Ina May's Guide to Childbirth

date Sep 7, 2019
authors Ina May Gaskin
reading time 20 mins

My thoughts:

I read this book and was so prepared for an unmedicated natural birth. But the opposite happened with induced labour, epidural and emergency cesarean. Be kind to yourself. All’s well that ends well :) I survived, the baby is damn well and I recovered physically and mentally a year later.

Birth interventions

A safe birth without any interventions

The woman who gives birth without interventions, on the other hand, is more apt to be through with pain when her baby is born. Often, she is euphoric, buoyed on the hormones released after the birth of the baby. Oxytocin, the love hormone, is released with the final stretch of the perineum around the baby’s head and body, a pleasant sensation for most women.

Modern thinking about birth

3 Ps: Passenger, Passage, Power

most U.S. women and virtually all obstetricians believe in a set of assumptions that obstetricians call the “Law of the Three Ps.” The Three Ps are the Passenger (the baby), the Passage (the pelvis and vagina), and the Powers (the strength of uterine contractions).

The problem with the 3Ps

The problem with the Law of the Three Ps is that it ignores the considerable evidence demonstrating the importance of emotional, psychological, and spiritual aspects of birth. This leaves many physicians thinking that a large percentage of U.S. women are born with some deficiency that prevents them from giving birth without enormous technological intervention, when in fact almost all would be able to give birth given the right care and circumstances.

Sphincter Law

THE BASICS OF SPHINCTER LAW: Excretory, cervical, and vaginal

  • They function best in an atmosphere of intimacy and privacy
  • They cannot be opened at will and do not respond well to commands
  • They may suddenly close down if that person becomes upset, frightened, humiliated, or self-conscious
  • The state of relaxation of the mouth and jaw is directly correlated to the ability of the cervix, the vagina, and the anus to open to full capacity
  • Laughter Helps Open the Sphincters
  • Slow, Deep Breathing Aids the Opening of Sphincters
  • Deep abdominal breathing causes a general relaxation of the muscles of the body, especially muscles of the pelvic floor
  • Immersion in a warm-water bath can also be very calming to a laboring mother

Pushing will take place naturally

It is a fairly common practice in hospitals in most of the industrialized world for laboring women to be strenuously commanded to push once they reach full dilation. Such commands are often given without the awareness that, in most cases, the urge to push will arise spontaneously in the mother. Pushing will take place without the mother requiring someone to shout at her when and how to do it.

What helps: changing positions, walking, eating, being upright

Nowadays, of course, it is possible to restart or to intensify labor with synthetic oxytocic drugs delivered intravenously. This may be convenient when truly necessary, but intravenous drugs used to keep women in labor also prevent them from moving around freely and cause more painful contractions. Changing positions, walking, being nourished, and being upright during labor are hugely important to women’s ability to give birth under their own power.

Blowing raspberries

This is called “horse lips” or “blowing raspberries.” When a person totally relaxes the lips and blows a good amount of air through them at considerable pressure, softly flapping them together in the process, it is reminiscent of the soft, lip-flapping sound that horses make. I find that when women in labor attempt to make this sound (even if they don’t quite succeed), it significantly relaxes their mouth, throat, and, at the same time, their bottom (cervix and perineum).

Midwifery

Midwifery

midwifery model of care is female-centered. Within it, birth is something that women do—not something that happens to them. The birth-giving woman is the central agent in the ancient drama of life bringing forth new life. The midwifery model of care recognizes the essential oneness of mind and body and the power of women in the creation of new life.

Nutrition and companionship

The midwifery model of care recognizes the importance of good nutrition as the best way to prevent the most common complications of pregnancy. It emphasizes the importance of companionship and encouragement during labor as a way to minimize technological intervention in the birth process.

Progressing labour and medical intervention when required

A laboring woman may move around freely, drink, eat, and be sexually playful with her partner within this model (if that is what best stimulates her labor). All of these activities help labor to progress. The midwifery model of maternity care, of course, recognizes that medical intervention is sometimes necessary and that it should be applied in these particular cases.

Techno-centric birth

Pregnancy and labor are seen as illnesses, which, in order not to be harmful to mother or baby, must be treated with drugs and medical equipment. Within the techno-medical model of birth, some medical intervention is considered necessary for every birth, and birth is safe only in retrospect. According to this model, once labor starts, birth must take place within twenty-four hours.

Baby’s heads down but facing front (OP)

During the last weeks of pregnancy, his head has pressed against mother’s cervix, helping to make it soft and pliable even before labor begins. This development is less likely to happen when the baby is in the occiput posterior (OP) position, which means that the back of baby’s head (occiput) is near mother’s back (posterior).

Labour

First birth and labour

If this is your first labor, you have no reference point for how intense labor must become before your cervix is dilating more than a tiny bit. You may lean toward traveling to your birthplace-to-be as early in labor as possible—if you like things being organized. Who wants to give birth in a car?

Progressing through labour at home by napping

It may help to know that labor often starts and stops a time or two before it becomes powerful enough to complete the birth process. This situation is most likely to happen in the early or latent phase of labor. If you think you are in labor and it’s late in the day, try taking a warm bath, drinking a glass of wine, and going to bed for a while. You may be able to take a nap before labor becomes intense. This is a good thing, as it reduces the likelihood of a stalled labor once you get to the hospital, it conserves your energy, and you may even make some real progress in labor as you doze.

Cons of induction

Let us not forget that induced patients are usually continuously monitored, have a higher epidural utilization rate than natural onset, have IVs running, and are basically confined to the bed. This is not natural. After twenty-six years, I have noticed that persistent occiput posterior presentations and C-sections for failure to progress are much higher in the women who get early epidurals than in the ones who move about.

Labour and pushing

She must remember that natural labor onset always wins. That letting her body do its job gives time for natural endorphins to control her pain. That she needs to move during labor. Get up, walk, labor in the tub or shower, or on a ball. Labor and push in a position that is comfortable rather than convenient. Know about intermittent monitoring, not having a running IV, and being allowed nourishment.

Induced labour

More pain in chemically induced labour

Women tend to have harsher, stronger, significantly more painful contractions with chemically induced labors, so one who can cope with a spontaneous labor often finds that she needs pain medication to bear the more insistent contractions of an induced one. There is no shame in needing pain medication in a chemically induced labor.

Higher fetal distress in induced labour

when induction is purely elective, there is a higher incidence of fetal distress than in labors that begin spontaneously. Oxytocin and prostaglandin inductions, the most common methods in use, are well known to cause longer, more intense uterine contractions, sometimes to the point of interfering with the flow of oxygen-rich blood from the placenta to the baby.

Cons of oxytocin-induced labour

An oxytocin-induced labor is twice as likely as a spontaneous labor to result in an instrumental delivery or a cesarean section, usually because of fetal distress stemming from harder, longer uterine contractions that interfere with the flow of oxygen-rich blood from mother to baby.

Fetal distress

Intermittent baby’s heart rate checking is better

Continuous EFM may be routine at many hospitals, but good evidence that it should be mandatory is lacking. We know that it slows labor, increases the incidence of fetal distress, increases pain, makes it harder to refuse vaginal exams, and forces the uterus to work against gravity. For all these reasons, it’s good to stay on your feet and insist on intermittent checks of your baby’s heart rate.

Food and drinking during labour

If you have a labor lasting more than five or six hours, you may get hungry. Lots of women want to drink or eat in labor, but many hospitals try to restrict eating and drinking once you have been admitted. The reasons for this are historic, not scientific. The fear is that if a woman should need a cesarean under general anesthesia (which is not likely to be used anymore), she might vomit and inhale some of the vomit into her lungs while unconscious.

IV instead of food and drinks

Hospitals that try to keep women from eating and drinking during labor generally want every woman to receive IV fluids. Large volumes of IV fluids can cause respiratory distress and seizures in newborns, because they cause low blood sugar and low blood sodium.

Moving around

Moving with tools

You may want to sit on your partner’s lap, a birth stool, a birth ball, or the toilet. Maybe you’ll feel like dancing. Slow dancing, figure-eight belly dance moves, the hula — all of these may help your baby find the best exit.

Common positions for birth

The labor postures common to traditional women’s cultures all over the world include sitting, kneeling, standing, squatting, or the hands-and-knees position.

When did lie on backs position start?

In 1668, François Mauriceau published a treatise on midwifery that recommended that women lie on their backs for giving birth. This recommendation was made for the benefit of the physician or man-midwife who might want to use forceps, not for the benefit of the laboring woman herself.

Medicated pain relief

Nitrous oxide

Nitrous oxide combinations have been used in Britain for many years to dull labor pain, in both hospital and home births. Women inhale the gas through a mask they hold tightly to their nose and mouth during the peak of a contraction. The effects are immediate and short-lived. No obvious side effects have been found in babies. A disadvantage of this method is that it takes a certain amount of effort to show the woman how to use the mask effectively, and some women don’t like the mask.

Epidural

Epidural anesthesia does have several side effects: Sometimes it causes a dramatic drop in blood pressure, which can put both mother and baby at risk

  • In about one woman in every five, the epidural causes a fever
  • Epidurals don’t always work. Even when the epidural is given correctly, it does not provide pain relief in about 3 percent of women.
  • Babies whose mothers have had epidurals sometimes have breathing difficulties and a difficult time establishing breast-feeding
  • Very rarely (one in 5,000 cases or so), an epidural can result in a maternal death or permanent paralysis.

General anesthesia

General anesthesia was once the preferred form of obstetric anesthesia, but it was abandoned, for the most part, when the epidural came on the scene. General anesthesia has a comparatively high hazard of producing breathing difficulties in babies.

Preparing for unmedicated birth

There are many good reasons for choosing to give birth in a hospital. That choice is yours. Maybe you are sure that you will feel safer about giving birth in a hospital, but you want to maximize your chances of having an unmedicated labor and birth experience. I have some suggestions.

  • Doula
  • Drink and pee
  • Using warm water bath
  • Darken lights
  • Massages
  • Meditation

Birth

Babies head advancing and receding slightly

It may help you to know that first babies’ heads normally advance toward birth during a push and then recede once that push is over. Women who don’t understand this process sometimes think that they are going backward when the baby’s head recedes between pushes. I explain then that this process is good, because it helps the vulva gradually attain the size necessary for birth. Circulation to the area increases with the alternate stimuli of pressure, release, pressure, release.

Baby lying on the belly

Many new mothers like the feeling of the baby lying belly-to-belly with them; this works well especially when the cord is relatively short. Don’t worry if there’s a thin layer of cloth between you. A warm blanket over the baby is all that’s necessary while you are cuddling your newborn.

Placenta ejection

My observation is that the stimulation provided by the baby’s movements triggers good uterine contractions, exactly what is needed for timely detachment of the placenta from the uterine wall.

Keeping the baby warm

There will be an effort to keep your baby warm. Hospitals are sometimes rather chilly places, and wet newborns (they never arrive dry!) can quickly lose body heat. A nice place for your baby to land is your abdomen or chest, to be covered with a warmed receiving blanket.

In case holding the newborn is not possible!

Don’t worry about bonding with your baby (and forgive yourself if you do turn to worrying!)—that you missed something irretrievable in that hour or two just after birth when you were not able to hold and cuddle your baby. Life will be full of opportunities ahead for you to gain the feeling of full connection with your little one.

After the birth

Plan to rest on bed!

Plan to spend most of your time on your bed with your new baby. Why? You need to take it easy, that’s why. Your internal organs are rearranging themselves, as you make the transition between pregnancy and fresh motherhood.

Take time for the transition

Stay close to home, don’t entertain, and rest. This is your best way to prevent extra bleeding and the emotional-physical crash that often follows being up and around too early. There are lots of good reasons why traditional cultures all over the world respect the need for new mothers to take some time to allow their bodies to make the transition from pregnancy to new motherhood.

Postpartum depression

Postpartum depression (PPD) occurs in as many as 20 to 30 percent of mothers in the United States. My observation is that the incidence is far less in societies in which there is greater social support for new parents. Typical symptoms include feelings of guilt, hopelessness, and despair, insomnia, difficulty focusing, feelings of inadequacy, irrational concern about the baby’s well-being, nightmares, and persistent thoughts of hurting oneself or the baby.

Birth complications

Placenta previa

The next case of placenta previa she faced was case number 1,250, and she executed her plan of delivering the woman as soon as possible. Like Louise Bourgeois, the famous French midwife of the previous century, she removed the placenta first, then turned the baby to a feet first position and pulled him out. Mother and child were both saved in this case, as well as in seven of the other ten cases.

Some body techniques during labour

The second set of techniques (upright birth postures, pulling on overhead straps or bars while pushing the baby down, breast stimulation to contract the uterus, and the all-fours position for resolving shoulder dystocia, for instance) are all found in cultures where indigenous midwifery survives.

Cesarean rates vary!

According to a 2013 report, the cesarean rate in the United States varies widely, with hospital rates as low as 7.1 percent and as high as 69.9 percent. Such extreme variation strongly suggests that there are reasons besides the safety of the mother and baby that influence whether a cesarean is done or not.

Cesarean reasons: medical or other

Part of preparing to give birth in the twenty-first century involves gaining an understanding of two categories of cesareans: those that are needed for medical reasons and those performed for other reasons.

Medical complications

Medical reasons for cesarean

  1. Placenta previa
  2. Prolapse of cord
  3. Placenta abruption
  4. Face presentation in which the chin of the baby is lying toward the mother’s tailbone
  5. Frank breech presentation
  6. Brow presentation where forehead of the baby leads into the pelvis
  7. Transverse lie during labor (the baby is lying sideways in the uterus and can’t be turned) and shoulder or arm presentation (if the baby’s position can’t be corrected)
  8. Cardiac arrest in the mother is another indication for emergency cesarean
  9. Placenta accreta, increta, and percreta are severe placental abnormalities in which the placenta grows over a prior uterine scar or into the uterine wall
  10. True fetal distress (a heart rate below 120 beats per minute) with meconium is an indication for instrumental delivery or cesarean unless birth is imminent
  11. Uterine fibroids or ovarian cysts fall into the debatable category for cesarean, depending upon their size and location. Unless they are very large and low, such growths will not usually block the baby’s exit
  12. A previous rupture of the anal sphincter

Normal cervix dilation rate

The document suggests that recent evidence has overturned the previous long-held idea that every first-time mother’s cervix should dilate at a rate of 1.2 centimeters per hour when larger, more recent studies have put the rate at 0.5 centimeter.

Common causes of death before and today

Three decades ago, the major causes of maternal deaths in childbirth were hemorrhage and pregnancy-induced spikes in blood pressure. Chronic diseases such as diabetes and heart disease are now among the major causes of maternal deaths, while rates of death from hemorrhage, hypertension, and infection are lower than they were a generation ago.

Delayed pregnancy does not cause rise in death rates

At the same time, the trend of delayed pregnancy is also going on in other well-resourced countries, without their maternal death rates rising.

Double layer closure after cesarean

My recommendation to pregnant women—at least in the United States—is to specify that if you should need a cesarean, you want your uterus to be closed in two layers. If you have already had a cesarean and are pregnant again, make sure that your placenta is not overlying your previous uterine scar before you go for a vaginal birth after cesarean.

VBAC worth considering

Even so, most physicians advised women not to have more than three children by cesarean and stuck with the warning that the lower rupture rate was not sufficient to make vaginal birth after cesarean (VBAC) worth considering.

Limiting cesarean births

In 1995, ACOG’s VBAC Practice Patterns bulletin had recommended limiting repeat cesarean births to those that were medically necessary. Obstetricians should counsel and encourage women to try to give birth vaginally, it said, as this would lead to shorter hospital stays, fewer transfusions, fewer postpartum fevers, and a savings of more than $4,000 per birth.

Future considerations

Questions to ask the labour or ob-gyn

  • Can my baby’s heart rate be intermittently monitored?
  • Do you do episiotomies routinely?
  • How do you feel about my eating and drinking in labor?
  • If I go into labor, come to the hospital, and then it slows down, can I go home? Can I walk around during labor?
  • Are you willing to leave the umbilical cord intact for several minutes after birth? Can I have my baby on my chest after birth?
  • Do you use pharmaceutical products to induce labor?
  • Are there tubs or showers that I can use in labor at the hospital?

New-age hospitals!

No longer are babies’ fathers routinely barred from being present during labor and birth or first-time mothers routinely compelled to have huge episiotomies and forceps deliveries. Some hospitals have installed tubs in birth rooms as a strategy for lowering epidural rates.

Checklist for hospitals

  • Provides accurate descriptive and statistical information to the public about its practices and procedures for birth care, including measures of interventions and outcomes.
  • Provides culturally competent care—that is, care that is sensitive and responsive to the specific beliefs, values, and customs of the mother’s ethnicity and religion.
  • Provides the birthing woman with the freedom to walk, move about, and assume the positions of her choice during labor and birth (unless restriction is specifically required to correct a complication), and discourages the use of the lithotomy (flat on the back with legs elevated) position.
  • Educates staff in non-drug methods of pain relief, and does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication.