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"Dedicated to Sharing Childbirth Knowledge"  If you have any article that you would like to submit to be added to this list please let me know.

Table of Contents:

* Rupture of the symphysis pubis
* Research on Prenatal Perineal Massage
* Perineal Massage
* Management of Shoulder Dystocia
* Super Glue Instead of Suture
* Code Blue Birth
* Fetal Alcohol Syndrome
* The Foreskin is Necessary
* Ultrasound
* Drugs Used during Labour
* Epidural Epidemic
* Treating and Preventing thrush
* Natural Induction
* Size Friendly Birth Attendants
* Sudden Infant Death Syndrome
* Turning a Breech Position

External Links to some excellent information:
Obstetrical Ultrasound
Gaskin Maneuver - by Ina May Gaskin, an excellent article about managing shoulder dystocia.

Tracking Your Personal Ovulation Pattern for Fertility
If you are wishing to conceive, it is important to locate the 8 days that you are fertile during the month. This can easily be done with information that allows you to track your personal ovulation pattern. When your cycle varies it is best to use different ways to locate your personal ovulation pattern. A resting temperature, first thing in the morning before your feet hit the floor and using a calendar method to track your changing body temperature is one method, you are looking for a a dip and then an immediate rise in body temperature to signal the beginning of ovulation. Looking for body signals is one method, you will find that you may experience heightened sexual desire, increased discharge, clear instead of cloudy discharge, you may feel a slight pinching or slight cramping as your egg is released and begins to travel. Another method is to check your discharge on a daily basis, clear discharge equals fertility, if your discharge is cloudy you are not ovulating. It is possible to feel the ever changing positioning of your cervix to determine the exact days that your ovulation will be occurring. You can also purchase an ovulation kit to assist in determining your ovulation pattern for the first month or two. Your body will always give you signs of ovulation and fertility as you move through your cycle. Using a few of the methods together will help you to quickly track down your own personal ovulation pattern so that you can have control over your fertility for your entire reproductive life. If your cycle is less than 28 days you may find that you ovulate during your period. That will make your most fertile days the 8 days including just before your period, during your period, and directly after your period. If your cycle is exactly 28 days you will most likely begin to ovulate 14 days after the first day of your last period. So the 5 days before you ovulate and the three days of ovulation are your 8 fertile days.
If your cycle is more than 28 days you will most likely ovulate 12 to 16 days after the first day of your last period. You will be fertile for 8 days during your cycle. For 5 days before you ovulate, because sperm has a life of up to 5 days within you, and for the three days of ovulation for a total of 8 days. Once you locate your own personal ovulation pattern, it will stay relatively consistent throughout your reproductive life. It is now time that women take control over their reproductive ability without the drugs and hormones that can cause life altering changes to a woman's body and her future fertility. This information must be distributed to every woman, most especially to our teens who otherwise will be chained to years of hormonal birth control potentially causing unknown damage to their present health and their future fertility. We need to understand our bodies so that we can take back control of our fertility and our present and future health. The following excellent websites will give you more information about tracking your personal ovulation pattern using the three methods together. Toni at Ovusoft and Cycle Savvy with “Taking Charge of Your Fertility” is known throughout the world as a leader in women's health issues. If you have a daughter, please buy her a copy of Cycle Savvy, this is an amazing book for our young women. Geraldine at Justisse has created a book to ovulation and fertility planning. Geraldine has also written a book to help women overcome the side effects of long term hormonal birth control use, this work which is also available on her site. These two women are freeing women from around the globe from expensive contraceptive drugs and their various health side effects and showing women how to take control of their fertility. As you learn how to use your personal ovulation pattern to create pregnancy, you can also use your personal ovulation pattern to avoid pregnancy for the rest of your reproductive life. It is a gentle, drug-free way to have complete and total control of your fertility throughout your entire life. Your period and ovulation are important to your health as a woman and keeping track of your ovulation helps you to monitor the health of your entire body. Your body is perfect, just the way it is, all we need is a little information on how it so perfectly works. Best wishes, Gail J. Dahl

Rupture of the symphysis pubis:

Two cases of spontaneous rupture of the symphysis pubis (SP) during delivery are reported.
The separations were associated with considerable pain, swelling, and tenderness over the symphysis pubis and were confirmed roentgen graphically. Both patients were treated conservatively with bed rest, mostly in the lateral decubitus position, within pelvic binders. Immobilization was discontinued when they were pain free. The SP separations remained in reduced positions. The patients were essentially asymptomatic and walked normally. Conservative treatment followed by early mobilization is adequate treatment for SP separations.
A severe case of separation of the symphysis pubis during labor and delivery is reported, which included severe pain and unusual complications of urinary outflow incontinence and fecal incontinence that gradually resolved with conservative treatment. The incidence of symphysis pubis separation is reported to be between 1:600 and 1:3400 obstetric patients.
Treatment should generally be conservative and symptomatic. Prognosis for recovery is excellent. Recurrent separation of the symphysis pubis could occur during subsequent deliveries but generally is no worse than the first occurrence. This case report illustrates the unusual complications that can occur with severe diastasis of the symphysis pubis during pregnancy. Family physicians, obstetricians, and orthopedic surgeons could encounter this complication of childbirth in their own practices. Although the symptoms are dramatically severe in presentation, a conservative management approach is effective.
Peripartum pubic separation (diastasis pubis) is an uncommon event with a reported incidence varying between one in 521 to one in 30,000 deliveries. The injury is caused by the fetal head exerting pressure on pelvic ligaments that have been weakened or relaxed by the hormones progesterone and relaxin. Diastasis pubis has been previously reported in both obstetric and orthopedic literature. However, the authors have been unable to locate any discussion of this condition in the anaesthetic literature. Historically, symphyseal separation has been frequently unrecognized. The authors present the case of a nulliparous woman who suffered a diastasis pubis during assisted vaginal delivery under epidural anesthesia.
METHODS. Epidural catheter placement and administration of medications were performed using standard techniques described.
RESULTS. The patient had an episode of breakthrough pain during labor despite adequate epidural analgesia and experienced postoperative pubic and thigh pain secondary to pubic separation.
CONCLUSIONS. Diastasis pubis is an uncommon injury that should be considered when evaluating patients in the peripartum period who are experiencing suprapubic, sacroiliac, or thigh pain.
OBJECTIVE: To present an unusual case of traumatic extensive separation of the symphysis pubis during pregnancy and rationale for mode of treatment.
DESIGN: Diagnosis for etiology of public and lower back pain following trauma in a 37-year-old woman in an advanced stage of pregnancy.
METHODS: Physical examination and plain anterioposterior X-rays.
CONCLUSION: Extensive traumatic separation of the symphysis pubis might result from a very forceful descent of the fetal head against the pelvic ring upon the mother's accidental falling. Propitious timing of a caesarian section permits the option of open reduction and internal fixation.

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Research on Prenatal Perineal Massage

Br J Obstet Gynaecol 1997 Jul;104(7):787-791
Antenatal perineal massage and subsequent perineal outcomes: a randomized controlled trial.
Shipman MK, Boniface DR, Tefft ME, McCloghry F Department of Obstetrics and Gynecology, Watford General Hospital, Hertfordshire, UK.
OBJECTIVE: To study the effects of antenatal perineal massage on subsequent perineal outcomes at delivery.
DESIGN: A randomized, single-blind prospective study.
SETTING: Department of Obstetrics and Gynecology, Watford General Hospital.
PARTICIPANTS: Eight hundred and sixty-one nulliparous women with singleton pregnancy and fulfilling criteria for entry to the trial between June 1994 and October 1995.
RESULTS: Comparison of the group assigned to massage with the group assigned to no massage showed a reduction of 6.1% in second or third degree tears or episiotomies. This corresponded to tear rates of 75.1% in the no-massage group and 69.0% in the massage group (P = 0.073). There was a corresponding reduction in instrumental deliveries from 40.9% to 34.6% (P = 0.094). After adjustment for mother's age and infant's birth weight these reductions achieved statistical significance (P = 0.024 and P = 0.034, respectively). Analysis by mother's age showed a much larger benefit due to massage in those aged 30 and over and a smaller benefit in those under 30.
CONCLUSION: Antenatal perineal massage appears to have some benefit in reducing second or third degree tears or episiotomies and instrumental deliveries. This effect was stronger in the age group 30 years and above.

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Perineal Massage
Excerpt from The Birth Book By William and Martha Sears
The better you prepare your perineal tissues for the stretching of birth, the less they will tear, and the better they will heal. Like training muscles to perform at their best in an athletic event, conditioning the tissues around the vaginal opening with massage prepares the perineum to perform. Midwives report that women who practice perineal massage daily in the last six weeks of pregnancy experience less stinging sensation during crowning. Mothers with a more conditioned perineum are less likely to tear or get an episiotomy. An added value of perineal massage is that it familiarizes a woman with stretching sensations in this area so she will more easily relax these stretching muscles when stinging occurs just before the moment of birth.
Try this technique:
Scrub your hands and trim your thumb nails. Sit in a warm comfortable area, spreading your legs apart in a semi-sitting birthing position. To become familiar with your perineal area use a mirror for the first few massages (a floor-to-ceiling mirror works best). Use massage oil, such as pure vegetable oil, or a water-soluble lubricant, such as K-Y Jelly (not a petroleum-based oil) on your fingers and thumbs and around your perineum.
Insert your thumbs as deeply as you can inside your vagina and spread your legs. Press the perineal area down toward the rectum and toward the sides. Gently continue to stretch this opening until you feel a slight burn or tingling. Hold this stretch until the tingling subsides and gently massage the lower part of the vaginal canal back and forth. While massaging, hook your thumbs onto the sides of the vaginal canal and gently pull these tissues forward, as your baby's head will do during delivery.
Finally, massage the tissues between the thumb and forefinger back and forth for about a minute.
Being too vigorous could cause bruising or swelling in these sensitive tissues. During the massage avoid pressure on the urethra as this could induce irritation or infection.
As you become adept with this procedure, add Kegel exercises to your routine to help you get the feel for your pelvic muscles. Do this ritual daily beginning around week 34 of pregnancy.
Many midwives and obstetricians believe that perineal massage is neither useful nor necessary as long as the mother's perineum is supported during crowning, her pushing is properly timed, and the baby's head and shoulders are eased out. Discuss the value of perineal massage with your birth attendant.

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Weighing the Propaganda Against the Facts by Beverley Lawrence Beech

The use of ultrasound in antenatal care is big business, and in any big business marketing is all-important. As a result of decades of enthusiastic marketing, women believe they can ensure the well being of their babies by reporting for an early ultrasound scan and that early detection of a problem is beneficial for these babies. That is not necessarily so, and there are a number of studies which show that early detection can be harmful.
In response to women's desire for information about the implications of routine ultrasound examinations, Jean Robinson and I wrote the book Ultrasound? Unsound, in which we reviewed the research evidence and drew attention to some of the hazards  (Beech and Robinson, 1996). But since then more evidence has accumulated. For example: Miscarriage
It is ironic that women who have had previous miscarriages often have additional ultrasound examinations in order to "reassure" them that their baby is developing properly. Few are told of the risks of miscarriage or premature labour or birth.
Obstetricians in Michigan (Lorenz et al., 1990) studied fifty-seven women who were at risk of giving birth prematurely. Half were given a weekly ultrasound examination; the rest had pelvic examinations. Preterm labour was more than doubled in the ultrasound group 52 % compared with 25 percent in the controls. Although the numbers were small the difference was unlikely to have emerged by chance.
A large randomised controlled trial from Helsinki (Saari-Kemppainen et al., 1990) randomly divided over 9,000 women into a group who were scanned at sixteen to twenty weeks compared with those who were not. It revealed twenty miscarriages after sixteen to twenty weeks in the screened group and none in the controls.
A later study in London (Davies et al., 1993) randomised 2,475 women to routine Doppler ultrasound examination of the umbilical and uterine arteries at nineteen to twenty-two weeks and thirty-two weeks compared with women who received standard care without Doppler ultrasound. There were sixteen perinatal deaths of normally formed infants in the Doppler group compared with four in the standard care group.
It is not only pregnant patients who are at risk, however. Physiotherapists use ultrasound to treat a number of conditions. A study done in Helsinki (Taskinen et al., 1990) found that if the physiotherapist was pregnant, handling ultrasound equipment for at least twenty hours a week significantly increased the risk of spontaneous abortion. Also, the risk of spontaneous abortions occurring after the tenth week was significantly increased for deep heat therapies given for more than five hours a week and ultrasound more than ten hours a week.
Diagnosis of placental praevia
The Saari-Kemppainen study also revealed the lack of value in early diagnosis of placenta praevia. Of the 4,000 women who were scanned at sixteen to twenty weeks, 250 were diagnosed as having placenta praevia. When it came to delivery, there were only four. Interestingly, in the unscanned group there were also four women found at delivery to have this condition. All the women were given caesarean sections and there was no difference in outcomes between the babies. Indeed, there are no studies which demonstrate that early detection of placenta praevia improves the outcome for either the mother or the baby. The researchers did not investigate the possible effects on the 246 women who presumably spent their pregnancies worrying about having to undergo a caesarean section and the possibility of a sudden haemorrhage

Since the publication of Ultrasound? Unsound further studies have raised questions about the value of routine ultrasound scanning.
Babies with serious defects
Almost all babies receive a dose of ultrasound, but even at the best centres wide variations occur in detection rates for babies with major heart abnormalities. Both national and international detection rates differ widely in published studies (which are usually undertaken in centres of excellence), but the majority of mothers will be exposed to older machines in ordinary hospitals and clinics. The skill of the operators will vary (everybody has to learn sometime), but even with the best machines and the best operators misdiagnoses occur. A study from Oslo (Skari et al., 1998) looked at how many babies born with serious defects had been diagnosed by antenatal scans, and whether the early diagnosis made any difference to the outcomes. Women in Norway have a scan at seventeen to twenty-one weeks done by trained midwives, who refer to obstetricians if an abnormality is suspected. In nineteen months, thirty-six babies were referred from a population of 2.5 million. They had diaphragmatic hernias, abdominal wall defects, bladder extrophy or meningomyelocele. Only thirteen of the thirty-six defects had been detected before birth (36 percent). They found that only two of eight congenital diaphragmatic hernias were picked up on ultrasound, half the cases of abdominal wall defects (six out of twelve), 38 percent of the meningomyelocele (five out of thirteen) and none of the three cases of bladder extroversion. The mothers had an average of five scans (from one to fourteen); those in whose cases abnormality was detected had an average of seven Three out of the thirteen babies diagnosed antenatally died. There was one death in the twenty-three undiagnosed. All thirteen babies with antenatal diagnosis were delivered by caesarean. Nineteen of the twenty-three undiagnosed babies had an uncomplicated vaginal delivery. The diagnosed babies had lower birth weight and two weeks shorter gestation. Although the babies with pre-diagnosed abdominal wall defects received surgery more quickly (four hours versus thirteen hours), the outcomes were the same in both groups. Although small, this is an important study.
Pregnant women often automatically assume that antenatal detection of serious problems in the baby means that lives will be saved or illness reduced. Knowing about the problem in advance did not benefit these babies; more of them died. They got delivered sooner, when they were smaller, a choice that could have long-term effects. All twelve babies with abdominal wall defects survived. But for the six detected on the scan, their length of hospital stay was longer and they spent longer on ventilators, though the numbers are to small to be significant. They were operated on sooner (four hours rather than thirteen hours) but the outcomes were the same.
Growth Retarded Babies
One of the promises held out by antenatal scanning is that obstetricians will be able to identify the baby with problems and do something to help it. A German study from Wiesbaden hospital (Jahn et al., 1998) found that out of 2,378 pregnancies only fifty-eight of 183 growth retarded babies were diagnosed before birth. Forty-five fetuses were wrongly diagnosed as being growth retarded when they were not. Only twenty-eight of the seventy-two severely growth-retarded babies were detected before birth despite the mothers having an average of 4.7 scans. The babies diagnosed as small were much more likely to be delivered by caesarean -
44.3 percent compared with 17.4 percent for babies who were not small for dates. If the baby actually had intrauterine growth retardation (IUGR) the section rate varied hugely according to whether it was diagnosed before birth (74.1 percent sectioned) or not (30.4 percent).
So what difference did diagnosis make to the outcome for the baby? Pre-term delivery was five times more frequent in those whose IUGR was diagnosed before birth than those who were not. The average diagnosed pregnancy was two to three weeks shorter than the undiagnosed one. The admission rate to intensive care was three times higher for the diagnosed babies.
The long-term emotional impact
The effects of screening on both parents can be profound. For example, women waiting for the results of tests try not to love the baby in case they have to part with it. The medical literature has little to say about the human costs of misdiagnosis unless the baby was mistakenly aborted, and even then it tends to focus on legal action. However, a letter in the British Medical Journal revealed how a diagnosis of a minor anomaly can have serious long-term implications for the family:
A couple was referred for amniocentesis during the wife's second pregnancy on the grounds of maternal age, thirty-five years, and anxiety. Their three-year-old son played happily during the consultation. When his wife and son had left the room after the procedure the husband confided that they had opted for amniocentesis to avoid having another "brain damaged" child. On questioning it became apparent that an ultrasound examination before their son's birth had shown a choroid plexus cyst. Despite having a healthy child, the husband remained convinced that this cyst could cause his son to be disabled. (Mason and Baillie, 1997).
Evaluating the risks
When ultrasound was first developed researchers suggested that "the possibility of hazard should be kept under constant review" (Donald, 1980), and they said that it would never be used on babies under three months. However, as soon as vaginal probe ultrasound was developed, which could get good pictures in early pregnancies (and get nearer to the baby giving it a bigger dose), this initial caution was ignored. Research by Lieberskind revealed "the persistence of abnormal behaviour . . . in cells exposed to a single dose diagnostic ultrasound ten generations after insonation." She concluded, "If germ cells were . . . involved, the effects might not become apparent until the next generation" (Lieberskind, 1979). When asked what problems should be looked for in human studies, she suggested: "Subtle ones. I'd look for possible behavioural changes, in reflexes, IQ, attention span" (Bolsen, 1982). Because ultrasound has been developed rapidly without proper evaluation it is extremely difficult to prove that ultrasound exposure causes subtle effects. After all, it took over ten years to prove that the gross abnormalities found in some newborn babies were caused by thalidomide. However, there are a number of ultrasound studies which raise serious questions that still have to be addressed.
The first evidence we saw of possible damage to humans came in 1984 when American obstetricians published a follow-up study of children, aged seven to twelve years born in three different hospitals in Florida and Denver, who had been exposed to ultrasound in  the womb (Stark et al., 1984). Compared with a control group of children who had not been exposed they were more likely to have dyslexia and to have been admitted to hospital during their childhood, but no other differences were found.
In 1993 a study in Calgary, Alberta which examined the antenatal records of seventy-two children with delayed speech of unknown cause were compared with those of 142 controls who were similar in sex, date of birth and birth order within the family. The children were similar in social class, birth weight and length of pregnancy. The children with speech problems were twice as likely as controls to have been exposed to ultrasound in the womb. Sixty-one percent of cases and only 37 percent of controls had had at least one exposure.
 A Norwegian study (Salvesen, 1993) showed an increase in left handedness, but no increase in dyslexia. While the increase in left handedness was not large, it does suggest that ultrasound has an effect on the development of the brain. It should be noted, however, that the scanners used in this study emitted very low doses of ultrasound, lower than exposures from many machines nowadays, the women had only two exposures, and it was real time, not Doppler, a more powerful form of ultrasound.
Assessing the risks "Present day ultrasonic diagnostic machines use such small levels of energy that they would appear to be safe, but the possibility must never be lost sight of that there may be safety threshold levels possibly different for different tissues, and that with the development of more powerful and sophisticated apparatus these may yet be
transgressed" (Donald, 1979). Donald's foresight was remarkable. The machines in use today are far more powerful than the machines used a decade or more ago, and new variants are being developed all the time.
There has been inadequate research into the potential long-term effects. Measuring the outcome of any intervention in pregnancy is very complicated because there are so many things to look at. Intelligence, personality, growth, sight, hearing, susceptibility to infection, allergies and subsequent fertility are but a few issues which, if affected, could have serious long-term implications, quite apart from the numbers of babies who have a false positive or false negative diagnosis. Because a baby grows rapidly, exposing it to ultrasound at eight weeks can have different effects than exposure at, for example, ten, eighteen or twenty-four weeks (this is one of the reasons the effects of potential exposure are so difficult to study). Women are now exposed to so many different types of ultrasound: Doppler scans, real-time imaging, triple scans, external fetal heart-rate monitors, hand held fetal monitors. Unlike drugs, whereby every new drug must be tested, the rapid development of each new variation of ultrasound machine has not been accompanied by similar careful evaluation by controlled, large-scale trials.
Despite decades of ultrasonic investigation, no one can demonstrate whether ultrasound exposure has an adverse effect at a particular gestation, whether the effects are cumulative or whether it is related to the output of a particular machine or the length of the examination. How many exposures are too many? What is the mechanism by which growth is affected? A large-scale study (Newnham et al., 1991) showed decreased birth weight, although a later study suggested the babies soon make up the deficit. It should not be forgotten, however, that numerous studies on rats, mice and monkeys over the years have found reduced fetal weight in babies that had ultrasound in the womb compared with controls. Nor should it be forgotten that in the monkey studies (Tarantal  et al., 1993) the ultrasound babies sat or lay around the bottom of the cage, whereas the little control monkeys were up to the usual monkey tricks. Long-term follow up of the monkeys has not been reported. Do they reproduce as successfully as the controls? And, as Jean Robinson has noted: "Monkeys do not learn to read, write, multiply, sing opera, or play the violin." Human children do, and perhaps we should consider seriously  whether the huge increases in children with dyslexia and learning difficulties are a direct result of ultrasound exposure in the womb. Furthermore, when a woman is scanned her baby's ovaries are also scanned. So if the woman had seven scans during her pregnancy, when her pregnant daughter eventually presents years later at the antenatal clinic, her developing baby will already have had seven scans. Do women really know what they consent to when they rush to hospital to have their first ultrasound scan, then trustingly agree to further scans?
Beverley A Lawrence Beech, honorary chair of the Association for Improvements in the Maternity Services (AIMS), is a freelance writer and lecturer and lives in the United Kingdom.
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Epidural Epidemic

Drugs in Labor: Are They Really Necessary. . . or Even Safe?
By Joanne Dozer and Shannon Baruth
The use of epidurals is so common today that many perinatal professionals are calling the 1990s the age of the epidural epidemic. Believed by many in the medical profession to be safe and effective, the epidural seems now to be regarded as a veritable panacea for dealing with the pain of childbirth.
It is true that most women experience pain during the course of labor. This pain can be intense and very real, even for those who have prepared for it. But pain is only one of many possible sensations and experiences that characterize the experience of giving birth. Barbara Katz Rothman, a sociologist who studies birth in America, writes that in the medical management of childbirth, the experience of the mother is viewed by physicians as pain: pain experienced and pain to be avoided. Having experienced childbirth ourselves, we have great compassion for women in painful labors. However, we also feel a responsibility to mothers and their babies to explore issues concerning the use of epidural anesthesia in labor issues that are seldom discussed prenatally.
Several factors make the use of epidurals potentially hazardous. The Physician's Desk Reference cautions that local anesthetics [the type used in epidurals] rapidly cross the placenta. When used for epidural blocks, anesthesia can cause varying degrees of maternal, fetal, and neonatal toxicity which can result in the following side effects: hypotension, urinary retention, fecal and urinary incontinence, paralysis of lower extremities, loss of feeling in the limbs, headache, backache, septic meningitis, slowing of labor, increased need for forceps and vacuum deliveries, cranial nerve palsies, allergic reactions, respiratory depression, nausea, vomiting, and seizures. In addition, a piece of the catheter that delivers the drug into the duraregion of the back may break off and be left in the woman, a dangerous risk that necessitates surgical removal. One of the most well-known side effects of spinal anesthesia is a spinal headache. Depending on the amount of anesthetic used and how the catheter was placed, the headache can be mild or severe, lasting between one and ten days after the birth. This is not how any of us wants to feel in our first days and hours with our newborn.
Epidurals also have been linked to an overall increase in operative deliveries: cesareans, forceps deliveries, and vacuum extractions. A meta-analysis of the effects of epidural anesthesia on the rate of cesarean deliveries was undertaken by a group of physicians who examined, categorized, and analyzed all available literature. Eight primary studies revealed that the rate of cesarean section was 10 percentage points higher in the women who had received epidural anesthesia. One study actually found that the cesarean rate increased to 50 percent when the epidural was given at 2 cm dilation, 33 percent at 3 cm, and 26 percent at 4 cm.3  What caused this increase? In the first stage of labor, the muscles of the pelvic floor may become slack from the numbing effects of the epidural, causing the baby to change an otherwise ideal position or fail to descend into the pelvic cavity. In the second stage of labor, the anesthetized woman often is unable to push effectively since she cannot feel her muscles. When the baby does not descend properly or is malpositioned, progress can slow or stop, resulting in a longer labor and the increased possibility of a cesarean section, vacuum extraction, or forceps delivery.
In addition, epidurals usually slow contractions, which prompts medical personnel to administer intravenous Pitocin in order to strengthen them and increase their frequency. Even with Pitocin, which carries its own set of risks, an anesthetized labor may remain prolonged, risking a difficult labor with lack of progress. Prolonged labors put both mother and baby at greater risk of infection, necessitating the use of antibiotics. The longer a labor and slower the progress, the more likely it will end in a forceps, vacuum, or cesarean delivery. Since cesarean section is a major surgery, it strongly influences a woman's recovery and the initiation of breastfeeding. Of course, the rate of postpartum infection is much higher with cesarean births. All vacuum extraction and forceps deliveries increase the risk of morbidity and birth injuries.
Another effect of epidurals during labor is the creation of hypotension in the mother, which can lead to bradycardia (a decrease in the heart rate) in the fetus. All types of anesthesia, including epidurals, can negatively affect the baby's heart rate, possibly leading to fetal distress and necessitating an operative delivery. The newborn can continue to have breathing difficulties after birth, requiring supplemental oxygen or even resuscitation. While these problems may be resolved immediately following the birth, they often require the mother to be separated from her baby for neonatal nursery observation.
This separation delays bonding and initial feeding. In addition, poor muscle tone and increased acidity in the baby's blood due to bradycardia and oxygen deprivation may affect her ability to suck effectively, hampering initial attempts at early breastfeeding.
A mother's temperature may become elevated with the use of epidural anesthesia, resulting in the infant being taken to the nursery and given a full workup for possible infection. This may include extensive blood work and a spinal tap.
Furthermore, though epidurals usually remove all sensation in the lower body, "windows" can occur which leave the woman experiencing the intensity of her labor (perhaps on one side of her body) but with extremely limited mobility - obviously hindering her ability to cope with her contractions.
The idea that pain medication can play a role in "natural childbirth" is deceptive, despite the assurance of the authors of What to Expect When You're Expecting that ". . . wanting relief from excruciating pain is natural.. . therefore pain relief medication can play a role in natural childbirth." This is rather twisted logic, since the concept of natural childbirth depends on the mother experiencing both mental and physical sensations of labor. The epidural may allow a woman to be awake and aware of what is happening, but she will not be experiencing a natural labor as she will be numb to any physical sensations below the waist. A split between the mind and the body is effectively created with this anesthetic, disengaging her mind from her physical feelings. Could such disconnection be natural childbirth? Robbie Davis-Floyd, an anthropologist who studies birth in America, argues that the woman in labor with an epidural ". . . is separated as a person as effectively as she can be from the part of her that is giving birth." There is an eerie quality to this kind of birth; the mother is robbed of her own connection to her power and life-creative force. She loses the opportunity to experience the inherent wisdom of the body and its ability to birth without interference. Indeed, most women who have felt childbirth agree that it was a deep, enriching, and positive experience.
What alternatives do women have for the relief of pain in labor? Unfortunately, many women enter the birth experience with a strong belief that birth is something horrible and nightmarish. They are already filled with fear, not only for their own and their baby's safety but also about what they have heard is the unbearable pain of childbirth. Another important fear is that of "losing control" during labor and delivery. A mother often is labeled out of control if she expresses the natural, primal sounds of labor. Technologically oriented medical practitioners who are sure that childbirth is something to be wrestled into submission feel that the sound of a mother wailing in pain is a sign that she is "losing it" and ought to be medicated. In hospitals, mothers are often told by well-meaning nurses to be quiet so as not to disturb the other "patients." But release of sound is a natural way to express and release painful, and intense, sensations. Suppressing a mother's natural instincts to move around freely and make noise in labor will increase her actual pain.
The prepared childbirth movement - in particular the Lamaze technique - has been successful for some women by helping them remain "in control" by training for structured labor breathing. However, some women actually do connect to their body rhythms and natural breathing patterns in labor, and if they are more loyal to themselves than to their training, they maybe seen as wild, out-of-control "Lamaze failures." This failure is defined as their inability in labor to be mannerly and controlled. In fact, one of the primary psychological reasons for lack of progress and cesareans is a fearful mother's unconscious attempts to control the intensity of her labor. Her lack of progress is due to her inability to let go and surrender. Mothers are told they must be in control when actually they need to let go.
So how does a mother let go and find her way through the pain of labor?
First, she needs to give birth where she feels safe. For some women this may mean a medicalized hospital birth; others may feel safest at home or in an alternative birthing center. Most women find that they feel safest in the loving hands of a practitioner with whom they have developed a supportive and loving relationship. This person may be a special kind of doctor or it may be a midwife. Midwives specialize in personalized, supportive perinatal care.
Support is the best form and prime source of nonpharmacological pain relief.
Support can also come from the love and care of a partner. If you are having your baby in a hospital, it may be worthwhile to secure the help of a knowledgeable friend or a doula.
Support can be active: massage, breathing together, encouraging words and attentiveness, and reassurance that what is happening is normal and that you are handling it well. Other support can be more passive: a midwife's calm demeanor, a gentle nurse's presence, the peaceful attentions of loved ones. A laboring mother needs to feel safe, loved, and accepted. And when she is, whether she screams, hollers, whines, moans, bargains, begs, or just plain does not act "civilized," giving birth vaginally without medication is a triumph in itself.
One of the ways to endure labor is to recognize (ideally, during one's prenatal education) the connection between fear, tension, and pain - the "fear-tension-pain syndrome." Basically, when a mother feels fear, she will be tense and experience more pain. Relaxation relieves the tension that helps create the sensation of intense pain. The notion of a relaxing labor might seem crazy, but it is possible, and we have seen it many times. Of course, a mother will feel more relaxed and safer in the birth environment of her choice and with her chosen caregivers. Perhaps the more the mother chooses about her birth environment, the more fully she can relax.
Childbirth education classes that focus on birth as natural and normal encourage women to trust the birthing process. Birthing is full of new sensations which can be frightening and difficult to integrate; some women tell us that they felt they might split in two! Understanding the reasons behind the sensations can make them more manageable, since we fear most that which we do not understand. Another key concept in prenatal education is truly believing we can birth our babies, just as women have done for ages. The world was well-populated long before modern obstetrics, and today the lowest maternal and infant mortality and morbidity rates are in the countries where natural, midwife-assisted births are the norm.
Not only can we birth our babies naturally, we can birth in our own style. Birth doesn't need to be performed in any specific way. It is a woman's right to create her labor her way, and she needs to be accepted for her way of doing it. She may find help in deep breathing, light breathing, dancing, singing, yelling, screaming, moaning, crying, walking, or bathing. She needs support for whatever works to assist her to birth her baby. Soaking in water can also help tremendously in reducing pain in labor. Prenatal yoga can be extremely helpful since it teaches women to relax by using deep breathing techniques and imagery. Both of these methods help her to connect more profoundly to her body and baby.
No woman should feel like a failure for having used pain relief medication during labor.
There is a time and place for it in specific circumstances, and epidurals may be very effective. However, the decision to use an epidural should be an educated one, made only after all other options have been exhausted. Birthing is very hard work. It is sweaty, noisy, and emotional, and it always requires our full attention. If we accept this, and stop trying to make birthing "civilized," we can help mothers to endure and cope.
Assisting a woman who is giving birth also is hard work, requiring education, much love, and our full attention.
Supporting birthing women in this way results in less fear, less pain, and a decrease in the need and desire for epidural anesthesia. The satisfaction of a natural birth including the sheer endurance of pain and sometimes overwhelming sensations is accompanied by great joy, even ecstasy. The realization of all these complex emotions is experienced not only by the mother but also by her partner and those who assist, attend, and support her in labor. The sense of joy and accomplishment from a natural birth is the right of every woman and a wonderful gift to any newborn in those very special, first moments of life.

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