Qualities of Childbirth
Experiences & its impact on Physiological Labor: The
quality of the childbirth experience as defined by the mother extends beyond
the moment or manner of delivery and can affect the mother physically and
physiologically for months or years, perhaps even becoming a pivotal point
in her life. The cumulative effect of the events of childbearing in
combination with other influences extend into the mother-child relationship
and can profoundly effect the quality and satisfaction in that central and
important fact of day to day parenting. Problems within the mother-child
relationship can trigger a cascade of difficulties that not only negatively
effect the individuals and their family but also the stability of the
community and greater societal goals. While there is no immutable evidence
that a good-parent-child bond prevents teen delinquency and violence, there
is evidence that birth complications in combination with a fractured
mother-child bond is a strong contributor to violent behavior in
adolescents, especially boys
[“Safety in Alternative Childbirth”, P. Schlenzka, 1999].
Therefore, events that contribute to the fracturing of the
mother-father-baby bond are to be avoided and those that protect and promote
it are to be pursued and supported by society. This is
"mother-friendly" maternity care [Coalition
for the Improvement of Maternity Care, 1996].
Non-erotic
sexual nature of childbirth: It is
useful both the childbearing woman and the practitioner to acknowledge the
non-erotic, but none-the-less sexual, nature of childbearing. Childbirth
involves the same biological structures and includes many of the same
physiological principles necessary for physiological function in both sexual
and excretory biology. These principles include acknowledgement of the
mother’s psychological need for privacy and her right to voluntariness in
participation of persons and procedures that transgress the boundaries of
her body or sexual psyche. It also includes freedom from performance
pressures and arbitrary time constraints. Spontaneous biology is heavily
influenced by psychological factors (both mental & emotional states)
that are themselves an extension of normal reproductive sexuality.
Quality
of Care: The childbearing woman has a
right to that quality of care from her companions and her caregivers that does
not disturb or interfere with normal physiology of spontaneous progress
in labor & birth. In the absence of this quality of active hands-on
support, which is the core of the traditional midwifery model of care, the
mother will frequently need narcotic medications to manage pain and anxiety
and secondarily the use of oxytocin to overcome the labor retarding effects
of narcotics. Additional surgical interventions of episiotomy, forceps,
vacuum extraction, cesarean section often represent the failure of the
maternity care system (or individuals within it) to account for the
influence of the mother’s psyche in regard to the physiological events of
labor and birth. [Safety
of Alternative Approaches to Childbirth; Peter Schlenzka, 1999]
A
socially appropriate environment is
one in which the mother feels unobserved and yet secure, with emotional
support as necessary. This is the purposeful mechanism of midwifery
care that addresses the mother’s pain, her fears, and privacy needs, so
that labor can unfold naturally. It is also necessary to take into account
the positive influence of gravity on the stimulation of labor, dilatation
of the cervix and decent of the baby through the bony pelvis. Maternal
mobility not only helps this process along but also diminishes the
mother’s perception of pain (perhaps by stimulating endorphins). To
ignore the well-known relationship of gravity to spontaneous progress is
to do so at the peril of mother and baby. The complex interplay of the
physical and the psychological are such a biological verity
of childbearing that women have an undeniable right to have the maternity
care provided to them
be structured to address gravitational influences and the quasi-sexual
nature of spontaneous labor and physiological birth. [Safety
of Alternative Approaches to Childbirth; Peter Schlenzka, 1999]
Conservation
of Maternal Effort
Through Right Use of Gravity
Mobility, Upright or Vertical Posture:
Maternal mobility and an upright or vertical posture are important to the
physiological mechanics of parturition and maternal psychology controlling
her experience. It is important to avoid all maternal postures that result
in the childbearing mother lying supine on her back or bearing her body
weight on her sacrum. During first stage lying on the back reduces uterine
blood flow, makes uterine contractions more painful and cervical dilation
less efficacious and leads to or contributes to fetal distress. At
present 10% of CS are performed for fetal distress. During second stage this
non-physiological position also closes the bony aperture of the pelvis by
20-35% and increase soft tissue resistance resulting in "mattress"
dystocia.
During the second stage (all stations above +3,
prior to presence of the fetal head on the perineum) the best progress and
the least maternal effort is achieved when the mother is in a vertical
posture. The most favorable accommodation of the irregularly shaped fetal
head to the irregularly shaped maternal pelvis is achieved via a combination
of maternal mobility (changes of position, walking) and the pelvic enlarging
effects of a squatting or lunging positions, in which abduction of the
thighs to the side and slightly back against the abdomen increases the
intra-abdominal pressure while increasing the pelvic diameter.
Management of
Perineal Stage: The concept of a
"perineal stage" is a functional definition of the latter part of
2nd stage used by many midwives to describe the biological and psychological
events from a +four station to the actual crowning of the baby’s head (+5)
and delivery of shoulders. Midwives separate both the timing and the
management of second stage into these two phases. Either one can be faster
or slower than average, irrespective of the alacrity of the other. Midwifery
management style differs quite dramatically depending on where exactly the
mother is in the spectrum of progress, from the first tentative pushes at
9-10 cms to the last expulsive effort which crowns the baby’s head. For
first time mothers the perineal stage is often a rather slow process of
stretching out the perineum via a series repeated pushes over the course of
15 to 45 minutes. Gravity is still physiologically useful and for some, it
may be absolutely essential if episiotomy and operative delivery are to be
avoided.
Other laboring women (often but not always
multiparas) may experiences a dramatic change in status after the cervix is
fully dilated as the mother’s body appears to simultaneous opens up
(relaxing normal muscle resistance) while forcefully propelling her fetus
downward. This reflexive surge efficiently overcomes the usual soft tissue
resistance and takes advantage of momentum to press the baby down and out.
While the example of gastric emptying (emesis) makes an unpleasant analogy,
in truth it shares the same biological chain of events, except going in the
other direction. To the observer it reminds one of the "dry
heaves" in which a sudden powerful contraction of the abdominal muscles
occurs. When the baby’s presenting part is quite low, the pressure of the
advancing head triggers the same expulsive receptors which triggers a bowel
movement. The powerfully abdominal contraction suddenly causes this dramatic
bodily event (pushing) to occur -- often to the surprise of the mother
herself. This is the last act in a phenomenon characterized by Dr.
Michael O’Dont as the “fetal-ejection” reflex (additional definition
and expanded discuss on this topic appears at the end of this essay).
In some multips the fetal ejection reflex can
be initiated long before the baby’s head presses on the perineum and even
before the cervix is fully dilation. For these mothers the baby almost
"free falls" through the birth canal and across the perineum in
the matter of 1 - 3 pushes. However for most mothers there is more to the
initiation of this reflex that just the physical trigger of cervical
dilation or pelvic floor pressure. Of equal or greater importance is the
psychological component. While it is impossible to predict which mothers
will and won’t experience this "labor-saving" biological event,
many birth attendants have observed that a confident mother is more likely
to do so than a fearful, anxious one. While no caregiver can program mothers
under her care to experience this beneficial reflex, acknowledgement of the
psycho-social/sexual nature of childbirth greatly helps.
Psycho-Social/Sexual
Aspects of Expulsive Labor ~ creates a maternal needs for
privacy and a feeling of security which shares many of the same
characteristics as the social norm for using the bathroom. These are brought
into play by the strong expulsive sensation of 2nd stage in which
many childbearing women are, quite naturally enough, convinced they need to
have a bowel movement. Fear of soiling in front of strangers often means
that the mother unconsciously uses the muscle of her buttocks to hold back
in the rectal area while simultaneously using her abdominal muscle in an
attempt to push the baby down through the birth canal. This creates a
push-pull war of sorts that works against the goal of expulsive labor.
Facilitating
Physiological Pushing:
The goal is
to help her push fully while she
simultaneously relaxes the gluteal muscles of the buttocks. For many women
in late 1st or early 2nd stage labor this is best
addressed by encouraging her to sit on the toilet for a minimum of 6 or more
pushes, right when she first begins to feel "pushy". Sitting on
the toilet produces a body posture which shares many of the same
characteristics of squatting. Supplying the mother with 3 or 4 inch prop
under each foot helps her maintain good flexion and abduction of the thighs.
This comfort measure also reduces the pressure on the under side of her
thighs which if prolonged will interfere with circulation and contribute to
vulvular edema.
Providing the mother with privacy in the
bathroom, except for the presence of her spouse or intimate family member
and/or the midwife/L&D nurse, addresses the intimacy needs of the
situation. If there is justifiable concern about precipitous birth (a multip),
the caregiver can monitor progress by holding a small mirror between the
mother’s legs. The perineum can be visualized to be certain that she does
not inadvertently deliver while on the toilet by shining a flashlight
between her legs while angling the mirror appropriately.
The creative use of
gravity shortens the 2nd stage, reduces the stress on the baby and
associated risks of fetal distress.
Use of physiological postures and acknowledgements of the
psycho-social/sexual aspects of the mother’s experience also help reduce
the number of times she must push and the quantify of finite energy that the
mother must expend to give birth to her baby. When a mother pushes while
lying in bed on her back she is bearing body weight on the maternal sacrum.
This means she must overcome the deleterious forces of gravity that now work
against her as the birth canal is a 60 degree right angle aiming up towards
the ceiling in this position. Bearing her body weight in this position
closes the pelvic aperture by 1/5 to 1/3 (equal to 1 to 3 cms), making it
harder for even an average sized baby to fit. The aggregate of these forces
means extra pushing at the very least 1/2-hour, often an hour or more and
increased expenditure of incalculable amounts of finite maternal energy for
very little gain.
Mothering the Mother by Husbanding her
Physical Resources:
The pushing stage comes at the end of labor, when the mother has lost sleep
and not eaten for many hours, suffers from fatigue and often is discouraged.
It is unkind to ask her to do the hardest physical work ever required by our
normal biology (especially if it is a first vaginal birth) under these
sub-optimal conditions. The normal amount of uterine force, expressed as
pounds pressure per square inch, required to give birth to a first baby is
approximately 120 psi. The uterus on its own produces only about 80 psi,
which means that either the mother must use abdominal muscles and gravity to
provide the missing 40 psi or the caregiver must pull with forceps or a
vacuum extraction device at that level of downward torque.
When every drop of maternal energy is expended
on pushing to baby down to the perineum, there is nothing left for her to
use for the perineal stage -- that is to push the baby’s head and
shoulders out and across the perineum. This sets up the situation for the
otherwise unnecessary surgical intervention of episiotomy and its risks of
bleeding, infection, prolonged postpartum pain, the need for narcotic
medications and the disruption of bonding and breastfeeding that pain and
drug use entails. For some mothers, operative vaginal delivery or Cesarean
surgery may be required to “rescue” her from this iatragenically-arising
complication. Cesarean surgery doubles the maternal mortality, makes her
“high risk” in future pregnancies and dramatically increases the risk of
placenta previa and percreta, which can be fatal.
Delivery Positions:
On those occasions when mothers are unable to be upright or out of bed
the side lying posture is the most physiologically appropriate position, as
the curve of Carrus is neutral to gravity with the mother on her side. This
position might be indicated because of a medical condition, epidural
anesthesia, maternal preference to give birth in bed, or high parity mothers
who are better managed with a slower, more controlled delivery. While not as
gravitationally effective as upright positions, at the very least side lying
does not require the mother to work uphill against the forces of gravity. In
addition to space-sparring aspects of side lying, some practitioners believe
this position may reduce the incidence or severity of shoulder dystocia as
the weight of the mother’s upper leg serves to help “bow” the pelvis
(always made flexible by the hormones of pregnancy), making it wider from
front to back and therefore providing more room for the shoulders which
present either obliquely or in an A-P diameter of the pelvis.
Protecting
the Physiology of Birth ~ Side-lying moms, preference of European Midwives
and American obstetrical icon, Dr. Joseph DeLee:
In a side-lying position, the mother’s upper leg can be held by a
family member or assistant or placed on a large pillow. Some mother’s
prefer to hold their upper leg in a flexed position with their own hand but
usually it is helpful to have stabilizing support.
Of
historical note, this is the position recommend and illustrated by Dr. DeLee.
Illustrations in his 1924 obstetrical text show the practitioner sitting to
the right of the mother (with the mother facing away from the practitioner).
The caregiver sits on the bed next to the mother, lightly touching the small
of her back, or on a stool or chair next to the bed. It is important to be
at the same level as the mother in order to have a clear view and easy
reach. Most midwives prefer to simply sit on a stool or low chair next to
the mother’s bed, slightly more toward to the south of the mother. The
rolling stool used by physicians in hospital births is particularly
convenient, as one must be sitting at the same level as the mother in order
to appreciate the benefits of this technique and to avoid back strain.
Flexion
of the fetal head is maintained by the practitioner by placing the fingers
of the top (or left) hand lightly on the crowning head of the baby. If
sitting on the bed, at the mother’s back, this can easily be accomplished
by reaching over and across the mother’s abdomen to the top of the
baby’s head. If sitting on a stool slightly toward the foot of the bed,
flexion is maintained by simply reaching up between the mother’s legs with
the left hand. The practitioner’s lower (or right) hand is then
placed, palm down, on the perineum (the web of skin between the finger and
thumb of the hand matching exactly the web of stretched perineum). In this
fashion the caregiver lightly supports the perineum during the birth of the
head and continues to support it during the delivery of the shoulders.
One of
the tactical advantages of this side lying position is the easy access one
has to the perineum during the delivery of the shoulders. When the mother
delivers while lying on her back, the already delivered head of the baby
obstructs the practitioner’s view and access during the birth of the
shoulders. Also the medical model teaches students that they must use both
hands to place traction on the baby’s head in order to deliver the
shoulders when the mother is in a lithotomy position, thus leaving no hand
free to guard the perineum. In a side-lying position, this active
“delivery” via traction on the head is unnecessary, as the curve of
Carus is not obstructed by “mattress dystocia” when the mother is not
bearing weight on her sacrum. With the birth canal unobstructed, the normal
expulsive force of the mother “delivers” the baby’s shoulders, taking
advantage of the normal physiological mechanism created by the curve of
Carus. This means that the posterior shoulder delivers first, followed by
the upper shoulder, which pivots around the public bone as soon as the
posterior shoulder is free.
As every practitioner can
attest, the baby’s head often delivers without causing any perineal
lacerations, only to have the shoulders and a compound arm/s delivers a
karate-chop to the perineum. The DeLee side-lying method is superb for
managing the delivery of the shoulders, as it offers a successful method to
control for compound arms, thus reducing or eliminating a lot of unnecessary
perineal trauma.
=====================================================================
~ Maternal-Fetal Ejection Reflex ~ the fruit of a physically
and psychologically undisturbed labor in a healthy mother
“Designer genes”
for spontaneous birth programs a natural
“labor saving devise” into human reproduction,
resulting in
a phenomenon referred to here as the “Maternal-Fetal Ejection Reflex.
There are quantifiable biological differences associated with undisturbed
spontaneous labor and birth. If one is fortunate enough to be present at a
great many “undisturbed” labors, those “designer genes” of the human
species for spontaneity can be observed as naturally advancing process that
combines biological and psychological resources to make human parturition
mechanically successful, physically tolerable for the childbearing woman and
safe for the about-to-be born baby. It is accompanied by a dramatic increase
in childbirth-specific hormones – endogenous oxytocins to stimulate
uterine activity, beta endorphins (the source of the “runner’s high”)
providing for naturally produced, internal (non-addictive) pain relief for
the mother. Maternal hormones also trigger adrenal hormone production in the
fetus to prepare it to breathe independently and maintain its body
temperature after birth.
This innate potential of normal
childbearing physiology for an expeditious labor and birth is central to
the midwifery model of care. Understanding it goes a long way towards
de-mystifying the normal practice of midwifery and giving it a useful
context. It also reveals the problems that arise when trying to provide
hospital-based care to this cohort of healthy women.
A great many of these women will, if undisturbed, enjoy labors
graced by a truly “labor-saving” mechanism -- the spontaneous birth
reflex. A large percentage of this same cohort of women, when confined by
the physical and psychological restraints of modern hospital care, will
have a vastly different and much less satisfactory, less spontaneous
course of intrapartum events.
In recognition of this
phenomenon Dr. Michael O’Dont, a French obstetrician, coined the term
Fetal Ejection Reflex. Midwives added the word “maternal” to this term
(maternal-fetal ejection reflex) to make it evident that the fetus does
not, independent of its mother, ‘eject’
himself from her body but rather it is the mother who permits the freight
train of spontaneous energy to run thru her for the purpose of safely (and
sanely) liberating her baby from its temporary uterine home.
Dr. O’Dont was attempting to
identify the biological mechanism responsible for rapid, apparently easy
&/or precipitous deliveries. It explains why after a short active
labor a mother could give birth to an 11# baby in just a few pushes and
without sustaining any significant perineal trauma.
The normal spontaneous birth reflex is the “physiological”
process (biology + psychology) that makes birth mechanically successful,
physically tolerable for the childbearing woman and safe for the
about-to-be born baby.
Maternal-Fetal Ejection Reflex Defined:
The idea of a Maternal-FER implies an innate physiological mechanism similar
to a slow motion sneeze, as if a reverse form of peristalsis was triggered. The
cervix dilates faster and easier than expected as the reflexive nature of
this mechanism efficiently overcomes the usual soft tissue resistance (for
example, a primipara progressing from 5cm to birth in 43 minutes!). The
advantage of this momentum is the efficiency of abdominal muscles pressing
the baby down and out without being impeded or countervailed by a
great deal of muscle & soft-tissue resistance.
Body structures (cervix and pelvic floor) that normally hold the baby
back suddenly relax and open up, the fetus does a free-fall thru the birth
canal, the pelvic floor melts way and within a few pushes the baby is born.
Historically speaking, unpredictable nature and timing of childbirth,
combined with this propensity of multipara mothers to have their babies
free-fall through the birth canal, are the very attributes of physiological labor and delivery that disturbed
the earliest obstetricians. Doctors DeLee and Williams and other
contemporary colleagues lamented that labors only came in two flavors –
too fast and too slow. First-time mothers were so slooow – average labor
(starting from 3+ cms) was said to be 15 to 20 hours in Dr DeLee’s 1924
edition of his obstetrical textbook. At the opposite end of the spectrum
were the grand multips who appeared to not even be in active labor just a
few minutes before their babies were born. With little or no preamble the
mother often experienced spontaneous rupture of membranes and the baby
washed out helter-skelter in some inconvenient or inappropriate place before
the doctor can get his gloves on or perhaps, even before he arrives. This
element of unpredictability fueled medical efforts to control messy Mother
Nature (i.e., the spontaneous physiology of parturition). For multips it
seems only logical to bring them in to induce via AROM so they wouldn’t
deliver in the doctor’s office or the parking lot of the hospital.
Psychological Factors:
A crucial facet of this normal birth reflex seems to be the psychological
component, especially the psychological comfort of the mother with
her situation. Dr. Michael O’Dont described this as creating psychological
circumstances for the mother so she “feels secure and unobserved at the
same time”. He observed that the birth attendant’s first
responsibility is not to disturb the natural process. For many mothers
her need to be undisturbed is balanced by an equally powerful need to be in
the “right” place – a concept to be defined by the mother but which
usually includes the presence of psychologically-importance family members.
Usually (but not always) the doctor or midwife must also be present before
she can “permit”, at least at a subconscious level, that dynamic labor
process to unfold. For those who planned on hospital care, the mother must
have arrived at the hospital before the Maternal-FER can complete itself. It
does not seem to require the presence of the doctor as much as admission to
the hospital and presence of the L&D nursing staff.
This phenomenon is a constant “exception” to the
rules of labor as expressed by Friedman’s Curve, which graphically
represents labor as a linear process, inexorably slow, innately painful.
Most importantly, this linear concept portrays labor and birth as solely
dependent on incremental hard work and ability of the mother to tolerate
the pain rather than using her internal resources to
“facilitate” or surrender to her labor.
The picture society has of so-called “normal” labor and delivery is one
of incredible effort in which the mother labors with the kind of slow
incremental progress reminiscent of climbing a rock face by hammering
pinions into cracks and painfully pulling oneself up again and again,
fighting for every inch of forward motion and constantly subjected to
excruciating pain. The maternal-fetal ejection reflex is almost the opposite
of that expectation of hard-fought incremental progress and overwhelming
pain. While it is impossible to predict who will experience this
labor-saving biological event, many birth attendants have observed that a
calm or confident mother is more likely to do so than a fearful, anxious one
who feels greatly unsure of herself or is starkly afraid of birth. While no
caregiver can program mothers to experience this beneficial reflex,
acknowledgement of the psycho-social/sexual nature of childbirth seems to
help greatly to facilitate its appearance.
In an environment that is free of exaggerated fears of childbirth, the
Maternal-FER appears to provide the “grace” that can only be matched in
a medical setting through the use of epidural anesthesia. Often (but not
always) the M-FER is further facilitated by submerging the mother in deep
water after she has reached 5cm dilatation and encouraging her and her
husband or partner focus together while limiting the caregiver interruptions
to as few as possible (FHTs q 30 minutes, minimum vag exams or
manipulations), thus permitting the mother to feel
both secure and unobserved. Unfortunately this spontaneous birth
reflex is easily disturbed and often (but not always) obliterated by
medicalization and/or hospitalization during the intrapartum period.
Sexual Nature of Physiological Parturition:
The Maternal-FER appears to represent in parturition what sex researchers
Drs Master and Johnson identified as the orgasmic plateau, that is to say a
natural state of being during which an overriding internal mechanism
triggers a series of discrete but perfectly timed and attuned events of
physiology which fire off in domino fashion when the conditions are right.
After reaching this point it seems to occur irrespective of the personal
wishes of the individual. In the case of labor this means that even if
uterine contractions seem painful or the mother becomes anxious, the labor
will continue briskly on and soon culminate in a NSVD without anesthesia and
often, without significant perineal trauma, perhaps even before the doctor
or midwife arrives.
Neo-Cortex ~ the Place
where Mind Meets Body: One theory explaining M-FER is the role of
primitive brain in facilitating the spontaneous processes of labor and
birth. This theory also identifies as negative the influence of the
neo-cortex (dominance of the left-brain or “late for the train”
mentality) and a host of institutionally-originating disruptions such as
bright lights, loud noises, coming and going or milling about of unfamiliar
people, unnatural, anti-gravitational positions and frequent disruptions
provided by invasive procedures such as vaginal exams, catherizations,
fussing with EFM belts, etc. The
“intensive care” nature of intrapartum nursing in hospitals
means most women experiencing the exact
opposite of “secure and unobserved”.
The routine nursing and medical
interventions and application of technology often triggers the childbearing
woman feels very much like a bug under a microscope.
Recognition of the M-FER: What
interferes with a recognition of this discrete physiological event is that
it so often follows anywhere from 4 to 48 hours of non-progressive or
prodromal labor or a lengthy painful latent labor. It is during this warm-up
phase that most women who plan on a hospital birth find themselves admitted
to L&D. This usually starts the medico-legal clock and if progress
cannot be documented within a few hours they will be given pitocin and
usually require epidural anesthesia. This will either derail or obscure the
physiologically fast-finish. In community-based care, midwives often see a
longish desultory phase and are derailed from appreciating what can only be
described as an “order of magnitude” shift up, resulting in an active
labor that is many times faster than normal. Because this rapid progress so
often comes on the heels of a long, psychologically difficult latent phase,
it is not perceived by either the mother or the practitioner as a “fast
birth”.
Like a form of foreplay, this long latency process (“forelabor”)
seems to set up the biological and social circumstances so that all the
“five elements for success” are simultaneously present. Latent labor
gets everyone gathered, involved and geared up to attend to the biological
and emotional needs of the mother and baby. This warm-up phase is neither a
waste of time or something to be rushed along.
The marriage of biology to psychology with its attendant association
to sociology (the right people present and the wrong people not) is
necessary for physiological function and is part of the process of
“self-assembly” that is unique to living systems.
This represents a “systems” event (involving many different body
organs and mental or emotive systems). This differs from the typical medical
focus on a single physical organ (example the uterus) and/or a single
non-mental function such as the progressive dilation of the cervix in labor.
While the latter is the usual focus of obstetrical medicine it provides a
poor foundation for physiological function. When this spontaneous birth
reflex is present, the latency period is sooner or latter abruptly replaced
by an accelerating labor pattern. Primagravidaes go from 5 or less
centimeters dilatation to delivery in under 4 hours. A multipara progresses
from 4 or less centimeters (or if no vag exam, begin counting from when she
was obviously prodromal / early latent labor) to delivery in less than 3
hours. Unfortunately for most
women, the fruit of the undisturbed labor is rarely seen in the modern
hospital L&D.
The Maternal-Fetal Ejection Reflex offers hope to childbearing women that
they can prevail in their goal of having a physiological labor and birth.
Knowledge of their potential for being blessed by this labor-saving devise
provides all of us with an antidote to the pathological fear of childbirth
that has dominated the public dialogue for the last century.