There is much awareness and conversation of what the routine interventions are that can occur during the labor and birth process within the hospital environment. These interventions can include induction, augmentation with Pitocin, epidural, or cesarean. In all my professional and personal roles, I am privy to a great amount of pregnancy and birth stories. Within these experiences there are many “silent” yet obvious interventions that are hidden in plain sight under the guise of protocol, practice and societal expectation.
My current list of hidden in plain sight interventions in no particular order that can make a difference on how a woman labors and ultimately delivers her baby is below.
The uniform -Asking and expecting the mother to give up her clothes for the hospital gown.
Who’s on first? – If care provider is part of a large practice or on-call group a woman may have never met or have any knowledge of the person who’s practice style and philosophy is helping to guide and steer her labor and delivery. On-call CP may or may not adhere to the birth plan the laboring woman worked out with her own CP.
On a short leash – Continuous monitoring even if she is not high risk, medicated, or being induced/augmented.
The big drag around – Requiring IV running with absence of medical need.
Staying put – Asking or requiring the laboring woman to stay in bed for ease of staff without medical need.
Ice chips and Jello – Disallowing snacks and sometimes even actual water even though labor is hard work.
The marketing tool – Disallowing the laboring woman to get into the touted tubs or showers since it isn’t convenient for staff and she will not want to get out.
One is enough – Limiting the amount or type of support persons a woman is allowed to have with her.
I know more than you – Treating the laboring woman as if she knows nothing or shouldn’t know anything.
If you don’t… – Instead of giving informed consent and refusal, telling only what bad could, maybe happen.
Attitude and atmosphere – Negative, non-listening, lacking compassion, leaving the door open, ignoring requests, and the like when a woman is laboring.
Only if you ask – Though some wonderful practices are in place, they are only offered if a laboring woman or postpartum mother ask/insist on it.
Bait and switch – The official tour of labor and delivery and the reality of labor and delivery don’t fit together.
New with bells and whistles – The pretty with all the fancy bells and whistles like wi-fi, flat screen tv’s, etc. have to be paid for somehow. Because of this investigate the intervention rates there.
Routine vaginal exams – By and large VE’s are very subjective and can vary greatly between one person to the next on how they score a VE. This variation can deeply affect the course of a woman’s labor and delivery. Women birthing in the hospital really only “need” a VE upon entrance for assessment of where she is in labor, if she desires an epidural/IV narcotics, if she is having a very prolonged labor, or if she feels pushy.
Pushing the epidural – When a woman is moving, moaning, making noise or just doing her thing in labor and it causes the staff discomfort or worry. It could even be that anesthesiologist is going in to surgery and it can only happen now.
Simply because a societal norm is birthing at the hospital, as well as, what routinely goes on there, doesn’t mean the hidden in plain sight interventions are wise or harmless.
My goal here is to give pause and broader thinking to what intervention means for labor and delivery as another tool in planning and preparing for childbirth with eyes wide open.
Many years ago I wrote this piece after attending my very first ICAN conference in San Diego in 2005. I read this and part of me weeps for her, for the me I was and for the women who are becoming part of this sisterhood willingly, wittingly or not. My pain has been transformed into outstretched hands and heart. It has given me a sensitivity and awareness of the birth world I would probably have never achieved on my own had my births been perfect, idyllic and without this trauma.
I love you dear sisters and my life would be far less without each of you.
Seems a long distance the ivory tower to the ground. The surprise in finding the thorny bushes with burrs that dig deep and puncture again at will? Well meaning onlookers say “Well a hundred years ago you both would have died?” And the farce begins. Stuff it down because it is crazy not to be grateful for the surgeon’s hand. Smile and pretend all the twisted darkness inside doesn’t really exist. The oft daily chore mixed with joy of caring for a baby whom we are unsure is truly our own. The continuing assault during lovemaking when a cringe comes from the depths when a loving and hungry hand brushes the incision site. “How can he think I am beautiful? How can he possibly want this?” Another thing of beauty and perfection quashed underneath the burden of the surgeon’s handprint. Oh no say it hasn’t already been a year. The birthday. THE birthday sounds so exciting but terror strikes. Preparation to be happy, preparation to feel joy. Preparation not to shortchange our amazing gift of a child under the pain of the surgeon’s knife print.
The anticipated day meant to birth us into motherhood and my child into my waiting hands to my craving breasts, I was birthed into the Sisterhood of the Scar forever.
Joy Szabo has been in the news lately for desiring a second VBAC for her fourth baby (vaginal birth, emergency cesarean, and vaginal birth). She has been denied locally in her area of Page, AZ to have a vaginal birth. Due to this situation, the International Cesarean Awareness Network has been assisting her in fighting the VBAC ban along with seeking out additional options.
After reading the latest article regarding Ms. Szabo, I am completely dumbfounded by the remarks made by other readers of her story. I am stunned by how it seems the general populous regards a woman’s autonomy and medical rights. I am also including positive comments as counterpoint. Where do you fall? What do you believe? Many of these comments point me in the direction of what is so wrong with the system. That of physician and hospital trumping patient.
You decide is the comment pro or con?
“…..it seems like many people do not grasp malpractice and insurance companies. This is not about the hospital, but about medical professionals and hospitals not wanting litigation. Can you blame them? After spending tens of thousands of dollars on an education before making a dime, I would do what I needed to to avoid a lawsuit, too! … we go to doctors because they DO know what is best for our health! Like another poster said, in health care, the customer is NOT always right.”
“My son was born by c-section, then my daughter vaginally, with no adverse affects. While I agree it’s the doctor’s decision to take the risk or not, it seems over-the-top conservative. Does the doctor’s insurance premium go up if this procedure is performed? Then charge more and give the patient the option.”
“C-sections are done in the US more routinely than in any other developed country but our infant mortality rate is not lower but higher. Doctors do not want to deliver on weekends, at night, if the mother is one week over her electronically determined due date. Yes complications can happen, more so if you are made to stay in a bed hooked up to monitors, a monitor screwed in to the baby’s head, your water broke prematurely, inducement before the baby or mother are physically ready to give birth. All of this leads to more injuries and deaths than needed. Doctors look upon birth as an illness, not the process that it is – an inexact human birth. I am not suggesting giving birth in a field alone, but a c-section has a greater risk than the V-Bac especially if she has had one already. C-sections for true emergencies yes, otherwise no.”
“Did anyone else notice that when they list the risks of a C-section, they failed to mention that the mother is 4-7 times more likely to DIE than with a vaginal birth.?!?!?! They also fail to mention all the potential complications to her health, the roughly 30% rate of problems following the surgery (some severe enough to require rehospitalization) and the challenges associated with caring for children while recovering from major abdominal surgery. Good for this mom and I hope more mothers will take courage from her”
“This story is exaggeration. If the woman wants a vbac, she just has to show up at that hospital in labor and refuse a section. They can’t force her to have a c-section no matter what they would prefer she do. You can’t force a woman to have a c-section under any circumstances, so as long as the docs and nurses say she and the baby are tolerating labor, she has no reason to fear being forced into an operation.”
“I worked in the hospital for 5 years and then in a birth center for the last 4 years. I had to get out of the hospital because I started feeling guilty about my complicity in that system in which so much goes on behind closed doors of which the patient is never informed. I’ve had docs tell me in the lunch room that they are doing a c-section because they have an important golf game, fishing trip, or hot date. Then they go into the room, lie to the woman and say, ” oh your baby is too big, your progress is too slow, it’s never going to happen.” the woman believes them and thanks them so much for saving their babies lives. Over and over and over again. In Miami we have over 50% c-section rate, and it’s way more convenient for the docs. If VBACS are not allowed at more and more hospitals, the rest of the country will soon be like it is here…..”
“I find this decision by the hospital(s) to not do a VBAC as a little crazy. My older brother was born (in 1955) by C-section; both me (in 1958) and my younger brother (in 1962) were born vaginally. NO COMPLICATIONS. It could be done 50 years ago, but not now??”
“The risk of MAJOR complication from a second cesarean is TEN TIMES that of the risk of uterine rupture in a VBAC mother. Someone please explain to me how an “elective” repeat cesarean is safer than a VBAC? Especially since more than 75% of uterine ruptures occur PRIOR to the onset of labor. How is a scheduled cesarean at 39 weeks (which is the ACOG recommendation) going to save the mother who ruptures at the dinner table at 34 weeks? Using their logic, we should all go live at the hospital the moment we become pregnant after a previous cesarean, just in case our uterus blows up and we need an OB and an anesthesiologist “immediately available”.”
So what do you think? It worries me that is seems the mother’s rights do not count for much. That in some of the comments the idea of forcing a cesarean is no big deal if it makes the doctor’s position safer.
I think that most people are woefully under educated on childbirth and what safety really means. A conservative physician errs on the side of evidence not defensive practice. Do your own research. Be your own advocate.
Below is a compilation of common terms and acronyms that women often will come across during pregnancy, labor, and delivery. Check back as more will be added from time to time.
AROM – Artificial Rupture of Membranes – using a finger or tool to open the amniotic sac to to allow the fluid to release.
PROM – Premature Rupture of Membranes – when the amniotic fluids releases before labor starts.
SROM – Spontaneous Rupture of Membranes during labor.
ROM – Rupture of Membranes
Miso – Misoprostol is the pharmacological name for Cytotec a drug used for cervical ripening and induction though a controversial, off and against label used ulcer Medication
VBAC – Vaginal Birth After Cesarean
HBAC – Home Birth After Cesarean
WBAC – Water Birth After Cesarean
UBAC – Unattended Birth After Cesarean
CBAC – Cesarean Birth After Cesarean – This is a repeat cesarean after a woman desires and tries to have a vaginal birth after cesarean.
ERCS – Elective Repeat Cesarean
RCS – Repeat Cesarean
Natural Birth – Labor and vaginal delivery free from intervention except for intermittent fetal monitoring. In the hospital only a saline lock and intermittent monitoring.
Vaginal Birth – Baby born vaginally with or without medication and intervention.
First Stage – Early, Active, and Transition. This encompasses the effacement to 100%, dilation to 10 centimeters/complete, position movement of cervix from posterior to forward as contractions begin while staying longer, strong and closer together prior to pushing and delivery.
Second Stage – Pushing phase after cervix is completely dilated to delivery of baby.
Third Stage – Delivery of baby to delivery of placenta.
Fourth Stage – First hours after placenta is delivered.
Oxytocin – A hormone made in the brain that plays a role in childbirth and lactation by causing muscles to contract in the uterus (womb) and the mammary glands in the breast. It also plays a role in bonding with mate, child, and socially.
Pitocin (oxytocin injection, USP) is a sterile, clear, colorless aqueous solution of synthetic oxytocin, for intravenous infusion or intramuscular injection.
Prostaglandin – Any of a group of hormone like fatty acids found throughout the body, esp. in semen, that affect blood pressure, metabolism, body temperature, and other important body processes such as cervical ripening.
Uterus -The muscular organ in which a fertilized egg implants and matures through pregnancy. During menstruation, the uterus sheds the inner lining.
Cervix -The lower portion of the uterus that provides an opening between the uterus and the vagina. Also known as the neck of the uterus that softens, effaces, dilates and changes position during labor.
Vagina – A muscular canal between the uterus and the outside of the body. Also known as the birth canal.
Perineum – The area between the anus and the vulva (the labial opening to the vagina).
Pelvis -The basin like cavity formed by the ring of bones of the pelvic girdle in the posterior part of the trunk in many vertebrates: in humans, it is formed by the ilium, ischium, pubis, coccyx, and sacrum, supporting the spinal column and resting upon the legs.
Pelvic Floor Muscles -The sphincter mechanism of the lower urinary tract, the upper and lower vaginal supports, and the internal and external anal sphincters. It is a network of muscles, ligaments, and other tissues that hold up the pelvic organs. Includes bladder, rectum, vagina and uterus.
Fundus - Top of the uterus. During labor contractions the fundus thickens and gets more firm as the strength of contractions increase and dilation increases.
Placenta -The organ that develops during pregnancy that transports nutrients to the fetus and waste away from the fetus. The placenta is attached to the uterus and is connected to the fetus by the umbilical cord.
Umbilical cord – The cord that transports blood, oxygen and nutrients to the baby from the placenta.
Bloody Show – Mucous and blood mixed together as dilation and effacement occurs. Starts off as blood tinged mucous and becomes heavier as labor progresses.
Stripping membranes - Pressing the amniotic sac away from the inside of the cervix.
Mucous plug - The mucous that blocks off the non-dilated and non-ripened cervix for protection.
Lochia – Post birth bleeding that though a wound site from the placenta detaching from the uterine wall, it mimics a heavy and long menstrual period.
Cesarean – Baby born via a surgical incision made through the abdomen into the uterus.
Obstetrician – Is the surgical specialty dealing with the care of women and their children during pregnancy, childbirth and the immediate post birth time.
Midwife – Is a person usually a woman who is trained to assist women during pregnancy, during childbirth, and postpartum as well as the newborn post birth. There are many types of midwives – some work in the home, at birth centers or in the hospital.
Doula – Is an assistant who provides various forms of non-medical and non-midwifery support (physical and emotional) in the childbirth process. Based on a particular doula’s training and background, the doula may offer support during prenatal care, during childbirth and/or during the postpartum period. A birth doula provides support during labor. A labor doula may attend a home birth or might attend the laboring at home and continue while in transport and then complete supporting the birth at a hospital or a birth center. A postpartum doula typically begins providing care in the home after the birth. Such care might include cooking for the mother, breastfeeding support, newborn care assistance, errands, light housekeeping, etc. Such care is provided from the day after the birth, providing services through the first six weeks postpartum. In some cases, doula care can last several months or even to a year postpartum – especially in cases when mothers are suffering from postpartum depression, children with special needs require longer care, or there are multiple infants.
Birth Center – Free standing location usually run by one or more certified nurse midwife. True birth centers are almost always independently run. They are not overseen by a hospital or in a hospital. May be near a hospital. Often set-up like a home birth space and epidurals or other pain medications are not available. Hospital “birth centers” are labor and delivery floors not birth centers in the true sense of the term.
Intervention – Anything that does not exist in a naturally occuring labor and delivery that is done.
Saline Lock/Buffalo Cap/ Hep Lock – Is the apparatus that the IV line hooks into. It is silicone tubing that is lightweight with a plastic needle that stays under the skin to allow easy vein access.
Foley – A foley catheter is used to release the bladder if a woman unable to urinate due to an epidural, post surgery, or with a swollen urethra post birth. It can also be used for successful cervical ripening in lieu of cytotec.
Induction – To attempt to artificially start labor usually by pitocin, artificial rupture of membranes with or without cervical ripening (Cytotec or Foley Catheter).
Epidural - A medical method of giving pain relief during labor. A catheter is inserted through the lower back into a space near the spinal cord. Anesthesia is given through this catheter, and results in decreased sensation from the abdomen to the feet.
Contraction – Tightening and loosening of your uterus. Productive contractions are often felt at the bottom of the uterus, start out like period cramps and progressively grow stronger, longer in length, and closer together.
Braxton-Hicks – Practice contractions that do not dilate or efface the cervix often felt at the top of the uterus versus the bottom.
Episiotomy – A surgical procedure to widen the outlet of the birth canal to facilitate delivery of the baby and avoid a jagged rip of the perineum. (Natural abrading or tearing is preferred and episiotomies are not evidence-based to be used except under specific circumstances).
Ina May’s Sphincter Law -Tapping into the concept that if one sphincter is open and relaxed, the others will also open, relax and be able to handle, quite adequately, the task at hand. This also includes the aspect of birth requiring privacy, sacredness, and honor as well so a woman feels safe, unwatched and supported.
Kegel Exercises – Named after Dr. Arnold Kegel, consists of contracting and relaxing the muscles that form part of the pelvic floor (sometimes called the “Kegel muscles”).
Here is the radio interview I did with Debbie Hull of the Whole Mother Radio show. We talked about the current percentage of cesareans, VBAC availability, where to obtain support, ways to prevent an unnecessary cesarean and much more!
Today the cesarean rate is an alarming 31.8% (CDC 2007 preliminary data). Only a maximum of 15% of birthing women should be having cesarean deliveries in order to keep mortality (death) and morbidity (poor outcomes) to the healthiest levels according to the World Health Organization. With the staggering discrepancy in what should be and what is, you NEED to care about this topic. You could have a questionable cesarean like so many others.
It is important that you the childbearing woman understand how to have the healthiest birth for you and your baby which is most often a no-to-low intervention vaginal birth.
When a cesarean occurs for a truly medical and/or life saving reason it is necessary and the benefits far outweigh the consequences for mom and baby. The cesareans that occur for other than truly medical and/or life saving reasons are often not necessary or became necessary due to external influence that skewed the labor and delivery outcome (routine induction, epidural, impatience by provider, mal-position of baby, staying in bed during labor, routine continuous monitoring, pushing in one position, lack of food and water during labor, routine augmentation of labor, lack of support, etc.)
Below is a list of ways to promote having a vaginal birth even if you have already had a baby this information needs to be known.
Interview before choosing your care provider – you are doing the hiring! Know his or her statistics. If you do not get a clear answer, that is a RED flag. You need individualized care. ou and your baby deserve no less.
Interview both midwives and OB’s.
Research your chosen birth location well. There are other options outside of the hospital – home and birth center.
Hire a doula who shares your philosophy and is comfortable with the type of birth you desire. Some searchable places for a doula are: www.cappa.net, www.dona.org, and www.alldoulas.com.
Without medical reason standing in the way, labor at home into active labor if traveling to a hospital or birth center. Well established labor upon arrival to the hospital or birth center decreases the opportunity for interventions, medications, and cesareans.
Get educated! Take a childbirth class that promotes confidence, consumer awareness (knowing rights and responsibilities), and evidence-based practices. A “good patient” class is not what you want to take. READ books that share positive stories and good information. A few of the searchable sites are: www.cappa.net, www.independentchildbirth.com, www.lamaze.org, and www.ican-online.org.
Turn off your TV – stop watching the dramatic birth shows. They are not real.
Use mobility in labor.
Drink and snack in labor.
Say NO to routine interventions – meaning interventions or medications without a true medical reason. These can include, IV with fluid running, artificial rupture of membranes, continuous monitoring, wearing of hospital gown, and vaginal exams.
Say no the the epidural completely or at the earliest at 6 cm’s dilated.
Push and deliver in positions other than the reclined or “C” position unless that feels good and baby is coming well that way.
Only have those around you who will support what you need and desire in labor and birth. When you close your eyes who is there with you in your labor “cave”? Who doesn’t fit well there?
Study yourself for what comforts, assures, and adds to your feeling of safety.
This is a slight re-do from a popular blog post from early 2008. The information is vital and pertinent to the near 1.5 million women (based on previous CDC data) who will have a cesarean surgery this year.
Having a cesarean section will almost always get you a baby. Generally there is much more to it and anyone could bargain for or anticipate even in the best of recoveries.
Let me count the ways in no particular order:
A scar that in no way makes a bikini look better. Sometimes described as a shelf or a pouch.
The feeling of failure, guilt or less than deserving of motherhood.
The struggle of living with the huge dichotomy of loving your baby and perhaps hating the birth.
Higher probability of losing your ability to have more children either through physiologic secondary infertility, pregnancy complications, self-induced secondary infertility, hysterectomy or lack of sexual intimacy in relationship.
Higher probability of difficulty in breastfeeding.
Postpartum depression or PTSD, especially in an unwanted cesarean.
The feeling of failure as a wife or partner.
Having others discount your feelings and needs. After all you “just” had a baby. Really you just had MAJOR surgery, perhaps by coercion, a true medical indication, or completely from interventions and medications.
Living with the idea that you failed to pass induction, you failed to push out your baby, you failed because _________ (fill in the blank).
Obtaining your records to find what you were told and what was written are different. Could your trusted care provider have lied and cheated you?
Simply finding out that no one told you and you didn’t think it would happen to you. That being induced, getting the epidural, allowing AROM, not getting out of bed, etc. is why you had the cesarean. Is maternal ignorance and fear enough to quell what you feel and make it okay?
How can you trust yourself as a mother when you ignored your maternal intuition and kept saying yes, because the nurse, midwife or doctor told you to?
The way your marriage or partnership takes a turn toward hell or in the least a divided place.
Living with dread when a hungry hand sweeps over your scar. Being sexual can be extremely difficult physically and emotionally.
Having great fear of becoming pregnant again.
Having great fear of going for a VBAC and ending up in the OR at the end.
Not being understood and having others say to your face how lucky you are that you got to take the easy way out.
Pain.
Difficulty moving, walking, getting up, rolling over, coughing, laughing, tending to personal cleaning…. You get the idea. It is surgery.
Though not every woman will experience what is on the list, many do. For all of these – there a stories layered and interwoven for too many women.
Every thirty seconds a woman is surgically having her baby delivered. Light her a candle. Offer her a meal. Let her speak. Listen to her intently. Don’t judge her. Send her to ICAN. http://www.ican-online.org/.
Putting effort into the initial postpartum period is in my opinion equally as important as preparing for pregnancy and birth. Sometimes it is even more important due to circumstance or birth outcome. Too many focus solely on the labor, delivery and perhaps the “stuff” that goes with having a baby while completely forgetting to look at all incredible change that occurs with having a new baby 24 hours a day, 7 days per week.
Below is a listing of important information to think about, investigate, understand and/or plan for. Make a note of people in your immediate life that can be a resource as you go through the list.
Look carefully at class descriptions you may take in your local area, some are very thorough and others do not go into information you need in detail.
Here’s to postpartum preparedness!
Common Physical Changes for the Mother
Uterine Change and Bleeding
Breast Expectations and Breastfeeding Norms
Hormones and Symptoms
Recovery Requiring Attention
Vaginal Tearing, Episiotomy, Cesarean, Extreme Soreness or Swelling, Hemorrhoids
Nutrition
Common Psychological Changes
Mother and Father/Partner Changes
Processing the Birth Experience
Processing Becoming a Family
Postpartum Mood Disorders
Peer and Professional Support Resources
Understanding Your New Baby
Babymoon
How Baby’s Feed
Attachment
Infant Development
New Family Dynamic
Coping with Sleep Deprivation and Exhaustion
Managing Stress
Grieving the Changes
Siblings and Pets
Knowing How to Get the Right Support
Postpartum Doulas and Practical Support
Making Your Best Decisions
Defining Parental Roles – Financial, Baby Care, Changing the Status Quo
Choosing a Health Care Provider for your Baby
Early Infant Health Care Decisions – Vaccinations, Circumcision, etc.
Parenting Philosophies
Developing Your Parenting Style
Where Baby Will Sleep
Boundaries with Family and Friends
When to Seek Professional Help
Relationship Care
Realistic Expectations
Sexual Intimacy
Practicalities of Life
“Dating”
Priorities
Single Parenting
Arranging Practical Support
Making a Community
Parenting Needs
Unexpected Outcomes
Processing a Difficult Birth
Babies with Medical Needs, Coping and Advocating
Dealing with Loss, Grief, and Trauma
I offer a Postpartum Strategies class privately in the Colorado Springs area that goes into more detail on many of these topics. My Bookstore lists several helpful books as well.
I have been invited to share with you an intimate and challenging (and graphic) journey of a mother from an unexpected primary cesarean, physician decided repeat cesarean and a home water birth after those two cesareans.
Before you watch it, take a deep breath and have an open mind. A box of tissues may be in order as well.
Watch how a baby is delivered in a cesarean birth and see the dramatic difference of what both the mother and baby experience in a home water birth after cesarean.
Thank you Alex for allowing me to share your story! Many blessings to you and yours.
For more information on cesarean recovery, support, prevention and VBAC information go to www.ican-online.org.
