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Thread: Unassisted Birth
December 2nd, 2012 01:04 AM #6
I suspect my perspective will probably be heavily discounted due to being a doctor, but I'll add my 2 cents.
A. the argument against biological essentialism
simply possessing a body part does not make one an expert in its physiology, pathophysiology, or function. I have a colon and poop daily, but it doesn't make me a gastroenterologist. Likewise, I have a uterus and have successfully gestated and given birth to a child, but that in no way qualifies me to understand obstetric or medical complications of pregnancy, or fetal well-being. The notion that a woman could provide her own prenatal care or, more importantly, manage her own childbirth in the face of any-- even the most humdrum-- complication simply by 'intution' or 'women's knowledge' is just a silly as pretending to be a cardiologist because you possess a heart and know it beats correctly.
B. The argument for experience
Reading books and googling is no substitute for real education and hands-on training. Whether you're an MD or a lay midwife with no formal schooling, simply attending births, managing labors and deliveries, and seeing what can and does happen and how one handles it is absolutely invaluable. Reading your driver's ed manual is a great start to learning to drive a car, but it is no substitute for your dad taking you to the school parking lot and letting you muck around. For obstetricians and nurse-midwives, there is a very rigid credentialing process. After passing multiple examinations testing theoretical knowledge, an OB or CNM must have managed X number of normal labors, obstructed labors, precipitious births, obstetric/medical emergencies, performed X number of Csections, etc before they are even permitted to sit for the final board exam and go out into practice. When you entrust your care in the hands of someone with training, you know you're getting a certain level of competence and confidence that a lay person could absolutely never replicate.
Not actually being a layperson is no protection. Even if you're the chair of Ob/gyn at Famous Medical School, you're fairly powerless to intervene in your own labor. How will you perform a vigorous bimanual uterine massage for a PPH-- the most common postpartum complication, affecting 10% of all vaginal births- if you've fainted from blood loss? It's easy to say 'McRoberts Maneuver!' on a test when discussing nonoperative management of shoulder dystocia, but how on earth can you perform that on yourself?
C. The argument for an honest acceptance of increased risk
this is incontrovertible. Even the most ardent UC advocate accepts that not all pregnancies are healthy and not all births are uncomplicated. There are emergencies that occur that can be successfully managed with a neonatal resuscitation team, IV medications, fluids and blood products, and obstetric surgeons; without such interventions and professionals, death or longterm disability can arise. These emergencies can happen in perfectly low-risk women with uneventful pregnancies. Even if you think you've done everything you can to minimize the risk of something happening to you, even if you happily accept this risk and are willing to play the odds, you must accept that such things exist. Therefore it follows that some bad things, for mother and baby, can/will happen at home with untrained attendants, that could have been prevented or successfully managed in a hospital setting. Perhaps you are willing to accept these risks for the perceived benefits of UC or HB. But an informed decision to have a UC must involve an honest acknowledgement to yourself that it is an unnecessary risk, however miniscule you think that added risk is, and that the risk is potentially going to affect your baby, **who cannot consent to such a risk himself.**
D. The argument against Divine Protection or Naturalism
Whether or not you believe in God and are having a religiously-motivated UC, or are a naturalist who believes "we wouldn't be here if we couldn't give birth without interventions," you are misinformed. Bad things happen to very good people (or will you argue that each loss mom actually deserved it, and you're a more favored person to whom God would never cause any pain?) On more solid ground, evolution doesn't give two shits if an individual baby-- or even an individual mother-- dies. If you give birth to ten babies and four of them survive, evolution is very happy. You've doubled the species, and perhaps the four stronger, fitter children survived. 3 billion people live without access to rudimentary medical care and give birth in low-resource, intervention-free settings, often without even traditional birth attendants. Population growth is still on the upswing in most of these places, but you do not want their birth/neonatal outcomes!
E. The argument discrediting the supposed safety net
this is the most important thing I want to say, because it's not often thought about. If you throw out all of the above as Evil Doctor Wanting to Control Womens' Bodies above, please think strongly about this.
"5 minutes to a hospital" is NOT ENOUGH TIME.
By the time you-- in the middle of the pain and physical exhaustion of birth-- have successfully diagnosed a problem and think you need to transfer to a hospital, it's too late.
It is an incontrovertible fact, not open to interpretation or bias, that a baby will experience some degree of permanent neurological damage within 7 minutes of hypoxia. You have 7 minutes from the time of detection of fetal distress until you get the baby safely out. Pretend you're at your UC. Perhaps you're intermittently checking your fetal heart tones with a stethoscope every, say, 15 min. You think it's slowed or stopped. You grunt through a couple more contractions and listen again. Yup, 80s. Got to transfer! The clock is ticking!!
You call 911. The ambulance arrives in 5 minutes, very fast. They load you up on the gurney, get you into the rig. 5 more minutes if you're ready to go. They drive to the hospital-- 3 minutes, very fast! You arrive and they unload you. You are seen immediately by triage and rushed back, where EFMs are placed-- 5 minutes. An IV is started. The diagnosis is confirmed by the ER doctor, who immediately pages obstetrics (let's pretend you're lucky and it's a big hospital with an OB in house 24/7, as opposed to a smaller community place where they have to drive in). OB get to the ED in 5 minutes-- very fast. She agrees-- fetal demise imminent, need a stat section: 2 min. The procedure is explained and consent is obtained (2 min). You are registered with the hospital and rudimentary labs are drawn, including the mandatory Type & Screen in case you need a transfusion (ultra-fast nurses: 2min). You are rushed to the obstetric operating room and make it in record time-- 2 min. You are intubated by the anesthesiologist (epidural placement takes 15min, no way, this is under general anesthesia), your abdomen is prepped and draped (5 min). The obstetrician is in the uterus in 30s. Baby is out.
How long was that-- this magical situation with no delays? 36:30.
Just keep that number in mind, please, whenever you feel reassured that you're "5 min from a hospital" or "10 min away if you need to transfer." Obviously not everything represents life-threatening ischemia, but the range of complications you'll be able to diagnose in a timely fashion while UC'ing is basically nil.
F. Some thought experiments
As a doula student, have you attended many births yet? Have you seen anything go wrong?
The umbilical cord can be anywhere at the end of pregnancy with a healthy, vigorous baby. It could well be nuchal, bunched above Baby's head, anywhere. You have your hand-held little doppler in your bedroom, you're picking up ominous long decels-- what could you possibly do to move the cord that's still inside your uterus out of the way of the baby who is also inside your uterus? Without fetal monitoring, how will you know there's a problem at all?
What if you have early placental detachment, or you're postdates and your placenta has somewhat calcified? Baby's oxygen supply is being cut off. Can you hold your placenta in place? Can you force it to re-implant back into your uterine wall to give your baby oxygen until he is born?
You have a breech baby (3% fullterm babies are breech). You're philosophically committed to the notion of homebirth and UC and decide to take your chances. Your chances turn out to be against you-- you, a primigravida with an unproven pelvis, have delivered the smaller body of your baby but can't deliver the fetal head. Head is entrapped. What do you do?
Your baby comes out at the end of a long labor and isn't breathing. The cord has stopped pulsing. Baby is blue and still, but you feel a heartbeat. What do you do?
You're GBS positive, like 25% of women, but didn't know it because you didn't seek prenatal care with anyone capable of diagnosing it or prescribing medications for it. You give birth to your healthy baby vaginally and cuddle with him for a few hours. Within a few hours your baby has increasing difficulty breathing and cannot breastfeed. He has a fever of 100. He begins to seize from hypoxia. What do you do?
You're a primigravida and since you're UC'ing, you don't have anyone assisting you with even gently slowing the baby's descent. You sustain third-degree vaginal tears through musculature (relatively common) as a result. How would you diagnose them? How would you repair them to prevent long-term disability, infection and anogenital malformation?
Your placenta is a bit difficult to separate at the end of birth. Finally you deliver it with gentle cord traction and notice immediately that it's jagged in appearance, and some fragments have surely been retained. In short order you begin to hemorrhage while holding your baby. What do you do?
Last edited by blade; December 2nd, 2012 at 01:37 AM.Blade, MD
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December 2nd, 2012 05:43 PM #8
My friend gave birth in her car en route, but it was an EXTREMELY rare case where a first time mother went into labor and had her baby 1 1/2 hours later. I personally would be very uncomfortable with and unwilling to take on the risks of an unassisted birth. I have no problem with a low-risk woman choosing to birth her baby at home, but I don't see the benefit of not having a midwife attend.
December 2nd, 2012 09:41 PM #10Senior Member
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- Flyover Territory
Not for me. I can totally understand doing an HB with an attending MW and crew, due to a pretty crappy hospital experience with my first (damn those grabby nurses!). However, all of the things that blade mentioned can and DO happen to women all.the.time. With a UC, you don't even have an MW to assess baby's level of distress and get you to the hospital right away (and obviously there is the "5 minutes away" not-so-perfect scenario mentioned above. I just don't get the point of not having someone who is truly experienced attending your birth. Even indigenous people usually have midwives or some equivalent.
That said, it certainly can't hurt to read up as much as possible on UC in case you find yourself in an emergency "baby hanging out" type situation! Personally, I was 6+ cm when I moseyed into L&D with DD and had NO IDEA I WAS IN LABOR (I chalk it up to having intense and incessant BH from about 25 weeks on). I was only there because I hadn't felt her move much that morning and was getting concerned. I have a feeling DH will be wanting to work from home from 36 weeks on with me next time around, for fear I'll be having my own unintentional UC
Last edited by tk.; December 2nd, 2012 at 09:43 PM.Tara, proud mama to a Honey Badger
... and a Badger in Training
December 2nd, 2012 10:44 PM #12
I agree, it's not a bad idea to know as much as possible. There was a woman in my area recently that had her baby at a bus stop and a grad student with her toddler in tow had to help. I don't know if she was taking the bus to the hospital or had no idea she was even having the baby--the article didn't specify. While it's an unlikely situation, it does happen from time to time.
December 2nd, 2012 11:30 PM #14
Thanks for the thorough reply, although I do find your "evil doctor" remark a little condescending. I wasn't really wondering about the risks since I am ready fully aware of them. I was wondering more about the experiences of people who have had a UC. I'm trying to decide if I would be willing to attend one or not. I already know tht I am not willing to attend a birth if the mother has received no formal prenatal care seeing as that is completely irresponsible and quite frankly, insane IMO. I have a question, have you ever heard an incidence of a woman having a UC within the walls of a hospital or birth center? By that I mean 0 interventions and self delivery with a nurse in attendance in case things head south and interventions are absolutely necessary. This would be a good option for me to offer clients who are interested in UC.