with a doctor or midwife who auto matically suggests professional labor support and is comfortable working closely with these individuals. Such doctors and midwives almost always have lower C-section rates than their colleagues.

5.
Don’t go to the hospital too early. It’s very common for a woman to go through many hours of “prodromal” mild labor before going into true labor, which is defined as the active dilation and effacement of the cervix. If you’re really in labor, you won’t want to talk through a con traction, your attention will be focused inward, and you won’t want to move around much during the contraction. Consider hiring a midwife who can meet you at your home or at another convenient location to check your progress before you get admitted to the hospital, where the atmosphere may actually slow your labor or cause it to be dys functional. (This is not always the case in a good birth center that offers family-centered maternity care.) Remember, your uterus is very sensitive to your environment. It works best whenever and wherever you feel the most relaxed and safe. This will vary from woman to woman.

Recent studies have suggested that labor may take longer than doc tors have been led to believe it should and still be completely safe and normal. Many doctors have been trained to follow the now-outmoded Friedman curves—named after a well-known Boston obstetrician whose advice influenced several generations of obstetricians—for determining the progress of labor. If your labor doesn’t follow these graphs, it may increase your chances for having a C-section even when everything is normal.

A significant number of C-sections are done for “failure to progress,” a condition often attributed to the fact that the baby is “too big.” This is usually not the case, since many women who have had C-sections for this indication go on to have even bigger babies in subsequent pregnancies following a normal labor and delivery. Failure to progress, in my experience, simply means that the uterus stops con tracting efficiently and the mother becomes exhausted. When this goes on for a number of hours, a C-section is often done to get the whole thing over with.

What you want to do is avoid the chain of events that leads up to this in the first place. Tune in to your body’s wisdom. Most women will be able to know when they’re really in labor. Don’t let the collective emergency mind-set of the culture invade your physiology here, because once you get all hooked up to the monitor, you may find that your labor slows—or stops altogether if you are really anxious. And try to avoid letting anyone rupture your membranes to “get things moving.”

Unfortunately, all too many women and their mates have been indoctrinated by TV shows and movies showing couples rushing to the hospi tal at the first sign of a contraction, fearful that the baby will simply drop out if they don’t arrive in time. Once they are there, the hospital staff will often be subtly (or not so subtly) pushed to do something because the woman is tired of being pregnant and wants it over with. If, in this state, you get into bed, allow your membranes to be ruptured, and then stay im mobile waiting for something to happen, you won’t be allowing your body and your baby to find their own timing.

6.
Plan to labor without an epidural. When you enter labor with the idea that your body will know how to deal with the sensations, you’re more likely to be in the receptive mode necessary for optimal uterine functioning. If, on the other hand, you believe you will need an epidural the minute you enter the hospital, you won’t be present with your own labor. The contractions will simply be something to be endured until the anesthesiologist gets there. Although epidurals can be very useful under certain circumstances, they are associated with prolonged labor and with relaxing the lower part of the uterus and pelvis so much that the baby’s head engages in the wrong position. And, as I mentioned above, even if an epidural does not increase your cesarean risk, it is still associ ated with maternal fever and the risk of your baby needing a sepsis workup. It also inhibits the release of the neurotransmitter beta-endorphin, which normally increases during labor and is responsible for the euphoria some women feel. Nature designed that euphoria as the best possible state in which to meet and fall in love with your new baby. If you do find you need an epidural, for whatever reason, wait un til your labor is well established and ask for the lowest dose that gives you adequate pain relief.

7.
Embrace the process. Labor feels very instinctive and primitive, but because our culture teaches us not to trust our instincts, we usually associate the word
primitive
with
ignorant
. The Random House dictionary defines
primi tive
as “unaffected or little-affected by civilizing influences.” Believe me, that’s exactly how labor feels. We cannot labor with our intellect. We women need to reclaim this animal part of us and embrace ancient and necessary wisdom. Preparing for birth with the Bradley Method (see
www.bradleybirth.com
) or the Calm Birth method (see
www.calmbirth.org
) surely helps. Above all, trust that your body knows how to give birth. During labor more than at any other time, women have the opportunity to experience their body’s wisdom in a dramatic way. Move into the positions that feel best (usually on your hands and knees). Don’t get into bed unless that’s the position that feels most comfortable. Don’t resist labor—dive in deeply and go with it. I’ve attended enough labors to know that when women feel comfortable, relaxed, and well supported, their bodies automatically know what to do to keep both themselves and their babies safe.

MY PERSONAL STORY

As a mother and a women’s doctor, I have experienced childbirth from both sides of the bed. Every mother has moments that she cherishes from the birth experience and insights and feelings she’d like to share with other women. I’d like to tell you my story and also some remarkable stories of other women.

The due date for my first child was December 7, 1980. I continued my work supervising the residency clinic at a Boston hospital, and flew or drove to Maine every other week to keep my practice going there. I had watched far too many pregnant women stop work early and then mope around the house eating, waiting for the baby to come, and sometimes begging their obstetrician to induce labor. I didn’t want to fall into that category. I had also seen dozens of women go overdue. I certainly wasn’t going to get excited about labor—at least, not until my due date.

On Thanksgiving we went to dinner at a friend’s house. Later that evening, back home in bed, I started to experience very mild but regular contractions that didn’t hurt. Like the good controlled doctor that I was, I went into the bathroom and decided to examine my cervix to see if I was dilating. When I did this, my water broke. I thought, “Damn, now I know this really
is
it.”
⁸⁶
Shortly thereafter, without the natural “padding” that the amniotic fluid provides, my contractions began coming every two minutes and were much more uncomfortable than initially.

I called my mother, who was planning to help me after the birth, and said, “I’m not going to like this.” She said that she understood (after six children, she knew) but that it wouldn’t last forever. When Mom gave birth in the 1940s, she always had to labor alone, strapped down in bed with no pain relief or personal support. Then for each delivery, she was knocked unconscious by drugs under the mistaken belief that the actual delivery was the worst part and required anesthesia. She was handed the baby later by the obstetrician, as though it was a gift from him and not the fruit of her own labor. Millions of women like her were never given a choice and didn’t even know there were other ways to deliver.