I have spent the past few days with a woman (hence no blog entries) and have had lots of time contemplating the modern obstetric attitude labour length and the active management .
Active management of labour was brought in initially by Odriscoll in 1973 as a means of speeding up labour. They had a busy unit and wanted to guarantee birth within 12 hours, they felt this would enhance the experience for the mother. The aims were not to decrease the section rate because in both Ireland and the UK at the time the rate was only 5%.
O’Driscoll wrote a letter published in the BMJ explaining his purposes. Even if you don’t agree with them they weren’t to save the lives of hundred’s of women and babies which appears to be the common approach of active management in Australia. O’Driscoll acknowledges the limitations and misinterpretations of his active management and seems to want to clarify the actions of his trial. Why has nobody paid attention to this?
This is from an article by Marsden Wagner on active management of labour’
There is no question that the clocks have been quickened. The definition of the normal upper limit to labor has been reduced from 36 hours in the 1950s to 24 hours in the 1960s to 12 hours in 1972 when active management was introduced. In describing active management, one of its practitioners says: “Twelve hours is considered the maximum safe duration of spontaneous labor and cesarean section is performed unless delivery is imminent at that time” (O’Herlihy). All of these time limits were arbitrarily based on clinical concerns and not on scientific evidence. putting a stop watch to labor, as is done in active management, precipitates many problems. When to start the stop watch and declare the race on is difficult and subjective. “The final component of active management is taking care to diagnose labor only when progressive dilatation or effacement of the cervix is observed. This has never been evaluated by a randomized trial, and the “diagnosis” of labor is fraught with all the difficulties of trying to categorize a continuous variable” (Thornton and Lilford 1994). Each labor is unique and idiosyncratic and frequently may not follow the linear thinking of the partogram which does not take into consideration such variations as the woman’s normal biorhythms or the woman’s natural need to occasionally “take a break” from the enormous effort of labor.
It looks like the definition of a long labour isn’t exactly what we are led to believe in modern culture. Without any indication of a deviation of normal it is ok to labour as your body takes you, with breaks and intensities.
To ensure that labour is on track the hospital staff need to put their fingers in your vagina on a regular basis. At our local hospital a midwife alternates with a doctor when doing this, so you have two people who you are unfamiliar with, one of them a doctor you have never seen before and you will never see again invade your body to see if your labour has progressed. My opinion is there is a place for a VE but the reasons for doing it are few and far between and it’s definitely not to check on a regular basis, as much as 2 hourly in some places. This is something to seriously consider when planning to go to the hospital. It wouldn’t be tolerated in any other circumstances – a stranger putting fingers in your vagina-. If you are not keeping to time then augmentation of your labour ensues. This is the cascade of intervention. One thing leads to another and another until your labour snowballs out of your control.
The homebirth I attended was long. It was over 33 hours long. There were sleeps and walks, the pool and the toilet. “I can’t do it” “please help me” . Bill and Teds Excellent adventure. Friends, photographs, children. A huge flood after a birth supporter took a shower unplugging the hose and popping it in the room with the pool in just on the floor. She then forgot all about it. When the birthing woman felt like getting in to the pool we opened the door of the specially made up room. 500lts of water had syphoned out of the pool via the hose onto the carpet. Lots of clearing up. -I must say I did a fantastic job of it.- The supporter was very upset about it. It was an accident. She was a great friend and fantastic attendant all the way through the birth.
Tears,hopes fears, worry and then A BABY and a fabulous heart shaped chocolate birthday cake.
What a few days. I love this work.
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The World Health Organization’s “Safe Motherhood” guidelines says, “The number of vaginal examinations should be limited to the strictly necessary; during the first stage of labour usually once every 4 hours is enough.” I’m not sure why hospitals find it necessary to check more frequently than this.
I’m so glad you’ve written this article — it’s important that women know they’re real rights and what the evidence actually shows.\
Kathy
I love this article by Wagner. Its my fave as it describes the potential for the cascade of intervention very succintly and the skewed logic of the medical paradigm surrounding birth.
Its one I pass on to friends without having to get on my homebirth ‘high horse’.