In this month’s edition of Obstetric and Gynecological Survey, the authors of Home Versus Hospital Birth: Process and Outcome¹, make the following statement:

Women opting for home birth seek and often attain their goals of a nonmedicalized experience in comfortable, familiar surroundings wherein they maintain situational control.

I will agree that most women who choose home birth have the goal of a non-medicalized experience in comfortable, familiar surroundings.  I don’t like the implication, however, that one goal of these women is maintaining situational control.  If anything, women who birth at home seek an environment wherein they feel safe giving up control.

If anyone seeks to maintain situational control, it’s hospital personnel.  For example:

• Hospitals and physicians prefer to plan the day and time of birth (cesarean delivery)
• Hospitals and physicians prefer to schedule labor (inductions)
• Hospitals and physicians prefer to artificially break the bag of waters (attempting to speed up the delivery)
• Hospitals and physicians prefer to administer epidural anesthesia to laboring women (controlling the speed of the labor and the sounds a woman makes)
• Hospitals and physicians prefer to routinely monitor all babies continuously, regardless of risk factors (attempt to guarantee perfect outcomes)
• Hospitals and physicians prefer to perform many newborn tests/vaccines prior to the newborn leaving the hospital, even if those tests are less accurate at such an early age and even if the vaccines are not truly needed at such a young age (attempt to control parent’s choice to have or not have procedures done)
• Hospitals and physicians prefer to speed up labors with Pitocin (attempt to control the length of labor)
• Hospitals and physicians prefer to set arbitrary limits for the length of time a woman can be in labor or pushing (controlling length of labor)
• Hospitals and physicians prefer to have IVs running for every woman (this limits the woman’s movement)
• Hospitals and physicians prefer to have women tethered to an electronic blood pressure cuff, external or internal monitors, and pulse oximeter (limits the woman’s movement)
• Hospitals and physicians prefer to tell a woman in what position she must give birth (controls the birth itself)
• Hospitals and physicians prefer to tell a woman when to push and when not to push (control of the birth itself)
• Hospitals and physicians prefer to remove a newborn infant from its mother’s arms until “it has a good cry, we get it cleaned up, we just check her over, we make sure she’s OK, we give him his eye drops and vitamin K, we get him weighed and measured, we check her blood sugar, we dry him off. . .” (control of the newborn infant and contact with mother)

In contrast, the women whom I have known and worked with, who have chosen home birth, opened their hearts to the unknown aspects of birth.  They trusted their bodies to know how to do it when their heads didn’t.  They waited, sometimes impatiently, for labor to begin in its own time.  They worked long and hard with a labor that was difficult, to birth their babies.  They accepted pain and discomfort as an important part of the process.  They were willing to embrace a birth that didn’t go the way they’d hoped.  They were willing to choose a road less traveled, weathering the skepticism and fears of family and friends, not because they set a goal of maintaining control, but because they set a goal of giving their births and their babies the best possible opportunity to unfold without unneeded interference. 

The same might be said of the woman who, for any reason, chooses a hospital birth but creates a birth plan for herself.  Hospital staff, rather than showing the typical scornful response (“Well, she’ll end out with a c-section for sure; what a control freak!”) might appreciate the woman’s efforts to choose the very best she can for her baby.  It’s not about control.  It’s about one in three mothers being cut open to deliver their babies.  It’s about every woman who is told she can’t get out of bed, can’t eat or drink, can’t walk, can’t get in the jacuzzi, can’t, can’t, can’t.  It’s about taking the fear out of birth and returning it to the calm transition to new life that it should be.  It’s about finally letting birth happen normally, just as ever-accumulating evidence indicates it should.

1.  Wax JR,  Pinette MG,  Cartin A.  Home versus hospital birth: process and outcome.  Obstetrical & Gynecological Survey:  February 2010 – Volume 65 – Issue 2 – pp 132-140.  Retrieved 2/9/10 from: http://journals.lww.com/obgynsurvey/Abstract/2010/02000/Home_Versus_Hospital_Birth_Process_and_Outcome.23.aspx

I’ve been thinking today about the following statement contained in the AMA’s Resolution on Home Deliveries:

“The safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.”

Despite a large body of evidence attesting to the safety of home birth for low-risk women, the AMA continues to propagate lies about the danger of birth at home.  Isn’t it amazing that the entire medical community will turn on a dime and stop supporting VBACs on the basis of one poorly designed study, yet turn a blind eye to the increasing number of studies supporting home birth as a safe option?

What is more, the illogic of the AMA amazes me.  For a group of individuals who are supposed to be highly educated and skilled in critical thinking, they show a surprising lack of insight into their own argument that home birth is dangerous but delivery in an accredited freestanding birth center is safe!

As a midwife experienced in both home birth and birth center births, I can attest that this argument is absolutely ridiculous.  During the time that I owned a birth center, I also maintained a home birth practice.  Women could choose the birth location they were most comfortable with.  A surprising number of women chose birth center birth because they dreamed of a home birth but felt “safer” in the birth center.

For some of my clients, I did feel the birth center was a safer location.  I worked in an area where a number of my clients lived a long distance from the hospital–up to three hours away.  If a woman did not have rapid access to a hospital, I would recommend the birth center because of its location only a block from the nearest hospital.  Some women did not have a home setting they felt comfortable in–for example, a client who lived with her in-laws and wanted more privacy for birth.  But in terms of safety, a birth center birth or a home birth with easy access to a hospital, are equivalent.

I had all of my emergency equipment and birthing supplies in portable bags which I used at either the birth center or at a home birth.  I had the same trained support people helping at a birth, regardless of location.  There simply is no difference in what happens in a birth center or a home birth.  For any serious complication, both settings will require transfer to the hospital.  There was nothing I could do for a woman in the birth center that I could not do for her in her own home.

The AMA demonstrates its own illogic by their assertion that birth in a freestanding accredited birth center is safer than a home birth.  I would suspect that not one individual who drafted Resolution 205 has ever seen a birth center birth or a home birth.  Once again, we have “experts” talking about things of which they have no firsthand knowledge.

Despite the fact that waterbirth has been around for quite some time now, and numerous studies have shown that it can be a safe option with an experienced birth attendant, ABC news this week spoke out against water birth.

The news report was triggered by the announcement that Giselle Bundsen had given birth at home in a bathtub.  While ABC admitted that studies have shown warm water relieves labor pain, they stated that “to learn more about this method of birth” they would turn to their resident expert, Dr. Tim Johnson, who in turn interviewed an obstetrician, Dr. Laura Riley, medical director of the labor and delivery unit at Massachusetts General Hospital.   ABC did not interview any expert who was experienced in water birth.

After listening to the interview (you can watch it here), I was left wondering if Dr. Riley has ever actually seen a water birth, and where she got her ideas about women giving birth in water.  Having personally been the midwife at dozens of water births, without a single complication, I question the following statements by Dr. Riley (my comments are in parentheses):

• A few studies “suggest” that women who labor in water are more comfortable, but there are also studies suggesting that it doesn’t really work  (Really?  The Cochrane Review states, “Evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia.”¹)

• The baby is submerged in water and this may prevent the baby from “taking a good vigorous cry” when it’s first born.  There have been case reports of stillbirth, and babies who needed positive pressure ventilation because they never had the chance to take that good first breath.  (As a midwife who’s attended many water births, I have seen numerous babies born who never had “a good vigorous cry”, but simply, peacefully, began breathing and turned pink without ever crying.  For a fascinating theory on why babies start breathing after birth, read Dr. George Morley’s article entitled Why Do Babies Cry?

• Babies can breathe in amniotic fluid but they can’t breathe underwater once the cord is cut.  ( Obviously, we are mammals, and mammals are air-breathing.  What this statement is not recognizing is that babies don’t “breathe” in amniotic fluid.  They make breathing motions, but no air is taken into their lungs.  At a water birth, the cord is not cut while the baby is underwater.  Every responsible care provider I know of brings the baby’s face out of the water immediately after birth so that the baby can breathe AIR.  The cord may be cut shortly after birth, or may be cut when it stops pulsating, but would never be cut and the baby left underwater).

• There are some reports of babies who’ve had serious infections because, obviously, it’s difficult to sterilize the water.  (How sterile is a birth on a bed?  Many women have a bowel movement while giving birth, and this can be difficult to keep out of the birth canal and off of the baby.  The provider’s hands may have sterile gloves, but once they touch the vagina, they are no longer sterile.  Most provider’s hands are maneuvering, checking, and repeatedly touching the birth canal and the perineum. . .not sterile at all.)

• I suspect that getting into the water at 9 months pregnant is a little bit tricky.  (Is this the biggest concern you can come up with, Dr. Riley?  Should this even be mentioned as a reason to avoid water birth?  I suspect that Dr. Riley is used to seeing women with epidurals who are unable to move their own bodies from one side to another on the bed.  I have never seen a 9-month pregnant woman with a healthy attitude toward pregnancy who had any problem moving in and out of a birthing tub.  Especially when she knows it will help ease her discomfort.)

The water births I have attended have been overall the most peaceful, calm, and gentle births for both mother and baby.  I believe water birth can be a safe option if common sense is used–baby is brought to the surface immediately so there is no chance of aspirating water.  Once again, we see physicians in authority speaking out against something they have never personally witnessed and know little about.

For more research on water birth and the pros/cons surrounding this topic, see Barbara Harper’s list of research articles.

1.  Immersion in water in labor and birth.  Cochrane Review.  Retrieved 2.2.10 from : http://www.cochrane.org/reviews/en/topics/87.html

A reader, Hannah, asks a very important question about normal twin birth:

Hi, I am 5.5 months pregnant with twins. My first pregnancy. I am fit and healthy and the twins are doing well.  I have had to change gyne already, as only one on the small island where I live would agree that I did not automatically need a c-section with a twin pregnancy.  The new consultant is much better, but insists that I have the 3rd stage active management as due to the twins over-stretching the uterus, he says I will absolutely need it as it will take too long to contract on it’s own.  He also insists that I am induced at 38 weeks and that I have drip throughout labour.  All these things I do not want, but as he is the most open-minded and the only one to permit a vaginal delivery, I can only hope that I have the ability to refuse these things on the day.  If any one has any advice about what I can do, I’d be mst grateful.  It is on my mind almost all the time, as I think I’ll be busy enough without having to argue my way out of these interventions when I’m in labour.  There is no such thing as a ‘birth plan’ here.

Hannah, I admire you for having the courage to change providers in order to have the birth you decide is best for you and your babies.  I think the best way to approach this situation is a common-sense approach.  We know that no birth is risk-free, and complications can and do occur in even the most low-risk of pregnancies.  Your pregnancy, carrying twins and planning vaginal birth, is slightly higher risk, but does that mean we need to pull out the “big guns” before any sign of problems occurs?  This is a matter of looking at the risks of waiting versus intervening, and deciding which risks you are most comfortable accepting.

You say the physician wants to induce you at 38 weeks.  This is pretty standard among many physicians, as there is a slightly increased risk of serious complications in twin pregnancies which continue past 38 weeks.  You can reduce those risks if you are a non-smoker, healthy, careful about your diet (getting plenty protein, avoiding refined foods, lots of fresh veggies & fruit, etc.).  Much of what health care providers recommend, such as induction at 38 weeks, is based in fear.  Will the woman sue me if I don’t recommend this?  What if there is a complication after 38 weeks?  I’m sure everyone can understand how this could be motivation to intervene.  As health care providers, we want to eliminate every possible complication and risk of birth.  The problem is, we can’t.  And our well-intentioned efforts often create more risk than allowing birth to unfold normally. 

I have delivered vaginal twins where the mother has gone full-term (her preference) and have had beautiful births.  It is not always necessary to induce a twin labor at 38 weeks.  The induction and oxytocin infusion itself will place you at higher risk of hemorrhaging.  Your physician is correct that twin pregnancies carry a higher risk of hemorrhage due to the size of the uterus, and how much it has to contract down to control bleeding.  However, this is only an increased risk, not a for-sure thing.  Since it is your first baby, you are less likely to have excessive bleeding.  If you are not induced, you are less likely to have excessive bleeding.  If your contractions were regular and strong throughout the active part of labor, and closer than 5 minutes apart, you are less likely to have excessive bleeding.  If you are able to put a baby to breast right away, you are less likely to have excessive bleeding, and it will also stimulate contractions without needing oxytocin, to birth the next baby. 

Some things about a vaginal twin birth are necessarily different.  Once the first baby is born, the cord must be cut and clamped without waiting for pulsing to stop.  This is because the babies can share circulation, and it would be dangerous to the second baby if the first baby continued to receive blood that should be going to the second.  The first placenta will not be delivered immediately (unless it were to come out on its own) but the cord is clamped with one clamp to identify it as belonging to the first baby.  Then the second baby is either turned into position by grasping the butt and head externally and manually turning it, or the feet can be gently brought down and the baby delivered breech.  Neither of these maneuvers needs to be done if the baby is already head down.  Once the second baby is born, the cord is clamped with two clamps, to identify it as belonging to the second baby.  At this time the placentas can be delivered or you can wait for them to separate if they haven’t already.  Many times, the placentas are fused and come right on the heels of the second baby.  At this time, oxytocin could be given if bleeding was excessive.

It is preferred that the time between delivery of the two babies not be too long, because the longer it takes between babies, the more likely there will be complications.  For this reason, some doctors will automatically start oxytocin at this time if it’s not been running before.  This is not always necessary, however.  In a recent twin birth I attended, both babies were head down.  The first baby was delivered normally and handed to the mother.  I then checked for the position of the second baby and found the head had moved into the pelvis, so I asked her if she felt like she could give me another push.  The cervix, of course, was completely dilated at this time and everything was very relaxed since a baby had just come through, so the second baby came out quickly with only one push.  Both babies were now in mother’s arms, and the placentas delivered right after, fused together.  Mother had less than a cup of blood loss altogether.  These were her first babies and both weighed over six pounds. 

I would not recommend waiting and trying to be strong enough to refuse things at the birth, unless you have no other option.  Here is how I would approach this situation:  “Dr. ____, I want you to know that I am very pleased to have found a physician that will help me to have a vaginal birth of my twins.  I understand that this carries some increased risks over having just one baby.  However, there are some things that are very important to me for this pregnancy, and I hope we can work together on them.  I respect your opinion, but having considered the risks of waiting to go into labor normally, I am more comfortable with the increased risk of complications if I wait to go into labor normally then I am with the risks associated with an induction.  Should my babies or I ever be in jeapordy, I would certainly be willing to be induced if necessary, but if all is well, I prefer to wait.  I would also like to first try putting my first baby to breast right after birth, and monitoring my bleeding rather than automatically receiving oxytocin.  If my contractions do not resume quickly and I need some oxytocin, I would be open to it at that time.  After both babies are born, I would like to try nursing them instead of automatically receiving oxytocin.  I am not against using medication, but would like to use it only if I am having a problem.  I am willing to sign informed refusals stating that I am requesting to do something different than you recommend, so that you are not responsible for my choices.”  If your doctor absolutely will not bend, and you cannot find another provider, then you may be left with battling out on delivery day.  If that’s the case, I would recommend taking a doula or other support person besides your partner, who can help you stand firm for what your wishes are.  You will have enough to keep you busy without having to argue with staff.

Readers, please share your experiences with natural twin births.  Has anyone else experienced a twin birth without induction or active management of third stage?  Hannah, I wish you the very best as you work to have a normal, healthy birth for your babies!

In response to my recent post on the risks of fever in epidural, Veronica, a Birth Sense reader,  made an excellent point:

This has been bothering me for the last few days.  If your advice is to get an epidural at 8cms, how likely is it that mother will have that epidural in place and feel any relief before she’s pushing?  Even in a perfect world, if mom already has an IV in, and the anesthesiologist is standing right outside the door, by the time the IV is started enough to start placing the epidural, and by the time everything is in place and the medication is starting to work, wouldn’t you agree that most moms would probably already be pushing or really close to pushing, or even DONE pushing?  Well, unless the epidural causes mom to stall at 8 cms.
I completely agree with the rest of your post, but that’s a very late point in transition to think about an epidural.  It just highlights the considerations that must be made when considering pain medication.  

 Veronica has  made a very good point, and I realize I need to clarify my statements. My advice to wait until 8 cm. until getting an epidural was meant for first-time mothers, who should have time to get an epidural at 8 cm. and get relief before it is time to push.  In the hospital where I practice, we have anesthesia immediately available.  If a woman knows she wants an epidural for labor but wishes to avoid epidural fever, she should already have an IV in place before she is ready for the epidural.

 Since incidence of fever begins to rise  significantly at four hours after epidural administration, I based my recommendation on the average of a centimeter an hour dilation for a first labor, plus two hours of pushing. This would total four hours of epidural administration. Of course, some labors will be faster and some slower, but this is probably a fair estimate for a first time mother. For women who’ve had babies before, fever was not seen as often because their labors tend to be faster and the epidural generally is not in place as long.

If a woman has had a baby before, and wants an epidural, I’d recommend getting it by 6 cm. unless her labor seems to be progressing very slowly. In that case, she should consider if she needs the epidural at that point for pain relief, and if not, I would wait a bit longer.

I don’t believe that women should never get an epidural before 8 centimeters.  For those who want to reduce the risk of epidural-induced fever, timing should be a consideration.  As with any suggestion for intervention in birth,  all the risks and benefits need to be weighed, as well as the individual situation and the reasons for the epidural. I believe there are several occasions where an epidural is valuable, and may even avert a cesarean section:

• When labor has been prolonged, the mother has not slept, and is exhausted.
• When labor is unusually painful, such as back labor.
• When procedures are planned which will be exceptionally painful for the mother, such as needing to manually turn a baby or doing extensive repair of the perineum after birth (I had this situation with a Somali woman who had had a severe laceration with a prior birth, which had never been repaired  We planned to repair it after delivery).
• When a woman has been the victim of sexual assualt or abuse, and has difficulty tolerating a cervical exam or the sensations of the baby moving through the pelvis.
• When a woman reaches the point she feels she is suffering with the pain rather than being able to cope.
• When a woman must have a cesarean section.  An epidural or spinal allows her to be awake and aware, but comfortable, during the surgery.

I appreciate your comments, Veronica, and agree with you that all of these considerations highlight the need to weigh carefully our use of pain medication or any other intervention in labor.

Another reader, an anesthesiologist, wrote:

I found your post contained a few very useful factoids regarding epidurals and fevers.  Unfortunately, I really was dissapointed that it seemed to be more alarmist than necessary. While it is true that many studies have found that maternal fever and epidurals do correlate, the fact that epidurals cause the maternal fever has not been proven.  But more importantly, studies have not shown that patients who have an epidural are at a higher risk for any of the negative outcomes you correlated with those mothers who have fevers.  There was a study published in 1997 that did find an increase frequency of workup in neonates for sepsis if their mother had an epidural, but a subsequent study was not able to show this.

I have been practicing anesthesia for several years, and in practice, I do not see a negative impact on mothers due to maternal fevers. I choose to follow ACOGs published guideline stating that if a mother asks for an epidural, it should not be denied, even if early in labor.

Certainly, I don’t have a problem for any women who chooses to wait until she is 8 cm, but placing an epidural in a women who is at 8 cm is far more difficult and potentially risky than placing one in a a women whose contractions have not yet reached a point that she can hardly sit still.

I’d like to clarify that I do not believe that any mother who wants an epidural should be refused.  My goal is not to prevent women from having epidurals, but to help educate women so they know what the risks and benefits are.  Yes, women are handed an informed consent to sign when they request the epidural, but at that point, many are in pain and not really hearing what the informed consent consists of.  I believe that informed consent for an epidural should be obtained prenatally, in the office, where there is ample time to review the consent form and make sure it is clear. 

In the facility where I work, fever is listed as one of the potential risks of epidural.  Even if epidural does not cause fever, several studies have established an increased incidence of fever when a woman has an epidural, particularly if the epidural is in use for more than a few hours.  In our facility, many newborns do receive a sepsis workup if the mother had a fever in labor, even though we know that these fevers are often benign.  I’m sure this differs somewhat from one facility to the next, but the following studies do report higher rates of neonatal sepsis workups when there was a maternal fever during epidural: