Friday, January 29, 2010

...And While We're on the Subject of Numbers...

...who cares much about the number of centimetres a woman is at? It is a guide, like timing contractions, but in no way the be all and end all of diagnostic tools in most cases. I am irate when I'm at a hospital and a woman won't be "admitted" because her cervix is 2cm and she's behaving as if in active labour. So we spend the next hour or two in triage, around a zillion other couples staring at this woman who's clearly "not coping well", sucking up projected scorn from an eye rolling staff who thinks she's just being a wimp and that this labour will probably go on forever, giggling about how she says she doesn't want an epidural now but will succumb to the flock any time now, until she is rushed into her private room "surprisingly" fully dilated, everyone exclaiming how fast she went. I can't tell you how many times I've seen someone go through this. She is not allowed the dignity of privacy, because her cervix isn't matching an expectation, this privacy being something to help her labour more comfortably. I understand hospitals don't want to admit women who are not in established labour, and that way too many women come in too early and clog up the hospital, so they get stricter about admitting. But just OBSERVE the woman! If she's maybe making some good noises (or focused intensely on breathing), is not chatty and worried much about social niceties, looking like she's wanting to be undisturbed during contractions and bothered very little in between, and seeming deeply internally focused, maybe, just maybe, she's ACTUALLY in active labour, whether her cervix is behaving numerically or not. And if she's been at home for a really long time doing that work intensively, and at the hospital her cervix doesn't open more after awhile, maybe she SHOULD be there, just to have her baby checked on periodically, and in a private room to help her cope with an obviously challenging labour more comfortably. Compassion and dignity go a long way in potentially preventing more "stalling".


I refuse to buy into the hype that a cervix HAS to be a certain amount of centimetres open before a woman is considered in active labour or not. I have even had experienced caregivers say, "A woman is never in active labour until she is 4cm." Often, but not always! I have seen women who are less than 2cm in howling active labour, yes, first time mothers, and they birth within a couple of hours. Conversely, I have seen women at 9cm NOT in active labour, I swear. It's not a common occurrence, but it happens. I've had a couple ladies come into the hospital at 9cm, feeling great, not looking like they're even working hard, and then they seem to have a labour that looks like it gets progressively stronger, longer, and harder, until they deliver 12 hours later. It just happened they had very open cervixes, but the uterus needed to catch up in order to make its expulsive efforts. Of course, they were told all kinds of things were terribly wrong and that labour was dysfunctional yada yada yada, but can't there be circumstances in which a woman's labour is unusual, but in fact normal for her considering she and her baby are fine? I'm not saying a woman shouldn't be observed and their babies listened to and thoroughly checked out when things aren't within the usual range of normal, but she shouldn't necessarily be pathologized either. Hitting a lady with those kinds of words is bound to have a negative effect upon her labour.

The effect of Friedman's Curve superimposed upon a healthy labour does just as much to unnecessarily pathologize it by its very expectations as it does determine a real problem. Perhaps even more so. There have been times I've wanted to shout, "Phooey on YOU, Friedman...and your little curve, too!" But why blame him? He just did a study. It's the people who run into the labour room with the curve on a sheet of paper, poking at it and telling the mom while she's trying to contract in peace, "See? You are HERE! And this is how far you have to go!" which aggravate their patients to no end. I suppose it's their way of trying to provide a container of security by helping a mother know a timeline, which, admittedly as a culture, we are obsessed with. But really, what it serves more to do is create a strong want for drugs when things rarely fit into this time line. As we all know, these have their own risks and repercussions, and usually contribute further to complications, whether obviously or subtly.

I am absolutely blown away by the audacity of some primary caregivers who announce to a woman who hits 4cm that she will go now on average 1cm per hour until she gives birth. This is just the wrong thing to say. If a woman is at 4 and looking like she's way farther along than the beginning of active labour, it might actually be a lot faster than that. I commonly see awesomely contracting first time moms go from 4 to 10 in less than 30 minutes.Telling her she still has 6 hours to go in that state is a sure fire recipe for an epidural request. A mother who is chatting happily and having really mild and far apart contractions might get her hopes up if she's told this information, only to be really discouraged 12 hours later when she's around 5cm and things are just starting to get challenging. Of course she'll doubt herself and think she needs pain relief. Also, this mom is probably going to be told she's not progressing properly and might end up in surgery unless "something" is done.

How would the practice of obstetrics change if only a woman were told, "you are doing just great where you're at" and were provided support instead of projected expectations upon something that's about as predictable as a hurricane?

If most birthing women only realized how this numerical expectation contributed to their intervention roller coaster ride and their feelings of subsequent failure that their body didn't work properly, we would create a different birth culture. If only we could harness the magnificent power of Medicine and be able to apply it in ways that didn't routinely harm birth, it would be a different world, indeed. If I had a dollar for every woman who is told "your labour is dysfunctional and your baby is in potential danger," I would be rich. I find myself in tears thinking about the amount of women who think their bodies failed them when in most cases, this was the farthest thing from the truth and they are berating the wrong party. While Medicine most certainly saves babies' and mothers' lives, and we ARE supremely grateful for those skills and the compassionate way they are usually used, it is frustratingly also the very same system who takes a perfectly beautiful, sacred, process that works well most of the time, and f***s it right up.

We don't measure rose buds with our fingers, pinning down an estimated time of blooming. We wait and trust we will eventually see them flower. Given enough time, space, love, and nourishment, most women will birth. Sure, be vigilant. But don't be frightening, making a woman feel like she's stupid and endangering her child for continuing a labour because her cervix is unfurling in its own gentle time, in its own wise way, not caring a whit about a curve.

Now this is not to say vaginal exams are never important. They have their place and appropriate usage, just like any other tool. But it is, and make no mistake about it, an intervention. It is surprising to many people to know that many midwives do NOT use this as a routine tool. There are those, bless them, who trust the woman's spontaneous progress, and that she will know when it's time to push her baby out without filling her mind up with images of swollen and damaged cervixes because she is uncontrollably bearing down without having intellectual information about whether or not she's "fully" dilated. Do you know how many women still believe they need a doctor to check inside them to tell them whether or not they have the right to push their babies out?! And others are filled with threats and fear about damaging themselves if they don't stop pushing, even if they couldn't if their lives depended on it? I have first hand experience with not having had vaginal exams in my normal births, having had a midwife who, though she would absolutely have intervened appropriately if she needed to, trusted me enough to give me the space to own my own birth and catch my own baby.

In some ways, we are still in the Dark Ages. With all our advanced knowledge and gizmos and life saving technology, we are still in our culture pig ignorant about birth and how to effectively hold it to create the best birthing outcomes. The evidence of that is in our bad birth result stats when compared to other more birth enlightened nations, and a country full of traumatized, wounded mothers, fathers, and babies. We need to do better.