© 1999 by Perigee Books
The Thinking Womans Guide to a Better Birth
The Slow Labor: The Bottom Line1. Problems with Typical Management
a. Active Management of Labor
2. The Bottom Line
Benefits and Risks of Techniques for Coping with Poor Progress
benefits: Studies suggest that activity and positioning can intensify contractions, bring the baby down, expand the pelvis, * and turn the baby to the favorable anterior position. Eating and drinking can avoid fatigue and dehydration, which may slow labor. Massage, acupressure, and warm tub baths or showers can ease pain and induce relaxation, which may enhance progress. Warm water immersion has been called the midwives epidural. Talk can provide comfort, reassurance, encouragement, relieve anxiety, and explore what psychological or emotional issues or adverse environmental elements might be affecting labor. Using these strategies as the primary approach avoids unnecessary use of oxytocin, instrumental delivery, and c-section along with their attendant risks.
risks: A full squat may be inadvisable in women with varicose veins or knee joint problems. Women may develop a fever if submerged too deeply for too long in warm water, but this can be alleviated by lifting more of the body out of the water or getting out of the tub, and infection is not a risk with ruptured membranes. As an experiment using a starch-impregnated tampon and iodine in the water proved, bath water does not enter the vagina. Exploration of possible underlying psychological factors may lead a woman to think that slow progress results from not thinking the right thoughts, which could lead to self-blame. Contrary to common obstetric belief, eating and drinking in labor pose no risks.
risks: May produce overly long, overly strong contractions. Stopping or reducing the stimulation will rapidly normalize contractions.
benefits: Routine early amniotomy shortens labor by an hour or two. It appears to reduce the incidence of 5-minute Apgar scores below 7 but has no other effects on the infants condition at birth. It may reduce the use of oxytocin and the number of women who report the most intense degree of labor pain. However, the use of oxytocin, which makes labor more painful, and pain medication, especially epidurals, makes it difficult to determine the relationship between amniotomy and labor pain.
risks: Amniotomy increases the incidence of abnormal fetal heart rate patterns. Studies may underestimate this risk because women not having early amniotomy are more likely to receive oxytocin, which also increases the odds of abnormal fetal heart rate patterns. Routine early amniotomy risksistently increases the cesarean rate. When data from seven trials in which women were randomly assigned to early amniotomy or not were analyzed (meta-analysis), women in the early amniotomy group were 20% more likely to have a cesarean. An additional two studies not included in the meta-analysis also reported more cesareans in the early amniotomy group. The percentage found in the meta-analysis may be low because cargivers in several trials were not able to stop doing amniotomies in the riskserve membranes group. Specifically, half or more of women in the riskserve membranes group in the two biggest trials had amniotomies, albeit somewhat later in labor. If amniotomy does, in fact, lead to c-section, this would tend to minimize the differences in cesarean rates between the two groups. Early amniotomy may also increase the risk of infection.
Benefits And Risks Of Amniotomy For Indication
benefits: Rupturing membranes may help labor progress, allow closer monitoring when there is concern about the baby, and permit caregivers to determine whether the baby has passed meconium into the amniotic fluid.
risks: Studies suggest that early amniotomy may not benefit slowly progressing labors and that late amniotomy may have unpredictable effects. Valerie El Halta, a prominent home birth midwife, suggests one reason why: if the baby is posterior, that is, facing the mothers belly instead of her back, labor often progresses slowly until the baby turns into the anterior position. With membrane rupture, the head may surge downward into the pelvis and get stuck. As for permitting closer monitoring for suspected fetal distress, releasing the amniotic fluid adds to the babys stress by exposing the umbilical cord to compression during contractions. In addition, one potential cause of fetal distress is that the umbilical cord has slipped between the head and the cervix. Rupturing membranes could then cause prolapse, converting a concerning situation into an emergency.
benefits: Strengthens contractions by increasing circulating oxytocin levels. May avoid the need for instrumental delivery or c-section.
risks: Increases pain. Especially when given in high-dose regimens, oxytocin can produce overly long, overly strong contractions and abnormally high resting uterine-muscle tension, which may deprive the baby of sufficient oxygen. If this is not addressed, it may result in fetal distress (abnormal heart-rate patterns), brain damage, or death. Treatments include reducing or turning off the drip, giving medication to suppress contractions (tocolytics), or if distress continues unabated, cesarean section. With prolonged use, oxytocin increases the risk of postpartum hemorrhage. It may also increase the risk of newborn jaundice. The authors of a recent review of research into oxytocin commented, If oxytocin had been discovered in the 1990s we would not sanction its widespread routine use and would conduct further clinical trials.
benefits: Adds to maternal pushing efforts and can be used to turn the baby from posterior to anterior. Less likely to injure maternal tissues than forceps and may avoid the need for c-section.
risks: Doctors may be more likely to perform an episiotomy, although it is not necessary for this procedure. Episiotomy introduces several maternal risks (see p. 000). As for the baby, the vacuum cup may cut the babys scalp, although plastic cups are less likely to do this. Vacuum extraction can cause a blood-filled swelling (cephalohematoma) beneath the cup, which increases the likelihood of developing jaundice. Occasionally, profuse bleeding occurs beneath the scalp (subgaleal or subaponeurotic hemorrhage. Unlike the relatively benign cephalohematoma, this bleeding poses a grave risk. Bleeding within the brain is another rare, serious complication. The growing number of reports on serious complications and deaths resulting from vacuum extraction has caused the FDA to issue a warning advisory about this procedure.
benefits: Delivers the baby when the mother cannot accomplish the birth on her own. Forceps can also be used to turn the baby into the favorable anterior position. May avoid the need for c-section.
risks: As typically practiced in the U.S., forceps poses little risk of life-threatening injury to the baby. However, the babys face may be cut or bruised, the collar bone broken, or there may be injury, usually temporary, to a nerve complex that controls the arm (brachial plexus injury or Erbs palsy) or to the nerve that controls the facial muscles. Forceps sometimes also cause cephalohematomas. Forceps delivery increases the risk of shoulder dystocia (the shoulders hang up during the birth), which can be life-threatening, but is almost always resolved without incident. Using forceps to rotate the baby 90 or more can cause spinal cord injury. Doctors will almost certainly perform an episiotomy, although it is not always needed, which introduces several maternal risks. Forceps delivery with episiotomy greatly increases the risk of anal tears, which, even though repaired, may permanently weaken the anal sphincter. The forceps may also cut or bruise the vaginal wall. For these reasons, forceps increase the probablility of severe pain in the days after birth.
benefits: Deliver the baby when no lesser means will serve, and the baby will be endangered by continuing labor.
risks: While relatively safe as major surgeries go, nonetheless, cesarean section poses risksiderable risks short-term and long-term to the mother and to any future pregnancies.
Strategies to Avoid the Need for IV Oxytocin, Instrumental Delivery, and Cesarean Section
Have a patient caregiver who sees his or her role as attending your birth not delivering your baby. Sheila Kitzinger, world-famous British author and founder of Britains National Childbirth Trust, says that the most invasive and potentially dangerous technologybecause from it proceeds all othersis the clock.
Have your baby at a free-standing birth center or at home. Oxytocin use rates and instrumental and cesarean delivery rates are much lower for out-of-hospital births.
Hire a professional labor support person. She will know nonmedical techniques to help keep or get your labor back on track. She will also provide continuous support, encouragement, and reassurance to you and your partner.
Have confidence in yourself and your body. Doctors tend to instill doubt. The fact that cesarean section is so common these days does the same: if you dont think you can birth your child, it may become a self-fulfilling prophecy.
Have realistic expectations of labor length and difficulty. Impatience and frustration are your worst enemy. They can lead you to make choices you may regret.
Address emotional issues that may be problematic in labor. For example, women who experienced sexual abuse in childhood or have prior traumatic birth experiences or have strong control issues may sometimes have difficulty surrendering to the labor. If this is true for you, risksciousness of this can help you and those with you work out strategies to prevent or cope with their potential effects on labor. Please, though, do not blame yourself if labor is slow and you cant fix it.
Avoid induction of labor. See chapter 3.
Unless there are medical reasons to go to the hospital early in labor, stay home until labor becomes active. If you arent sure, during the day you can go into your caregivers office to be checked, and at night, they can check you at the hospital. dont stay, though, if not much is happening. Studies show that women who are admitted in prelabor or very early labor are more likely to have oxytocin, instrumental vaginal delivery, and c-sections.
Refuse a cesarean for poor progress prior to active phase labor. This means at least 3-4 cm dilation if you have had children before and 4-5 cm dilation if you havent. Both the U.S. and Canadian obstetricians professional organizations state that cesareans for this reason should not be done in early labor.
Avoid frequent vaginal exams, but when you have them, get information on more than just dilation. Avoid frequent exams because finding there is little or no change in dilation can be intensely disappointing. Find out about the state of the cervix, how far down the baby is, and, if possible, the babys position. You may be making important progress even though you are not dilating, and often, advances in these areas may be necessary before dilation continues.
In labor, stay active, change positions frequently, maintain liquid and calorie intake, use warm tub baths or showers, and avoid flat-on-the-back or nearly flat-on-the-back pushing positions. These strategies promote good progress. You can bathe or shower with an IV as it can be covered with plastic and taped. You can bathe with ruptured membranes.
Take steps to rotate a posterior baby. dont wait until you are dilated enough for someone to tell the babys position by feeling her head vaginally. Assume a posterior baby if contractions are strong but produce little progress. None of these recommendations will hurt if the baby isnt posterior. Activities such as climbing stairs, crawling, pelvic rocks, and hip swivels help jiggle the baby around. Assuming an all-fours position, or an open lunge during the cervical dilation phase and all-fours or squatting during pushing uses gravity to swing the babys back into your belly or the leverage of your legs to expand the pelvis. Likewise, the double-hip squeeze opens the pelvis. Assuming a knee-chest position in early labor (this may be too uncomfortable in active labor) disengages the head from the pelvis, and the dangle during pushing elongates the torso, both of which give the baby more room to come around. Some midwives may offer to turn the baby manually early on during a vaginal exam. This will be painful but can transform the labor according to midwives who do it. However, there are no formal data on the efficacy or safety of this procedure.
Avoid epidural anesthesia. Epidurals slow labor, cause persistent posterior babies, and increase the risk of cesarean for poor progress.
Nipple stimulation can intensify weak contractions and can avoid the need for IV oxytocin. Stimulating the nipples causes the release of additional oxytocin. Stimulation can be manually, by electric breast pump, or via a TENS (transcutaneous electronic nerve stimulation) unit, a physical therapy device that painlessly delivers a low electric current through pads applied to the skin.
If you require oxytocin, make sure it is given a fair trial. A study of a protocol mandating at least 4 hours of adequate contractions on oxytocin in women with arrested labor progress and longer if contractions could not be brought up to par achieved an 8% cesarean rate. This was despite nearly all women having epidurals (epidurals slow labor). If, as is not uncommon, cesareans had been done after 2 hours on oxytocin with inadequate progress, the cesarean rate would have been 23%.
Refuse an instrumental delivery or cesarean section recommended solely on an arbitrary time limit. Both the Canadian and U.S. obstetricians professional organizations state there is no need to deliver the baby provided some progress is being made and the baby is doing well.
cesarean section: See p.00.
2. The Bottom Line
© 1999 by Perigee Books
Tue, Oct 12, 1999 by
Donna Dolezal Zelzer,