By Diane Donaldson
(Originally printed in our Autumn 2009 Newsletter)
After forty years of preoccupation with all things around birth, it would be a daunting task for me to list all of the many positive and negative changes that have taken place over the years. Rather, I will compare some of the worst and best aspects of the standard practices of the sixties, seventies and the present decade.
I observed the practices around birth as a nursing student in the sixties and then again as I gave birth to our sons in 1969 and 1973. I feared many things that I thought might be done to me while birthing our first child in 1969. I was as comfortable as a person could be in a large hospital, Vancouver General Hospital, given that I knew every inch of it having trained there as a student nurse and worked there as a graduate nurse for eight years. Despite this familiarity, I was aware that it was not in the vanguard of change, and that the facility was old, stark and operated under a system of rigid rules uninfluenced by the community. Women laboured in tiny, bare rooms with a fan attached to the wall above the foot of the bed as the only amenity. Even though it was November, the hospital was stuffy, I was hot from the work of labour and the little fan proved to be a huge help. I have since wished that modern “birthing rooms” had such a simple comfort measure. But let me take you through the process of admission while in labour, to the actual birth itself, and to the early postpartum that was accepted practice so long ago.
Upon arrival at the hospital women were subjected to having their pubic hair shaved. This practice was in the process of being modified in 1969 to one half of the hair shaved. This was thought, erroneously, to decrease the incidence of infections in the episiotomy that was certain to be done just before the baby’s birth. Quite the opposite: any nick from the razor left the previously intact skin now open to infection. Women were also given a large enema whether they had stool present in their bowel or not. This was justified by saying that it prevented the indignity of passing stool during the pushing of second stage. Another claim was that it would speed up labour, but in some cases it sent a very active labour into a precipitous birth in the admitting area or en route to the delivery room. For my part, trying to expel the contents of my bowel while sitting on a bedpan, atop a stretcher, without its brakes on and within earshot of the waiting room was infinitely more undignified.
Once settled in the delivery room, the labouring mum was virtually alone. Husbands were told to stay in the waiting room, and the nurses checked the labouring mother and her baby once every thirty minutes to listen to the baby’s heart. They assessed cervical dilation about every four hours (or more often if progress demanded it) by an uncomfortable rectal exam. Only physicians were allowed to assess the cervix via the vagina directly. Husbands paced the floor of the waiting rooms unable to support their wives. No same sex partners, friends, mothers or other relatives were allowed near the labouring woman either. Because VGH had the most progressive doctors and a few nurses who would break the rules, a few of my contemporaries did have their husbands by their sides. Fortunately, my husband was with me, but he was an exception.
The “Case Room” was the OR-like room in which women gave birth to their babies. It had an operating room table with stirrups and the bottom half that rolled under the top to allow the physician to sit on a stool between the mother’s legs in order to perform an episiotomy, to direct her to push, to catch the baby and to suture the episiotomy following the birth. The modern birth bed is often used in a similar manner to enable the birth assistant/doctor to be comfortable, with little consideration foe the mother’s comfort. With my doctor I negotiated many modifications for our second birth. He wrote an order to allow my husband to be present at each step of the labour. I made sure that I arrived at the hospital in good labour to reduce the actual time that I would be under their control. During the birth in the Case Room, I did not use stirrups and the bottom of the was bed was in place but a little lower than the top half so that the doctor had a little room to manoeuver the baby’s body during the birth if it was necessary. The top half of the table was raised to a 45 degree angle so that I could push more effectively and watch the birth of our baby. I did not feel that I was pushing my baby out into an open, unsafe space. I asked if I could lean my legs on my doctors belly and to this day I can remember that feeling of being surrounded by breathing, warm, caring people. Those moments at the birth were precious to me.
The one intervention that was standard practice was the episiotomy. I requested that my doctor let me tear rather than do an episiotomy but at the last moment he lost his nerve and asked my permission to do one. It wouldn’t be until the early 90’s that the first research studies proved that a cut in intact tissue increases the probability of an extensive tear rather than a tear, if it happens, along natural cleavage lines. I had a painful perineum for months following both births and I often wondered if a tear’s healing would have left me more comfortable. This same obstetrician worked with me as a colleague for many years and after irrefutable evidence from research he and most other physicians changed their practice during the nineties. In later years, this doctor claimed that I taught him about warm compresses and slowing the birth to allow the tissue to stretch and prevent a large tear. Although that may not be true, I was one of the first people he knew to question the conventional practice of episiotomies leading to fast births and large tears. The weight of evidence from modern studies has proved what midwives have always known.
Not all women had a goal to have none or very little medication in labour in those days. Many drugs were often used in labour starting with sedatives in early labour, and narcotics and gas at the second stage. Epidurals were heavy and frequently left women incapable of moving in the bed or pushing their baby out. Forceps were used often because caesareans were considered to put women and babies at greater risk. Doctors used forceps to reposition babies and then pull them down from a high position relative to the mother’s pelvis. Only after research showed that it was safer to do a caesarean rather than use high forceps when the baby was not well descended into the pelvis, did the frequency of the use of forceps go down. This type of intervention has not really diminished over the intervening years because low forceps and vacuum extraction of babies is widely done when women are unable to push their babies out following an epidural. Today, the majority of women having their first babies have an intravenous line in place, an epidural and many have an oxytocin augmentation of labor and are assisted with a vacuum extractor at the time of the birth. Second babies deliver much faster on average so women who have prepared for a birth without interventions sometimes get to experience this with second and subsequent babies.
In the sixties and seventies, directly after the birth, and while still in the Case Room, the baby was bathed in tepid water and phisohex, a lotion-type antiseptic soap that was later proven to be harmful to babies, but was done because we had the misguided notion that babies were somehow contaminated during their journey through their mother’s birth passage. Little did we know that even full term babies are stressed by exposing them to the cooling effects of the water directly after birth. Bathing a newborn is still a contentious practice. Some believe that babies are better left alone and allowed to derive the benefits of their own flora and protective barrier that the amniotic fluid provides. Others think that, when the baby’s temperature has been stable for six successive hours, and if the bath is warm and of a short duration and they are placed skin to skin immediately following, parents benefit from learning to handle and care for their newborn. Most parents still want to be shown how to bathe their babies and find doing it with the nurse helpful.
Postpartum in the hospital was dictated by old hospital routines based on years of stultifying practices never put to the test of studies. With our first baby I went along with the practice of four-hourly feeds with the baby being kept in the nursery for the first day. I did get our baby at my bedside on the second to fourth day because I was in a four bed ward, for which I paid extra. Had I been in the open ward with twenty or more mothers, I would not have had him near by and would have had to endure the smoking and disruption caused by the other patients and their visitors. Prior to my second postpartum I had read about “rooming-in” and requested that I have our baby with me at all times. The hospital staff was caught a little off guard but decided that after their one hour of observation of our son that I could have him only if I paid for a private room and accepted their requirement to be put on isolation. We now know our baby was much safer from infections when isolated with me than taking his chances with the handling from staff members in the central nursery.
In the seventies, breastfeeding education was inconsistent and mostly based on old tradition. Most caregivers were not aware of the process of how the mother’s milk supply matches the demand from the baby, or how to help a mother latch her baby or how to solve the many little issues that can crop up in the first days and weeks. I was fortunate to have read a lot and was in close touch with the La Leche League, a group of breastfeeding mums who had lots of experience solving common problems and who had a willingness to listen and to even make home visits. My colleagues in Childbearing were also a big help and my partner also believed that it was the best way to feed our babies and supported me in many ways. Women who did not have this support usually introduced formula (that the hospital or doctor gave to them) early on which began the process of weaning their babies. Today, lactation consultants are available in most cities to help women who are experiencing difficulties.
Let us take a critical look at the present. In some hospitals we now have beautiful birthing rooms that women can use without moving to another room for the labour, birth or postpartum. The system has come a long way to give families the facilities that they deserve and to educate families and staff about the unique possibilities for every woman. Women still have to seek out caregivers who have a non-interventionistic approach but many are willing to support their goals. If women are motivated, educated, and luck is on their side they can have a drug-free labour and birth with a midwife or physician, nurse, doula, partner or other support people chosen by the mother available to help. All are prepared to give ample labour support to help her have the best birth possible. Women need to probe the culture of the hospital that they plan to use so that there will be few surprises during their stay. They need to be even better educated if they are planning a home birth with a midwife so that they and their family can handle the additional responsibilities. In either case, as it was in the past, women need to surround themselves with supporters who will advocate for them, help them access their strength, remain open to unforeseen circumstances, help them make adjustments as needed, and help them trust and listen to their bodies.
Some of the changes that were needed forty and more years ago are still needed. The erythromycin ointment for baby (that is now not recommended), is still sometimes suggested, or the parents are asked and need to then sign a waiver if they refuse. The Vitamin K shot can be done safely within six hours after birth and should be done when the baby is suckling well at the breast, so as to reduce the pain of the injection for the newborn. Breastfeeding at the time of any injections or heel pricks has been proven in many studies to be an effective pain reliever. Some nurses are committed to latching the baby first, but many are not. The lab staff are particularly rigid about their methods and, unless reminded, do not initiate breastfeeding prior to their blood draws. Parents need to speak up on behalf of their babies and ask for the laboratory staff’s patience while they latch their babies.
As always, parents need to be their own advocates to ensure that they have a satisfying, well-informed and positive birth experience. It all begins with comprehensive childbirth classes, reading widely, watching informative videos or talking with health professionals, family or friends. Having a baby is one of life’s most significant experiences and leaves us with memories that will last a lifetime.
Diane Donaldson is one of the founding members of The Childbearing Society. A retired Childbirth Educator and Perinatal Nurse, mother of two, and an inspiration to all of us.