A & A Farmer 2005
What is the point of being a professional? It ensures a certain status, it usually requires many years of training and professionals are held in higher esteem and trust than a common or garden lay person. When the professional is an obstetrician the majority of women feel confident that they are the best people to approach when they are pregnant and are confident that the information they give is accurate and without bias. A book written by an obstetrician, therefore, would have a certain cachet.
On my visit to Ireland to help launch the AIMS Ireland group I was given a copy of The Irish Pregnancy Book with the suggestion that I might review it. Obstetricians in Ireland have closed down small, free standing maternity units, as did obstetricians in most of Britain. In Ireland, two midwifery units have just opened, in Britain they are still always under threat of closure as we described in our Journal on Birth Centres. As I was intrigued to see what was on offer, I began reading.
The book is written by Dr Peter Boylan who was 'The Master' of the National Maternity Hospital, at Hollis Street, in Dublin - a hospital that delivers (and I use that word advisedly) over 8,000 babies a year.
The fact that the head of obstetrics in the hospital is called the Master speaks volumes and is a reflection of the presumption that the women are there to do as they are told.
The book began well enough (it does have a pretty cover) but it did not take long for my blood pressure to climb. Not only because of the amount of misinformation but also in the way it is delivered. Patronising is, perhaps, an understatement:
'Is there such a thing as a stupid question? There is, of course, but that shouldn't stop you asking'
'Nobody expects you to know anything or to take responsibility for anything so don't be scared!'
'If you have already had a child, and are used to being pregnant, it can be difficult to assimilate the fact that each pregnancy is different and needs to be treated individually'
'The key to coping with your disappointment is to have realistic expectations about birth and keep an open mind as labour unfolds.'
'The choice is yours, but remember you are not making it just for yourself '.
The National Maternity Hospital was the home of Keiran O'Driscoll, the promoter of Active Management of Labour. The obstetricians in Ireland closed down small, free standing, maternity units so that there were four large centralised ones left. Their campaign resulted in a huge increase in the numbers of women being processed through the delivery rooms and in order to do so Active Management was introduced and promoted on the grounds 'that effective uterine action is the key to normal delivery'.
As the numbers increased so the 'advice' about the length of a normal labour decreased, but women were not told the reasons for that. In 1963 women were told that a 'normal labour' lasted 36 hours. As the numbers of women going to the large centralised obstetric units increased so the length of labour decreased (O'Regan, 1998) so that now, in this book, women are told that 'if your labour had started twelve hours ago there is a better than 90% chance that you would be sitting in bed holding your newborn baby! In fact the average length of time a first labour takes from arrival in the labour ward to delivery, is less than seven hours in the National Maternity Hospital.'
Instead of informing women that their labours are being induced and accelerated in order to get them through the labour wards as quickly as possible (in Dublin there are over 20,000 births for 30 delivery beds) active management of labour is referred to as 'A sensitive approach to the care of women in their birth labours.'
It is clear, throughout the book, that Dr Boylan has little understanding of normal birth. 'Birth can only be defined as perfectly normal in retrospect.' This is still the basis for obstetric care in Britain and Ireland, and it is still said in all sorts of different ways. Active Management is alive and well in both countries. All births are potentially normal until the labours (or during pregnancy) show signs that they are deviating from normal. To assume that you cannot define normality until the labour is over is ridiculous, but it does allow obstetricians the opportunity to portray birth as a dangerous, uncertain, event.
Peter Boylan's failure to understand normal birth colours the whole book and the advice given.
'There is no advantage to keeping the waters intact, indeed not having the waters broken could slow your labour significantly.'
The research does not support Peter Boylan's claim. Amniotomy (breaking the waters) results in significant disadvantages:
And where is the evidence that a slow labour needs speeding up?
'During labour the stomach does not empty, so eating during labour is discouraged.'
The first high quality study of eating and drinking in labour was carried out in Canada. The study concluded that 'women enjoyed being able to control their own oral intake; no other benefits or harmful effects were found'. It has been stated that withholding food and drink from women in labour is unlikely to be beneficial.
'Some women prefer to let the baby's cord stop pulsating and to attempt to breastfeed in an effort to make the third stage as physiologically normal as possible. There are no great advantages to be had however, and it is probably simpler not to delay.'
Professor Peter Dunn's research (Dunn, 1984 and Dunn PM, 1993) revealed that early cord clamping 'traps around 100ml more blood in the placenta than could be the case if cord-clamping were deferred until cord pulsation had ceased. As 100ml of blood in the term fetus is equivalent to 2.5 pints of blood in an adult, it is not surprising to observe that, following immediate cord occlusion, the newborn infant typically exhibits signs of hypovolaemia [too low blood volume due to excess fluid loss] and hypotension [an excessively low blood pressure]' (Dunn, 2004/5).
'Squatting or kneeling on all fours confers no advantage, gravitational or otherwise. In fact these positions make it more difficult for medical staff to see what's going on and to help accordingly.'
A randomised controlled study reported that for primiparas (mothers undergoing first delivery), the duration of the expulsion period was significantly shorter in the group of mothers who remained seated in a birthing chair than in the group opting for the lithotomy position [on their backs]. The efficiency of uterine contraction for dilating the cervix is also greater in a vertical position than in a horizontal position ... It has been shown that appropriate position [squatting] of the mother increases the capacity of the pelvis' (Caldeyro-Barcia, 1985).
Interestingly, at a World Health Organisation conference in Fortaleza, Brazil, Professor Caldeyro-Barcia remarked that 'there was only one position worse than lying on one's back for birth and that was hanging by one's heels from a chandelier'.
'Many interventions are designed to assist you achieve a normal birth in a reasonable period of time'
A 'reasonable period of time' is defined by doctors not by women. When doctors fail to understand that the standard interventions in labour pervert the course of a normal labour, and suggest that it is 'assisting' women those women then fail to realise that the, often traumatic, experience they have had was not 'normal' but caused by that 'assistance'. As a result of this lack of knowledge they then stoically accept what happened, and some go on to book a caesarean or an epidural for the next birth because of the trauma they suffered.
'There is no reason why you shouldn't have a normal birth in hospital.'
The book omits to point out that fewer than one in ten women will succeed in having a normal birth in hospital. As the National is extremely coy about revealing its statistics one can only speculate how many women actually have a normal birth in that hospital.A normal birth does not include artificial rupture of membranes, induction or acceleration of labour, epidurals or episiotomy. But according to this book it does.
'If you are having your first baby, you will have an approximately 50% chance of requiring stitches either from an episiotomy or perineal tear; as the rate of episiotomy goes down, the rate of tear goes up! Look on the bright side though - you have a 50% chance of not having stitches, too!'
Not with a 20% caesarean section rate you won't.
This suggests that episiotomy prevents tears - it does not. A randomised controlled trial in Canada concluded that 'there is no evidence that liberal or routine use of episiotomy prevents perineal trauma or pelvic floor relaxation'. (Klein MC et al, 1992).
'The slower recovery may be because your labour was long and you are exhausted or because you have a larger episiotomy than you would have had with a normal birth.'
If a woman has an episiotomy at all, no matter how small or big she will not have had a normal birth, it is not normal to perform genital mutilation during birth.
'Of course, induction can often be very successful and result in a normal labour and a normal delivery.'
In a normal labour a woman's uterus increases the strength of contractions as the labour progresses, an induction of labour drives the uterus at the highest levels immediately, the labour is no longer normal.
Space prevents me from highlighting all the misinformation in this book, but here are a few:
'There is no evidence that ultrasound harms the fetus in any way'... 'There is no risk whatsoever associated with having a scan.'
A randomised controlled trial from Helsinki of over 9,000 women found 20 miscarriages after 16 to 20 weeks in the group that had routine early ultrasound scans and none in the controls (Saari-Kemppainen, 1990). Another randomised study of 2,475 women in London (Davies, 1992) of babies exposed to routine Doppler ultrasound examination of umbilical and uterine arteries at 19-22 weeks and 32 weeks reported 16 perinatal deaths of normally formed infants in the ultrasound group, and none in the controls. Despite being asked to explain these findings the researchers have not responded.
'The position of the baby's head before labour is of no consequence whatsoever.'
In that case why are women told that they have to have external cephalic version, or a caesarean section, when the baby is presenting by the breech?
'The midwives will perform an internal vaginal exam to see if you are in labour, and if so, how dilated you are. This procedure is the only way to assess your progress in labour.'
Skilled midwives are very competent at assessing progress in labour without performing internal vaginal examinations, obstetric nurses, however, rarely have this skill.
Midwives will be concerned about the following statements as they casually dismiss potentially important warning symptoms:
'You may get visual disturbances in pregnancy such as flashing lights before the eyes or blurred vision. These are of virtually no consequence but mention them to your doctor if they bother you.'
Visual disturbances often accompany pre-eclamptic toxaemia and skilled midwives will be concerned, and would be seen to be negligent should they fail to investigate should a woman mention that she has this experience.
'Sometimes the mother gets leverage by holding her own knees, or the two midwives let the mother push her feet against them to brace herself.'
Research clearly shows that lying on one's back for birth restricts the birth outlet.
'Good, good, take a deep breath - no talk or sound. Put your chin on your chest and push that breath into your bottom as long as you can hold it, then quickly two more times within this contraction.'
'... you should push as if you are severely constipated ... your midwife and doctor will help coach you.'
'Working right up until labour is fine from a physical point of view and doesn't harm the baby but is probably unnecessary.'
Finally, the message in this book is that the doctor knows best and you will do as you are told:
'Vitamin K will be given to your baby soon after birth'
No question here then of the woman being asked whether or not she wishes her fit and healthy baby to be overdosed with Vitamin K.
'...you can decide who you want to be with you. You can even have a relay of a few people with you if you wish - but only one at a time.'
So, you can choose who to have with you, but if you choose to have two people you will not be allowed to do so. Some choice!
The following is a question posed in the book:
'How can I get the most out of my antenatal visits? Be informed - read this book!'
On the contrary, by reading this book you will be misinformed and my advice is save your money, there are better books on the market.
Radcliffe Publishing 2003
For the father of a toddler, the effect of James Torr's book, 'Is There a Father in the House?', is to bless the presence of the father in the home. This territory, who looks after the children and the issues surrounding men's involvement, Torr explores in his rewarding book.
A personal angle: about 20% of the time I am at home looking after my son during the day while my partner, Nicola, works. I find the background pressure of needing to bring in income, as a freelance worker, can mean there is pressure I put on my being with my son. Probably, some of this is real and, I think, some is imagined. I can sometimes find myself in such fear of not having enough income that I am not 'present' emotionally as I look after my son. I might find I am behaving in a perfunctory way, looking past the (divine) present to when I can get on with something 'more important', My Work. And, of course, this means I am not receiving the gift of my son's presence, nor of my own fatherhood as if this isn't My Work also! A common enough perspective, I suspect, and one that James Torr with his book has created more space around, and an alternative vision for. He has made a small clearing where we can pitch a tent of 'involved father' more firmly and more satisfyingly.
His journey from city solicitor to 'daddy at home', strongly involved in parent-toddler groups, while his wife/partner is the key breadwinner is a courageous one. He has put himself into the cross currents of politics surrounding childcare and through doing so has elicited much fascinating information. This decision also gives him a unique vantage point to observe the process of how childcare is managed. His central thrust and interest has to do with the opportunity pregnancy and the time of birth offers for men's deeper involvement in the family. Torr points out the interesting fact that most men want to be present at the birth of their child. He therefore sees this as a time, which he supports with the available evidence, when there is an opportunity for bonding. This interest, growing over the last 20-30 years, he suggests, is a golden opportunity for the agencies that work with men to make the most of improving father/child relationships and therefore society. The case for 'why' this is important was not made so strongly, however. What you feel is that he is pointing towards the moment of birth as the time where there is potential for evolution in the way men are fathering and therefore how parenting is done.
It is interesting in this context to refer to Lloyd DeMause, author of 'The Foundations of Psychohistory' and the 'History of Childhood' among other books. DeMause says that parenting is evolving with each generation and actually our parenting has radically improved over the centuries. It used to be normal for infants to be exposed to the elements to die, in Greek and Roman times if they were inconvenient or supposed to be 'an offering to the gods'. It used to be usual for beating of children and sexual abuse within the family to be tolerated in society as a whole. What DeMause points out is that this evolution is based on parents becoming a little bit more aware than their parents before them, deciding, however subtly, that they are going to 'do it differently' than the way their parents brought them up.
Whether to smack your child or not is the current edge of parenting evolution, it's possible to argue, with DeMause and others insisting smacking internalises rage in the child with long term consequences. Some people carry on as their parents did before, others step into the new and decide something else; improvements take place over the generations. Sometimes things slip back and the 'snakes and ladders' counter slides down the snake to the bottom of the board and we have to start over, but there is incremental progress overall.
Whether you agree that its evolution or just an ongoing mess (and is there a difference?), Torr's observations about men and the moment of birth suggest he's seeing the point where an evolution in parenting DeMause talks about is taking place and is most visible. How men want to be at birth, are they involved or not, are they more there than ever, what does it mean? The questions he raises and the information he elicits are particularly useful when it comes to trying to persuade people in organisations to think differently or at least know there is another way of thinking about the beginnings of fatherhood. He offers practical thought provoking checklists to help ensure men's involvement.
To sum up, it seems that Torr is talking about two things. Firstly a phenomenon; the evolution of men's involvement in the family, starting with birth and secondly (at the same time), he describes, as Kazanstakis said, the 'whole catastrophe' of how we do it as families, men and women at this time, and it is rich in that. The book is a blessing, by a man, of men's involvement in parenting.
Collector Books 1998
Benig Mauger is a psychotherapist, pre and perinatal psychologist and former birth teacher (as well as a mother) who writes from a psychological and spiritual perspective. I've read good books before which give practical advice about healing from a traumatic birth but this book goes much deeper. It explores the spiritual and psychological effects of labour and birth and also looks at the effects on the baby.
I found the section about how the time in the womb, labour and birth can imprint the psyche of the baby and have long lasting affects extremely enlightening. For example if a mother doesn't want her baby and she feels no emotion then this will effect that baby on a subconscious level throughout their life. Benig describes how these effects often come to the surface when a woman becomes a mother herself. She describes how one woman in labour saw an image of her father sexually abusing her, it turned out that her father had actually raped her mother when she was 8 months pregnant. As a baby in her mother's womb she had felt her mother's fear and helplessness and carried that with her.
This book certainly hit home on why it is so important that women feel loved, safe and secure throughout pregnancy, labour and birth. Benig describes how the medicalisation of birth often does not provide this and causes women unnecessary soul wounds. These wounds are often overlooked because they are not visible but they can be extremely damaging to both mother and child. She also describes the affect on the baby and how studies are emerging which link drug addiction and violent behaviour to such birth practice, for example the use of forceps at delivery can lead to brain damage which predisposes a boy to violent behaviour in adulthood.
I found the section about the affects of a caesarean delivery on the baby absolutely fascinating. It certainly explains to me why my son who was born by emergency caesarean under general anaesthetic can be extremely difficult at times. Benig describes how caesarean born baby's might feel frightened and alone, caught up in a terrifying and even life threatening experience as the mothers anaesthetised body lies helpless. The caesarean born baby is denied the struggle to come into life and enters a world for which in some senses it is ill equipped. Benig has noted in therapy that caesarean born adults have many common characteristics such as impatience which she relates to their birth.
As a wounded mother myself who has recovered I pretty much agree with Benig's approach to healing. She describes how a good birth can heal and she also suggests that to move forward you must fully understand what happened for it to stop hurting. Benig quotes Freud's words: 'A thing which has not been understood inevitably reappears; like an unlaid ghost, it cannot rest until the myster y is solved and the spell broken.' She gives a positive outlook by describing trauma as something we must experience to enable us to grow.
I thoroughly enjoyed this book and would highly recommend it.
End Table Books 2005
I hesitated to pick this book up when Beverley asked for someone to review it, because it comes from America! However, despite my prejudices, I am really glad I did as it is beautifully written and compiled.
The first part is about rights and responsibilities and 'hiring the help' - written for the American system but oh so interesting. I had a woman with an American accent in my head asking her assertive questions to prospective physicians, midwives and doulas, for example - What is your philosophy about childbirth? What kind of postpartum care do you provide?
Then onto 'Medications in Labor', with a sub chapter on Narcotics - no not about drug dependent mums but the legal pain reducing drugs you are given in hospital for your labour. Power of language is underrated isn't it? There are 16 pages on the risks and side effects of Epidural Anaesthesia on Mother and Baby, which is well worth reading. The drug warning concerning unapproved use of intravaginal or oral misoprostal is also listed. You would have to find out what some of the drugs mentioned are called over here, but otherwise it is a fantastic chapter.
Herbs in Pregnancy and Childbirth and Complementary methods are subjects of further chapters and there is good advice about VBAC, Home Births and Water Births and Breastfeeding.
I am really impressed by the Birth Plan chapter - Breck's advice is very straightforward and logical. Get your doctor to sign it, she says, so that it becomes 'doctor's orders' - hospital staff are less likely to ignore your birth plan. Her birth plan includes a section for care of the newborn too.
The book finishes with a chapter of Bir th Wisdom from across the country - good practice and ideas from all sorts of people deeply involved in childbirth; a chapter on an organisation called CIMS which is a similar organisation to AIMS, I think and the final chapter on other resources.
The book is very easy to read and one of those that you can dip in and out of; it is described as a Guide and Workbook. I like the layout with the different 'worksheets' to help you ask the right questions and do your birth plan. I checked and it is available over here via that Internet bookshop or via Deep Books Ltd
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