How to Keep Normal Labor Normal – Part 3 – Philosophy

This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Today we’ll look at the costs of “birth philosophy.” Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. Today we’ll look at the first “P” of my 10 “P’s” of keeping labor shorter and birth safer — philosophy.

In the past, labor has been viewed by many (perhaps most) physicians as a process that can and must be managed by physicians for their pregnant patients.

Standard obstetrical text books discuss the three “P’s” of labor management:

  • Power,
  • Passage, and
  • Passenger.

Some have expand these basic 3 to include a fourth “P”: either “Positions” (meaning position changes during labor and delivery) or “Psyche” (meaning psychosocial preparation and support).

However, there is appearing in the literature increasing comment that most labor does not need to be interventionally managed and that knowing when and how not to intervene may be an higher order skill than routinely intervening.(26-28)

Said another way, “if you mess around with a process that works well 98% of the time, there is potential for much harm.”(29)

“In populations where medical intervention is used only when clearly necessary, more than 90% of women will have a healthy birth outcome without any intervention.”(13)

Asking the birthing literature the question, “What then can maternity care providers do to keep normal labor normal?” has lead this me to develop what I call the “Ten ‘P’s’ of keeping normal labor normal.” In this blog we’ll look at the first “P.”

1) Philosophy

There appears to exist among maternity care professionals a philosophical spectrum that extends from that which views labor as a “natural process” to that which views labor as a “disease process.”

Maternity care givers always lean towards one end or the other of this philosophical spectrum as “… underlying these contrasting views are incompatible assumptions about the nature of women.”(16)

“One model assumes that women are capable, reasoning beings who can actively manage their birth experience, whereas the other sees them as possessing a reproductive system that is unreliable, inefficient, and tricky, thus requiring expert monitoring and management.”(30)

The “disease process” approach to maternity care has been expounded since the onset of the specialty of obstetrics, at least in America, where founders of the specialty reported, “Childbirth is a decidedly pathologic process … analogous to being impaled on a pitch fork”(31) and “… the fundamental reason why obstetrics is on such a low plane in the opinion of the profession … (and) in the mind of the public, is just because pregnancy and labor are considered normal, and therefore anybody, a midwife, a medical student, or even a neighbor knows enough to take care of such a function.(32) “By declaring labor and delivery a ‘disease,’ it was possible for an obstetrician to attain the same professional status as his (sic) medical and surgical colleagues.”(33)

Recent reviews are sharply critical of this philosophy: “(I use) the metaphor of production in the workplace for the act of reproduction in the medical model, in which women are seen as powerless and separate in some sense from their bodies.  The uterus is viewed as a machine, the woman as a laborer, and the physician as the supervisor-mechanic-fixer.”(34)

Partially as a result of this philosophy “… the current US pregnancy care system commonly applies technological interventions to most mothers.”(26)

Others have clearly elucidated the opposite end of this philosophical spectrum: “Whether childbirth is experienced as a natural physiologic, family-oriented event or a ‘high-tech’ medical procedure has far more to do with the attitude and approach of a parturient’s medical and nursing attendants than with her clinical condition.”(27)

“Whereas common obstetric practice manages the parturient’s physician functions to conform to a medically determined ideal (the medical pathway), the more conservative ‘physiologic pathway’ gains maximum benefit from her inherent physical and psychological resources to make childbirth more natural, more satisfying, and safer.”(27)  “This approach to pregnancy care recognizes that most women do not need to be technologically delivered of their babies but, rather, need to be allowed to have their babies simply and physiologically born.”(26)

“The term “family-centered maternity care” (FCMC) developed (in the 1970s) as a consumer reaction to the depersonalization of birth that had been the management standard for childbirth during the first half of the century.

The philosophy and focus shifted from technologization to personalization, from birth as a biomedical event to birth as a normal developmental task.”(28)

The existing technological system used in most hospitals is “… an expensive system and tended to overlook and sometimes ignore the individual woman and her childbirth process … and (is) called … high-tech, low touch obstetrics.”(26)

Therefore, “it is not surprising that … women have been the prime instigators in a movement toward … efforts to naturalize and humanize childbirth.”(26)

After consumers came nurses who stated in 1978 that, “… family-centered birthing should be the norm in American obstetrics …”(35)

At about the same time the term “family-centered birthing” appeared in a physician’s article, but only as an alternative: “The Homestyle Delivery Program, an alternative birth service at UC Davis … was developed … in response to the needs and desires of patients and physicians to participate in a more natural family centered birthing process.”(36)

It wasn’t until 1993 that this term entered the mainstream physician literature: “We need to recognize that the attempt to model obstetrics in family practice after highly a technical obstetrician-gynecologist model has failed. A different paradigm — family-centered birthing — is more appropriate …”(37) and could be “… called the low-tech, high-touch obstetrical approach … as family-centered birthing is both a philosophy and a learned group of skills and practices that emphasize a natural process, and not a disease. Women must be encouraged, equipped, and enabled, without unnecessary and nonindicated intervention, to complete one of the most essential roles given to them, to birth their children.”(26)

One obstetrician’s interventionalistic policies were lampooned by Sheila Judge, the night midwifery sister at Sheppey General Hospital, in 1968:  “Blood pressure erratic, they lose an ounce — That’s enough! The boss will pounce!”(38)

For midwives or general practitioners who sought to emulate their interventionalistic obstetrical colleagues, she wrote:  “Aseptic, scientific, and quite spell free, is how modern midwifery aims to be — The newest procedures are always the greatest, it’s bound to be good if it’s the latest!”(38)

One amusing analogy of the technologically obsessive states that, “The bomb squad approach to maternity care, which asserts that every pregnant woman is a time bomb ready to ‘go off’ and needs a bomb disposal squad, is to most family physicians and midwives dissatisfying, unsafe, and unsatisfactory, particularly for the provision of routine family-centered maternity care.”(39)

One author showed that “physician beliefs … (link) directly to clinical actions and their consequences …”(40) ; however, there is little in the literature describing how or if maternity caregivers can or will change from one end of the philosophical spectrum to the other, but that which exists indicates that this process is both difficult and prolonged and usually progresses along a somewhat predictable continuum.(26,41)

What does the research say about one philosophical approach or the other?

“To date, all studies of … expectant, non-interventional style of pregnancy care have shown, that when applied to low-risk women, the approach has excellent outcomes, compared to similar women managed in more interventionalistic methods.  This appears to be true whether the maternity care providers are family physicians, midwives, or obstetricians.”(26)

There should be no question that “… it is critical that the style of practice be geared toward keeping healthy patients healthy.”(42)

It does appear that a care giver’s belief and philosophy effects the maternity care that they practice.

Here’s the entire series:

  1. Philosophy,
  2. Partners,
  3. Professionals,
  4. Pain control,
  5. Procedures,
  6. Patience,
  7. Preparation,
  8. Positions,
  9. Payment, and
  10. Prayer.

Citations:

  • (13) Scherger JE.  Management of normal labor and birth.  Primary Care 1993;20:713-719.
  • (26) Larimore WL. Family-centered birthing: history, philosophy, and need. Fam Med 1995;27:132-138.
  • (27) Fenwick L. Birthing: techniques for managing the physiologic and psychosocial aspects of childbirth. Perinatal Nurs 1984, May/June:51-62.
  • (28) Midmer DK. Does family-centered maternity care empower women? The development of the woman-centered childbirth model. Fam Med 1992;24:216-21.
  • (29) Hon, E. In: Young D. Crisis in obstetrics-the management of labor. Int J Childbirth Education 1987, August: 13-5.
  • (30) Moore M, Hopper U. Do birth plans empower women? Evaluation of a hospital birth plan. Birth 1995;22:29-36.
  • (31) Pomeroy, DeLee JB, In: Thacker SB, Banta HD. Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860-1980. Obstet Gynecol Surv 1983;38:322-338.
  • (32) DeLee JB, In: Fishbein M. Joseph Bolivar DeLee: crusading obstetrician. New York: EP Dutton, 1949.
  • (33) King CR. Where is the woman in obstetrics and gynecology? Pharos 1989;52:8-11.
  • (34) Martin E. The woman in the body. A cultural analysis of reproduction. Open University Press, 1987.
  • (35) Joint statement endorses family centered birthing. Am Nurse 1978;10:1, 11.
  • (36) Rollins AJ, Kaplan JA, Ratkay ME, Goodlin RC, et. al. A homestyle delivery program in a university hospital. J Fam Pract 1979;9:407-14.
  • (37) Larimore WL. Family-centered birthing: a niche for family physicians. Am Fam Physician 1993;47:1365-6.
  • (38) Mathews D. Birth of the midwife/obstetrician. Lancet 1995;345:532.
  • (39) Larimore WL, Reynolds JL. Family practice maternity care in America: ruminations on reproducing an endangered species – family physicians who deliver babies. J Am Bd Fam Pract 1994;7:1-11.
  • (40) Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, et.al. Physicians’ beliefs and behavior during a randomized controlled trial of episiotomy. Can Med Assoc J 1995;153:769-79.

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