What the doctor said, what the evidence says

This past week I attended the fastest birth I have ever (and maybe will ever) attend.  By which I mean, the mother's water broke at 7:30, and the baby arrived at 9:30.  We all got to the hospital at 9pm, and she was 8.5cm dilated.  The mother had a history of rapid labor, so this wasn't exactly a fluke.  Regardless, everyone was wonderful by the end of the night, including the mama who, while a bit shell-shocked, felt like a total rockstar for the way her body was able to work.

After a history of high-intervention preterm birth, this family was determined to have a normal birthing experience.  And normal it was, except for the sheer rapidness... of course, seeing how the labor began on its own and progressed without any medical intervention (including pain medication), it was normal.  Fast, but normal nonetheless.

The doctor, however, was not exactly an advocate for "normal birth" in many respects.  In the short 30 minutes of contact I had with him, I found him to be abrasive, paternalistic, condescending, and just plain rude.  I keep turning the story over and over in my head, and I just can't make sense of several things he said and did.

Let me be clear: this is not just some sort of wingnutty vendetta by some conspiracy theorist doula (see previous post).  My philosophy of birth is based in sound, evidence-based research.  I respect anyone who provides care according to the research, be they midwives, obstetricians, lactation consultants, nurses, doulas, or educators.  This isn't me railing against the obstetrical field just because some guy was mean to my client... this doctor displayed a clear disrespect for the evidence-based practices from which positive birthing outcomes have shown to come.

His major offenses are as follows.

1) Physician-Directed Pushing

What happened: 
The mother was completely dilated minutes after I arrived in her delivery room.  However, she did not feel an urge to push right away.  This did not stop the doctor from trying to speed things up.  Once he found her to be complete, he immediately started telling her to bear down and "hold it for 10 seconds."  The mother said she did not feel the urge to push yet, so she was going to rest.  The doctor's response was, and I quote, "Honey, you're not going to have a baby by just lying there and resting."

What the evidence says: 
Once the cervix is completely dilated, the baby's head drops into the the birth canal.  During this time, the uterus must "re-form" over the baby's buttocks.  This can take up to 1 hour, though it generally takes about 20-30 minutes.  This has been fondly named the "rest and be thankful" phase of labor.

A woman who has not had an epidural will get a strong urge to push, called the Ferguson reflex, when the uterus has completely clamped down and is ready to help her deliver her baby.  There is much research to suggest, in fact, that pushing before the urge is completely pointless; all the mother is doing is wasting much-needed energy.  This is so true, in fact, that many caregivers will advise a woman who has had an epidural to "labor down" for at least 30 minutes (rest and wait) before they begin pushing.

So really, the doctor was completely wrong... she was going to have a baby by sitting there and resting.  In fact, she was doing her body a favor. 

2) The Friggin' Lithotomy Position

What happened: 
When mama was finally ready to push, the doctor immediately began placing her legs into stirrups.  This, to me, seems like a major violation.  To place a woman's body into such a position without asking first, well, that's just wrong.  The mama cried out, "NO!!!" and quickly moved her legs back to a place that was comfortable for her.  Her husband then explained that she hadn't wanted to give birth in this position.  The doctor visibly rolled his eyes and said, "I can't deliver a baby when your legs are shut!"


What the evidence says:
Here's a "duh" moment for you: the human body is capable of a number of different positions! {gasp!}  There's really no reason to think that a laboring woman's legs can only be either in stirrups or completely shut.

In fact, lying flat on your back with the legs in stirrups increases your likelihood of tearing and decreases the elasticity of the perineum by 30%. Our Bodies, Ourselves declares this position "the single most dangerous position" for childbirth.

3) Immediate Cord Clamping

What happened:
It was the parents' wish to wait to cut the cord until it has stopped pulsating.  This is not common practice with obstetricians, though it is usually done with midwife-assisted birth.  Seconds after the baby girl was born, the obstetrician reached for the clamps.  The husband, keeping a close eye on the doctor's every move, asked, "Has it stopped pulsating?"  The doctor looked at him with a condescending glance and said, "Yeah... sure."

What the evidence says:
More and more parents are asking their care providers to delay cord clamping, and with good reason: immediately following birth, the remaining blood retained in the placenta rushes into the newborn infant.  To immediately clamp off the cord is to waste a boost of high-nutrient cord blood that could very well benefit the newborn.

The umbilical cord will usually stop pulsating on its own in about 2-3 minutes, during which time the newborn can receive up to 25% more blood than an infant whose cord was clamped within the first minute of life.  This boost has been associated, in healthy full-term infants, with higher APGAR scores, higher red blood cell counts through the third month of life, and decreased iron deficiency during the first year of life.  In preterm infants (>37 weeks gestational age), delayed cord clamping is associated with decreased risk of late-onset sepsis and better health outcomes overall. 

Why is this not a more common practice amongst American obstetricians?  Their midwife counterparts usually wait at least 2 minutes, and obstetricians in European nations delay clamping as well.  The only known risk is hyperbilirubinemia (jaundice), but such a condition generally resolves itself with early breastfeeding.

The only explanation I can come up with is that delayed cord clamping takes time, and when you're in a hospital labor and delivery unit, time is always against you.  The wam-bam-congratulations-ma'am mentality leaves countless women feeling like they are being worked through a machine instead of experiencing a joyous, empowering occasion that they can feel good about.  Such a mentality also explains why the doctor didn't want to wait for the mama to feel the urge to push.

Of course, the medical field in general just doesn't jive with the process of childbirth.  Childbirth is unpredictable, and doctors don't like unpredictable.  Hence we've seen an alarming rise in the induction rate... an alarming (and unnatural) percentage of babies being born Monday-Friday, 9am-4pm.  While medical science has indeed saved countless lives in managing births that have become problematic, normal birth should be left to take its own course.  Care providers who work with laboring folks need to take a breath and slow. It. Down.

“The woman’s body is smarter than the doctor. Time, patience, and the baby will come. Respect the woman’s rhythm."  -Dr. George Tiller