Interventions in birth

“The first intervention in natural childbirth is the one that a healthy woman does herself
when she walks out the front door of her own home in labor.”
Michael Rosenthal, OB/GYN

This quote is an attention grabber and one that should set us all to thinking. We know about the “cascade of interventions” that sends most North American births down a tunnel of medical mishaps– strip membranes, Pitocin gel induction, continuous fetal heart monitoring, pain medications, distress in the infant, cesarean, post-surgical infection, breastfeeding problems, postpartum depression, etc., etc., etc. Iatrogenic meddlesomeness at its most blatant is easy to spot and condemn.
We like to shake our heads, point our fingers and tut-tut-tut about this type of intervention.
But what of the interventions that we don’t see, the ones we are guilty of ourselves? The Oxford dictionary defines intervene:

“to interfere, modify course or result of events.”

Something that seems as small as turning on a light could be classified as “an intervention.” Is it an intervention to wear perfume to a birth? To monitor the heartbeat of the baby every half-hour? To leave a clock within the mother’s view? To watch the mother? To speak to the mother?
To ask her to take a walk outside? To tell her husband to get in the water tub with her? Do midwives take any time at all to ask themselves these questions?
What would “the course of events” be like if we weren’t there? How could we possibly know?
Recently I came into possession of an amazing video. This video is the raw home movie footage of the births that are shown in the unassisted birth film” A Clear Road to Birth”. There is no attendant present at the births.
The families have, for the most part, just put the video camera on a tripod and let it run. The result is an amazing view into a place that I have never been privileged to enter–a birth that follows the natural course of events.
I found it difficult to watch because it is so very intimate, and I wasn’t sure that they’d want me to ogle their beautiful, private family moments. It is a sacred film. I came away from it with questions about how my presence at a birth affects the behavior of all the participants. The women on this film are not asking, “How much longer will it be?”
They are not saying, “I can’t do it anymore.” There is no illusion or possibility of some other woman “saving” them.
They are going to do it themselves, and they seem to have an inner core of resolve about it. Their husbands and children mostly seem “surprised” that the baby is really there. This is unlike births where there is an “expert” present, and the waiting and watching seem to go on forever.
This film of unattended births leads me to question,

“What about women who have unassisted prenatal care?”

We are told that prenatal care is essential. We believe it is a cornerstone of good maternal/natal health.
But is this true? Are there interventions that take place in childbirth classes that are subtle and affect the course of events? If we think of the spoken word as “an intervention,” we must wonder if we are causing changes in the course of the birth long before the membranes release. I cringe at some of the “meddlesome midwifery messages” that women are given at prenatal checkups. Messages can be imparted both verbally and nonverbally. I remember when I took prenatal classes 25 years ago, the nurse managed to impart the message that she didn’t approve of breastfeeding with just the look on her face when she said, “How many of you are planning to breastfeed?”. Her attitude changed the course of events for a lot of the women in that class. It was absolutely an intervention.
I have learned a lot about how to question my own interference in birth from listening to Michel Odent. His message is repeated over and over: “The most important thing is do not disturb the birthing mother.” What does a nice midwife do that would disturb? Several years ago, I went to a birth as assistant to the midwife. I was assigned to take a video of the birth and so I familiarized myself with the family’s camera and began to do a little filming of the mother while she was in the water tub. I was getting some nice footage when, all of a sudden, the room went completely black, and I couldn’t get an image in the camera. I looked up to see what had happened: the brother-in-law of the birthing mother had turned out the lights. I went over and turned them back on so I could get on with filming and, presently, the man came back and turned them out again! I was very annoyed and, in that moment, I realized that he was right! He was more in tune with what his sister-in-law needed than I was. Birth seems to flow best for human beings in the same conditions as most other mammals. Darkness, familiar smells, privacy and quiet are the main ingredients for a smooth birth.
Who in North America can give these simple things to a birthing mother? Are we willing to trade monitoring and charting for births that truly flow along smoothly? Are we willing to sit, out of view of the woman, completely still while she focuses inward and makes her own journey to meeting her child? Can we forgo the acknowledgement and appreciation for all we “do” and be deeply satisfied with “being” unobtrusive?

… I believe that the “3 Ps” of obstetrics should be “patience, patience, patience” and not “passage, passenger and powers.”
I am fond of the Buddhist words from

    The Tao of Leadership

:

Being a Midwife

Remember that you are facilitating another person’s process. It is not your process. Do not intrude. Do not control.
Do not force your own needs and insights into the foreground. If you do not trust a person’s process, that person will not trust you. Imagine that you are a midwife; you are assisting at someone else’s birth. Do good without show or fuss.
Facilitate what is happening rather than what you think ought to be happening. If you must take the lead, lead so that the mother is helped, yet still free and in charge. When the baby is born, the mother will rightly say: “We did it ourselves!”

–The Tao of Leadership by John Heider

This is an exerpt from an article originally published in Midwifery Today (22 September 2002).

13 thoughts on “Interventions in birth

  1. as a UP/UC mom, i am always greatly appreciative of those who not only don’t immediately fly off the handle when presented with the concept, but look closer, and question their own preconditioned ideas of what birth should be. i have the utmost respect for you, gloria. thank you for writing this post.

  2. Gloria I have also been strongly influenced in the past decade or so by Michel Odent’s teaching about not disturbing the labouring woman.

    The camera is one of the most insidious and unrecognised disruptions in spontaneous birthing.

    I am very concerned about the growing trend to unattended birth. I think our society will be poorer, and our mothers and babies not well served, if we lose the skill of midwifery, which is so beautifully described by Tao Te Ching.

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  4. So much here to learn from. I can’t imagine that there are many midwives who wouldn’t be properly chastened after reading this.

  5. I had a UP from 20 weeks and UC with my first child in May. It was a long journey to get there and most of the trip was made by my husband, not me. There was just something in the depths of my soul (I guess that would be instinct) that told me this was supposed to be private and calm, in a familiar environment.

    When I decided to stop having prenatal care it was because my GP had first used my trust in him to tell me I should have an ultrasound when I felt it might be dangerous (something I very much regret) an then called me to tell me the images of our baby’s mouth were not clear. When I said I wasn’t concerned about cleft lip and we would cross that bridge if we came to it, he bold-face lied and told me it was important to know as babies with cleft lips often needed resuscitation! I was so infuriated, I vowed not to go back. My husband, though, was not so easily convinced. I finally got through to him by explaining that I just couldn’t trust my body and baby if the constant message I was receiving was that no one else did. How could I grow a healthy baby when I was being checked and tested and told I was faulty at every turn? The decision to continue with an UP was freeing in a way I can never describe with words.

    As for our UC, your words above are beautiful: “I found it difficult to watch because it is so very intimate, and I wasn’t sure that they’d want me to ogle their beautiful, private family moments… The women on this film are not asking, “How much longer will it be?” They are not saying, “I can’t do it anymore.” There is no illusion or possibility of some other woman “saving” them. They are going to do it themselves, and they seem to have an inner core of resolve about it… This is unlike births where there is an “expert” present, and the waiting and watching seem to go on forever.”

    Our UC was very much like this. I had no idea how much time had transpired, I wasn’t asking anyone else for direction or trusting them to ‘save’ me but only taking one rush at a time, slowly working with my body and baby to birth him into this world.

    Last night I was watching a video of an expected breech homebirth turned surprise vertex that many women had said was ’empowering’ and ‘beautiful’ (http://www.youtube.com/watch?v=jMAzrLSz4lI). Neither of those words crossed my mind when watching and a few choice other words did but I digress. My husband came in and asked what I was watching. I said it was a birth video and he asked why I would want to watch *that*. I asked what he meant and he said, “Well, you hate watching hospital births.” He’s right, they make me very anxious – bordering on panic – I want to rescue the women so I never watch them. I laughed and said it wasn’t a hospital birth but a homebirth with a midwife and he said, “Well, I’m glad we didn’t have one of those, either, then. Ours was so much more special. I can’t imagine having had strangers there.”

    • Wow Amy, I wish I’d had your courage. At eight months preggers with my first Gloria convinced me to leave my OB, because she was stressing me out with all her tests (which had perfect results). She told me that my baby would be “abnormally small” because my fundal height was small. Thankfully I listened to Glo and trusted my body and birthed a healthy 8 pound 7 ounce baby.

      The second time around I rarely went to my MW appointments, but still found them to be a waste of time. It also gave my MW the opportunity to bully me into unnecessary ultrasounds. Wish I lived closer to Glo.

  6. Joy we already lost that approach to midwifery. Why do you think more women are choosing autonomous birth and eschewing the external careprovider? But then again our greatgrandmothers birthed with their sisters and mothers in attendance and no one criticised them for it or called it “unattended”. It was just called birth then. Surely xmas time is the perfect time to remember all the freebirthers throughout history?

    A lot of midwives and birthworkers could use this kind of fearless reflection. “What do I add to this birth?” is a question we all need to ask ourselves when we are privileged enough to attend a birth. “Am I really needed here?” is another. Being concerned about the loss of midwifery when women are already telling us it’s gone, is really worrying about the horse too late down the track. Women can’t turn the tide of midwifery, midwives can though. I invite you to give it a go.

  7. I’ve had two wonderful midwife attended hospital deliveries, and as perfect as they were for me, I know that for some women that would have been way too much intervention. I’m amazed to hear a birth worker take the time to ask these questions that more people in the “birth industry” should be asking. My sister, after being induced 4 times in the last 7 days has just been told that her due date was incorrectly calculated . . . please come back on the 26th, unless you go into labour on your own! I highly doubt her OB ever thought about how his interventions might be adversely effecting her labour, or her ability to even go into labour on her own before she hits his new deadline!

    I am however greatly concerned by the trend toward truly unattended birth. I have a friend who delivered her frank breech baby at home with just her husband and 3 small children under 6. I know it was the right choice for her to birth without a birth professional – she is the “expert” of what her body does in labour, but I was terrified about what might have happened in that home if there were complications. Who would watch the children, who would catch the baby if she needed additional support from her husband through her labour as I did through mine.

    When we birth with our mothers and sisters we are not birthing alone. We are asking trusted members of our family/friends to support us by being near, by being available when the need arises. In days past women who birthed without doctors had their whole community to rely on if they needed them. How many of us could count on our neighbours if we needed them in and emergency? Could most of us name 5 people in walking distance that would drop everything to care for our children?
    If it takes a village to raise a child, might it not require a small team to support a birth? albeit a quite team that sits on the sideline until and unless needed?

    I too am concerned about the loss of midwifery, I think that leaving birth to mothers and doctors with no middle ground for birth support is a scary way to go. I know I would not have wanted to go through my pregnancies with a dr. but I know far too many women who would not be strong enough to choose to birth alone, if that was the only other choice.

  8. I have had three births. The first two were typical medically managed births, the third was a natural Bradley birth, in the hospital which I felt afterwards was still too medically managed. My next birth will be at home. I plan on hiring a midwife who I already trust to be hands off. If the midwife I want is not available, then I would really have to think long and hard about whether I want to trust a different one or go it “alone”. But we certainly would not be alone. We would make sure we had trusted and experienced friends who would leave well enough alone, but be there if wanted.

  9. Ok, that got garbled in my copy and pasting. Let me try again.
    I agree with Megan. I think it was valuable to women that they had mothers and sisters who were experienced supporting them during birth. Most of us are not so lucky to have many, if any, relatives who have experienced truly natural birth let alone home birth. In fact I am the only woman I know in my family who has given birth in the U.S. since I have been born. I’m adopted, my mother has never given.birth. My grandmothers are gone. I just have no family to turn to for birth support. My mom freaked out about me giving birth in a natural birth center inside a labor and delivery ward of a hospital. She thought even that was too risky.There is no way I am even telling her that I am planning a homebirth.

  10. I LOVE this. After 3 disappointing hospital births, I became an unassisted home birther. I had spent 15 years being a birth nerd, reading and re-reading Varney’s Midwifery and studying placenta anomalies for fun. More importantly, I had spent time reading texts from homebirth midwifes who trusted birth. These women confirmed what I had always suspected: that no one needs to tell the mother when to push. We will not hurt our selves by following our birthing instincts! So there I was, in my bath tub, the lights turned out, free to spiral my hips, to make long drawn out moaning sounds, to find the way to ride each wave, to PUSH OR NOT TO PUSH AS I FELT THE URGE. And it was a beautiful birth! The baby was malpositioned, and OP for much of the time… and it was more difficult than the the last 2 births…. but it was done MY way with no interference and I was totally free to trust my body. I can not even tell you how wonderous, how amazing, what a difference it made to be with my family who had complete trust in me and my ability to birth. If I HAD had a midwife, I could imagine her sitting downstairs reading a book or knitting…. making her loving presence felt, but trusting me and my body and the process of birth.

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