Sunday, October 17, 2010

Babies Behaving Badly

There are certain phrases that, every time you hear them, they make the hair on the back of your neck stand up on end. For some, it's "you're going to need a root canal procedure", for others it's "while we were changing your oil, we noticed a problem...". For me, it's "if your baby behaves".

If your baby behaves, we'll let you go ahead and deliver vaginally.
If your baby behaves, we will let you get off the monitor and walk around.
If your baby behaves, you can get in the birthing tub.

Let's forget for a minute how ridiculous a concept it is that an unborn child would "misbehave". It is just as ridiculous as the concept that a newborn baby, or any baby for that matter, would misbehave.

Birth is an active, interactive and dynamic process. It is not simply a matter of an object (the baby) being pushed through an opening (the birth canal). There are complex physiological, chemical and psychological processes involved in normal birth that we (health professionals, physicians, researches, midwives) don't even fully understand yet. When women are monitored continuously during birth through Electronic Fetal Monitoring, the baby's physiological responses to the processes of labor, active processes for both mother and baby, are picked up by the technology and converted into waveforms on a piece of paper. This technology has been repeatedly shown through clinical research to bring NO IMPROVEMENT to outcomes (maternal and fetal well-being, absence of birth-related brain injury, and mortality rates for both mother and baby). What it does provide is a minute-by-minute record of every heartbeat the baby experiences throughout labor if someone is sued by someone else after the birth occurs. That's it. That's the role that continuous electronic fetal monitoring plays in a normal vaginal birth that is not altered by intervention. I do not know a physician who would not admit this. It is not a secret.

When you start adding interventions to the mix, which you are likely to do if you are having a baby in the hospital, the monitoring technology plays an additional role. It watches how your baby reacts to the interventions (as most babies do because the intervention represents a change in the normal process in which the baby is designed to participate) so that attendants can remedy issues with additional interventions.
Your blood pressure drops from an epidural and your baby receives less oxygen, causing a change in heartrate pattern. You get supplemental oxygen and more I.V. fluid.
Your baby's cord appears to be compressed by the weight of his body after your membranes are artificially ruptured at 4cm's, you are told to turn over to the other side.
Your baby's heartbeat slows with stronger-than-natural contractions as a result of Pitocin admministration, your dose is titrated.

Of course, this monitoring technology draws a picture as opposed to opening a window. We don't REALLY know how your baby is doing, but we have some clues offered by the technology. The technology, like many things done to women under the medical model of childbirth and unlike MOST (non-obstetrical)healthcare technologies, was actually widely applied before much research was done on its accuracy, safety and efficacy. As a result, the guidelines for interpretation of the printouts have evolved over the past couple of decades and some practitioners have failed to keep up with the new standards. This means that the person reading your fetal monitoring strip and making decisions about your care has as much influence on what happens to you during your labor as what your baby does or does not "do" during your labor.

And Im explaining all of this so that, hopefully, you will understand what bothers me so much about the phrase "if your baby behaves".

Most of this is not adequately explained to most of the women who undergo this type of monitoring during their labor. I would venture to say that in many cases, none of it is explained. The fact that we can't make a diagnosis based on the strip. The fact that the technology has not been shown to improve outcomes. The fact that the processes represented on the strip are not fully understood. The fact that the only thing we can say based on a strip is that we are or are not reassured about the status of your baby.

Now, I know my readers are of above-average intelligence, but really, did anything I just said in the above four sentences befuddle and confuse you? Were you able to appreciate the meaning of the words I just put together to convey a concept?
Granted, you are probably not reading this while in labor anticipating the birth of your baby and your entire life changing in the course of about a day.
But, still. You understood me, right?
So, why then, is it that instead of explaining to women, say, when they are pregnant and NOT in labor, the way that this technology works, its strengths, shortcomings and implications, we instead approach adult women and their adult partners and utter the words "Your baby is not behaving. Do as I say now." or "Your baby is not behaving. We are going to have to do a cesarean."

Even without taking into account the well-documented shortcomings of the technology being relied upon, even without taking into account the desire to not get sued as a motivator, even taking into account all the reasons, founded or not, fact-based or fear-based, that women undergo continuous fetal monitoring during hospital labors, the crux of my issue with this phraseology is that it offers a glimpse into the crux of one of the biggest problems with the medical model of childbirth as it is routinely applied to low-risk, normal pregnancies.

That problem is that it does not respect the basic rights of women.

If you walked into the ICU to find your mother or your father intubated and on a ventilator and asked the physician or nurse "What happened?" and they replied to you "He was not behaving so we had to apply these interventions", would you be satisfied with this answer? Would you say "Okay, doctor, whatever you think is best."? If you took your newborn to the emergency room for signs of dehydration and you were told "She is not behaving, she needs I.V. fluid." would the conversation stop there?

It's almost laughable, isn't it?

And yet this is the kind of information women are given about their babies during labor.
"The baby does not like the pitocin. She is not behaving."
"Your baby doesn't like when you lay on the left side. Turn over."
"The baby is just not cooperating with your induction. You tried, but you are going to need a c-section."
Laughable? Or insulting?
Laughable? Or misogynistic?
Laughable? Or failure to gain informed consent?
Laughable? Or denial of the right to self-determination and refusal of treatment?

Every time Ive heard this phrase uttered, I have waited for the woman who calls out the offending person. I have waited for the person who says "You are going to have to give me more information" or "I think I can understand the concepts at play here if you would please take the time to explain them to me."

Why don't they?

Because they have been trained for nine months or more that their role in birth is to passively accept what is done to them in order to secure the ultimate, best-case outcome of a "healthy mother and a healthy baby".

The bar is lowered and the rules are strongly implied. And women follow them. Giving up their rights. Their power. Their birth.

A compelling reason to choose care under the midwifery model if at all possible, or at the very least to choose your medical birth attendant with extreme, thoughtful care.

If women consistently demand a practitioner/patient relationship that is respectful and cooperative in nature, I believe that practitioners will respond. Under this new dynamic, the practitioners will be able to give better care to more empowered patients and everyone will have a better birth experience.