Safe Motherhood, pt. 2

The following is taken from the World Health Organization’s report on Safe Motherhood, Care in Normal Birth: a practical guide. There are a couple of introductory pages and about fifteen pages of references, and the remainder of the 57 pages of this pdf file are devoted to a discussion of the typical practices in birth around the world, finally dividing them into one of four categories: 1) practices which are demonstrably useful; 2) practices which are clearly harmful; 3) practices for which insufficient evidence exists; and 4) practices which are frequently used inappropriately. They arrived at these conclusions from studying birth practices around the world (from the high-tech U.S. to the impoverished third-world countries), citing a plethora of published research along the way. This document is pretty “meaty” or “heavy” reading, but quite understandable. Some of the practices (like using sterile instruments) are obviously always done in the U.S., but other countries need to improve on them. I would encourage you to read the full document, especially to see how they arrive at some of the following conclusions (the numbers at the end of each point correspond to the discussion sections in the document, and they are in chronological order–pregnancy, first stage of labor, second stage of labor, etc.). This discussion is for normal labor with normal women; there are things that could make a woman high-risk during pregnancy, or things that happen during labor that would change the “risk category”. But this is for most of the women in the world. (I will put italicized explanatory notes on some of these; and I will emphasize certain words from the original in bold.) This is part two.

6.2 Practices which are Clearly Harmful or Ineffective and Should be Eliminated

[Several of these practices are common in U.S. hospitals, so if you’re one of the 99% of women who are planning a hospital birth, it would be beneficial to discuss these with your doctor or midwife now, to see if you are going to be subjected to a practice which is “clearly harmful or ineffective.”]

1. Routine use of enema (2.2). [This used to be standard in U.S. hospitals, and some still do it.]

2. Routine use of pubic shaving (2.2). [This used to be standard in U.S. hospitals, and some still do it.]

3. Routine intravenous infusion in labour (2.3). [Since getting an IV is standard in U.S. hospitals today, I strongly encourage you to read the corresponding section in the full WHO document.]

4. Routine prophylactic insertion of intravenous cannula (2.3). [This may also be called a “Heplock”; it’s essentially an IV inserted into your hand, but not set up to a bag of fluids with the IV pole. It is capped off so germs can’t enter your bloodstream, but allows a quick access to a vein should an emergency arise. Most hospitals require either this or the full IV. The WHO document says that this “invites unnecessary interventions.”]

5. Routine use of the supine position during labour (3.2, 4.6). [In case you are unfamiliar with the term, “supine” simply means lying down on your back. (As an interesting aside, the dictionary includes this definition for the word: “failing to act: utterly passive or inactive, especially in a situation where a vigorous reaction is called for.”) Since most U.S. hospitals require you to lie down in the bed for most or all of your labor, I strongly encourage you to read these sections of the WHO document–3.2 covers first-stage labor (dilation), while 4.6 covers second-stage labor (pushing). And here is a link for some alternative labor and birth positions.]

6. Rectal examination (3.3). [Used as an alternative to vaginal exam in some countries, in an attempt to avoid vaginal/uterine infection.]

7. Use of X-ray pelvimetry (3.4). [The use of X-rays to determine if a woman’s pelvis is “adequate” to give birth. The practice of “pelvimetry”–attempting to measure a pelvis to see if the woman’s body grew a baby too big for her to birth–infuriates me more than just about anything else, because it instills in women fear and mistrust of their own bodies. Plus, it’s notoriously inaccurate! In cases of women who had childhood diseases that stunted their growth, and specifically the growth of their pelvis, then perhaps pelvimetry is useful; but most normal, healthy, American women will be able to birth their own babies, thank you very much. And using X-rays increases the risk of childhood leukemia.]

8. Administration of oxytocics at any time before delivery in such a way that their effect cannot be controlled (3.5). [Again, from the WHO document, ” This (giving oxytocin/Pitocin/”Pit” only in “facilities where there is immediate access to a C-section should the need arise”) is a reasonable precaution, given the unpredictable nature of artificially managed labour.”]

9. Routine use of lithotomy position with or without stirrups during labour (4.6). [“Lithotomy” is lying on your back, with your legs open and knees flexed. It is for the doctor’s benefit only, so he doesn’t have to assume any awkward position while he’s working. The fact that you’re doing all of the work in an extremely unnatural and awkward position doesn’t seem to matter. This is another of my pet peeves, can you tell?]

10. Sustained, directed bearing down efforts (Valsalva manoeuvre) during the second stage of labour (4.4). [Otherwise known as what you see on all the birthing shows–“Okay, here’s the contraction, hold your breath and PUSH, 1….2…..3……..8….9….10. Take a quick breath, OK, AGAIN……. AGAIN!!!”–also called “purple pushing” because most moms get blue in the face from the lack of oxygen. Imagine what it’s doing to the baby. Typically, they try to get the mom to push three sustained times each contraction; all this while holding her breath, and taking a quick breath between each loooooong push. Pregnant or not, I would suggest as an interesting and informative exercise to assume the lithotomy position on your couch, and hold your breath (don’t worry about pushing) while somebody is in your face yelling at you to push while counting slowly to ten….three times in a row. I just did it and feel out of breath, dizzy, and light-headed, and that was just for one “contraction”; now multiply that experience by doing that every few minutes for an hour. You can try a variety of positions–even just right now, sitting at your computer desk, hold your breath like that and see how you feel.]

11. Massaging and stretching the perineum during the second stage of labour (4.7). [Many midwives and doctors will massage the lower vagina and surrounding tissues to attempt to keep the woman from tearing. While there is evidence to suggest that perineal massage done in the latter part of pregnancy will reduce the incidence of tearing during birth, massage done while the woman is pushing does not seem to help.]

12. Use of oral tablets of ergometrine in the third stage of labour to prevent or control haemorrhage (5.2, 5.4). [Not usually done in U.S. hospitals.]

13. Routine use of parenteral ergometrine in the third stage of labour (5.2). [Not usually done in U.S. hospitals.]

14. Routine lavage of the uterus after delivery (5.7). [Not usually done in U.S. hospitals.]

15. Routine revision (manual exploration) of the uterus after delivery (5.7). [May be standard in some hospitals. According to the 2002 “Listening to Mothers Survey” by the Maternity Center Association, 58% of all women had a “gloved hand inserted into their uterus after birth.” While this is beneficial if part of the placenta is missing, and this is how doctors will check to make sure a C-section scar didn’t give way during labor, the WHO report states, “There is not the slightest evidence that such a policy is useful; on the contrary, it can cause infection or mechanical trauma or even shock.”]

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