Interventions to Opt Out of...Part 3

In Part 1 we looked at the evidence against some common pregnancy interventions, and in Part 2 we examined common practices during labor, including continuous fetal monitoring and cervical checks. There are two more interventions that the evidence strongly recommends against, yet they are, in my experience, recommended or nearly forced on a majority of women who are birthing in the hospital. However, that doesn't mean that you can't examine the evidence and make your own decision about if you would like them to be a part of your care.

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Artificial Rupture of Membranes (AROM)
    It's estimated that 10-20% of women will experience their water breaking before labor, but for the rest, the amniotic sac doesn't break until some point after contractions have started and labor is established. There is a good reason for this! The fluid surrounding the baby in the amniotic sac cushions the baby during contractions and helps to protect the cord and baby from being overly compressed when pressure from the uterus is greatest. Australian CNM Rachel Reed reminds us, "Most babies can cope well with this, but the experience of birth for the baby is probably not as pleasant." Have you ever thought about what the birth process must feel like for your baby? Would you rather be squeezed tightly with a cushion of water around you, or with no cushion? I know which scenario I would choose!
    The intact amniotic sac also helps to protect the baby and uterus from infection, which can be especially important during a longer labor, or when several vaginal exams are performed. Many hospitals have a policy that after a woman's water has broken, the baby must be born within 12 to 24 hours, because of the heightened risk of infection. This is another reason to keep the membranes intact as long as possible, in the event that labor lasts longer than this time period.
    It's commonly thought that if the membranes are ruptured, that the baby's head will apply more pressure to the cervix and therefore shorten the length of labor. Hence, many inductions begin with the provider breaking the mother's water. However, this is not supported by evidence. This Cochrane review of the available evidence "showed no shortening of the length of first stage of labour and a possible increase in caesarean section." 
    Another risk of AROM is rarely spoken about, as it is rare, but it is a risk that you should be aware of. In "Breaking Water Balloons and Amniotic Sacs", Judy Cohain, CNM discusses the chances that AROM at term will cause cord prolapse, which is a life-threatening emergency for your baby and nearly always necessitates and immediate "crash" cesarean birth. Perhaps because of AROM is so commonly used, few studies have actually looked at the relationship between cord prolapse (when the umbilical cord drops between the baby's head and the bones of the pelvis, cutting off the blood supply to the baby), but a few did, and found a probable relationship. One study found that "obstetrical intervention preceded 41 (47%) cases of cord prolapse: 9 cases occurred after amniotomy, 4 cases after scalp electrode application, 6 after intrauterine pressure catheter insertion, 7 after attempted external cephalic version, 1 each after manual rotation of the fetal head and amnioreduction. We conclude that obstetrical intervention contributes to 47% of umbilical cord prolapse cases." ACOG  lists cord prolapse as a risk of AROM, but doesn't advise limits on it's use in labor induction. WHY NOT? Cord prolapse is still rare; even among induced, full-term hospital births it only occurs in about 7 per 1000 births, but in less than 1/1000 of home births.

The evidence is clear! The amniotic sac protects your baby! Treasure it! Keep it intact as long as possible.

Apparently, even hundreds of years in the future birth attendants are still telling women how to push...let's hope not.

Directed Pushing

    Ahh...my favorite. I'm sure we're all aware of what happens in the movies. And in most hospitals, for that matter. Mom says "the baby's coming", or, "I have to push!" and, after an exam to make sure that she really is ready (go back to that cervical exam stuff in part 2..), the doctor or nurse says, "Okay, hold your breath and PUSH PUSH PUSH PUSH PUSH"......mom is red-faced and holding her breath and veins popping out and screaming....you know what I'm talking about. Legs are in the air and everyone is just staring at mom's vagina, waiting for that baby. Another contraction, mom barely has a chance to catch a breath, and again "PUSH PUSH PUSH PUSH PUSH". This is "normal" to us. But is it evidence-based? Is is healthier for mom and baby to tell the mother exactly how to push her baby out, and to make her do it as quickly as possible?

NO! The evidence does not support this approach to pushing.

    First of all, the perspective is all wrong. Why should a woman have to be TOLD how to push a baby out of HER body? Of course there may be extenuating circumstances that necessitate some direction (if the baby is obviously in distress, or stuck), but in general, the woman is the expert in how to push out her baby! Directed pushing (also called Valsalva pushing), involving holding long breaths and pushing at the same time was implemented in an attempt to shorten the pushing stage of labor, however there is no evidence that this is actually helpful, or, even if the second stage is shortened, that there is any clinical significance or benefit to mom and baby. Directed pushing has been shown to produce less effective pushing contractions, and less placental blood flow to the baby, most likely because of the prolonged time that the mother is instructed to hold her breath and work (push) at the same time. Can you imagine lifting weights and ALSO holding your breath for an hour? Two hours? Why would anyone ask this of a pregnant woman?

    How do women push when they are doing so instinctively and without direction? Rachel Reed, CNM, notes in her examination of the literature, "Roberts et al. (1987) also found that most women did not hold their breath whilst pushing, and those that did, held it for less than six seconds. Women gave much shorter pushes and took several breaths between each push." And, "A later study by Thomson (1995) supports these findings and provides further evidence that women’s spontaneous pushing behaviour varies considerably from the instructions given during directed pushing. Women in the study did not commence pushing at the start of contractions, nor take a deep breath in before pushing. They altered their pushing behaviour throughout the second stage and used a mixture of closed glottis and open glottis pushing. The number of pushing efforts per contraction also varied, with some women not pushing at all during some contractions."

    So basically, women who push spontaneously do so in many different ways, and usually without holding their breath. They are often observed making multiple "smaller" pushes and exhaling instead of one big push. This is logical and likely maximizes blood flow to the uterus and the placenta and baby. Directing ALL women to push in one way is unhelpful, potentially harmful, and sends the message that the woman doesn't know what's going on in her own body.

    The main point to this is that the birthing mother is the expert in pushing out her baby, and the evidence supports allowing her to push as she feels compelled to do so. It's generally safer for the baby, and psychologically healthier for the mother as well, since she is being empowered to give birth instead of being told how to give birth. This empowerment has implications for the mother/baby unit far beyond this short time in the birthing suite, but that is a topic for another time. As always, I write this only to inform, and not to guilt-trip or force anyone into any particular choice in their birth. KNOW YOUR OPTIONS, and OWN YOUR BIRTH.

Next time! Is your baby at risk of contracting Hepatitis B? Why are all newborns given this vaccine? The answer may surprise you!