Introduction:  Born in the USA

 * *http://peristats.modimes.org/  PeriStats provides free access to US, state, city, and county maternal & infant health data.

This books focus is fundamentally on health, normality and wellness and promotes an evidence-based, less interventional philosophy of care rooted in the concept that in most women birth is not a disease, but a natural event normally calling for little intervention. This book addresses the pregnant woman's changing situation at the third trimester of pregnancy, during labor and birth, and through the early weeks after birth. The chapters discuss various issues of obstetric management drawn from obstetrical textbooks, journals, and research data in chronological order, as you would encounter them.  When you understand what is happening in labor and birth,  you will recognize each stage as it comes and feel more confident about trying different ways of coping.  As you learn your own personal strengths and resources for labor and birth, you will learn to trust your body and the energy of the birth process. 

             Over the course of the 20th century as a the result of an increased standard of living -- hygiene, education, improved nutrition, appropriate access to medical care when needed and the safety net of social programs combined with wide-spread availability of effective contraception has led to a great improvement in maternal-child health.  Advances -- Caesarean section among them, have made labor and birth safer and are to be welcomed as the valuable interventions that have contributed to the relative safety of modern childbirth. Pain management options for the woman in labor have changed dramatically over the last decade. The shift from regional anesthesia with significant motor-blockade during labor, where the woman is a passive participant during the labor and birth, to a collaborative approach for pain management, where the woman becomes an active participant, has resulted in a new philosophy of analgesia for labor and birth.

            But today these very medical and surgical procedures originally intended to treat life-threatening complications are often routinely used on healthy women with normal pregnancies, without having been proven more effective than non-low interventional physiological management.

            We forget that there is a purpose to labor and birth and that purpose is a baby; a finite product of conception that is profoundly affected for better or worse by all that ensues during pregnancy, labor and birth.  Current medical research and reams of clinical evidence shows that these experiences create chemical pathways in baby’s central nervous system that become the physiological foundation of life-long thought patterns, emotional feelings and behavior.         

            Birth is also a developmental process for the woman, the way she feels about her ability to master this life event can have profound effects on the birth outcome.  How a woman experiences labor and birth affects her mothering in the first few weeks after birth.  How she feels about her experience may affect her relationship with her baby.

            The benefits of non-low interventional physiologically-based care for healthy women with normal pregnancies and interventive obstetrical care for high-risk complicated pregnancies has been amply documented in current research-based medical literature as well as in maternal-infant statistics (Johanson, Newburn, and Macfarlane, 2002). Non-low interventional physiologically-based care is cost-effective and psychologically sound and has always been strongly associated with low rates of mortality and morbidity and the long-term well-being of mothers and babies (Johanson, Newburn, and Macfarlane, 2002).

Historical Perspective

             Up until the middle of the 18th century, birth in the United State was largely a social event called confinement. Birth was at home, with a midwife, or an experienced mother. These women nurtured the philosophy, principles or techniques of physiological management of birth. These physiological methods included time, patience with the natural ebb and flow of labor, continuity of care with one-on-one social and emotional support, the full time presence of the primary caregiver during  labor,  an upright and mobile mother during labor, non-drug pain management and vertical positions during birth.

Birth was women’s domain; her tools were her hands; her education, her experience; her focus, the whole woman.  Women assumed whatever birth positions brought them increased comfort. Birth pain was seen to be an unavoidable result of original sin, called the curse of Eve. Death was accepted as a possibility; suffering was seen as inevitable (Leavitt, 1986).

The serious medical problems in pregnancy and birth at the end of the 19^th century were generally caused by poverty and frequent close-spaced pregnancies. Remember this era was pre-antibiotics, pre- blood transfusion, and pre-birth control.

As the latter half of the 18th century turned into the early 19th century, it became “fashionable” in the upper to middle class to be “delivered” at home by a male physician.

During this time there was a dramatic increase in obstetric physicians and a decrease in midwives. While their intentions were to make childbirth 'safer', physicians took over the practice of midwives without any idea of the philosophy, principles or techniques of physiological management.

The physician’s tools were the forceps and the scissors; the focus was the birth canal.

Developed in the 17th century in Europe to extract stillborn infants from their mother’s wombs, forceps (called iron hands) became standard procedure in the United States to extract the living infant.

Because of the horrendous lacerations caused by the forceps, routine episiotomy had to be used to accommodate the routine use of forceps.  To ensure a painless labor and birth chloroform was administered to render the woman unconscious.

The lithotomy position, on the back with legs elevated strapped down and held apart control the semi-unconscious woman as well as to facilitate the forceps, became routine.

At the end of the 19th century, birth began to move to hospital birth as physicians continued to attempt to improve on nature, prevent death and demystify birth (Leavitt, 1986). It was erroneously assumed that childbirth in the controlled environment of the hospital would eliminate the great killer of childbearing women and newborns, puerperal sepsis or ‘childbed fever’. Nurses in the employ of hospitals and acting under the direction and authority of physicians, replaced the care of the midwife during the many hours of labor. When the birth was imminent, the doctor would be called to come in and attend the “delivery”.   

By the end of the first third of the 20th century hospital birth began to become the norm as more middle class women embraced the new obstetrics. Twilight sleep, a mixture of morphine, scopolamine, chloroform and ether, rendered the woman semi to unconscious. Childbed fever became rampant due to lack of sanitation between procedures and/or patients, and women labored in special wards, sometimes separated only from each other by curtains (Leavitt, 1986). 

By the middle of the 20th century the “new obstetrics” was in full swing and became the standard of care. Women received routine enemas, episiotomy, and forceps deliveries.  Arm restraints became necessary due to the combative nature of women unexpectedly coming out of twilight sleep, and stirrups with straps became necessary to hold the semi to unconscious woman’s legs up and apart. Pitocin was given to speed up labor and get the whole unpleasant experience over with, and the drugged baby needed to be resuscitated after being pulled out (Leavitt, 1986).  

By the latter third if the 20th century hospital birth was the norm. Before 1900 5% of women delivered in a hospital, by 1936 75% delivered in a hospital, and by 1970 99% of all women were delivered in a hospital. The perception was that hospital birth with medical interventions was safer than a non-interventional birth (Leavitt, 1986).

Today's Perspective

Routine medicalization and over-treatment of healthy women has become the foremost standard for 21^st century maternity care. Today medical and surgical procedures originally intended to treat life-threatening complications are routinely used on healthy women with normal pregnancies, without having been proven safe or more effective than physiological management.

Medicalized childbirth is well intended but  there is a contradiction between current obstetrical practice and what current research-based medical literature supports:

•  Every year in the United States over one in four pregnant women have a cesarean section despite the consensus of the current medical literature that half of these operations were not needed (ACOG, 2000; AHRQ, 2004, Maslow, Sweeney, 2000; NCHS, 2004, Ventura, Martin, Curtin, Menacker, Hamilton, 2001).  
   

• Electronic fetal monitoring has risen steadily, despite current medical literature showing its use does not improve baby’s health and that routine use threatens the mother’s health by increasing medical interventions (ACOG, 1995; AHRQ, 2004, AWHONN, 2000; NCHS, 2004,Thacker, Stroup, 2000). 
   

• Almost every laboring woman wants an epidural despite current medical literature documenting epidural use often leads to an increased use of forceps or vacuum extraction, which leads to episiotomy, or else leads to cesarean section, which can lead to fever in the mother, which leads to painful tests and treatment for the baby (AHRQ, 2004, Cunningham, MacDonald, Grant, 1997; NCHS, 2004, Robinson, Norwitz, Cohen, Lieberman, 2000; Putta, Spencer, Conemaugh, 2000).  

• In addition, many women giving birth vaginally still have an episiotomy despite the fact that current medical literature proves this procedure does no good and does serious and permanent harm (ACOG, 2000, AHRQ, 2004, Carroli, Belizan, Stamp, 1999; Eason, Labrecque, Wells and Feldman, 2000; Eason, Labrecque, Wells, Feldman, Robinson and Norwitz, 2000).
   

• Current obstetrical practice tells women to avoid drugs in pregnancy and pushes them in labor, despite the fact that current medical literature states no drug has proven safe for the unborn baby (AHRQ, 2004, Cunningham, MacDonald and Grant, 1997, NCHS, 2004,). 
   

• Most women have an amniotomy in labor, despite the fact that current medical research states that amniotomy is not part of normal physiological labor and should be reserved for women with abnormal labor progress (AHRQ, 2004, Bricker, Luckas, 2000; Cunningham, 1997, NCHS, 2004,). 
   

• Most women have repeated vaginal examinations, which current medical literature states are an invasive intervention with unproven value and high risk (AHRQ, 2004, Cunningham, 1997, NCHS, 2004,). 
   

• Current medical research states that the reclining position lengthens labor (AHRQ, 2004, Cunningham, 1997), yet still most women spend their labors in bed with IV’s, epidurals and continuous fetal monitoring. 
   

• Most women assume that these now routine invasive interventions must be safe. Yet current medical research shows all of these interventions can have short-term and long-term effects on the physical and emotional health of mother and baby. (ACOG, 1995; AHRQ, 2004, AWHONN, 2000; NCHS, 2004,Thacker, Stroup, 2000;Tourangeau, Carter, Tansil, McLean, and Downe. (1999).

• Almost all of the hospital births in the United States occur Monday through Friday, 9 a.m. to 5 p.m. (AHRQ, 2004, NCHS, 2004,Ventura, 2001). Could this fact be influenced by hospitals and health care providers using induction of labor for their own convenience, and not the safety and welfare of mother and baby?  
   

• Each year in the United States over 4 million babies are born (AHRQ, 2004, NCHS, 2004).  Fewer than 5% of these births occur without medical interventions, despite the fact that overwhelming medical research shows women can give birth safely with minimal interventions as they do in the countries that have the lowest infant and maternal morality rates (AHRQ, 2004, NCHS, 2004, Ventura, 2001).

The way women give birth in the United States should be shaped and influenced by research-based science and medicine. Today’s obstetrical practices should emphasize evidence-based practice. Well-controlled trials of safety and effectiveness have been conducted and the results have been combined in meta-analysis, and these practices have been proven to be ineffective, and to increase the risks of iatragenic injury to both mother and fetus. The research data behind this book will give you the ability to decide what is right for you. This book will change your beliefs and attitudes about labor and birth, and teach you both the physical and emotional aspects of labor and birth. 


You know how to birth, this innate knowledge is inside every woman just waiting to be rediscovered.  This book will give you the knowledge to make informed choices for yourself and your unborn baby. By presenting the knowledge you need to choose wisely and to practice "informed refusal" as well as "informed consent." 

The chapters discuss various issues of obstetric management in chronological order, as you would encounter them. All information in this book is drawn from research based evidence data. Here is a sample of  current information this book gives you :

• Coming to terms with the emotional milestones to becoming a mother.
• Prenatal bonding techniques.
• Birth from the baby's point of view
• The incredible intricacy of the hormonal regulatory mechanisms of labor
• Self-hypnosis, un-doing your response to pain.  Learn to alter your response.
• Understand how to help yourself by learning ritual movements to allow your body to relax 
• Breathing  to enhance relaxation and the flow of hormones.
• Practical knowledge of how to move to coordinate passenger and pelvis and how to respond to contractions.
• The importance of nutrition, exercise and mind body work.
• How to take more responsibility for birth. Knowledge is power. You have the right and responsibility to come to your own informed decisions.
• Choosing a birth team
• Writing a birth plan. Take responsibility to prepare together with your health care provider with research/evidence-based information, making preparations for it to be the best experience possible.
• Physical and psychological interventions in labor and birth
• Current information about risks and benefits of medical interventions.
• Realistic risk assessment, and learn what to do in the event that risks and then to decide what to do, to decide what risk is acceptable.
• Ways to avoid unnecessary cesareans
• The safety of vaginal birth after cesarean (VBAC)
• Support and comfort measures for labor and birth with the comprehensive compilation of low-risk measures to prevent and treat problems in labor and birth.
• Postpartum care
• Breastfeeding baby
• Baby care and what baby wants after birth.

When you understand what is happening in labor you will recognize each stage as it comes and feel more confident about trying different ways of coping. As you learn your own personal strengths and resources for labor and birth, you will learn to trust your body and the enigma of the birth process will be rediscovered.

• To enhance a productive labor trust your body, trust yourself and your innate ability to give birth. 
• Acknowledge the role of hormones during labor and birth. Birth is the result of complex, well-defined, and coordinated events, which are tightly regulated by neurohormonal responses.
• Come to terms with the pain of labor. 
• Resist unnecessary interventions. 
• Give birth in a setting that enhances the natural powers of labor and provide an attitude and atmosphere for their release. 
• Get good labor support. 
• Avoid induction and augmentation and epidurals unless there is a proven medical necessity. 
• Prepare to ease your baby out slowly. 
• Most of all,  remember,  despite your plans and the staff's good intentions, what was planned as a low interventional birth can turn into an involved medical procedure if last minute, unexpected complications arise. If, for any reason, your birth experience is not what you hoped for, it doesn't mean that you have failed.  It may simply mean that forces beyond your control have entered the picture.

Remember, birth is a powerful experience of the unknown.  Not a predetermined set of events. 

There is no right way to give birth. There is only each woman’s way. 

There is no single ideal birth.  There is the birth you have. 

There is no right method just the need to be integrated into the physiological, psychological, and emotional process of the intensely private experience of birth.  This experience that is truly your own is an adventure in physical sensation and intense emotional discovery of your own inner power and strength.

Labor is an awesome treadmill of contractions and incredible intense sensations. However difficult the labor may be, you are in your own space and discover in yourself the power to give birth with the same love and passion that created your baby. As the power of the swing of contractions spreads through your body, if the power of the physicality of birth is respected, it allows you to use your body to bring forth life with strength and confidence. 

                         References

Agency for Healthcare Research and Quality (AHRQ) 2004, Nationwide Inpatient Sample. Retrieved July 16, 2004, from www.marchofdimes.com/peristats .

American College of Obstetricians and Gynecologists. (2000). News Release.Clinical Commentary: much ado about a little cut: Is episiotomy worthwhile? Http://www.acog.org/from_home/publications/press_releases/nr03-31-0

American College of Obstetricians and Gynecologists. (2000). News Release. Issue: Recommendations on Cesarean Delivery Rates.          Http://www.acog.org/from_home/publications/press_releases/nr08-09-00.htm.

American College of Obstetricians and Gynecologists. (1995). Fetal Heart Rate Patterns: Monitoring, Interpretation, and Management (Technical Bulletin Number 207). Washington, DC: Author.

Atrash, H., Lawson, H., Ellerbrock, T., Rowley, D., and Koonin, L. (2000). Pregnancy Related Mortality, United States CDC Surveillance Summary for Women, Infants and Children MMWR: p141-154

Association of Women’s Health, Obstetric and Neonatal Nurses. (2000). Position Statement. Issue: fetal assessment. http://www.awhonn.org/resour/position/psresp.html.

Bricker, L., and Luckas, M. (2000). Amniotomy alone for induction of labor. In The Cochrane Library, Issue 4, Oxford: Update Software.

Carroli, G., Belizan, J., and Stamp, G. (1999). Episiotomy policies in virginal births. In Pregnancy and Childbirth Module Issue 3, of the Cochrane Database of  Systematic Reviews. Oxford: Update Software

Cunningham, F.G., MacDonald, P.C., and Grant, N.F., (Eds.). (1997). Williams Obstetrics (20^th edition). Stamford, CT: Appleton and Lange.

Curtin, S.C., and Park, M.M. (1999). Trends in the attendant, place, and timing of births, and in the use of obstetric interventions:  United States, 1989-97. National vital statistics reports; vol. 47 no. 27.  Hyattsville, Maryland: National Center for Health Statistics.

Eason, E., and Feldman, P. (2000). Much ado about a little cut: Is episiotomy worthwhile? Clinical Commentary. Obstetrics and Gynecology, 95 (4), 616-8.

Eason, E., Labrecque, M., Wells, G., and Feldman, P. (2000). Preventing perineal trauma during childbirth: a systematic review. Obstetrics and Gynecology, 95(3), 464-471.

Huyang, D.Y., Usher, R.H., Kramer, M.S., Yang, H., Morin, L., and  Fretts, R.C. (2000) Determinants of unexplained antepartum fetal deaths. Obstetrics and Gynecology, 95(2), 215-21.

Johanson, R., Newburn, M., and Macfarlane, A. (2002).Has the medicalization of childbirth gone too far? British Medical Journal, 324: 892 - 895.

Leavitt, J.W. (1986). Brought to bed: Childbearing in America, 1750 to 1950. New York: Oxford University Press.

Maslow, A.S., and Sweeney, A.L. (2000). Elective induction of labor as a risk factor for cesarean delivery among low-risk women at term. Obstetrics and Gynecology. 95(6), 917-22.

National Center for Health Statistics (NCHS) 2004, final natality data. Retrieved July 16, 2004, from www.marchofdimes.com/peristats.

Neilson, J.P., Crowther, C.A., Hodnett, E.D., and Hofmeyer, G.J., (Eds.). (1999). Pregnancy and Childbirth Module, Issue 3 of the Cochrane Database of Systematic Reviews. Oxford: Update Software.

Putta, L.V., Spencer, J.P., and Conemaugh, T. R. (2000). Assisted vaginal delivery using the vacuum extractor. American Family Physician, 62(6), 1316-20.

Robinson, J.N., Norwitz, E.R., Cohen, A.P., and Lieberman, E. (2000). Predictors of episiotomy use of first spontaneous vaginal delivery. Obstetrics and Gynecology 966(2), 214-8.

Thacker, S.B., and Stroup, D.F. (2000). Continuous electronic heart rate monitoring for fetal  assessment during labor. Cochrane Database of Systematic Review. (2): CD000063. Oxford: Update Software.

Thacker SB, Stroup DF, Chang M. Continuous electronic heart rate monitoring versus intermittent auscultation for assessment during labor. Cochrane Database Syst Rev 2002;(1):CD000063.

Tourangeau, A., Carter, N., Tansil, N., McLean, A., and Downer, V. (1999). Intravenous therapy for women in labor: implementation of a practice change. Birth, 26(1), 31-6.

Ventura, S.J., Martin, J.A., Curtin, S.C., Menacker, F., and Hamilton, B. (2001). Births: Final data for 1999. National Vital Statistics Report; 49(1), 1-99.