"What Interventions Should I Opt Out of?"...Part 2 (of 3) Okay maybe 4.

fetal monitor image from scienceandsensibilty

In Part 1 we looked at some routine procedures that you might reconsider (routine ultrasound and cervical exams, for example) that, although common, have been repeatedly proven to be either unreliable, or possibly even harmful to your or your baby. You can find Part 1 here.

Next in the trilogy are some interventions that are so commonplace in the management of labor and birth, that many parents don't even realize that they have the option to decline them! Many of them are "standard of practice", despite never being proven useful or applicable to ALL or even MOST women. One study looked at practice recommendations and the evidence behind them, and found “Among the obstetrics recommendations, level A evidence (defined as "good and consistent scientific evidence") was noted for 24.6% of the diagnostic recommendations." (bolded type mine). Did you get that? Less than 1/3 of obstetric practice recommendations are based on good and consistent scientific evidence. I decided during my first pregnancy that I had to take responsibility for researching some of these practices myself, and I'm sharing some of my findings here. Please also keep in mind that this research generally replies to physiological birth; labor that does not include drugs to induce or augment labor, or epidural pain relief. These interventions increase the risk of fetal distress, and necessitate other interventions. You still have some options in your care, but you may not be able to safely decline some of these procedures. Without further ado, Part 2.

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What Interventions should I Opt Out of....During Labor and Birth?

Continuous Fetal Monitoring
    This one is so common, that many parents have no idea that not only is continuous fetal monitoring (you know, with the belts around mom's belly) NOT based on evidence, that it also is likely a major contributing factor to the dramatic rise in cesarean sections in countries where it is commonly used. How could that be possible? It seems most likely that although continuous fetal monitoring was developed to reduce the chance of babies dying of oxygen deprivation during labor (often resulting in cerebral palsy or death if this occurs), in reality the machinery is not very successful in identifying which babies are really in distress. This study in the UK examined continuous monitoring vs. intermittent ascultation ( listening to baby's heart rate for 60 seconds every 15-30 minutes with a doppler) and found no difference in birth injury or death related to oxygen deprivation, but a significant increase in cesarean births and instrumental (forceps or vacuum-assisted) births in the continuous monitoring group. Some researchers suggest a 20% increase in cesarean births and the complications associated with them, but no statistically significant decrease in the types of birth injuries that continuous monitoring is supposed to help prevent. There is also NO research to suggest that intermittent monitoring (being on the monitor for 20 minutes out of the hour, for instance) is any better than continuous monitoring.

    The physical and psychological effects of confining a laboring woman to bed also cannot be ignored. Women in labor often feel a need to get into different positions to help them be the most comfortable. Walking, rocking, hands-and-knees, squatting, or sitting on a birth ball may be helpful for coping with contractions and help the baby to rotate and move through the pelvis. Hydrotherapy, in a tub or shower, has also been powerful pain relief for many women. Unfortunately many of these positions are either impossible or quite difficult to do while "on a monitor". Some hospitals provide waterproof monitors, or portable monitors....but the REALITY is that ALL of these are not evidence-based!

    There have been much longer and more detailed articles on the dangers of continuous fetal monitoring and the benefits of intermittent ascultation. Here is one of them. Please remember that you do have a choice in this matter, and if you choose to opt out of continuous monitoring, you have ample evidence to support this decision.

medical model of dilation vs. actual shape via midwifethinking

Cervical Checks

Cervical checks...where to begin? Well, where did the idea of measuring labor progress by cervical checks even begin? To be honest, I don't know. I've been researching it, but I haven't found any concrete information yet. It's probably in a big medical history book somewhere. Or maybe in this book about how obstetricians took over midwifery in England, which I don't have. I think we can maybe agree on something, though.

WOMEN NEVER WANTED CERVICAL CHECKS BEFORE MEN TOLD THEM THAT THEY SHOULD.

   Ladies, if you've ever had a pelvic exam, you know that they are generally not comfortable. In labor, when the body is focusing on birthing a baby, and the cervix is very sensitive, this procedure can be downright excruciating. This is not a problem for the examiner, unless he or she gets kicked in the face by the woman who is enduring the exam. However for the mother, cervical exams can be painful, demoralizing, and risky, especially if her water has broken. So why do them? My personal feeling is that by nature, most men prefer to measure progress using concrete measurements. They tend to think of things from a mechanical perspective, as opposed to women, who generally focus more on feelings and perception as opposed to visible, physical units of measure. This isn't necessarily a bad thing for either party...unless the man's perspective is forced on what is purely a female process, as childbirth inherently is.

    Robbie Davis-Floyd, author of Birth as an American Rite of Passage, explains the medical perception of the uterus this way. "Medical texts see the uterus as a mechanical involuntary muscle producing "efficient" or "inefficient" contractions; judge good or poor labor by the "progress" made in certain amounts of time, and hold Friedman's curve to be a good measure of the overall efficiency of the machine. The woman is viewed both as a passive host for the contracting uterus and a laborer to be supervised, controlled, and exhorted to further effort, while the physician acts as the supervisor or foreman of the labor process. This set of metaphors fundamentally opposes mother and child: the perfect baby is the desired product, while the motherlaborer is such a threat to that product that delivery by Cesearean comes to seem inherently desirable." That was a mouthful, but doesn't it make sense when viewed in the context of how women are treated during labor? The mother is constantly monitored and told what to do, even though SHE is the one undergoing the process!

    Can you imagine someone following you to the bathroom and telling you exactly how to relieve yourself? What if you said that you didn't have to go, but that person insisted that you weren't trying hard enough? What if you said that you really had to go, but they told you that you weren't allowed to because it wasn't time? That sounds crazy, and you may think it's a stretch to apply that to birth, but I disagree. Just as your body knows when to use the bathroom, it also (most of the time) knows when and how to give birth. The best person to be in charge is the mother, since she is experiencing the process in her body. Measurements of cervical dilation are often used to convince a woman that she really has no idea what's going on. I'm not saying that this is malicious or intentional, but if the result is the same, it really doesn't matter, does it?

    It would be one thing if cervical dilation actually had valuable information to give in the process of a normal labor, but generally by itself, it does not. A woman could go into the hospital with painful, close contractions, and be told that she is only 2cm and not in labor. She is sent away but comes back 1 hour later and nearly gives birth in the elevator. Was she in labor? Umm....turns out yes, despite what her cervix was "telling" them. Another woman may have been laboring for 10 hours with strong contractions, but is told that she will certainly be in labor at least 3 more hours because she's only 6 cm dilated. Her mother leaves to run some errands, and the baby is born 2 hours later before she returns and she misses the birth of her grandchild. Another mother has no cervical checks and gives birth to her baby without anyone telling her that she is or isn't in labor. All of these are possible (actually, all of them have happened to women that I know personally)! There are no absolutes in labor, no measurement that can tell ANYONE how long it will or won't be. If anyone tells you "you will be in labor 'x' amount of time"....just go to your happy place. THEY DON'T KNOW THAT. THEY CAN'T KNOW THAT!

     The picture above from Midwife Thinking also illustrates why even the common practice of checking cervical dilation before pushing can cause more problems that it solves. (See the whole post here). Although childbirth educators and doctors show the cervix to dilate in a perfect circle, this is simply not representative of the shape of the pelvis or how the cervix really dilates. Almost all women will have a "cervical lip" at some point; the question of whether it will be detected is just when a cervical exam is performed. A woman who says "I have to push" is often forced to undergo a cervical exam to "make sure she's fully dilated". She is told that if she isn't fully dilated, that she risks damaging her cervix. However, if a woman is feeling the urge to push and is pushing with her body's urges and not being directed, there is no evidence that this is a real concern. This study examined women in labor who had an "early" pushing urge and found no evidence that this was damaging, although the study size was not large.

    The Bottom Line. Cervical checks are not a necessary part of labor. If you decide that you will allow them, be aware of the demoralizing effect they may have on you and others on your birth team. If you are feeling the urge to push, the evidence supports pushing with that urge.    

    This blog post has several other ways to assess cervical dilation if you really want to know. Again, I think that it's best if everyone focuses more on the mother, and less on the cervix, but that's just me. Just know your options! This article also has a list of when vaginal exams may be helpful, as well as some strategies for avoiding them without seeming argumentative.

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Okay, well that was only two interventions and I've already made this too long! Next time I'll focus on artificial rupture of membranes and directed pushing. Sorry for being so long-winded, but I'm sure that you can tell that I feel passionately about these things. As a doula, I feel like the the bottom line is that you should HAVE A CHOICE as to whether you wish these procedures to be a part of your birth, and you should be provided the information that the evidence for their routine use is sketchy at best. So do what makes you feel the most comfortable, as that is the best way to help labor progress!

Born without cervical checks or continuous monitoring

If you would like to read a really long, but detailed report on the state of maternity care in the US, please see here to learn more about Evidence-Based Maternity Care- What it is, and What it Can Achieve.