From EverCurious:
This touches on something I'd been meaning to say but it never seemed quite the right time to say it:
One of the main reasons I started reading this site was because I was looking for the answer to a simple question that I had when one of my friends was insisting that her next birth would be unassisted (she's still convinced; I can only wish her well at this stage) and reading media reports on the 'freebirth' movement: what's the dystocia rate for women? It was something that was notably missing from the articles on the matter and without it, without some knowledge of how often things went wrong during birth, there simply wasn't enough information to make an intelligent assessment.
*Every* live-bearing species has a complication rate: it could be very low like dromedary camels (approx 0.2% of births have *any* complications) or very high like spotted hyenas (10% maternal death rate among studied wild packs), but it's there. Heck, even egg-laying can be problematic -- we used to rear laying hens and you'd get a few prolapsed oviducts, some which could resolve themselves and others, well, nothing for it but humane slaughter.
I do believe I've gotten a sufficiently good answer here: it mayn't be a nice simple number, but we're a lot more like spotted hyenas than camels.
There's something else that you haven't mentioned that's even more germane to why childbirth (I'm ignoring the complications that pregnancy itself can cause) can go wrong with such frightening frequency.
Bluntly: children do not matter. In the eyes of evolutionary success, what counts are grandchildren: the capacity to have children who will grow up to be successful *adults* in their own right able to have children of their own is what makes for success, not the mere fact of having them.
Running into difficulty when giving birth would seem a bad thing (and it is) but the factors that make birth problematic for us (secondary bipedialism; relatively large fetuses at term [huge compared to those of our nearest relatives] and that very big head) are things that we need to be successful human beings. If it becomes possible to be a successful human going around on all fours or with microcephaly, then that'll persist and given the lower complication rate at birth, that'll spread. Looking at our evolutionary history, the trend has been clearly away from that -- it seems not to be a winning formula.
It becomes even more clear when you look at spotted hyenas. Their problem is that females have an elongated clitoris through which to give birth and to be born, their large, precocious fetuses have to negotiate a 180 degree bend and that long, narrow passage. It'd be unquestionably easier to be born smaller and to be female and to have a 'proper' vagina and vulva instead of that almost perfect penis mimic, but any such hyena can't succeed in spotted hyena society. As every other successful spotted hyena is in the same boat, it persists.
My point is that complications in birth aren't in the slightest bit incongruent with nature or evolutionary success. And we're not unique in having made compromises along the way.
From Amy Tuteur, MD:
EverCurious,
Wow, I have learned quite a bit from your post.
You have illustrated the general principle very well: reproduction of all animals, including humans, contains a tremendous amount of wastage. We are aware of this in the animal kingdom. Many species lay thousands of eggs to get a few adults in the next generation. We tend to forget that wastage is a part of human reproduction, too. Every woman has millions of eggs that she will never use, and every man produces billions of sperm that will never fertilize an egg. Many eggs are defective and cannot be fertilized and many fertilized eggs fail to divide or fail to implant. Many pregnancies miscarry before a woman even realizes she is pregnant (chemical pregnancy) and approximately 20% of established pregnancies result in miscarriage. The idea that childbirth can be trusted to produce a healthy baby and a healthy mother flies in the face of everything we know about biology.
Homebirth advocates start with a bedrock principle that is entirely wrong. It's like trying to be a "direct entry astronomer" while believing that the earth is the center of the universe. If you start with the wrong fundamental assumptions, most of your conclusions will inevitably be wrong, too.
From faith gibson:
Dr Amy: “inadequate education and training of [unlicensed] American DEMs. They, like Canadian DEMs and European midwives, will be forced to adhere to higher standards of education, training and practice.”
A standing ovation for Dr Tuteur, for so aptly delivering a message that the community-based midwifery world really needs to hear. We will all thank you in years to come.
As more community-trained midwives provide care to more women, the wisdom of expanding the direct-entry education programs will become obvious. Important features of traditional training programs in EU and Canada should be available here in the US, including a mutually cooperative relationship between the medical and the midwifery professions.
Ideally, comprehensive education for community-based midwifery practice would also include hospital-based experience with high-risk labors and babies who need neonatal intensive care and ‘internship’ after graduation. New graduates should have a substantial period of co-management with an experienced professional midwife before practicing independently. All community-based midwives should be articulated with the healthcare system through complimentary relationships with professional midwives and physicians who provide hospital services.
Now it’s the obstetrical world’s turn to hear from Dr. Tuteur with equal passion and energy. The obstetrical profession has a commiserate need to “retool” its own educational programs and policies in order to provide evidence-based care to healthy populations. Physiological management is the model of care already used by nurse-midwives in free-standing birth centers that meet standards set by the American Association of Birth Centers.
This was the criteria identified in ACOG’s February 6th press release, which confirmed that physiological management and intermittent auscultation in a non-medical setting met the standards of safety for a healthy population as defined by ACOG. Surely the use of physiological management by obstetricians and professional midwives in an institutional setting, with access to EFM and surgical facilities, would be no less safe or satisfactory than the care already being rendered in AABC birth centers.
This is the science-based model of care used by the rest of the world for healthy women with normal pregnancies. It is what many women want and have every ethical right to receive. If one wants to reduce ‘white flight’ to community midwives, this is the logical strategy. It’s the smart choice. ACOG is the only organization with the authority to directly re-configure the policies and practices of the obstetrical profession and to restore balance to our national maternity care system.
For scientific, economic and ecological reasons, reforming the maternity care in the US is the big challenge for 21st century. In today’s global economy, no industrialized country can afford to medicalize 100% of its healthy women or perform 4 million Cesarean surgeries a year and still stay economically competitive with the rest of the world. For example, United Kingdom has already concluded that it could not afford to have a quarter of its births occur as a result of major surgery. Any perceived reduction in perinatal mortality is off-set by an increase in maternal morbidity and mortality and delayed and downstream complications for mothers and babies in future pregnancies.
As a result, the UK is turning to a physiologically based maternity care system to reduce the medical costs associated with normal childbirth. The Ministry of Health is reconfiguring the National Health Services (NHS) so that by 2009 every expectant mother in the UK will be able to choose among three options:
1. Home birth supported by a midwife
2. Birth in a local midwife-led unit, based in a hospital or community clinic and promoting natural birth
3. Birth at a hospital, supervised by a consultant obstetrician, for mothers who may want epidural pain relief or may need specialist care to deliver safely
[The Guardian, Feb 6, 2007; Speech by Prime Minister Gordon Brown during a Q&A in the House of Commons, Jun 2007]
For the last century, the American obstetrical profession has had total control over the place and the process of childbirth. This deconstruction of normal childbirth represented the most profound change in childbirth practices in the history of the world. Medicalized childbirth in a healthy population and ‘delivery’ as a surgical procedure was a unilateral choice by the obstetrical profession. The major rationale was to eliminate epidemics of childbed fever in hospitalized maternity patients in a pre-antibiotic era.
Midwifery-based physiological care during labor was replaced by putting women to bed and medicating them all with narcotics and scopolamine. Spontaneous birth became a sterile surgical procedure conducted in the OR under anesthesia and including the routine use of episiotomy and forceps. Like the precipitous adoption of EFM in the early 1970s, these obstetrical practices for healthy women were enthusiastically embraced, promoted and systemized country wide without first determining relative safety thru scientific research.
No studies compared the two methods side-by-side, no control group was preserved so that outcomes of obstetrical practices could be accurately evaluated. Many physicians of the day objected, some even conducted and published studies refuting the safety of interventionist obstetrics or the wisdom of eliminating midwifery care for healthy women. Voices of caution or protest were ignored.
The big switch from midwife-attended physiologically-managed childbirth to physician-attended medicalized labors and birth occurred between 1910 to 1920. During this time, a campaign to eliminate midwives was orchestrated by organized medicine, laws were passed outlawing them in some states and their numbers plummeted from approximate 50% to 13%. The only large group that was allowed to practice were black midwives in the South, where white doctors and segregated hospitals refused to provide care to ‘colored’ patients.
Maternal mortality skyrocketed, going up by a third in the five years between 1913 to 1918, from 16,000 to 23,000. Studies evaluating the maternal-infant mortality rate associated with the new obstetrics revealed an annual increase in maternal deaths by 15% for more than a decade and 44% increase in neonatal birth injuries over the same period (1910-1920). In 1925, there were 25,000 maternal deaths. The Committee on Maternal Welfare (Philadelphia County Medical Society) noted in 1934 that the rate of deaths of infants from birth injuries had increased 62% from 1920 to 1929.
According to a modern day reporter (Dr. Atul Gawande) “in 1933, the New York Academy of Medicine published a … study of 2,041 maternal deaths in childbirth. At least two-thirds, the investigators found, were preventable. There had been no improvement in death rates for mothers in the preceding two decades; newborn deaths from birth injuries had actually increased. … many physicians simply didn’t know what they were doing: they missed clear signs of hemorrhagic shock and other treatable conditions, violated basic antiseptic standards, tore and infected women with misapplied forceps.”
Nonetheless, policy decisions made in this pre-antibiotic era to eliminate the teaching and use of physiological management resulted in a highly medicalized model of childbirth that has endured for the entire 20th century. Luckily, medical science discovered the antibiotic drug in 1937, followed by other antibiotics, safer anesthetics, better surgical techniques and other medical improvements that accompanied WWII. As a result, the maternal mortality rate dropped dramatically, perinatal outcomes improved (thanks in part to Dr Virginia Apgar) and are now relatively consistent with other industrialized countries.
For these complex historical reasons, integrated midwifery training programs modeled on those used in EU and Canada were also eliminated early in the 20th century. Complimentary midwifery education was replaced by coordinated efforts from within the obstetrical world systematically to restrict or eliminate clinical experience for nurse-midwifery students. Nurse midwife graduates from these 3 lone training schools were restricted to providing care to populations that the obstetrical community didn’t want to serve or who couldn’t pay.
In more recent times, a new move to marginalize nurse-midwives is under way and even the most historic of hospital-based midwifery programs eliminated. One after another, medical schools have taken over hospital midwifery practices, cannibalizing midwifery patients as clinical material for their medical students and obstetrical residents.
This is an economic double whammy, as the medical schools are billing each of their residents for their medical education, while are hospitals are billing third party payers or the federal Medicaid program under the name of the supervising obstetrician who is rarely present or involved in providing this care.
By replacing midwives who scrupulously avoided unnecessary medical intervention, with residents who typically utilize the whole spectrum as often as possible, the hospital enjoys a much higher level of billable units. In addition, the hospital’s reimbursement rate is far greater than if those same patients had been cared for by staff midwives, as the policies of the federal government only reimburse CNM care at 66% of the rate they pay for obstetrician care.
Over the last century obstetrics has mainly been tone deaf to childbearing women who objected to being routinely medicalized or midwives who tried to re-introduce physiological practices. This reflects the circular logic that childbirth is an obstetrical procedure that can only be influenced from within, by the obstetrical profession itself.
The consequence of these historical an
From faith gibson:
Continued fro Above:
The consequence of these historical and contemporary obstetrical politics is a systemized discrimination against physiological childbirth. However, this status quo is not universally welcomed by childbearing women or all members of society. Many of us believe that we need to re-evaluate 20th century obstetrical practices in light of 21st century science.
Until the out-of hand rejection of physiological management comes to an end, the same politics of organized medicine that eliminated midwifery training programs in the early 20th century will continue to poison the water for everyone. It was this blind spot that gave rise to ‘lay’ midwifery in the 1960s and the CPM in the 1990s and that continues to eliminate consumer choice in contemporary times, giving rise to the current undifferentiated, often inappropiate demand for planned home birth. This will continue until women do not have to choose between a midwife and a doctor or between home and hospital in order to have a physiologically-managed labor and birth.
To correct these historical problems, the obstetrical profession must reverse these long-standing policies. Physiological principles should be integrated with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women with normal pregnancies. Obstetrical educators must learn and then teach physiologically based care as the universal standard for healthy women. This model must embrace midwives as well as physicians, community-based as well as hospital birth settings and a complimentary (instead of competitive) relationship between midwifery and medicine. In clinical practice, each healthy childbearing woman, via informed consent, must have the right to choose whatever level of medicalized care is appropriate for her. This includes elective termination of term pregnancy by induction or Cesarean delivery.
In conjunction with improved clinical training and post-training internships for direct-entry midwives, physiological management must be incorporated into the mainstream of American obstetrics as our national maternity care policy.
From m:
Faith, this phrasing:
"This includes elective termination of term pregnancy by induction or Cesarean delivery."
Is awfully loaded, no?
From Susanne:
m, were you thinking Faith was referring to abortion? I read it as saying that just as the woman should have the choice to go midwife or OB, she should have the choice to wait for spontaneous labor or have the option to end her pregnancy (not terminate the fetus) by elective induction or elective CS. Perhaps I'm reading it incorrectly though?
From m:
No, I know she *wasn't* referring to an abortion, and yet she used abortion language in reference to a birth via c-section or induction. If someone said to you "I elected to terminate my first pregnancy", would you think that they gave birth to a child via c-section? It was a very odd choice of words, and I wonder why she chose them.
From Caryn:
It was a very odd choice of words, and I wonder why she chose them.
They are quite common in the medical literature. I have frequently told women that the only cure for preeclampsia is delivery, but Googling [preeclampsia "termination of pregnancy"] returns about 46,000 hits...
From faith gibson:
" ...elective termination of term pregnancy by induction or Cesarean delivery."
I did not choose the language to be loaded, was just running out of time (its Sat, family wanted me to do something).
But the operative word was "TERM". The point is that women who are nine months pregnant have just as much right to be medicalized or have an elective C-section as they do to decline both of these things. I have worked with women who were so afraid of labor that i encouraged them to consider an elec. CS and they agreed.
However it is expected that such a choice would not threaten a pre-term pregnancy unless induction was based on medical necessity. I also support a woman's right to terminate a pregnancy via abortion in the first or very early 2nd trimester but not after the baby become viable.
When i was pregnant with my first baby, one of the OBs at our hospital routinely induced his 'unwed' mothers before they began to show (at 6 1/2 or 7 months). Afterwards, we sent these bummed up preemies to to the state hospital for the mentally handicapped.
Of course, this was prior to passage of Roe v Wade. As an ER nurse in the early 1970s, i also took care of women suffering from septemic after a botched back-alley abortion. You could smell them from way down the hall.
Every time the mother dies, the unborn baby dies, so making abortion unavailable is no answer. When people ask if i'm pro-lie or pro-choice, i say i'm pro-mother and baby.
From Jamie:
"Surely the use of physiological management by obstetricians and professional midwives in an institutional setting, with access to EFM and surgical facilities, would be no less safe or satisfactory than the care already being rendered in AABC birth centers."
But not as safe for the OBs, Faith. This is what I've been lead to believe on this blog. As Dr. Amy herself put it, it is impossible to defend a vaginal birth in court.
Basically, the OB who 'lets' my child have a physiologically managed birth is putting her or her reputation and career on the line.
From daedalus2u:
This particular blog post is very interesting to me and is quite relevant to my research in nitric oxide. I think that virtually all of the “disorders” of pregnancy have their roots in evolved “features” that are now not adaptive. Some of the difficulties of human pregnancies are fairly unique among mammals, for example placental difficulties including preeclampsia.
EverCurious makes several excellent points. It is reproducing descendents that is important, not just children. Something to think about, if we average over evolutionary time, the average number of reproducing descendents that each person had was 2. No more, and no less. For every person who had more, someone else had fewer. In the absence of birth control, how many times would a woman get pregnant over her reproductive life? Only 2 of those children would survive and have children of their own.
How do we know it was only 2? Because if it was different than 2, humans would have gone extinct, or the population would have reached levels we know it didn’t. If the average was instead 2.1, then in 500 generations the population expands by a factor of 39 billion.
I think some amount of premature birth might be a “stress response”. If conditions are not good enough for an infant to survive to weaning and to being self-supporting in food hunting/gathering, a premature birth may be “better” because the smaller the fetus is, the less risk there is for the mother at birth.
From Jamie:
"I think some amount of premature birth might be a “stress response”. If conditions are not good enough for an infant to survive to weaning and to being self-supporting in food hunting/gathering, a premature birth may be “better” because the smaller the fetus is, the less risk there is for the mother at birth."
That's an interesting idea -- are you talking about premature birth where there seems to be no clear cause?
I'm asking because I thought we "knew" that premature labour can start when the mother is clearly compromised -- if the body doesn't feel it has enough resources to support two organisms, it tries to evict the baby. This happened to my friend when she caught the stomach flu around 32 weeks. She was eventually hospitalized with premature labour, but they were able to stop it, get her rehydrated and adequately nourished, and then she wound up being induced at 39 (ish) weeks.
In terms of evolution, there is no value in an orphaned human infant. It will die. A mother can survive losing a baby, and potentially bear more children.
From Caryn:
In terms of evolution, there is no value in an orphaned human infant. It will die. A mother can survive losing a baby, and potentially bear more children.
No, that's wrong: our species adopts.
I think there's some argument to be made that these "disorders" are themselves adaptive, particularly the ones that occur with such incredible frequency.
From Jamie:
"No, that's wrong: our species adopts."
Are we 'wired' to adopt? Throughout history, we haven't. Orphaned or unwanted infants were abandoned. The simple fact that an infant can be 'unwanted' suggests to me that we are not hard-wired to adopt.
From Caryn:
Throughout history, we haven't. Orphaned or unwanted infants were abandoned. The simple fact that an infant can be 'unwanted' suggests to me that we are not hard-wired to adopt.
Throughout history, we have. Heck, we have myths about it. And it doesn't take but 5 minutes in Google to find books talking about adoption law in Sparta.
We also have alloparents -- wet nurses, mother's helpers, nannies, childcare, foster parents -- so that the mother is not wholly responsible for survival of the offspring.
We're a flexible species. Sometimes abandoning babies is not incompatible with sometimes adopting babies.
From Susanne:
"Are we 'wired' to adopt? Throughout history, we haven't. Orphaned or unwanted infants were abandoned. The simple fact that an infant can be 'unwanted' suggests to me that we are not hard-wired to adopt."
I don't think it matters whether we're 'wired' to adopt - if we do, then that's the behavior that counts. The fact that unwanted infants were abandoned is cultural in nature (and also puts the lie to the every-birth-was-a-blessed-union-of-women-under-
the-light-of-the-moon, but that's another topic).
From Jamie:
"We're a flexible species. Sometimes abandoning babies is not incompatible with sometimes adopting babies."
I agree with that completely -- but I'm doubting that our willingness to adopt has altered our evolution on a biological level.
From Susanne:
"But not as safe for the OBs, Faith. This is what I've been lead to believe on this blog. As Dr. Amy herself put it, it is impossible to defend a vaginal birth in court."
Here's a way of thinking about it, Jamie. Pretend there are 10 pregnant women and that outcomes are measured on a scale from 1-10 (10 being best).
If you had to choose between these two options as a health care provider, which would you choose:
A) 10,10,10,10,10,10,10,10,10,1
B) 9,9,9,9,9,9,9,9,9,9
.
From Erica:
We are wired so that we CAN adopt. We have evolved so that a helpless little baby is very difficult for us to resist caring for, even if it isn't biologically related to us. This is why we think babies are so cute and wonderful even though they poop and pee and spit all over us, cry, interfere with our sleep, and can't do anything for themselves. However, hardship and cultural taboos can certainly interfere with this protective instinct.
Even other mother mammals will sometimes adopt in certain circumstances.
From Susanne:
Sorry, Jamie, I hit publish too soon.
A represents what you're calling physiologic management - optimal for most, but not right for one with catastrophic results.
B represents "typical" year-2007 OB hospital management.
From Erica:
"I'm doubting that our willingness to adopt has altered our evolution on a biological level."
I don't know about that. Just speculating, it may be one of our species' greatest advantages--that children can survive even when their parents die or abandon them.
From Caryn:
I agree with that completely -- but I'm doubting that our willingness to adopt has altered our evolution on a biological level.
I wouldn't be surprised if it had, just because we adopt, and take care of the children of other women, with much more alacrity than even other primate species.
But I'm saying that because I can't think of another species with substantial alloparenting as a general practice. It's what, 60% of babies under the age of 1 in some form of daycare? (Does anyone have current stats?)
From Susanne:
"But I'm saying that because I can't think of another species with substantial alloparenting as a general practice. It's what, 60% of babies under the age of 1 in some form of daycare? (Does anyone have current stats?)"
But that's cultural, no? That's now in the US in the year 2007, but hasn't always been that way.
From Susanne:
"I agree with that completely -- but I'm doubting that our willingness to adopt has altered our evolution on a biological level."
"I wouldn't be surprised if it had, just because we adopt, and take care of the children of other women, with much more alacrity than even other primate species."
Isn't that because we have the technology to do so? That is, a baby can be fed by anyone, it doesn't require a lactating mother -- but in the animal world, it requires some other lactating animal to "adopt," and therefore there's a competition because that other lactating animal has her own offspring to contend with?
From Caryn:
Isn't that because we have the technology to do so? That is, a baby can be fed by anyone, it doesn't require a lactating mother -- but in the animal world, it requires some other lactating animal to "adopt," and therefore there's a competition because that other lactating animal has her own offspring to contend with?
Well, historically there were wet nurses, and despite all of the scenarios where they fed their own babies preferentially or simultaneously, there were plenty of cases of lactating mothers with dead babies because of birth or measles epidemics or whatever.
If the maternal mortality rate is 1%, and the fetal mortality rate is 7%, that leaves a lot of lactating mothers. Even if some of those were the second twin.
From Caryn:
But that's cultural, no?
Yes, but common to many cultures. Many of them seem to have had groups of women who took charge of groups of children to free up some of the other women for hunting/gathering, or whatever.
It's been a while since I read Sarah Blaffer-Hrdy's _Mother Nature_ but it has a prolonged discussion of alloparenting.
From Amy Tuteur, MD:
faith gibson:
"Now it’s the obstetrical world’s turn to hear from Dr. Tuteur with equal passion and energy."
I'm not sure what one thing has to do with the other. The problems in obstetrics are very different, and far more complicated than the basic problems of homebirth midwifery.
"The obstetrical profession has a commiserate need to “retool” its own educational programs and policies in order to provide evidence-based care to healthy populations."
No, I don't believe that the obstetrical profession has a commensurate need to "retool" its educational programs. They are already evidence based. Contrary to the thinking of homebirth advocates, the big issues in obstetrics are NOT episiotomy and pain relief. The big issues involve providing excellent care to widely divergent populations, many with serious economic and cultural issues that defy medical management.
"Surely the use of physiological management by obstetricians and professional midwives in an institutional setting, with access to EFM and surgical facilities, would be no less safe or satisfactory than the care already being rendered in AABC birth centers."
Why should the personal preference of a small group of women to recreate childbirth "in nature" guide the provision of care to the vast majority of women who have other needs, beliefs and desires? You make it sound like "physiologic management" is some sort of gold standard, when it is not.
"If one wants to reduce ‘white flight’ to community midwives, this is the logical strategy."
I'm not sure what you are talking about here. Less than one quarter of 1% of women choose homebirth with a DEM. That's hardly "white flight".
"Maternal mortality skyrocketed, going up by a third in the five years between 1913 to 1918, from 16,000 to 23,000."
So what? What does that have to do with anything? If the last time midwifery looked good compared to obstetrics was almost 100 years ago, then midwifery is in a pretty desperate state. It is simply inane to refer to medical conditions of a century ago as if they tell us anything about obstetrics today.
"In today’s global economy, no industrialized country can afford to medicalize 100% of its healthy women or perform 4 million Cesarean surgeries a year and still stay economically competitive with the rest of the world."
Says who? You just made that up.
"As a result, the UK is turning to a physiologically based maternity care system to reduce the medical costs associated with normal childbirth."
Yes, they are going to take away services to pregnant women to save money and pretend that they are actually giving them better services. Homebirth advocates should not be so gullible. The British health care system is imploding. Hospitals in many places are filthy, and elderly people are literally dying of malnutrition in nursing homes. Unfortunately for the NHS, they can't convince people that dirt is therapeutic, or that malnutrition is a new kind of diet. However, at least they can convince homebirth advocates that taking something away from them is a "benefit".
"For the last century, the American obstetrical profession has had total control over the place and the process of childbirth. This deconstruction of normal childbirth represented the most profound change in childbirth practices in the history of the world."
Yes, and neonatal mortality dropped 90% and maternal mortality dropped 99%. Midwifery has never had anywhere near the same success.
I'm sorry, Ms. Gibson, but your claims are absurd and your prejudices are obvious. Your personal preferences are NOT the gold standard for other women. They are nothing more than your personal preferences. Obstetrics has been spectacularly successful. Midwifery has not. You may not like it. You may think it is wrong, but it is reality.
From Caryn:
That is, a baby can be fed by anyone, it doesn't require a lactating mother -- but in the animal world, it requires some other lactating animal to "adopt," and therefore there's a competition because that other lactating animal has her own offspring to contend with?
Also, as I thought of this after hitting post 
, prehistoric groups were small and interrelated. If I were to adopt my sister's child and raise her, I'd be helping to pass many of my own genes along, since that baby would share a substantial portion of the same genes, aka "kin selection".
From Amy Tuteur, MD:
"Just speculating, it may be one of our species' greatest advantages--that children can survive even when their parents die or abandon them."
That's not what the scientific data tells us. The death rate of babies whose mothers die in childbirth is astronomical. No, it is not 100%, but the death of the mother of any infant represents a life threatening catastrophe.
From Jamie:
Here's a way of thinking about it, Jamie. Pretend there are 10 pregnant women and that outcomes are measured on a scale from 1-10 (10 being best).
If you had to choose between these two options as a health care provider, which would you choose:
A) 10,10,10,10,10,10,10,10,10,1
B) 9,9,9,9,9,9,9,9,9,9
A represents what you're calling physiologic management - optimal for most, but not right for one with catastrophic results.
B represents "typical" year-2007 OB hospital management."
Susanne, I am not convinced that our choices are between A and B (nor do I think modern obstetrics gives us a neat row of *almost* perfect 9s).
And unless you've actually read that paper I posted from the WHO, you don't know what *I'm* calling physiological managment. I don't have any problem with monitoring, or with a just-in-case hep-lock. I just think there needs to be good reason to interfere with the natural process, and I think a hospital, with trained staff and surgical capabilities available close at hand (which is the whole reason I'm supposed to deliver my baby there, right?), has the *least* excuse of any setting to be unwilling to labour watch, if that's what the mother wants.
From Caryn:
For a recent paper on kin selection, see here.
From Liz 1:
there needs to be good reason to interfere with the natural process
Faith Gibson's post troubled me, and I couldn't quite figure out why. Here was someone speaking with seeming authority, with knowledge and experience far beyond my own. Her figures from the early 20th century were particularly startling. Did things really get worse under the "obstetrical model"? Perhaps, after all, midwives DID have some secret skills? I then thought she glossed rather easily over the enormous change from the 1940s on - the difference that antibiotics, improved anaesthetics and the increasing use of CS made. It is very easy to bewail the CS rate - but if it means an decrease in the suffering of mothers and babies, I'm afraid I am all for it. I wouldn't for a moment dispute that their are problems with hospital birth, and that they need to be addressed, but it was this loud cry for a return to "physiologic" - i.e. "natural" birth that troubled me most. Is that what the majority of women want? I think not. I am an anomoly here, in a lot of ways. For a start, I am a grandmother, not a young woman for whom these choices are of pressing importance. But I am the mother and grandmother of women, so still have a stake in the game. Second, I come from a very different culture. Bit less of the pioneering spirit, possible a bit more rooted in history, and this is reinforced by my own personal interests. I was brought up in the industrial north of England, a culture that in my youth was very matriarchal - a place where older women talked to younger, and memories of hardship were long. And I realised, or remembered, that in the world of my childhood that for the older women and grandmothers "the midwife" was not some gentle creature who provided support but just as often a feared authority figure who would deal rather briskly with the dread of "confinement". The kind of woman who believed, as Jamie does, that there needed to be a good reason to "interfere" with a natural process that most women did NOT see as liberating. Clearly, there are women who prefer to let nature take its course - but given the small numbers clamouring for HB, I suspect there are a greater number who definitely do not. There may be a small number who "grieve" their loss of an experience they believe to be their birthrite, but I believe that when it comes to trauma, the imposition of a "natural" unmedicated birth on to women who would prefer safety and pain relief to an a rather too unforgettable experience is NOT a good thing. Fortunately, OBs are unlikely to compromise safety too much - but here in England there was a clamour from some midwives to restrict the use of epidurals, and as that would, of course, save money it would not be too difficult to change the practice of hospitals in the guise of a change in ideology. I would cheer on any woman who wanted a "natural" birth, but would be very hostile indeed to anyone who insists that everyone should have one. There IS a good reason to interfere with the natural process - it is what most women want.
From Antigonos:
folks, since i managed to break my left arm this morning--and guess which i write with--i shall be uncharacteristically quiet for a while. but still reading everything...
antigonos a.k.a archie the cockroach
From The Mommy Blawger:
""Are we 'wired' to adopt? Throughout history, we haven't. Orphaned or unwanted infants were abandoned."
Most breastfeeding mothers have had the experience of milk let-down when in the presence of someone else's tiny baby, especially when that baby was making "I'm hungry" sounds. Sometimes just looking at a cute infant can do it. That's an involuntary, hormone-based response to an infant's cries. So yes, I think we are "wired" to adopt - if by adopt you mean "care for" - abandoned infants.
Besides, infants who were "unwanted" were abandoned by *their parents*, not by whole communities. In this country, there are more adoptive parents seeking babies than there are (elective) abortions. So from that perspective, just because an infant is "unwanted" by someone doesn't mean he is wanted by no one.
From faith gibson:
From Jamie: "But not as safe for the OBs, Faith. This is what I've been lead to believe on this blog. As Dr. Amy herself put it, it is impossible to defend a vaginal birth in court.
Basically, the OB who 'lets' my child have a physiologically managed birth is putting her or her reputation and career on the line."
That is exactly the point and the reason why ACOG needs to redefine childbirth care for a healthy population as the management of a physiological process rather than a surgical ‘procedure’ performed by the physician.
Having defined childbirth as a 'procedure' performed by the obstetrician in the very early 1900s, the obstetrical profession inadvertently created what lawyers call “an independent risk of litigation”. In that case, failure to perform Cesarean becomes the equivalent of a surgeon performing the wrong operation – like amputating the wrong foot. If the ‘procedure’ of vaginal birth – delivery from below -- is performed instead of Cesarean -- delivery from above -- the patient has an independent reason to sue if anything is less than perfect.
It’s a Mission Impossible for obstetrician to take on the complete responsibility for the normal biological process of pregnancy and childbirth in a healthy population. This unrealistic promise has created something of a monster for everybody involved.
The only way this medicalized system could work is if it was accompanied by fully informed consent that permitted the mother to “opt out” if she didn’t want a Cesarean. In essence, the obstetrician would simply state that he or she always recommended a Cesarean section because it was impossible to defend a vaginal birth in court if anything should go wrong. Then the mother would be given the opportunity to decline his/her medical advise. If she did so, it would eliminate the physician’s need to ‘defend’ him or herself for attending a vaginal birth.
But the real answer is for ACOG itself to change its policies so that obstetricians were not being crucified for providing physiologically-based birth services to people choosing normal labor and birth instead of prophylactic Cesareans. It is the obstetrical profession, thru published policy statements and the testimony of obstetrician-expert witnesses in litigation, that makes attending a vaginal birth impossible to defend in court for other obstetricians.
Notice that this same sentence does not apply to midwives who are trained in the physiological management of vaginal birth and are expected to provide care for vaginal birth.
For example, contrast Dr Amy’s above comment with what it would have been like in 1901, before childbirth was redefined by the obstetrical profession as a surgical procedure. In that case a mother would be ‘contracting’ with a midwife or physician to support her in giving birth vaginally (sans major medical complication in which case the mode of care changes) and to be there in case the mother needs evaluation or additional assistance.
The same thing already applies to contemporary nurse midwives providing care in a AABC- approved birth center. The expectation up front is that the mother is the one who, by her own choice, is going to labor and give birth. The CNM is taking on a role similar to the life guard who sits at the side of the swimming pool and watches carefully, able to jump and help but ONLY if there is a problem, but without the unrealistic expectation that the baby is a product provided by the birth attendant with a money-back guarentee of perfection.
Obstetrical polices over the last 100 years have intimated that the physician delivers the baby TO the mother – that is, she doesn’t give birth but like a surgical patient, lies passively while the baby is removed from her body like an unnecessary organ (a baby-ectomy!) .
From a logical standpoint, there is no way to argue that physiological care is appropriate when used by a CNM but not when used by an OB unless we are referring to the LEGAL issues of an OBSTETRICIAL standard of practice. Since the really issue is a legal one – one that is created voluntarily by the ACOG membership, then those same obstetricians can change the rules so they are not getting slammed. The current situation is horrifically out of balance.
ACOG is the only organization that can change this unnatural and unnecessary risk for a litigation. That can be done by officially acknowledging that physiological care should be the obstetrician's first responsibility when providing care to a healthy woman with a normal pregnancy who is not asking for medical interventions.
From Emma B:
ACOG is the only organization that can change this unnatural and unnecessary risk for a litigation.
It's not the medical system that needs reforming, Faith -- it's the LEGAL system. When you've got a lawyer like John Edwards, a jury of twelve regular Americans, and a heartbroken mother of an injured or dead child, do you think anyone is going to care what ACOG recommends or doesn't?
The central problem is that juries give money to mothers of bad babies because they feel sorry for them, and they think it'll just come out of the malpractice insurer's pockets. The actual performance of the physician is often a minor issue in malpractice cases, let alone whether he followed ACOG recommendations.
From Jamie:
"I would cheer on any woman who wanted a "natural" birth, but would be very hostile indeed to anyone who insists that everyone should have one. There IS a good reason to interfere with the natural process - it is what most women want."
Sorry, Liz. I should have been more clear. I understand that I am speaking from a minority position, and my interest is in protecting my own rights, not 'inflicting' my desires on other women. I don't want to see a woman's existing choices disappear -- what I don't want is *my* choices limited by fear of lawsuit, rather than the application of evidence-based care, and *that* is the climate that currently exists.
I've said it before: I don't mind having my baby in a hospital. I understand why being in a hospital reduces certain risks. What bothers me is that I can't just be *in* a hospital with a minimum of monitoring so that I can give my child the birth that I would like to. That's what I can do in a birth center. And ACOG approves. What is stopping hospitals from doing the same for women who desire that kind of care? That is the specific issue that bothers me, and the only excuse I've managed to ferret out is fear of lawsuit.
And frankly, I have no power over that excuse. I can see why it's debilitating, and *if* that's the climate I'm facing, I'd rather avoid a hospital altogether.
From Liz 1:
A lot of different things seemed to be getting mixed together in the question of whether we are "hard wired" for adoption. Dr. Amy's point that dead mothers are frequently accompanied by dead infants is presumably accurate for things like PE, protracted labours and other obstetric disasters that affect both at the same time, but in other cases would presumably not always apply - though I think I have read that babies with no-one to love them don't thrive very well.(And no, that doesn't mean that a temporary separation leads to dire consequences) What about dads? And the "wicked stepmothers" of folklore? It may be less common nowadays for sisters and grandparents to assume automatic responsibility (and these days, in England at least, Social Services frequently stick a spoke in that particular wheel, in the interests of something or other) But there is a difference between abandonement and infanticide in relatively advanced cultures at least. No, we are probably not hard wired for adoption in the "selfish gene" sense, but fortunately still hard wired to care for and respond to helpless infants so that abandonement is done in circumstances that don't leave a child without carers. In evolutionary terms, what about surrogacy? Egg donation? It seems to me that trying to figure out evolutionary benefits and "survival of the fittest" leads to some very strange and unreliable conclusions in the context of childbirth.
From Susanne:
Faith: "Since the really issue is a legal one – one that is created voluntarily by the ACOG membership, then those same obstetricians can change the rules so they are not getting slammed. ACOG is the only organization that can change this unnatural and unnecessary risk for a litigation. That can be done by officially acknowledging that physiological care should be the obstetrician's first responsibility when providing care to a healthy woman with a normal pregnancy who is not asking for medical interventions."
Faith, with all due respect, I believe you are extraordinarily naive when it comes to the legal system and the "power" that ACOG has (which is in reality very minimal).
Let's take a big baby with shoulder dystocia who now requires millions of dollars worth of care. The plaintiff claims that the doctor should have CS'ed prophylactically. It DOESN"T MATTER if the defendant can point to ACOG policy statements saying that there is no evidence behind prophylactically CSing a baby of such-and-such size. It DOESN"T MATTER if the defendant says that there was no reason to CS this woman so he opted for vaginal delivery, or that he believes in the beauty of vaginal delivery and physiologic management, blah blah blah. There's a bad baby, there's a suffering mother, and there are twelve sympathetic jurors who know that if they rule for the plaintiff, the baby will be at least taken care of and, well, the doctor's insurance company will pay and he's rich anyway so who cares. That's the reality out there, Faith. It has nothing to do with what ACOG says or doesn't say.
From Susanne:
EmmaB: "When you've got a lawyer like John Edwards, a jury of twelve regular Americans, and a heartbroken mother of an injured or dead child, do you think anyone is going to care what ACOG recommends or doesn't? The central problem is that juries give money to mothers of bad babies because they feel sorry for them, and they think it'll just come out of the malpractice insurer's pockets. The actual performance of the physician is often a minor issue in malpractice cases, let alone whether he followed ACOG recommendations."
Yes. Exactly! Part of the naivete often seen from the HBA/NBA side is that they seem to think that juries care about ACOG standards.
From Susanne:
"It is the obstetrical profession, thru published policy statements and the testimony of obstetrician-expert witnesses in litigation, that makes attending a vaginal birth impossible to defend in court for other obstetricians."
Whoa, whoa ... ACOG published policy statements and the actions of an individual who testifies in litigation are two different things, entirely. Drag a $20 bill anywhere and you'll find a whore to pick it up, as the saying goes.
From Amy Tuteur, MD:
faith gibson:
"physiological management of vaginal birth"
What does that phrase mean? It sounds scientific and learned, but, as far as I can tell, it means absolutely nothing.
There is nothing about childbirth in contemporary American that even remotely resembles childbirth in nature, so why do you insist on pretending that there is or there should be?
In nature, the average age at first birth was 16-18, which was approximately 1 year after the first period. The average woman had 8-10 children during a reproductive lifetime, and her life expectancy was 35 years. The lifetime risk of death in childbirth was 1 in 13 and neonatal mortality was approximately 70/1000. No one could control her fertility, or postpone childbearing, and abortion was not available.
I presume that you have no problem with the non-physiologic postponement of childbearing by 10 years or more, the use of birth control methods, the smaller family size, the dramatically decreased risk of maternal mortality, the dramatically decreased risk of neonatal mortality, and the dramatically increased lifespan of women.
So why do you venerate vaginal birth, and why do you pretend that anything about contemporary childbearing (particularly vaginal birth) is physiologic? Why are homebirth advocates obsessed with transit through the vagina?
From Jamie:
"Why are homebirth advocates obsessed with transit through the vagina?"
I'd also rather use my esophagus than a feeding tube.
From Susanne:
Sure, but the end goal is to be fed, not to use one's esophagus.
From Susanne:
Jamie: "I don't want to see a woman's existing choices disappear -- what I don't want is *my* choices limited by fear of lawsuit, rather than the application of evidence-based care, and *that* is the climate that currently exists."
Jamie - fear of lawsuit is the same thing as fear of a bad outcome.
From Sailorman:
I'd also like to hear faith's answer to what, exactly, she is defining the term "physiological management" to be. I thought I asked a few posts back, but I don't think she's explained it yet.
Faith, would you mind providing a definition?
From Jamie:
"Sure, but the end goal is to be fed, not to use one's esophagus."
And if I need to be fed, and my esophagus isn't working, fine. But I don't want to be given a feeding tube just because the esophagus has a certain rate of failure.
From Jamie:
Why does Sailorman get to edit his posts?
From Liz 1:
Suzanne, I am curious. If your husband was to become aware of a horribly mismanaged birth that resulted in disaster, would he stand up in court and say so?
From Susanne:
"Suzanne, I am curious. If your husband was to become aware of a horribly mismanaged birth that resulted in disaster, would he stand up in court and say so?"
Sure, and he has. He has no reason or incentive to "protect" fellow OB's who haven't practiced good medicine.
From faith gibson:
From Liz1: "There may be a small number who "grieve" their loss of an experience they believe to be their birthrite, but I believe that when it comes to trauma, the imposition of a "natural" unmedicated birth on to women who would prefer safety and pain relief to an a rather too unforgettable experience is NOT a good thing."
{the Google blog system rejected my orginal post because it was longer than a 1,000 words, so i will have to post it in two parts. So sorry}
Wow, i couldn't agree more. My point is simply that there is no ethical reason to force women who are bravely committed to an unmedicated birth and willing to tolerate a 'naturally' painful labor (the only kind i know of, since Mother Nature is a real b-i-t-i-c-h!) into a form of care that erects stumbling block, sometimes insults her and often makes it impossible.
If you look around the world, the majority of births in the majority of industrialized nations includes some form of pharmaceutical pain relief and no doubt always will. I think it is fair to note that obstetricians have built-in job security.
As for English midwives as b-i-t-i-c-h-e-s, it is a truism that absolute power corrupts absolutely and each time that happens it is a sin -- even more so for midwives who know (or should know) better. Shame on them!
At least from my perspective, every word that i have contributed to this blog has been an impassioned plea for supporting women who want an unmedicated, un-intervened with birth in being able to at least give it the old college try AND simultaneously, supporting women who want an elective Cesarean section so they have the best and safest surgical delivery.
I find it odd that after so much time and energy spent on resisting and criticizing PHB midwifery, that it is now suggested that this is such a miniscule number as to be dismissed as irrelevant.
Aside from 'white flight' for PHB is the growing number of VBAC women and the staggering litigation rate for obstetrics, which is the real reason to reassess the business-as-usual obstetrical model as applied to a healthy population.
I am an expert reviewer and am familiar with the facts as established by the courts and can tell you the reason for high levels of obstetric litigation is not because childbirth in healthy women with good access to medical care is so dangerous. Obstetrical claims account for 61% of all lawsuits because something is happening that makes it get sued more often than any other practice of medicine.
The most salient issues for obstetrics are:
(1) dysfunctional communication between hospital nurses who are managing labors at the patient's bedside and doctors who are in their office or at home and 'supervising' the nurse's care via telephone
(2) the lack of true informed consent, especially for routine inductions based on simple post-dates, with a normal NST. (This is often heavenly influenced by physician or hospital scheduling issues, which patients figure out later)
Patients are not told ahead of time that induction often means two grueling days stuck in bed hooked up to IVs and EFM. They also are not told that as a first-time mother with a Bishop score of 5 or less, they face a 35% risk of a C-section at the end of the two days.
(3) Induction of pre-term women and "Pit to distress" policies, which has become an acceptable "standard" of care -- Unfortunately, this puts L&D nurses in a horrible bind. They can be independently sued for "permitting" the obstetrician to do things which were obviously over the line. ($10 million award against the nurse and her employing hospital in one case)
During the 1976 malpractice crisis, the most sued speciality was anesthesia. At the time, a single anesthesiologist routinely provided care to two or more surgical patients at one time, going back and forth between the two or even three ORs as needed. Disasters were far to frequent.
As a result of astronomical malpractice awards, the malpractice 'crisis' was that anesthesiologists could not afford the equally astronomical premiums. In California, they wound up self-insuring. Now that the docs had a dog in the fight, they made big policy changes and one of the very first things was to forbid any anesthesiologist from ever providing care to more than one patient at time and to require that he/she actually stay in the room the WHOLE time the pt. was unconscious (or to get another anesthesiologist to cover). Now anesthesia is one of the very safest medical disciplines as defined by a very low level of bad outcome and very few malpractice suits.
part ll to follow
From faith gibson:
part two:
So again i suggest that perhaps we could all agree that physiological care is not "bad" or wrong, its just not the popular choice. However, it's a respectful, evidence-based choice, used around the world and in CNM-run, AABC birth centers in the US. It should be supported by the medical establishment just as much as the decision to be induced or have an epidural. And as Jamie's post so adroitly points out, where better to 'labor watch' a physiological labor (even a VBAC) than in a fully-equipped hospital L&D unit ?
I want to end with an insight from a Cesarean mother's group for women who were planning a hospital VBAC. At that time (1980s) i worked with the only OB in northern California who would attend a VBAC hospital labor. Women drove hundreds of miles for the chance to have a normal birth and had to paid a lot of extra, out-of-pocket expenses.
For 10 years I sat and listened to a group of 4-6 women every other week say some version of the same thing over and over and over again -- a disillusionment with business as usual obstetrics. As one of these frustrated mothers put it:
"The problem with obstetrics is that it is all about obstetricians."
What mothers described went like this:
"We just did everything the doctor told us to do, expecting that s/he knew what was best. I mean, he was the expert, it was our first, so what did we know about having a baby?"
(The next part of this story often includes being induced because she was 'post-dates' with normal NST, or a 'physician preference' for Pitocin augmentation of a slow labor or a host of other issues).
"I didn't think i needed to be in the hospital (or be induced, etc) but we went when the doctor told us to. Things didn't go at all like we expected. The longer i was there the worse it was, until thing were completely out of control. The doctor dropped by for a few minutes, but he didn't stay. He didn't came back to the hospital until he had decided i needed a C-Section."
(Here they list a whole host of issues about the simple and complex problems of hospitalization -- no place to get food or for their husband to sleep, not getting the help they needed from the nurses, technical problems with EFM or epidural, feeling pressured into procedures they didn't want or didn't believe they needed, their doctor not being available when they needed him, etc).
The women in this VBAC group invariably end with some version of this impassioned statement:
“The first time we did everything just exactly the way 'they' said we should, but it didn't work out like they said it would. In fact, we had just a horrible experience. I hated lying there alone in bed in the recovery room, all doped on pain meds, while my baby was down the hall in the nursery with my darling husband. All that work -- nine months of pregnancy, imagining the day i got to hold my new baby, tolerating hours (or days) of labor with needles in my arm and harpooned to that bed round the clock and and all i got was a empty hole in my uterus where my baby used to be.
Finally they brought me the baby, but I was in such pain that the days in the hospital are just one big blur. It was like being drugged for my wedding and my whole honeymoon. I was devastated, i was depressed. It took me 9 more months to feel normal again. l I even considered not having any more children if i had to go through that again.”
(some admit to having aborted an earlier pregnancy because they couldn't deal with the idea of a repeat CS, a statistics that matches longer inter-conception times and fewer subsequent births in women who had a previous Cesarean).
“Then i started reading and talking to people and found out that there were other options. This time its going to be different. I know what i want and my husband and i are going to be pro-active. I’m not letting them induce me. I'm going to have labor support and stay out of the hospital until I'm in good labor. I'm going to say NO to all forms of unnecessary intervention. I don’t even want the electronic monitor, but I know I have to have it.
It's OK if i have to have another C-section because something is wrong, but I'm willing to work really hard to have a normal vaginal birth. I remember what it was like to be post-op from my last C-section. Now i have a two-year old at home and i can't imagine taking care of him and our new baby, breastfeeding, being up at night and everything else, while taking pain pills and trying to recover from major surgery. We can't afford to hire a housekeeper to run things while i lie in bed and recuperate for 6 weeks.
If i could tolerate 36 hours of being induced before they did the C-section, i can cope with a normal labor. Even if i decide to have an epidural, that’s OK. It’s very important to me to have a vaginal birth if at all possible, even if i need some kind of help."
So let me finish this post by saying that I too am I'm a grandmother, my eldest daughter had a CS for breech and a VBAC the next time. My 15 y/o grandson has a girlfriend already, so some day his wife will be having babies. I would fight just as hard against going back to the 'bad old days’ of just ‘suck it up’ childbirth with no access to effective pain management, such as fentinyl and epidurals, as i do for the right to choose hot showers, deep water tubs, walking around, right use of gravity and one-on-one labor support.
In the mean time, could we agree that a balanced system -- one that acknowledges and respects the right of women to choose and benefit from each side of the spectrum -- is a worthy goal for all of us to work for?
From Amy Tuteur, MD:
faith gibson:
"Obstetrical claims account for 61% of all lawsuits because something is happening that makes it get sued more often than any other practice of medicine."
Yes, and that "something" is unrealistic expectations of the kind promoted by homebirth advocates. If you believe that all you need to do is "trust" birth in order to have a perfect outcome, then you inevitably think that someone must have done something wrong to CAUSE a less than perfect outcome.
"physiological care is not "bad" or wrong, its just not the popular choice."
I still don't understand what that means. You could explain the parameters?
From Susanne:
"Obstetrical claims account for 61% of all lawsuits because something is happening that makes it get sued more often than any other practice of medicine."
Because bad babies require expensive care, engender a lot of sympathy from juries, and there's a feeling that someone ought to help the nice grieving family who didn't do anything other than try to have a baby.
Amy, while I agree with you that the perfection expectation is behind med mal, I don't think it's homebirth advocates who are driving it. I don't think their influence on the average American woman is all that great. I think it's really the legal system and lawyers such as John Edwards who are responsible for it. Hasn't JE gone on record and said that our CS rate probably isn't high enough?
From Susanne:
"(The next part of this story often includes being induced because she was 'post-dates' with normal NST, or a 'physician preference' for Pitocin augmentation of a slow labor or a host of other issues)."
Post-dates does carry with it risks, though. I wouldn't ever let myself go past 42 and I don't even know if I'd let myself go past 41, based on the data. And there are legit reasons to pit a slow labor - better to pit a slow labor and keep it vaginal than let it piddle around and ultimately go to CS.
From Sailorman:
Faith,
What is physiological care? You keep talking about it--it would be helpful if you could explain what it is.
Actually, it would be more than helpful--I would propose that it is necessary to define your terms. Otherwise your point has less meaning, and that's probably not what you intend.
From faith gibson:
From Sailorman:
"Faith,
What is physiological care? You keep talking about it--it would be helpful if you could explain what it is.
Actually, it would be more than helpful--I would propose that it is necessary to define your terms.
"
Wasn’t being mysterious, just away from computer for a while, and I missed your original request.
Stedman’s Medical Dictionary defines physiological as: “..in accord with or characteristic of the normal functioning of a living organism”.
In regard to the biological functions of the human body as they are of concern to healthcare (or childcare) providers, physiological methods (…in accord with the normal functioning) describes the artful and purposeful use of normal or natural methods to facilitate function.
For example: recommending or providing a glass of water instead of an IV; fruit, fiber and exercise instead of a laxative; providing or suggesting a quiet room, a glass of milk or boring book instead of sleeping pills; taking an anxious patient to the bathroom and leaving him alone with a urine specimen cup and ample time instead of catheterizing him; hot or cold packs, massage, counter-irritants (Bengay) instead of pain pills; privacy, lack of performance pressures, appropriate environment for intimacy, affectionate interaction by a person of the opposite (or same!) sex, instead of Viagra, etc.
My spin on this area of physiology is that bodily functions (blushing, perspiring, digestion, voiding, elimination, sexual responsiveness, let-down of breast milk, labor, etc.) stand at the intersection of the purely automatic (involuntary) and the completely voluntary. Many of the bodily functions listed above usually occur spontaneously (w/o volitional effort) and yet, if we have to or want to, we can stop them – stifle a sneeze, hold our breathe, suppress sexual arousal, etc.
For the purpose of conversing on these topics, I identify a distinction between the pure ‘biology’ (organ or tissue) and ‘physiology’ (the dynamic function that occurs within the organ or tissue). Functionally speaking, the connections between the two – how biology & physiology come together to orchestrate the ‘dance’ of spontaneous bodily functions -- is the realm of psychology, that is, our mental and emotional states. This often includes the sociology of the specific situation or more global cultural norms and taboos. So for purposes of thinking and talking about the concept, I suggest the following equation: biology + emotional triggers &/or inhibitors = physiology.
Physiologically-based principles include a basic expectation of normal biological function and caregiver support for the spontaneous process of labor and birth. Physiological management is neither passive or neglectful nor just a matter of abstaining from unnecessary interventions. It is always articulated with the healthcare system and includes the appropriate use of obstetrical interventions in the event of complications or at the mother’s request.
It includes a pro-active process for initial and on-going evaluation during labor. Preservation of maternal-fetal well-being relies on a formal body of knowledge and a specific skill set for addressing the (1) physical, (2) biological and (3) emotional needs that women and their fetuses normally face during the stress of active labor.
(1) Physical Needs – caregiver attention to hydration, nourishment, control of room temperature, regular voiding, comfortable clothing and bodily positions, helpful movement, right use of gravity, etc
(2) Biological Needs – regular assessment of maternal vital signs, tracking cervical changes and decent of baby in the pelvic, fetal size, position and heart tones (including normal baseline, moderate variability, accelerations of 15 bpm X 15+ sec and absence of pathological decels); documentation of pertinent information in the patient’s chart
(3) Mental/Emotional/Social Needs -- continuity of care throughout active labor by individuals known to the mother, patience with nature, an absence of arbitrary time limits and the right use of gravity. It recognizes the laboring woman’s need for physical and psychological privacy as defined by her.
A healthy, mentally-competent woman with a normal pregnancy has a constitutional right to control her environment, to include or exclude persons of her choice and to direct her own activities, positions & postures during spontaneous childbirth. It may be necessary to change institutional policies if they interfere with the requirements of normal physiology.
Physiological management employs a system of one-on-one social and emotional support and a variety of non-drug methods of pain relief (such as movement, touch and warm water) and the judicious use of pain medications or anesthesia when requested or if medically necessary. It encourages the mother to be upright and mobile during both labor and birth by walking around at will, changing positions and activities frequently, getting in and out of the shower or using a deep-water tub.
Being upright and able to move about during contractions also diminishes the mother’s perception of pain (perhaps by stimulating endorphins) and takes into account the positive influence of gravity on the continued progress of labor. Right use of gravity helps dilate the cervix and assists the baby to descend down through the bony pelvis, greatly reducing the need for medical and surgical interventions.
The principles of physiological management can be summarized as:
1. Continuity of care
2. Patience with nature
3. Social and emotional support
4. Mother-controlled environment (place) for labor and birth
5. Provision for appropriate psychological privacy (persons present)
6. Mother-directed activities (positions & postures) for labor & birth
7. Opportunity for an upright and mobile mother during first-stage labor
8. Full-time presence or immediate availability of primary caregiver during active labor
9. Non-pharmaceutical pain management such as walking, one-to-one care, touch relaxation, showers & deep water tubs, other traditionally effective strategies for assisting the mother to cope with her pain and anxiety
10. Judicious use of drugs and anesthesia when needed (hospitalized women)
11. Absence of arbitrary time limits as long adequate progress, mom & babe OK
12. Vertical postures, pelvic mobility and the right use of gravity for pushing
13. Mother-directed pushing-no prolonged breath-holding (Valsalva maneuver)
14. Birth position by maternal choice, unless medical factors require otherwise
15. Physiological clamping/cutting of umbilical cord - after circulation between baby and placenta has stopped (average 3-6 minutes)
16. Immediate possession and control of healthy newborn by mother and father
17. On-going & unified maternity care and support of the mother-baby couple during the postpartum/postnatal period by primary caregiver
From Amy Tuteur, MD:
faith gibson:
"physiological methods (…in accord with the normal functioning) describes the artful and purposeful use of normal or natural methods to facilitate function."
"For example: recommending or providing a glass of water instead of an IV; fruit, fiber and exercise instead of a laxative; providing or suggesting a quiet room, a glass of milk or boring book instead of sleeping pills; taking an anxious patient to the bathroom and leaving him alone with a urine specimen cup and ample time instead of catheterizing him; hot or cold packs, massage, counter-irritants (Bengay) instead of pain pills; privacy, lack of performance pressures, appropriate environment for intimacy, affectionate interaction by a person of the opposite (or same!) sex, instead of Viagra, etc."
Those are not physiological. There is nothing physiological about cow's milk; for most of human existence humans did not drink it. There is nothing physiological about hot packs, cold packs, Bengay, or books. That's my point. Your definition of "physiological" is "I prefer it", and has nothing to do with normal functioning.
This is what is so disingenuous about homebirth midwifery. They hijack medical language to dress up their personal preferences as superior to those of other women. Homebirth advocates are entitled to their personal preferences, but they are not entitled to pretend that their personal preferences are safer, healthier or better in any way for women in general.
From Antigonos:
actually, quite a few of these so called "physiologic" measures are available to most women in most hospitals. but a good deal of the time they simply aren't adequate, or aren't feasible. if it wasn't so hard to type, i'd do a point-by-point rundown, sorry.
From Sailorman:
Faith, I'm having trouble distinguishing your use of the term "physiological" from a lot of the woo out there. It seems pretty subject to interpretation, and it doesn't seem that it really provides a definition.
From faith gibson:
Stedman’s Medical Dictionary defines physiological as: “..in accord with or characteristic of the normal functioning of a living organism”.
Sure.
In regard to the biological functions of the human body as they are of concern to healthcare (or childcare) providers, physiological methods (…in accord with the normal functioning) describes the artful and purposeful use of normal or natural methods to facilitate function.
THAT didn't take long.
You started with normal. You ended up with "natural". What happened to the nice definition of physiological you posted above? I don't see anything about "natural" there.
Furthermore, what's with "artful and purposeful?" Who gets to decide that? Me? The terms are meaningless.
For example: recommending or providing a glass of water instead of an IV;
[shrug] works fine, ASSUMING that the patient can drink, that the water will be absorbed rapidly enough, that (for whatever reason) giving the water isn't otherwise problematic, etc.
But this is a straw man. How many people do you know who get an IV started when they're thirsty?
fruit, fiber and exercise instead of a laxative;
Of course, many laxatives ARE fiber. You know that, right?
As with the above--sure. Assuming (boy, your model really relies on some pretty serious assumptions!) the patient can eat, can exercise, can live with any delays--some laxatives are faster--etc, etc.
providing or suggesting a quiet room, a glass of milk or boring book instead of sleeping pills;
What on earth does this have to do with treatment? "I can't sleep" is met with "well, try harder?" Yeah, if you lie in bed long enough you'll sleep eventually. But the results ARE NOT the same; falling asleep at 3 AM with a boring book isn't the same as falling asleep at 11 PM with a pill.
taking an anxious patient to the bathroom and leaving him alone with a urine specimen cup and ample time instead of catheterizing him;
This is standard practice, unless the patient can't move, or unless there's a time sensitive need for urine, NOW.
hot or cold packs, massage, counter-irritants (Bengay) instead of pain pills;
Normal? Natural? Wasn't taht what you were saying way back when in the beginning of this very post?
What do hot cold packs have to do with normality? What does a counter irritant have to do with normality, much less "natural" theory? It's INSANELY inconsistent. What is this, a "what faith likes" model of care?
From Sailorman:
Continuing on...
privacy, lack of performance pressures, appropriate environment for intimacy, affectionate interaction by a person of the opposite (or same!) sex, instead of Viagra, etc.
OK, that's simple idiocy.
Do you understand what a disease IS? Do you understand what erectile dysfunction MEANS?
You are trying to say "hey, I know, let's use a different definition of "function" and then the dysfunction is gone!" That's... wrong.
My spin on this area of physiology
OK, well, that's honest at least.
But why is your personal spin valid at all?
is that bodily functions (blushing, perspiring, digestion, voiding, elimination, sexual responsiveness, let-down of breast milk, labor, etc.) stand at the intersection of the purely automatic (involuntary) and the completely voluntary. Many of the bodily functions listed above usually occur spontaneously (w/o volitional effort) and yet, if we have to or want to, we can stop them – stifle a sneeze, hold our breathe, suppress sexual arousal, etc.
That's an unusually simplistic, three-example summation of a variety of complex systems. If you're basing an entire philosp[hy (or worse, a medical treatment plan) on this, you need more data and more support.
For the purpose of conversing on these topics, I identify a distinction between the pure ‘biology’ (organ or tissue) and ‘physiology’ (the dynamic function that occurs within the organ or tissue).
OK. so:
1) define the distinction.
2) provide a model to be used by others, which will consistently result in third parties reaching the same conclusions regarding the distinction.
3) provide a modeal for treatment based on the distinction, which is likewise consistent, etc.
THEN you've got a dog in the fight. Otherwise it's just woo.
Functionally speaking, the connections between the two – how biology & physiology come together to orchestrate the ‘dance’ of spontaneous bodily functions -- is the realm of psychology, that is, our mental and emotional states. This often includes the sociology of the specific situation or more global cultural norms and taboos. So for purposes of thinking and talking about the concept, I suggest the following equation: biology + emotional triggers &/or inhibitors = physiology.
You forgot quantum physics. Did you mean to include it?
Look, faith, this is SCIENCE. You claim to understand how this world works. Why are you constantly making all these references to ? Don't you know better?
Physiologically-based principles include a basic expectation of normal biological function
Great, that's what I think, too! WE AGREE!! But hey--what's your definition of "normal?" Going back to the topic, what do 10,000 "normal" births look like?
and caregiver support for the spontaneous process of labor and birth.
Wonderful! But just to be sure we're agreeing, what do 10,000 "spontaneous" births look like?
Physiological management is neither passive or neglectful nor just a matter of abstaining from unnecessary interventions.
I would hope not. After all, in the factual context, those words are essentially meaningless.
It is always articulated with the healthcare system and includes the appropriate use of obstetrical interventions in the event of complications or at the mother’s request.
Again, with the "appropriate" dreck.
Look: Why don't you come up with a good instruction set to tell other people what is and isn't appropriate? Then we can try it, and see what happens. But YOUR view of what is appropriate is meaningless without testing.
It includes a pro-active process for initial and on-going evaluation during labor. Preservation of maternal-fetal well-being relies on a formal body of knowledge and a specific skill set for addressing the (1) physical, (2) biological and (3) emotional needs that women and their fetuses normally face during the stress of active labor.
Not sure why you'd separate physical and biological here. And are you implying that the fetis has "emotional needs' during labor?
.
.
Sigh.
You know what this reminds me of?
It's like a generalized instruction manual written by someone slightly mad:
1) Take your item out of packing.
2) Do what is necessary and good. Don't do anything wrong!
3) Use to its full limits to avoid waste, but be careful not to exceed them or the item may break.
Only the writer knows what she means.
From Susanne:
"My spin on this area of physiology is that bodily functions (blushing, perspiring, digestion, voiding, elimination, sexual responsiveness, let-down of breast milk, labor, etc.) stand at the intersection of the purely automatic (involuntary) and the completely voluntary. Many of the bodily functions listed above usually occur spontaneously (w/o volitional effort) and yet, if we have to or want to, we can stop them – stifle a sneeze, hold our breathe, suppress sexual arousal, etc."
I have a family member with Tourette's syndrome, and you might be interested in some of what the research tells us about whether movements like the ones you describe are truly voluntary or involuntary. It's a lot more complicated than you think.
But this "just relax and your labor will be better" is fundamentally insulting, Faith. It's a variant of "just relax and you'll conceive already" directed at the infertile, or "just keep your chin up and you'll beat this!" directed at women with breast cancer.
And ONE MORE TIME, why can't women in preterm labor stop their labor of their own volition?
From Susanne:
"A healthy, mentally-competent woman with a normal pregnancy has a constitutional right to control her environment, to include or exclude persons of her choice and to direct her own activities, positions & postures during spontaneous childbirth. It may be necessary to change institutional policies if they interfere with the requirements of normal physiology."
I have the "right" to go to my eye doctor and tell them I don't want them to shine that nasty light in my eyes or give me those drops that dilate my eyes because that's not natural, I have the "right" to go to my OB and tell him I don't want my breast slammed in a drawer because it violates my sense of space, but then I've pretty much wasted my time and his, haven't I?
Is the point of medical care to make you have more pleasant experiences that are under your control, or is it to ensure your safety and optimum health?
From Susanne:
"So for purposes of thinking and talking about the concept, I suggest the following equation: biology + emotional triggers &/or inhibitors = physiology."
This would be nice, except it has nothing to do with anything. How does adhering to this equation prevent or impact shoulder dystocia, pp hemorrhage, preeclampsia, amniotic fluid embolism, etc.? It doesn't. The proof is in the pudding, and there ain't no Jello here.
From Caryn:
My spin on this area of physiology is that bodily functions (blushing, perspiring, digestion, voiding, elimination, sexual responsiveness, let-down of breast milk, labor, etc.) stand at the intersection of the purely automatic (involuntary) and the completely voluntary. Many of the bodily functions listed above usually occur spontaneously (w/o volitional effort) and yet, if we have to or want to, we can stop them – stifle a sneeze, hold our breathe, suppress sexual arousal, etc.
Are you suggesting that women could stop the let-down *reflex*? Then why do they sell breast pads? Are we all just not up to speed or something?
Physiologically-based principles include a basic expectation of normal biological function and caregiver support for the spontaneous process of labor and birth.
Complications are a "normal biological function" (and I agree that it should be basic to expect them) but preclude spontaneous labor and birth in many cases.
From Susanne:
"So for purposes of thinking and talking about the concept, I suggest the following equation: biology + emotional triggers &/or inhibitors = physiology."
EmmaB, if you'd just relaxed more, you'd have conceived naturally. Caryn, if you'd just let go of stress, you wouldn't have developed preeclampsia. Denise, if you had just taken a deep breath, your uterus wouldn't have ruptured. Liz, if you'd just relaxed more, your dd wouldn't have had brain damage. Birdie's Mama, if you had just done ... I don't know what ... your baby wouldn't have gone into distress.
Faith, with all due respect, this line of thinking is merely blaming the victim. It has no basis in science and no place in health care.
From Chris:
"You forgot quantum physics. Did you mean to include it?"
Thank You. I found that entertaining.
From Sailorman:
If you read a lot of woo analysis--which I understand most people don't--you find that woo tends to read in a very similar fashion.
One of the first and most important aspects of woo is vagueness. A position can't be tested or attacked if it can' be nailed down. Faith's posts contain considerable vagueness--which is, surely, an intentional tactic. "safe" or "natural" or "artistic" or "appropriate" or "neglectful" or "necessary" are all JUDGMENT CALLS, not factual statements. I wonder what they're doing in a purportedly scientific comment?
From AyCarumbaTX:
Sailorman:
"If you read a lot of woo analysis--which I understand most people don't--you find that woo tends to read in a very similar fashion."
I'm unfamiliar with the way you're using "woo". What is woo?
From m:
"woo" is pseudoscience.
From Sailorman:
From AyCarumbaTX:
I'm unfamiliar with the way you're using "woo". What is woo?
Woo is pseudoscience, like M said.
IOW, "woo" is something that generally LOOKS like real science, and often SOUNDS like real science, but isn't. Unfortunately, it is surprisingly difficult for laypeople to determine what is or is not 'real.' The vagueness that I wrote about is one, but by no means the only, indicator.
If you are more interested in knowing about woo, consider reading Respectful Insolence (google it; it's a blog written by a scientist) or the Skeptic's Circle (google it; it's a collection of anti-woo writings)
From AyCarumbaTX:
Sailorman:
"Woo is pseudoscience, like M said."
But why "woo"?
Is it "woo," as in to court or to seek or to invite?
Or "woo" like "woo woo! that's so impressive!"
From Susanne:
Who knows, AyCarumba?
From AyCarumbaTX:
Susanne:
"Who knows, AyCarumba?"
I guess I was hoping that those who use the term understand what it means.
From Susanne:
It means pseudoscience, as I believe was explained upthread by m and by Sailorman.
From Susanne:
Faith, I wanted to get back to your hypothesis above: "My spin on this area of physiology is that bodily functions (blushing, perspiring, digestion, voiding, elimination, sexual responsiveness, let-down of breast milk, labor, etc.) stand at the intersection of the purely automatic (involuntary) and the completely voluntary. Many of the bodily functions listed above usually occur spontaneously (w/o volitional effort) and yet, if we have to or want to, we can stop them – stifle a sneeze, hold our breathe, suppress sexual arousal, etc."
I was thinking about voiding. Yes, I can voluntary stop and start. Yes, I have some control over how much I produce if I drink a lot or a litte water. But if I have overactive bladder or stress incontinence, simply telling me to hold it and exercise mind over matter is not enough - there's a real physiological need that requires either medication or in some cases surgical intervention. If I have HELLP syndrome and my kidneys are shutting down and I'm not producing any urine, the solution is not to get me to drink gallons of water to try to get me to urinate. I think what you're suggesting is overly simplistic and negates the fact that real medical issues can and do occur in life.
From m:
AyCarumba, I think you're thinking of it as a *word* while I imagine it as being more like a *noise*. It's a common internet term... think of it like you were pretending to be a ghost and saying "wooOOOOooooOOo!"
It's like the noise you'd make if you were making fun of someone who said that they could cure migranes with a crytal that filters extraterrestrial magnetic interferences with positive brain clouds, you know? It's a catch all to describe pseudoscientific explanations and remedies - ones that refer to and require acceptance of magical thinking and things not-of-this-earth.
From Sailorman:
Google is your friend. I googled "What is woo" and here you go:
http://scienceblogs.com/
insolenc...at_is_woo_1.php
http://www.skepticwiki.org/index...dex.php/Woo-
woo
Personally, I think of woo as a more-polite term for "pseudoscientific bullshit of a particular persuasion." But that's just me.
From Sailorman:
And one last one, i can't resist (this one is great!)
http://www.watchingyou.com/woowoo.html
One drink for each of those 41 things that happen here, and you'll be a dead drunk by morning...
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