Da Capo Press, 2003
As a somewhat relaxation-obsessed antenatal teacher and hypnotherapist, I was keen to read and review this book. Dr Moberg is a professor of physiology, who is dedicated to raising the profile of oxytocin, not only with regards to childbirth, but also relating to health and well-being generally.
Moberg points out that there is now ample research about the effects of stress on the body, our 'fight or flight' responses, but very little looking at relaxation and calm. She hypothesises that the focus on physiological and psychological stress may be due to our 'goaldirected culture' and the dramatic effects that stress produces. As a contrast, Moberg describes the effects of the alternative 'calm and connection system' as occurring slowly, gradually and subtly.
The word 'oxytocin' comes from the Greek words meaning 'quick' and 'childbirth labour' and was first identified as being produced by the pituitary gland in 1906. Moberg expands on this, explaining that oxytocin is not only a hormone, but also a neurotransmitter, influencing operations throughout male and female bodies. She gives the examples of lowering blood pressure, heart rate and stress hormones, increasing skin circulation, and creating a more effective digestive system. Oxytocin and the calm and connection system are promoted by touch, warmth, sexual activity, relaxation and meditation, by security and support, and by breastfeeding our babies. Moberg believes that we all need this system to grow, heal, bond with others and experience happiness. The implications for childbirth and breastfeeding are immense but not unfamiliar to us: women will produce more oxytocin throughout labour and the postnatal period if they feel safe, nur tured and relaxed.
There are sections in the book that deal with how the brain, the nervous system and hormone interactions work, and these are well explained, giving illustrations and everyday examples that are easy to relate to if the reader is not medically qualified.
As the 2nd edition is due to be published on 1 July 2011 (www.pinterandmartin.com £9.99), with a foreword by Michel Odent, I shall be keen to see if there has been any more empirical evidence concerning the calm and connection system since the 2003 edition. Even without further evidence, there is a great deal to learn by reading this book, not only for birthing and breastfeeding women, but also for society as a whole.
Written by Nadine Pilley Edwards, Vice Chair of AIMS, and Sara Wickham, an experienced midwife and author, this is a very timely and necessary book. The book begins with a powerful quote from Justus Hofmeyr et al2:
'Care for pregnant women differs fundamentally from most other medical endeavours. "Routine" care during pregnancy and birth interferes in the lives of healthy people, and in a process which has the potential to be an important life experience. It is difficult to measure the extent to which our efforts may, for example, disturb the development of a confident, nurturing relationship between mother and baby. The harmful effects we measure in randomised trials are limited to those we have predicted may occur. Sometimes after many years unexpected harmful effects surface only because they are relatively common, or striking in their presentation. Many unanticipated harmful effects probably never come to light. For these reasons, interventions in pregnancy and childbirth need to be subjected to special scrutiny. Our guiding principle is to advise no interference in the process of pregnancy and childbirth unless there is compelling evidence that the intervention has worthwhile benefits for the mother and/or her baby – only then is there a good chance that benefits will outweigh both known adverse effects and those which may not have been thought of.'
In the last couple of years research has increasingly questioned the supposed benefits of many routine interventions commonly carried out by midwives and doctors during birth. Written in clear and jargon-free language, this book provides a comprehensive overview of relevant evidence relating to the birth of the placenta (or the 'third stage of labour' as it is often termed), with the aim of assisting women to make informed decisions about this central part of their birth experience. As the authors note: '[this] can be a particularly delicate and awesome time, as the mother sees her baby for the first time and, if all is well, is able slowly to come to terms with becoming a mother and get to know her baby'.
The book explains many different issues women may have questions about, for example, what it means when a 20-week ultrasound scan repor t states that the placenta is low, what are the side effects of oxytocic drugs used to help contract the uterus, lotus birth, birth of the placenta in water, and timing of clamping the cord – to name only a few of the aspects covered. The chapters of the book cover the historical background, the development and birth of the baby and placenta, active management of the third stage, research evidence, and wider issues, with a list of useful resources and references.
Reading this book I was impressed by the care the authors take throughout to use language which conveys respect for the power of women's bodies and the amazing complexity of the birth process. There is an interesting discussion of the term 'management of the third stage'. The authors prefer to use the term 'placental birth' pointing out that 'management' is something done to women, and that indeed a physiological process does not need to be 'managed'. They also note that 'the artificial division of labour into stages that has emerged as part of the medical view of childbirth is not necessarily representative of how women themselves experience this journey' (p17). Language is crucially important and indeed the terms 'physiological' or 'expectant' management sound quite offputting, while 'active management' could be confused with 'active birth'. When I discussed this recently, my midwifery students suggested that midwives should start to offer women the choice between a 'natural birth' of the placenta or a 'medically managed' one, as these are clearer descriptions of the two approaches.
The chapter on active management summarises the evidence and explains the procedures and drugs used, including the disadvantages and side effects of the drugs on the mother (hyper tension and nausea being the most common). There is a discussion of the latest evidence regarding the detrimental effects on the baby of early cord clamping, including lower iron stores and anaemia, increased intraventricular haemorrhage (bleeding into the brain), fewer stem cells going to the baby and less 'protected' time for adaptation to extrauterine life. In the chapter on the research evidence, the authors carefully examine the research studies which led to the widespread implementation of routine 'active management' and analyse the more recent evidence which shows that a physiological third stage has many benefits for mother and baby. There is discussion of the most recent Cochrane systematic review which suggests that women should be informed about the benefits and harms of active management and that their decisions should be supported1. There is an interesting section on 'Women, birth and time' which will strike a chord for many; it quotes from an ethnography of midwifery practice: 'Syntometrine was said to be used in the third stage of labour 'to shorten the third stage' as if there was some urgency to end this undesirable condition.' 3. One of the strengths of this book is the insight the authors bring to the context in which care is given.
There is also a section on how a woman feels during the birth of her placenta, a subject sadly ignored in most of the research studies, with some great quotes which you will need to read for yourself when you buy the book (very reasonably priced at £8!) I liked the drawings of separation of the placenta which depict the mother in an upright position holding her baby, beautifully showing the symbiotic nature of the mother-baby relationship (p16).
Overall this is a powerful, readable short book (116 pages), packed with relevant research evidence. It describes the contradictions of a system where midwives are committed by their statutory rules to providing woman-centred, individualised care, yet at the same time many are working in hospitals where guidelines (based on NICE 20074) advocate routine active management of the third stage for all women (including those who have had a normal labour), unless a woman specifically requests otherwise. This book makes it clear to me that it is time such guidelines were changed and provides copious evidence (including 22 pages of references!) to inform anyone setting about this task. It will be of use to midwives, doctors and students, giving detailed evidence and reminding them of the importance of respecting this special time, interfering only if medically necessary. It will be invaluable for women wanting information to help them take control of their own birth experiences.
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