How many really know?

AIMS Journal, 2016, Vol 28 No 4

Gemma McKenzie asks who understands what normal really looks like

Recently, I read an article by Christiane Schwarz in the German midwifery magazine, Hebammen.1 In it, the author explored how labour is currently managed and questioned the reliability of the research underpinning it.

In particular, she focused on contractions, their ideal length, intensity and frequency. One of her points was that maternity professionals may actually be unaware of what ‘normal’ labour looks like. The risk is that interventions are then unnecessarily employed to control labour, to speed it up, intensify it, or to assume that natural physiological breaks are pathological and need fixing.

My mind began to contemplate this issue and I couldn’t help but wonder whether the same point applied not only to labour, but also to childbirth. I asked myself whether we – and by that, I mean society and the maternity profession – actually know what normal labour and childbirth looks like? Do midwives and obstetricians ever witness it? And perhaps most importantly, is it written about in the medical literature?

I am not a midwife, but I do read medical, midwifery and bioethical research. In those studies, I sense what Scammell and Alaszewski describe as ‘an ever-closing window of normality’2, based largely on concepts of risk, the medical profession’s fear of litigation and the process of birth being dictated by charts, timescales, phases and stages. But I think this is also coupled with a skewed sense of normality based on what health care professionals actually perceive and experience as ‘normal’.

I thought back to the births of my own children. When I was pregnant with my third baby, I remember the midwife asking me whether my previous babies had been ‘normal vaginal deliveries’? With a shudder, I recalled the events of the previous births and was informed, that yes, these deliveries were indeed ‘normal.’

Really? In my mind, there had been nothing ‘normal’ about my son’s birth. I’d been induced for being ‘postdates’. My husband had been sent home, and I was left in early labour, alone, in a hospital gown in a bright shiny room. Everyone around me was a stranger. I was strapped on my back to a bed with a syntocinon drip in my arm. The contractions became a murderous, brutal, excruciating pain, inflicted by a machine and controlled by a third party. By the time my husband had returned, I was covered in vomit and was hallucinating. Faces came and went, cleaners, paediatricians, an obstetrician, midwives. I was then paralysed from the waist down, before someone took a pair of scissors to snip and widen me. Two midwives then held my legs up and back as I pushed for two and a half hours to bring my son into the world.

And my midwife perceived this to be ‘normal’?

I really have to wonder how we got to this point. I am reminded here of the cat analogy written about by Tricia Anderson in her article ‘Out of the Laboratory: Back to the Darkened Room'.3 She starts by highlighting how cats need to be in a dark secluded space to have their kittens, and then goes on to imagine that a group of scientists wanted to research how cats give birth. The scientists take the pregnant cats and put them in a brightly lit laboratory, and study them with monitors and probes. Over the years, the scientists discover that the cats were becoming distressed and their labours erratic. Consequently, the scientists developed tranquilisers to ease the cats’ distress and technology to improve their labours. As time went on, new generations of scientists arrived and they had no idea that moving the cats into the laboratory had originally been an experiment. The end result was that everyone now believed that cats do not labour well and the safest place for them to give birth was at the laboratory.

The analogy certainly strikes a chord with me. The maternity system seems to have lost sight of what ‘normal’ actually is. Perhaps there is some relevance here to the distinction between 'normal delivery’ and ‘normal birth.’ In the eyes of a health care professional who works within a system where women are regularly induced, frequently undergo episiotomies and often birth on their backs, my experience probably does reflect a ‘normal’ delivery. My midwife had probably seen this scenario a hundred times over – maybe more. As a result, it was well within the confines of what she would deem ‘normal.’

However, I, as the pregnant mother, do not deliver babies. I birth them. So, what may be deemed a normal delivery, may in fact be a million miles away from a normal birth. And it is this knowledge of what normal birth looks like – just like in the cat analogy – that seems to be disappearing overtime. It is being buried by partograms and delivery wards and syntocinon drips and epidurals.

So, what is a normal labour and birth? I would argue the jury is still out on that point. My personal opinion is that each woman, (and possibly even each baby) has her own normality, her own physiological quirks and nuances that mean there may never really be an accurate, across the board standard. And I would argue that until we know more it is probably dangerous to try and create one. What I do know is that my own third birth was as close as I am ever going to get to experience my normality.

After much soul-searching and for numerous complex reasons, I decided not to have a midwife present for the labour and birth of my daughter. It was two weeks after my estimated due date, and I made a little nest in my living room with candles, a deep birthing pool and a roaring fire. After five days of slow labour, there had suddenly been a surge of intensity in the pain. But it had been manageable, because I wasn’t physically tied down and restrained. And perhaps most importantly, my own body was creating that pain – it wasn’t artificial or manmade. There were no measurements; I had no idea how ripe my cervix was, or how many centimetres it had dilated. I moved around and for not one second did it ever cross my mind to climb onto my bed and lie down on my back. The contractions came and went. Perhaps they were regular. Perhaps they were all over the place. I made no note of them.

What I do remember, however, is that after some allconsuming, knee buckling contractions, the pain suddenly stopped. For forty minutes, there was nothing – not even the sensation of being pregnant. Everything had switched off. Yet something else had switched on: instinct. I knew with 100% certainty that my baby was absolutely fine. I ate toast and drank tea, and lazed about in the pool.

It took mere seconds for my daughter to be born. This rest and be thankful phase was like having a foot on the pedal when waiting for the traffic lights to turn from amber to green. There had been no pushing involved. Standing, I had instinctively and involuntarily expelled her from my body. It was only later that I learnt Michel Odent had coined the term Fetus Ejection Reflex – in our society, a phenomenon rare to experience and even rarer to witness.

So, what are we to make of all this? Exploring the concept of normality won’t be easy, but it is not a task we should shy away from just because it is difficult. We need to better understand what happens during normal birth, so that health care professionals can more confidently pinpoint abnormality. Conversely, such an understanding may also help to highlight when maternity professionals don’t need to intervene. At the moment, research seems to be heavily weighted in how to deliver babies, how and when to monitor, to measure, to surveil and to begin an intervention. And it is my belief that much of this is done under the presumption, or at least an acceptance, that women don’t labour and birth well.

Worryingly, much less is written on how women actually birth babies, and most of the medical literature that I have seen contains very little – if any – input from birthing women. More studies need to include the narratives of mothers, and these need to converge with traditional medical research so as to create a more accurate understanding of normality during labour and birth. Perhaps in the right environment, with the right support and understanding, phenomena such as the Fetus Ejection Reflex would become many women’s birthing normality. But if the maternity system continues in the direction it is going, that is something we will never know.

2. Scamell M and Alaszewski A (2012) Fateful moments and the categorisation of risk: Midwifery practice and the ever-narrowing window of normality during childbirth. Health, Risk & Society. 14:2, 207-221. doi: 10.1080/13698575.2012.661041
3. Anderson T (2002) Out of the Laboratory: Back to the Darkened Room.

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