How to have a natural birthor not

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Dear Pearl Obstetrics,

Earlier this year there was a big kerfuffle about the information you were giving women in the process of selling caesareans. I wrote a letter to you at that time, but received no response. It looks like you’ve been at it again – this time selling “natural birth” that is anything but natural . Again there has been an outcry on Facebook and calls to report you for disseminating such misinformation. I decided that, rather than write specifically to you (since it didn't achieve anything last time), I’d just address each of your recommendations for a natural birth here:

Recommendation 1) Having a trusted obstetrician

You are on the right track here – Continuity of care HAS been shown to increase outcomes for mothers and babies and to reduce caesareans. It’s just that this has been shown with continuity of care with a midwife, NOT an obstetrician. Private obstetricians are very widely accepted to have significantly higher intervention and caesarean rates than midwives. Even “all risk” midwifery group programs and independent midwives who support high risk women have lower caesarean rates than the average private obstetrician. It’s also a good idea to remind women of the likelihood of you providing continuity of care during LABOUR (which is where most of the benefits can be found). Are you going to hang around and encourage, support and care for a labouring woman? For 24 hours or more? Without interfering in some way? Come on now, be honest!



Recommendation 2) Training for the labour

This is a fantastic idea! After all, you wouldn’t run a marathon without some preparation. Great idea to direct women to child birth classes for help with preparing for the first stage. As for the pushing stage, you seem a little misinformed. Firstly, it sounds like you impose a one hour time restriction on pushing which is not evidence based…But I digress.

The Hypnobirthing Australia program teaches some FANTASTIC techniques for the second stage of labour that don’t involve the purchase of an expensive gadget. The same visualisation and relaxation tools that women use for the first stage of labour will help them to relax their pelvic floor and visualise bub turning and descending. But Hypnobirthing Australia also teach an awesome technique for breathing the baby down and out. It’s called Birth Breathing and women practice it during the third trimester while pooing. The added benefit of this breathing technique is that the mother is constantly breathing, rather than holding her breath for long counts to 10 and therefore the baby remains well oxygenated. And therefore it doesn’t really matter if the “pushing” stage takes a little longer. If you really want your clients to have a better experience in the second stage I highly recommend that you find a Hypnobirthing Australia practitioner in your area and have a chat to her.

As to the other things that the epi-no helps: You could very easily decrease your episiotomy rate by simply not performing them routinely! There is a lot of evidence out there to suggest that tearing naturally heals quicker and easier for mum. Other ways to improve the second stage for mum and bub is to ensure that mum is able to move in whatever way her instincts tell her. And access to waterbirth is also shown time and time again to improve mum’s second stage experience.

As for anxiety and confidence – if you stop telling mums that birth sucks and they NEED an obstetrician to save them, they won’t have anything to be anxious about!


Recommendation 3) Perineal massage

As with all the points for the epi-no…but I guess on the plus side it’s free.


Recommendation 4) Being well rested

I admire your guts for recommending this. I’m sure it pisses off a LOT of women, especially those who have other children. I think that this point really shows how out of touch you are with the realities of life as a busy mum. This point also sets women up to believe that they won’t be able to cope with labour unless they are well rested. Meaning that they are likely to have in their mind, before labour even starts, that they can’t do it. If a woman is unable to have a nap in the afternoon or is woken by a toddler or needing to pee 500 times a night this won’t stop them for having the energy needed for labour. Because you’ll be encouraging them to eat and drink during labour to keep their energy up, won’t you? And you’ll be doing everything you can to ensure that all those awesome natural hormones that help women power through labour are released, won’t you? Women left to labour and birth unhindered and instinctively will generally have enough energy to get through labour and birth - even if they can't find someone to take their toddler overnight.

Recommendation 5) Having a birth supporter

You almost had this one perfect! Doulas are shown to help women to labour effectively and to have positive experiences. However…a senior student midwife is a great option if you would like a student midwife. If you want a doula then I would recommend you hire a doula. The role of a doula and the training that she undergoes is different to that of a midwife or a student midwife.

Recommendation 6) Inducing labour

Well…at least you acknowledge that this isn’t “natural”. I found this recommendation a little bizarre…but I’m going to address a really important issue that came up for me here – INFORMED DECISION MAKING . Any woman making a decision based on the information you have given in this point will not be making an informed decision. You have basically blown off the risks associated with induction. Prostaglandin gel increases the risks of hyperstimulating the uterus, artificially rupturing the membranes increases the risk of the woman being on a time limit, infection and cord prolapse and syntocinon drip increases the risk of foetal distress, uterine rupture and has been associated with hypoxic brain injury.

TANGENT: I had a doctor try and bully me into an induction with my vbac attempt. She was really clear that the only risk is possible increase in maternal discomfort. I advised the hospital that there was no way in hell I was going to consent to an induction being done by a doctor / hospital who wasn’t aware of the risks associated with it. No way would I feel safe being induced by a doctor who wasn’t then going to be keeping a super close eye out for the many complications that can occur as a result.



Recommendation 7) Upright positions in labour

Yep – totally. I’m really pleased to hear that you are willing to catch babies while mum is in an upright position and I’d love to hear what percentage of babies are born while mum is NOT on the bed. Really…I would! Particularly given your other recommendations...

Recommendation 8) Having some nourishment in labour

Again – YES! It is really important for mum to take nourishment during labour. Although rather than tell women to have “nothing too heavy”, you could just tell them to eat whatever the heck they feel like. Some women feel like pizza, some yoghurt and some nothing. We’re all individuals! I’m really curious to know under what circumstances it would be “looking like a caesarean will necessary” though, and therefore under what circumstances you would recommend nil by mouth.



Recommendation 9) Having an injection of a muscle relaxant – relaxes the cervix and shortens labour

Firstly NOTHING has no risks – anyone who tells you that is lying. Secondly...why is everyone so obsessed with making labour shorter? I get it that labour is HARD work. But it’s only going to shorten labour by 1 – 2hours. How about you stop telling women that the amount of time spent in labour matters and just leave them to labour as long as it takes for them to birth their bub. And again – I’d much rather use visualisation and relaxation techniques as taught by Hypnobirthing Australia before I have something injected into me.

Recommendation 10) Epidurals

There are many reasons why a woman might choose to have an epidural during labour. And there are even occasions where having one can help a woman to relax and dilate and achieve a vaginal birth. However, getting an epidural isn’t something that would be recommended as a way to achieve a vaginal birth for everyone. And again…the risks aren’t really explained at all – and therefore I wonder how much interest you have in ensuring that your clients are making an informed decision. Epidurals can and often do cause labour to stall. This means that augmentation with syntocinon will be recommended. This increases bub’s risk of distress. And, again, I think that you need to re-think your definition of “natural”. Epidurals are not found in nature. Neither is syntocinon. If you are really interested in helping women to have a natural birth perhaps you could spend some time giving them hints and tips to avoid an epidural. Encouragement has far fewer risks than an epidural!



Recommendation 11) Manual rotation

While I’m sure most women would find this preferable to a caesarean it sounds like a very traumatic procedure – for both mum and bub. A huge number of babies that are in the posterior facing position will turn during pushing – especially if mum is able to move as her instincts are telling her. Perhaps rather than offering this as a way you help women to have a “natural” birth you could spend a bit of time encouraging women to practice optimal foetal positioning, see a chiropractor or acupuncturist, to move freely and instinctively during labour and pushing and then remind them that posterior facing babies come out of vaginas all the time and are nothing to be afraid of. Encouragement will often hold less risk than intervention with significantly greater benefits!

Recommendation 12) An oxytocin drip at full dilation if contractions ease off

Firstly – it’s not oxytocin in the drip. It’s syntocinon – a synthetic form of oxytocin that makes the uterus contract but gives none of the other benefits of the natural stuff. Secondly – it’s really normal for contractions to ease off at full dilation. This physiological occurrence even has a name – the “rest and be thankful” stage. It’s a great opportunity for mum to rest, catch her breath and prepare for the hard work of pushing her baby out.




So after all that here’s what your tips on how to have a natural birth tell me. They tell me that you don’t believe a woman can birth vaginally without help. They tell me that you think my body won’t work without intervention or interference of some kind. They tell me that your idea of a natural birth is NOT an unhindered physiological birth. They tell me that you don’t really support a natural birth but prefer to use interventions of some kind. They tell me that you don’t feel that women need to be aware of all the risks and benefits of a course of action.

And here’s what they don’t tell me: They don’t tell me how you will support me to achieve the birth I want. They don’t tell me what your actual intervention and / or caesarean rate is. They don’t me what policies I will be subject to and what will happen if I make a decision that you disagree with.

Your advice tells me that we desperately need a maternity care revolution here in Australia. Increased choices, increased autonomy and increased respect – the women of Australia deserve it.

DISCLAIMER: THE AUTHOR OF THIS ARTICLE IS A HYPNOBIRTH AUSTRALIA PRACTITIONER IN TRAINING


For further reading on care providers:

Choosing a care provider

What women need to know before hiring you


Dear obstetrician

And further reading on the maternity care revolution:

Why Australia needs a maternity care revolution

A birthing revolution for Australian midwives

Why I'm joining the birthing revolution


#Birth


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