Empowered Birth: The Trouble With Interventions (And When They May Be a Good Thing)

Over the years, the definition of “medical necessity” has become interchangeable with “medical convenience.” And there’s no better example of this than birth, and its tedious list of interventions. The issues around interventions aren’t surprising when you realize that they were originally devised, prescribed, and pushed by male “experts.”

Many believed that new medical instruments and processes could outperform the body in its natural birthing process. Of course, none of these birth “experts” had ever experienced the act of birth, so they never got to try these interventions out for themselves.

Sadly, the medical twist on birth has led to a world full of heartbroken and furious mothers. But prenatal care and birthing has taken a huge shift in response. Today, women are taking charge of their own bodies, and women are infiltrating the healthcare system and taking a stand for the needs of women everywhere. And this is so important. Because while interventions have hurt many women and children, there will always be mothers forever grateful they had them.

While I didn’t experience an intervention with any of my four natural births, I did have an ectopic pregnancy. And had it not been for my doctor’s team of surgeons, I would have died from internal bleeding. It was a heck of an experience, and it taught me that I was an idiot to shun and shame the medical world — because it absolutely has a time and a place. So, I’m inviting you to consider that an empowered birth can involve interventions. Because, really, an ideal birth is a birth that ends delivers a happy mama and a healthy baby.

So, let’s educate ourselves on the pros and cons so we can do just that.

Induction

When a pregnant woman goes over her due date, modern medical practice is to induce labor using pitocin or syntocinon (a synthetic form of the contraction-inducing hormone oxytocin). Inductions happen all the time because of the higher risks of certain complications after 40 weeks. Which is totally understandable, except for some very obvious flaws. A pregnant woman’s Estimated Due Date (EDD) is based on the date of her last menstrual cycle (aka Naegele’s Rule). But a look at birth stats show that this method of estimation is totally unreliable, and it offers no more than a generalized guess. That’s because the standard EDD doesn’t account for ovulation or the day of embryo implantation (source). The actual day of ovulation is especially important because EDD calculations presume that every pregnant woman has a 28 day menstrual cycle, with ovulation happening on day 14 (which every doctor knows is not the case). Because of this, a woman can end up being labeled “overdue” when she’s really days away from 40 weeks. A study shows that ultrasound performed at 11-14 weeks are far more accurate at predicting approximate gestational age and EDD.

Induction comes with further controversy because inductions are often prescribed for low amniotic fluid levels, and suspected big babies are often induced out of fear of shoulder dystocia or birth complications. However, there’s a handful of evidence that stresses that low fluid or a possible large baby aren’t actually medical cause for induction, and other evidence suggests that inducing these births come with greater risks than waiting for labor to happen on it’s own. And induction may be provoking labor for a baby that isn’t properly engaged in the pelvis, or a cervix that isn’t yet soft and ripe — and that may mean a longer and harder labor. The information out there certainly alludes to that as induction nearly doubles the odds of a Cesarean.

Pitocin and syntocinon are used in hospitals every single day, and pregnant women are often electing for them on the grounds of discomfort, picking the perfect birthday, or to ensure that their provider is actually present for the birth. Doctors throw out the option all the time, and women may even request it. Naturally, we would assume that it’s safe — a presumption which is absolutely NOT true. The Institute for Safe Medication Practices, has synthetic oxytocin as listed as one of the top 10 “high-alert” medications. The risks of oxytocin revolve around tachysystole (excessive uterine activity).

For mothers, this means a greater risk of placental abruption, uterine rupture, postpartum hemorrhaging, hypotension, and infection. For babies, this means a higher chance of complications like acidemia, asphyxia, hypoxemia, brain damage, and even death. According to Heidi Leftwich — an obstetrician specializing in maternal and fetal medicine — synthetic oxytocin is the drug “most commonly associated with preventable adverse events during childbirth.” She also reveals that accusations of oxytocin misuse are involved with approximately half of the obstetric medical claims being paid out. So, as common as induction may be, it comes with more risks than most pregnant women could ever imagine.

When it can be helpful

There are legitimate medical reasons for having an induction. Some of them include a baby that shows no signs of growth, reduction in movement, or signs of distress. Inducing labor will get baby out before problems like a knotted umbilical cord can exacerbate. If mama’s health is jeopardized by pre-eclampsia, mild placental abruption, a chronic health condition, or dangerously-high blood glucose levels from diabetes, then induction can help prevent serious complications from developing further. All legitimate causes for induction. And while “prolonged labor” and premature rupture of membranes are often cited as cause to augment — or “speed up” — the birth process, these factors alone aren’t actually medical cause for it. Experts have attempted to define “norms” for contraction, dilation, and length of labor, but there is a huge variation in labor — even between the births experienced by a single woman. Because of this, there is no magic number that tells us when labor is “too long” or “ineffective.” There are actually drug-free augmentation methods that can help birth by softening the cervix (using prostaglandins), or opening the cervix (via Foley Balloon). “Sweeping the membranes” and “breaking the water” are other drug-free methods for inducing or augmenting labor. However, their possible benefits also come with potential risks (especially for infection), so they’re not exactly a safe and simple alternative to oxytocin.

It’s important to note that induction has a reputation with hellish contractions thanks to a continuous release of oxytocin (versus the natural pulses of spontaneous labor). These long and intense contractions reduce the flow of blood and oxygen to the placenta; and thus to baby. The pain has many induced mothers opting for pain relief through an epidural — and that’s where things get whacky. Pitocin acts to encourage and intensify labor, while the epidural weakens contractions and slows things down (the ultimate medical contradiction?). This can lead to yet another intervention; instrumental delivery via forceps or vacuum cup. A retrospective case study from November 2016 confirmed this with an evaluation of over 1,000 induced births involving women under 40 with normal BMI. Their analysis concluded that “the use of an epidural during induced labor […] is a risk factor for instrumental delivery.”

Electronic fetal monitoring

If you’re having a hospital birth, then you’ll surely be strapped with an electronic fetal monitor (EFM) the moment you walk into the labor room. Which seems like a really good thing, given that it’s monitoring baby’s heart rate, but constant and continuous monitoring can actually spark drastic — and unnecessary — interventions. RN Rebecca Dekker of Evidence Based Birth researched the evidence behind electronic fetal monitoring, and all the studies she could find concluded that continuous monitoring of high-risk women had the same outcome as intermittent monitoring. Meaning that there’s no evidence to show that continuous monitoring can increase the chance of detecting complications.

But there is something it can increase… Cesarean sections. According to Dekker’s research, women who receive continuous EFM are nearly twice as likely to end up with a Cesarean. Brain damage by oxygen deprivation is a legitimate concern among birth professionals, so they use heart rate as a way to assess fetal oxygen levels. When low or abnormal heart rate patterns are seen, it’s determined that a Cesarean is necessary.

The trouble is, abnormal heart rate patterns are common the last hour of birth. And analyses of EFM readings from babies born with brain injury show that “irregular” heart rate readings aren’t actually indicative of brain damage. So, heart rate readings are being used to indicate brain damage, but yet they offer no sign of it. Obviously, EFM has a very high rate of false positives for complications. And that’s not at all helpful during the last rush of labor. A baby may just need a little extra time to shift their way through the pelvic, but if the beeps of the EFM are making doctor anxious, they may end up introducing interventions that were never necessary.

When it can be helpful

EFM can be expected in any sort of hospital birth. If an epidural is used during labor, then continuous EFM will be required. And given that an anesthetic dulls the sensations — sensations which clue a women into what’s happening with her baby and her body — monitoring may be for the best. Continuous EFM can also be expected with high-risk pregnancies. If possible, request intermittent auscultation — the monitoring method of choice for The American College Of Nurse-Midwives. It’s generally done using a doppler, but strangely enough, most hospitals lack this inexpensive device. However, intermittent auscultation can also be done with an EFM. This alternative may make it easier to get staff on your side since an EFM gives hospitals a heart rate reading for their medical records (lawsuit defense). If it offers staff peace of mind, it will only help to promote a more relaxed birthing situation. And that’s the key to a safe and pleasant birth.

Assisted delivery

Also known as an instrumental delivery, or a vaginal operative delivery, this intervention involves birth via forceps or a specialized vacuum cup. Episiotomies are commonly used in conjunction with them — forceps especially. Both forceps and vacuum deliveries have maternal and neonatal risks. Mother’s are at high risk of severe tearing (especially when episiotomy is performed), and they have a greater chance of postpartum hemorrhaging. The risks for babies include facial injury, brain hemorrhage, skull fracture, neuromuscular injury — and, in rare instances, death. No matter how low the odds of these injuries may be, these are risks no parent wants to take.

The idea behind assisted deliveries is to help get baby out, but there are times where they may do the exact opposite. A 2012 analysis by UK’s Norfolk and Norwich University Hospital of nearly ten thousand births showed that assisted delivery increased the chances of shoulder dystocia; with vacuum/ventouse delivery increasing the risk almost threefold, and forceps upping the odds nearly 3.4 times.

It would be very interesting to see the rates of assisted deliveries and episiotomy among women with drug medication versus women without it. Being confined to a bed may be the biggest factor for making these interventions “medically necessary,” because laying down pushes the tailbone forward and narrows the pelvic opening. On top of that, drugs dull a woman’s senses, so she’s lost to the sensations that would naturally guide her movements and positioning (because the positions that ease baby’s descent naturally offer relief and feel more comfortable). Moving around and changing positions during labor help baby to drop into the pelvis and turn their way through the birth canal. If we’re stuck in one position while we labor, we could be denying baby some simple yet powerful help.

When it can be helpful

If baby just can’t get out of the birth canal, then an assisted delivery is obviously in your favor. However, a change in position may address that without the risks of operative assistance. Try movements and birth positions that widen the birth passage and help baby to navigate the pelvis and naturally shift their way through it. Squatting, standing squats, side-lying, one-leg-up position, and even gentle hip-rocking (the original inspiration behind belly dancing) can all help a women with this. The Gaskin Maneuver (the “all-fours” position) is especially helpful with shoulder dystocia and larger babies. Even if mama has an epidural, she can request to have the drip turned down once her body’s ready to push. She can also ask for a birth bar bed-attachment that will allow for her to push in an upright squatting position while sitting on the edge of the bed.

Episiotomy

Back in the day, doctors got the idea that birth would be easier if they widened the birth canal by cutting open the vagina (an episiotomy). They claimed that a man-made cut was preferable to a natural tear because the straight cut of an episiotomy was easier to sew than the jagged line of a natural tear. Some actually saw an episiotomy as a preventive measure with benefits like faster healing, reduced postpartum pains, and a reduced risk of more severe tears. Clearly, none of these episiotomy proponent had vaginas. Evidence from studies and stories from angry mothers make it clear that the exact opposite of these claims are true. Look online, and you’ll see testimonies that state they’re extremely painful, and take weeks or even months to heal. And rather than reducing tears, they can actually be the cause of severe 3rd and 4th degree tears that damage the anal sphincter, leading to a lifelong problem with incontinence. So mom will be buying diapers for herself and baby.

Even if “all goes well” with an episiotomy, issues may not become apparent until after the cut has scarred over. The web is full of women complaining of intense pain and swelling months after their cut should have healed. Others speak of terrible pain and discomfort years later because of nerve damage and scar tissue (and that’s a big problem when it comes to sex and relationship issues).

An analysis of episiotomies by Boston’s Brigham And Women’s Hospital revealed that their incidence of episiotomy was higher among women who had (1) received an epidural, (2) were induced, and/or (3) birthed babies at higher weights. The real shocker was the rate of episiotomy between the types of care providers. Compared to midwives, faculty physicians were almost twice as likely to perform episiotomies. As for private practitioners, they were four times more likely to slice during birth.

When it can be helpful

There may be times where baby just can’t get through the birth canal, especially if mama had an episiotomy with her previous birth and was sewn up “too tight” (though squatting, side-lying, or all-fours positions may do the trick). Until recently, episiotomies were believed to prevent brachial plexus injury. The nerve injury was believed to be connected to shoulder dystocia (getting “stuck”) during birth. However, a 2010 study of by the American Journal of Obstetrics and Gynecology revealed that episiotomies had no impact on rates of brachial plexus injuries. An episiotomy may be warranted if baby is under distress, but as we discussed earlier, EFM readings are notorious for giving false positives. Episiotomies may also be used because pushing isn’t “effective” or it’s taking “too long,” but again, baby may just need help with their descent. A change in birth positions might be all the help they really need .

Cesarean Section

Many years ago, C-sections were a major surgery saved for emergency situations. Today, they’re routine procedures as quickly suggested by doctors as they are demanded by mothers. But when Cesareans aren’t scheduled in advance, they end up being the last step in a long list of interventions (and perhaps even the result of them). As discussed above, the use of pitocin complicates labor because pitocin’s unnaturally strong and consistent contractions reduce placental blood flow (the source of baby’s oxygen). This can cause a drop in heart rate, which is cause for doctors to perform Cesarean. The common practice of “coached/directed pushing” may further complicate birth. Studies suggest that encouraging women to push in an unnatural manner can cause a drop in heart rate and fetal oxygen levels, and cause exhaustion in laboring mothers.

The epidural may be another risk factor for Cesarean births. It’s often used in conjunction with pitocin, but even when the epidural is used alone, it affects labor by reducing production of oxytocin (the leading hormone behind contractions and bonding). Many Cesareans are deemed a medical necessity because of “failure to progress,” but when the epidural is involved, it really may be a “failure to wait.” A study published by Obstetrics And Gynecology shed light on this after comparing the births of over 40,000 women. Their evaluation revealed that the average epidural birth took 2-3 hours longer than their non-epidural counterpart.

Breech babies are also seen as cause for Cesarean, but there’s hot debate over this. A baby can absolutely be born breech. However, babies have a higher risk of prolapsed cord. There’s also the frightening chance that baby’s head and arms may get stuck in the pelvis, or that the umbilical cord could have blood flow cut off and cause oxygen deprivation. But while the risks of breech births are real, there are alternatives to Cesarean that women should be offered. Many babies have been turned by a skilled practitioner by way of External Cephalic Version. Some mothers have avoided ECV all together by following the exercises from Spinning Babies, and/or by undergoing specialized chiropractic adjustments that cater to uterine ligaments and the pelvis.

When a C-Section is necessary

Cesareans have saved the lives of babies and mothers. There are times where a Cesarean is absolutely medically necessary, including but not limited to uterine rupture, severe placental abruption, placenta previa, severe preeclampsia, and a prolapsed umbilical cord. Fetal distress is another legitimate cause for surgery. As mentioned earlier, when professionals detect “distress” via EFM, there’s an extraordinarily high chance of getting a false positive. “Abnormal” heart rate patterns are a normal part of the birthing process, and there isn’t a single medical practitioner who can distinguish an endangered heart rate pattern from a normal and acceptable one. Because of this, it’s imperative to select a birth provider you can trust.

Get familiar with all of your options

Labor has yet to become the natural and empowering rite of womanhood that it was in ancient times. But it’s getting there, and it gets closer with each and every woman who chooses to educate herself and to trust in her own body. With a little guidance and a LOT of instinct, we can choose supportive and empowering professionals to assist our birth.

We should be interviewing doctors the same way we would interview (interrogate?) a nineteen year old boy looking to date our teenage daughter. We’re putting our well-being — and our lives — in the hands of another person. So, we should be educating ourselves, and consulting the hell out of doctors and midwives and OBGYNs until we find someone we have complete and total faith in. Because we don’t want to be sliced and diced, but if our life or our baby’s life is on the line, then medical interventions suddenly become a blessing.

So, let’s take a stand that advocates both female empowerment and safe delivery. Because when we combine mother’s intuition with skilled medical expertise, we will create a powerful birth team.