It is hard for me to observe the progression of events that sometimes occurs during labor and birth in the hospital. I will give an example of a situation with a fictional patient, called Susie.
When my shift begins at a hospital, I receive report from the nurse who has taken care of the patient for the previous eight hours. The day nurse explains that Susie had come to the hospital in early labor. In order to speed things up, the doctor broke the bag of waters–artificial rupture of membranes. He also ordered medication to augment labor.
The amniotic sac encloses the growing baby in a sterile and cushioned environment. It protects the mom and baby from infection. At full term the sac contains approximately a liter of amniotic fluid. When the bag is broken the fluid leaks out, sometimes in a big gush.
The opening in the bag of waters allows the doctor to install a catheter in the uterus that measures internal pressure with each contraction. The synthetic hormone, pitocin, is added in an intravenous drip to increase the frequency and strength of Susie’s contractions. The contractions become strong quickly and Susie has difficulty coping.
The day nurse continues her report. “We just finished placing the epidural catheter. She has pain relief, but keep an eye on her blood pressure.”
Inwardly I groan. I have the task of guiding Susie through labor while she has limited mobility and an increased risk of infection. The bag of waters is ruptured, and the intrauterine catheter is a potential pathway for infection. The epidural gives good pain relief but also numbs Susie’s legs and pelvic floor muscles.
Sarah Buckley, an Australian physician, has gathered statistics. She states: “When an epidural is placed the baby is four times more likely to be persistently posterior.”* Posterior position means that the back of the baby’s head is pressing against the mother’s back instead of turning and slipping under the pubic bone.
During labor the cushion of fluid around the baby’s head, along with the mothers movements, helps the baby’s head to adjust to the best position for birth. When I worked with women in labor in the home setting, the bag of waters was left intact. It seemed to me that it was helpful in allowing the baby to adjust his position and align better in the pelvis–especially for women that were giving birth for the first time.
In Susie’s case, I have to find ways to work with the limitations in place. I will need to place a foley catheter to keep her bladder empty because she no longer feels the urge to urinate. I will turn her side turn her side to side in bed so that there is some change in her position. And I will focus on supporting her emotionally, encouraging her with every little bit of progress.
I still have not come up with a good response to the statement, “I don’t know how women ever got through labor before epidural anesthesia.” I had witnessed physiological birth in the home setting but how can I explain it? Once a path of care has been chosen, explanations seem futile.
In the hospital setting, breaking the bag of waters might speed up labor for a woman that is well established in labor, when the baby’s head is engaged. Unfortunately this practice has become almost routine, and it is done much earlier in labor than in the 1970s. Women should be informed of the risks and benefits of this procedure. It is a good idea for women to discuss the practice of artificial rupture of membranes during prenatal visits and then again when entering the hospital. The fourth healthy birth practice advised by ASPO/Lamaze is to avoid interventions that are not medically necessary.
Here is an interesting quote from Marorie Tew’s book, Safer Childbirth? She quotes Dr. Kloosterman, a Dutch professor of obstetrics:
“. . . Spontaneous labour in a normal woman is an event marked by a number of processes so complicated and so perfectly attuned to each other that any interference with them will only detract from their optimal character . . . the danger will arise that the physiological part of obstetrics will be threatened by doctors who all too often will change true physiological aspects of reproduction into pathology.”**
I am in agreement with Dr. Kloosterman’s perspective. We could learn from the Dutch. The Netherlands has better maternal/infant outcomes than the United States. Statistics listed in an article by Emily Sciarillo are as follows: The U.S. has an infant mortality rate of 6.26 while the Netherlands has a rate of 4.73. The U.S. has a cesarean section rate of 31.8% while the Netherlands has a rate of 12%.***
*Sarah J. Buckley, “The Hidden Risks of Epidurals,” Mothering, vol. 133, November-December. 2005
**Marjorie Tew, Safer Childbirth? New York; Chapman and Hall. 1990.
***Emily Sciarillo, “Dataset of the Day: Birth in the USA, 04/22/09