Wednesday, August 05, 2009

Thoughts on Labor

I've never written about Pumpkin's birth. That is largely because labor and delivery was inconsequential when compared with all that has come after it. But now that I'm looking ahead to the birth of a second baby, I'm thinking about my first labor and delivery, and what I might do differently.

Pumpkin was born 5 days before her due date. I'd been having occasional contractions for a couple of weeks, and was already dilated to 2 or 3 cm, depending on whether it was my doctor or the nurse practitioner doing the measurement. My water broke at about noon on April 4. I was admitted to the hospital at about 2 (dilated to about 4 cm, if I remember properly), and because I am strep B positive, I was induced when active labor hadn't started by 8 p.m. I was free to walk around, but hooked up to an IV (with antibiotics- again, because I'm strep B positive). I didn't feel much like getting up and about because of all the amniotic fluid. I probably should have made more of an effort to do so, anyway.

Once I was induced, labor proceeded relatively quickly. Contractions came fast and hard, as advertised for induced labor. I got an epidural, but I think I only pushed the button to administer more drugs once. I started pushing at about midnight, and I could feel the urge to push, which had been my goal in resisting the lure of the epidural drug delivery button. I also had feeling in my legs, so the policy at the hospital I was at would have allowed me to change positions in bed. I didn't do that, though, and no one encouraged me to do so. I pushed Pumpkin out from a half sitting-half reclining position on the birthing bed.

I pushed for four hours. A doctor came in and said that if the baby didn't progress further soon, I'd have to have a C-section. This made me push harder, and after a couple more pushes, Pumpkin was down far enough that they could use the vacuum extractor to help finish the job.

I've since learned that four hours is about the cutoff for when they'll move you to a C-section, and that the doctor wasn't lying to me- I was really close to having a C-section.

I look back on this experience and am fairly happy with it, except for the part about pushing for four hours in a position that has been shown to be suboptimal for pushing. I have since learned that all beds in this hospital have squat bars, which can be put on to allow women to labor in the squatting or semi-squatting positions that use gravity to help with the pushing process. I had feeling in my legs, and could have done this. But no one suggested it. Instead, they were going to let me go and have major abdominal surgery.

This illustrates to me how badly broken our current health care system is, even for people like me, who have good health insurance and are reasonably healthy.

Some of my friends, upon hearing my birth story, tell me I should have had a doula. Maybe. But if our system is set up so that I need someone other than my doctors and nurses to help me avoid surgery, then that additional person should be a standard part of the labor and delivery process, not an extra person I have to find and pay outside of my usual payment scheme. Otherwise, there is one level of care for people wealthy enough to afford a doula (usual fees are about $700-$800 in my area) and another level of care for people who can't.

Others have said that my husband should have advocated for me. Maybe. My husband has many wonderful qualities as a labor and delivery coach, but assertiveness is never going to be one of them. Should my labor and delivery really depend that heavily on my husband's personality traits? And what happens to women who don't have a coach?

There is a lot of concern about our C-section rate (which was 31.1% in 2006, and is apparently still rising). I do not know what the "correct" C-section rate is- the WHO says about 12%, I think, but this article argues that that number is not really based on firm evidence, and that the best rate in terms of protecting both maternal and infant health may be higher. Regardless, it is pretty clear to me that I shouldn't have been as close to a C-section as I was back in 2007. The baby wasn't in distress, and there at least one other, much cheaper and frankly better option to try- namely, changing my position. As I said earlier, the hospital 's policy allows this with an epidural, as long as the patient can feel her legs and stays in the bed. They even have beds equipped to facilitate this.

So why did no one suggest I change positions? Hubby thinks it is because of liability concerns and that the C-section option is the "safer" one from the standpoint of not having a catastrophic outcome that leads to the hospital being sued. (I should point out that he has no evidence on which to base this theory. My hospital's C-section rate is about 20% and they are considered one of the more progressive hospitals in my area.)

I don't know. Maybe I had an old-school nurse who doesn't believe in using different labor positions. I saw at least three different doctors during my time in the delivery room- maybe they all assumed someone else had said something. During some recent research into what my options are for labor and delivery #2, I came across a blog post from a medical student who is going to do a study to try to find out why upright positions aren't used more during the pushing stage of labor. I wish her luck.

Anytime someone tells me that we shouldn't reform our health care system because we might "break what we have" I have to stiffle a laugh. It is already broken. The story of Pumpkin's birth is just one tiny illustration of one small way in which it is broken. If I weren't so tired tonight, I'd probably go on and on about my thoughts on the current health care debate. I'm fairly disgusted by most of the public participants, to be honest. I'll probably get disgusted enough that I come back and write up my thoughts later. In the meantime, you can read my comment on Pundit Mom's post on the issue if you're really curious about what I think!

8 comments:

  1. Wow, that's really interesting. I don't know why I enjoy reading other people's labour stories so much, it just seems fascinating.

    When my daughter was born (at home with midwife, 10 days prior to her due date, ridiculously fast labour) my instinct was to either be vertical, or on my feet leaning over the bed. At one point I had to lie down so they could check me and was immediately in agony - if I'd been forced to lie on my back I would have been begging for an epidural - and I refused to lie down again. Luckily for me I had a midwife, and she had brought a birthing stool - which means that you don't even have to be supporting yourself in a squatting position.

    I'm sitting here trying to imagine 4 hours worth of pushing - you're one brave & strong lady!

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  2. I haven't read your blog long enough to know how old your child is, so how long ago you delivered. I delivered quite awhile ago and have relatives delivering more recently. I am pleased at the progression of how maternity and infant care is different in the intervening years. It seems to be moving forward in terms of "allowing" more for the mother and better at home care, such as portable bili-lights, for baby.

    I am someone who probably should just stay out of the hospital as my labor basically stopped once I got there for both babies I bore. I found your story interesting. I think there is a lot of change that has happened and probably still needs to happen in women's healthcare especially. Good luck with figuring out the best way to make your birthing plans for your new little nugget.

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  3. @Balancing Act- my daughter is a little over 2 years old. I should put that in my "about" section.

    I don't think the "rules" have changed much since my last delivery, but I have a doctor's appointment today and a list of questions, so I guess I'll find out.

    I want to add, too (and this has nothing to do with Balancing Act's comment)- I have nothing against C-sections when they are necessary. I certainly don't buy into the idea that C-sections aren't "real" birth or any other such nonsense. I just think that in my case, I should have been encouraged to change positions well before a C-section was looking likely. And that the fact that I wasn't says something about our medical system and why we spend so much on health care.

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  4. Hey, thanks for the link!

    I was fascinated by your birth story. You know, I have read so many of them online, but reading yours while I am learning about qualitative research through my fellowship gave me an idea.

    I wrote a long reply turned post on my blog if you want to check it out.

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  5. I can't believe you pushed four 4 hours! I completely agree with you that it is a symptom of our broken health care system that no one suggested you get in a position that is KNOWN to be comfortable and efficacious for laboring.
    I did most of my laboring in a tub and then squatted next to my hospital bed during pushing. My midwife caught my son as he slid out and nearly hit the floor.
    But my urge to squat was so completely instinctive, no one suggested that I do it, it just happened when I felt the urge to push.

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  6. My labor was much like yours only that when I was admitted after my labor broke I was only one centimeter dialated. They started the pitocin and epidural shortly thereafter and my doctor said I'll see you in the morning and if you aren't dialated to ten we'll do a c-section and left. Seriously. Left the building. That was a really long 12 hours. When she came back I had thankfully dialated enough and pushing commenced and an hour later he was born but I can't say I ever got comfy with the caviler way she just said that about a c-section and left.

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  7. Anonymous2:32 PM

    That really is so typical unfortunately. I am an L&D nurse and have seen it many times where that is the only position the nurse and dr.'s seem to acknowledge exists for pushing. I really try to get pt's in different positions if their epidurals will allow it, especially if they have been pushing for awhile with no progress. You are really fortunate to not have had a C section. At my hospital 3 hrs of pushing is the "limit." I had a pt recently who was on her second hour of pushing change to a squat position. She was really bringing the baby down. As soon as her dr. came in the room she made her lie flat on her back and said that was the best position to open her pelvis. Whatever! I would encourage you at your next birth to tell your nurse up front that you would like to try some different positions pushing. I always appreciate pt's who have educated themselves on the birthing process. Good luck!

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  8. @anonymous- the funniest thing about the pushing/position issue is that when I've asked questions of my OB and his nurse practicioner to clarify hospital policy and practice before this birth, they both looked at me, surprised, and said of course I could change positions, and I should if I'm pushing unproductively for any length of time.

    And we really, really liked our labor and delivery nurse at the time. Thought she was great (and in retrospect, she did keep me from being very reclined while pushing- she put the bed pretty upright).

    So I'm not really sure what happened.

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