A mother-to-be came to my clinic recently with a list of her childbirth wishes. She would like to experience a natural birth and she has attended a series of natural birth educational seminars organized by natural birth advocates in Kuala Lumpur.
Of late, there is an increasing demand of natural birth or gentle birth by mothers-to-be, perhaps brought about by the advocates of natural birth who actively promoting back-to-nature kind of childbirth experience. They associate natural birth with multi health benefits to the mother and the newborn however not elaborating the harmful effects.
I love to give my patient the best and pleasant childbirth experiences and to some extend I support natural birth however it must be carried out within the boundary of standard care, proven safe, do no harm and supported by reliable scientific evidences. Some of the childbirth wishes in the list provided are of no harm as it is within the standard care and has been proven beneficial to the mother and the baby by medical research. However some of the wishes are against the standard care, unsafe and potentially harmful to the mother and baby’s health. So, I informed my patient that some of her wishes can be fulfilled because it is proven safe and beneficial but those wishes that are potentially harmful cannot be fulfilled.
Childbirth wishes of natural birth that are beneficial
Here are among the wishes on the childbirth wish list of the natural birth practice that are in accordance to standard care of labour and they are beneficial to the labouring mother.
- I wish my labour pain to start spontaneously
- I wish not to have any injection of analgesia and wish to cope the pain of labour with my own alternative way
- I wish not to be tied down to the bed for fetal monitoring and intravenous fluids
- I wish not to have augmentation of labour with oxytocin
- I wish not to have unnecessary cesarean section
- I wish for less disturbance and less frequent vaginal examination unless indicated
- I wish for the water bag to rupture spontaneously, not for artificial rupture if not indicated
- I wish to have my husband or companion by my side during labour and childbirth
- I wish not to have an episiotomy at the delivery of my baby
- I wish to have skin to skin contact with my baby immediately after birth
- I wish to initiate breastfeeding immediately after birth
- I wish to have my baby rooming-in with me after delivery all the time
- I wish to exclusively breastfeeding my baby through out the hospital stay
The majority of mothers are from low risk of maternal and fetal complication category. These group mothers should be allowed to go into labour naturally and the labour progress is expected to be satisfactory without any needs of intervention to accelerate labour, use of electronic fetal monitoring or intravenous fluids for hydration. The best medical evidence has proved that electronic fetal monitoring is only beneficial to high risk pregnancy where there is an increase chance of fetal compromise. In accordance to standard care, if the labour is progressing well and as long as the baby is healthy state, there is no necessity to rupture the water bag or amniotic membranes artificially. In fact leaving it intact until it breaks spontaneously may help with the dilatation of the cervix due to roundness and slippery nature of the membranes. However, in the event when fetal compromise is suspected, and labour does not progress as per expected, intervention will become necessary to hasten the delivery of the baby and reduce the risk of morbidity or need for longer hospitalization due to complication.
In expectant care of labour, the labouring mothers are encouraged to ambulate and walk about as it has been proven beneficial in coping with the labour pain and likely to have a shorter duration of labour as compared to those mothers who are confined to bed. To avoid and combat dehydration during labour which may interfere with the progress of labour and inefficient uterine contraction, mothers are encouraged to drink lots of water, thus there is no necessity for intravenous fluid infusion.
Labouring mothers who have companion during labour especially the presence of their spouse to offer a moral support has been shown by the medical evidence to require less analgesia and coping well with the labour and childbirth. As a result, many hospital and labour facilities have become spouse-friendly.
There are increasing number of labouring mothers who wish to cope with the labour pain with alternative ways i.e. by hypnobirth, breathing exercise etc and do not wish to have any intervention to reduce labour pain as they are concerned about the side effects of the medication to the unborn baby. With regards to the choice of pain relief during labour, mother is free to make an informed choice about her wishes to apply her own method and free to change her mind to use other choices of analgesia.
Episiotomy is a small cut usually made on the perineum to ease the delivery of the baby head and to reduce risk of injury or extended tear to the mother’s perineum and intracranial bleeding in the event the baby popped out too sudden. However, medical evidence showed routine episiotomy to all labouring mothers brings more harm than benefits to the mother, thus it should be done only when it is deemed necessary and not routinely. For mothers who wish not to have episiotomy, it is encouraged that they do prenatal exercise and perineal massage to improve the flexibility of the perineal tissue and muscles thus reducing the risk of serious tear to the perineum during childbirth.
The most pleasant experience during childbirth is mother-baby skin to skin contact immediately after delivery. In many labour facilities, immediately after delivery the baby is taken away for cleaning, drying and other procedures at another place nearby. The baby would then be shown and given to the mother after nicely wrapped up and then taken to nursery for observation. Mother-baby skin to skin contact is when the naked baby is dried & and is placed immediately after emerged from the perineum onto the bare mother’s chest, chest to chest position for a certain duration. Scientific studies have proven that mother-infant skin to skin contact immediately after birth is beneficial as it would promote mother-infant bonding, improves mild breast-milk production and increase rate of successful breastfeeding. It is also has great effects on the baby cry less and feeling safe and much more happier. In this position, the newborn baby often automatically search for the mother’s nipple and begin to suckle the breasts.
Breast-milk production and successful breastfeeding is very much determined by the mother breastfeeding practices in the first 7 days of postnatal period. Early initiation, mother-baby rooming-in, frequency and exclusivity of breastfeeding in the early post-partum period is proven beneficial by medical evidences and thus it is part of a standard care in most labour facilities.
Childbirth wishes of natural birth that are potentially harmful
Here are the wishes or natural birth practice that are potentially harmful and hazardous to the health of the mother and her newborn.
- I wish to deliver my baby in a squatting position on the floor or assume any position that I feel comfortable.
- I wish not to have injection uterotonic (Oxytocin/Sytometrine) after delivery of the baby
- I wish to have the placenta detached and come out spontaneously itself without assistance
- I wish to have a delayed umbilical cord clamping until the pulsation of the cord has subsided
- I wish to have the cord and the placenta left alone with the baby until it dried up and detached itself from the baby umbilicus (lotus practice)
- I wish my baby not to be given injection Vitamin K and other immunization after delivery
Delivering baby in squatting position is perhaps the best position for childbirth. This is because the upright position of the mother, vertical axis of the uterus and the effect of gravity are perhaps improve bearing forces and facilitate descend of the fetus down to birth canal without much resistance. However if the mother is squatting and bearing down on the floor, there is a danger that the baby head might hit the floor first as a result of sudden expulsion from birth canal due to uncontrolled bearing force and unprotected perineum. In the case of cord around the baby’s neck or shoulder dystocia (stuck shoulder) after the baby’s head had popped, the baby would be in great danger as it might not be readily identified when the mother is in squatting position.
Upon delivery of the baby, all delivering mothers are at risk of postpartum haemorhage. Injection of uterotonic drug like sytometrine or pitocin to the mother immediately after the baby has delivered is a standard care of childbirth to prevent postpartum haemorrhage. If it is omitted, the care can be considered substandard or negligent on the part of the caregiver should complication arises as a result of the omission. It has been proven by scientific evidence that injection syntometrine is beneficial to reduce postpartum blood loss and it used has reduced almost 50% of maternal death due to postpartum haemorrhage worldwide.
Spontaneous expulsion of the placenta may happen 10 -15 minutes after childbirth as the uterus contracted and the shearing effect bring about detachment of the placental surface from the surface of the uterus. If let alone the placenta can come out by itself. However, it is not going to be easy and uncomplicated for everybody. There is a danger of excessive blood loss if the expulsion takes a longer time. There may be a complication where the placenta is firmly adherent and retained in the uterus requiring manual removal of the placenta. There may also be a danger of postpartum haemorrhage and uterine atony in the event of accumulation of blood in the uterine cavity inflating the womb but not revealed as the detached placenta is obstructing the cervical os. There will be a danger of serious postpartum haemorrhage due to outpouring of the blood with coagulation failure after the placenta is expelled out. Controlled cord traction (CCT) is a standard care applied after sign of placental separation is seen and the doctor or midwife would pull the cord with another hand pushing the uterus upward to give counter traction to reduce risk of the postpartum haemorhage. CCT has been proven beneficial by medical evidence to reduce danger of postpartum haemohage.
Delaying the cord clamping after birth of the baby has been proven beneficial to the baby especially the premature baby by scientific medical evidence recently. It has been shown that delayed clamping of the cord for about 6-8 seconds allows extra 100 – 200 ml of blood from the placenta return to the baby circulation and this extra volume of blood improves baby haemoglobin level and stabilize blood pressure but it increase the risk of neonatal jaundice. Although it is proven beneficial but it cannot be taken out of context by the natural birth advocates. The recommendation is only to delay around 6-8 seconds and not longer or indefinitely because there is greater harms if it is clamped too late. This is because the blood from baby circulation may reverse back to the placenta when the pressure in the placental end drop shortly after it complete detachment from the uterus. As the pressure in the umbilical cord drop and the blood flow slowing down, there will be formation of thrombus or micro blood clot which might escape into the baby circulation causing embolism.
There is a belief by certain group of natural birth that the detached placenta should be left with the newborn until it dried by itself as placenta is seen as a companion to the baby. This belief is very tribal and has no scientific basis to it. A detached placenta is a dead tissue and thus it will naturally undergo a decay process. As it is a tissue that filled with blood and nutrient, it is a fertile ground for bacterial growth. Thus exposing the baby longer with a non functioning placenta put the baby at greater risk of infection and shock due to sepsis which often fatal.
Injection Vitamin K to the newborn immediately after birth is a standard care as a prophylaxis to prevent incident of haemorrhagic disease of newborn. This is the condition where there is a sudden bleeding in the baby’s brain soon after birth up to 24 hours of life due to vitamin K deficiency. Newborn infants are at risk of developing vitamin K deficiency, and this coagulation abnormality leads to serious bleeding. Transplacental transfer of vitamin K is very limited during pregnancy, and the storage of vitamin K in neonatal liver is also limited. This makes the newborn infant uniquely vulnerable to hemorrhagic disorders unless vitamin K is given for prevention of bleeding immediately after birth. A mother who refuse injection Vitamin K to be given to her newborn is irresponsible and it is considered substandard care amounting to negligent in the part of care-giver if injection vitamin K is not given to the newborn should this unfortunate event occur to the baby.
Message to natural birth advocates
Most of the natural birth practices and wishes are not a new trend or new flavor of childbirth but are already imparted in the standard care of labour & childbirth in modern practice where it benefits are supported by scientific medical evidence. Childbirth, although a natural process but not all are without complication. Maternal and neonatal death are a national issue and the rate of maternal and neonatal mortality is a reflection of the standard & quality health care of a country. Thus, while the mother wishes is to have a special experience of natural birth but the care-giver has a duty to ensure the safety of both mother and her baby under their care. The quality care of childbirth has to be delivered according to the guidelines of standard care which are supported by medical evidence, not by perception and belief of the mother,
Mothers who have list of natural childbirth wishes to discuss with their doctor or care-giver of their wishes before they come in labour to make sure those wishes can be carried out without compromising the quality and standard care.
Dr Sharifah Halimah Jaafar
Regency Specialist Hospital