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Ik wil mijn werk graag goed doen. Kwaliteit van zorg toetsen aan het naleven van regels heeft misschien voordelen omdat je dan iets hebt om te 'meten'. Maar in mijn dagelijks werk loop ik in toenemende mate aan tegen het gevaar ervan: dat aan het eind van de rit het enige dat werkelijk telt de belangen van de zorgverlener zelf zijn. En wat is dan nog 'goed doen'? Vragen hierbij en ideeēn hierover genoeg - lees maar.

donderdag 24 november 2016

Shoulder dystocia, revisited.

1.
Where I return to the topic of shoulder dystocia and explain why*.

“Safety is the disguise of obstetric ideology.”
(Robbie Davis-Floyd, ‘Birth as an American Rite de Passage’)

“(...) any research is always created and measured against what is already dominant”.
(Nadine Edwards, ‘Birthing Autonomy’)

‘Shoulder dystocia’ is one of my favorite topics, mainly because it’s where I started doubting my own profession. As I dived deeper into the topic, I wondered: could it be that we’re doing more harm than good? 
First, from what I can see, only a fraction of the situations labeled with “shoulder dystocia” had anything to do with the way a baby’s shoulders might have been stuck in the mother’s pelvis. 
And second, the fact we reflect so little on the topic of shoulder dystocia is, in itself, enough to make me recognize the importance of discussing it.
So few changes are made in our policy and I feel desperate. Year after year, the same emergency training on “shoulder dystocia”. Not so long ago, the symfysiotomy (an obsolete intervention) was 're-invented' in the Netherlands. I’m going gray from the horribleness of it all.

Fortunately, this topic keeps me positively engaged as well: by reflection about it in my own practice, by the multiple ways in which the physiology of labor amazes me in my daily work, by a renewed sense of professional pride in the midwives I’ve gotten to know who do not fear shoulder dystocia. These midwives are my heroes.

I don’t think I have all the answers, but I do hope I can contribute to the framing of birth mechanics and birth dynamics. I hope I can shine another light on it. 
And I hope to capably describe something about how our presence permanently alters birth physiology and, in so doing, turns a complication like shoulder dystocia into a self-fulfilling prophecy.
I think changes are necessary and possible. 
There is a midwifery world yet to be discovered, one where working as a midwife is a hundred time more appealing than it ever could be given our current framework.

But it’s thorns before flowers in this rosebush.

I’m taking the liberty of shaking ground, the very foundation of what has served as midwives’ basic knowledge, and which serves as an unscientific basis for interventions. Usually that’s not problematic: most of what we do lacks scientific foundation (and it’s hard to research anyway). 
But this does not let us off the hook for scrutinizing our foundation in a critical way. We are still obligated to recognize when solidified insights are untenable. 
I recently wrote about this in my post “Let’s look beyond our fishbowl”.
Shoulder dystocia is a topic that exposes the inadequacy of our knowledge base, as though we were examining fissures with a magnifying glass.

If you feel attacked by what I’m writing, I hope that will motivate you to approach me. If you disagree with me, I’d like to hear why. I’d like to hear what you think is wrong.

I would like to get a discussion started on how to prevent shoulder dystocia because, in my opinion, it is possible to avoid in most cases. 
I would like to discuss situations that look like shoulder dystocia and how to prevent permanent damage. 

If we could be more consciencious of our blind spots when it comes to a woman’s pelvis and a baby’s head and all the interventions performed in the name of both, well, then maybe birth trauma like Erb’s palsy (caused by caregivers) will become the stuff of history books. I very much hope so.

We – women and caregivers - need more movement in our foundations. Women need to be able to actively use their pelvis when giving birth. Caregivers need to stir up what they think they know.

And so, shoulder dystocia, revisited.

(* I wrote about shoulder dystocia earlier, but these posts have not been translated yet)


2. 
Where the meaning of a shoulder dystocia in the lives of many is mentioned.

“(...) Obstetrics is an utterly social body of knowledge, that is, a human activity built on strong feelings, intuitions, prejudice, entrenched positions, considerations of institutional power, and high passions, all of which have been an intrinsic part of its reasoning and careful observations as it has slowly lumbered along constructing its theories.”
(Jo Murphy-Lawless, Reading Birth and Death)*


Shoulder dystocia is a rare phenomenon, but unfortunately, one with a huge impact on the baby, as well as the mother, her partner, and the caregiver. 
Babies can suffer permanent damage and in the Netherlands 1 to 5 babies out of every 1000 suffer damage to the brachial plexus (Link: definition brachial plexus). 
An unsettling statistic.
Because: what does that mean? Does it mean that, in the Netherlands, upwards of 900 children suffer such damage each year?
Even if it were to happen to 'only' 180 children a year, wouldn't we make an attempt at preventing such irreparable damage?

A shoulder dystocia is traumatic for mothers too, and not just because of the increased probability of physical damage, but because of the violence that accompanies it. In many cases, all communication with the birthing woman was interrupted, reduced to yelling at her to push (contraction or not), while she had no idea of what was happening.
A woman’s partner weathers the events even worse, perhaps. They witness something that is sometimes best described as a battlefield. Yelling caregivers, tensed to their utmost. Ever more people standing around her, fear on their faces. It's not an event easily forgotten!

Later in this series, the experiences for mother and baby are discussed further. But first: let’s address the caregivers themselves.
‘I won’t be able to get this baby out’. The feelings we feel while thinking this thought are the most feared in our profession. 
How to act when encountering shoulder dystocia is covered in all emergency trainings. These trainings focus on what we can do to optimize outcomes in a potentially life-threatening situation. We take part in these trainings every year.
I’ve been known to give cynical accounts of such training (found here, but not translated yet). 

But the reality is compelling and nothing to be snickering about. 
There is a staggering amount of pressure put on us caregivers: the head of the baby is born, the rest of the body isn’t yet, and now it’s up to you whether this baby lives or dies. And every minute counts!
Consider the consequences for the caregivers who inflict damage on a baby, be it a broken arm or clavicle, be it an Erb’s palsy. Oh, but that weighs very heavily.

Is it possible, then, to simply claim that this damage was not necessary? No, it is not. It would be jumping to conclusion. Your intention was to prevent a disaster and if it resulted in damage, well, it was in exchange for something good. Better damage than death.
We cannot just ignore the perceived need to intervene. What else would justify our presence at a birth?

And yet: what if it’s not true? What if our take on shoulder dystocia is not valid? What if the way we choose to resolve it was not necessary in most cases? 
What if it were very much possible to reduce the incidence of brachial plexus damage without even one more baby dying? What if it were equally as possible to ascertain if an intervention was or was not needed?

Opportunities!


*Jo Murphy is a genius. Although she is not ‘easy to read’ I sincerely hope you will take time to read what she has to say.


3.
In which the problem of working defensively – and its consequences - are addressed.

“If I were to extract only two words whereby to classify the concerns of contemporary obstetric practice, they would not include birth, but risk and death.”
(Jo Murphy-Lawless, ‘Reading Birth and Death’)


Shoulder dystocia is a sensitive and taboo subject. It’s a topic where, when you make critical remarks about whether injury to the baby could have been avoided, for example, all the doors slam shut immediately. No critical comments on what happened!

Maybe it’s unavoidable, this feeling of being attacked or criticized when others question the necessity of what we’ve done. 
A useful start: ‘Is it true that...’ But not in this particular case! Wasn’t what happened bad enough?!

‘Neonatal injury following shoulder dystocia is one of the more common reasons for legal action against the gynecologist involved.” So reads the first subsection of the NVOG guideline on shoulder dystocia. 

It’s honest to be open about this, but then let’s also be honest about the possible consequences of making such a statement. One of the possible consequences is that we may start posing less critical questions for the fear that someone be sued.

It’s important to recognize that ‘fear of litigation’ is not cowardice. It’s a logical consequence of a worrying social development where the way to give providers a hard time is to initiate legal proceedings against them. This happens to also be the way to seriously hold innovation back. There should be a discussion about this in our society and we should take a position. There must be a better way than this. If we don’t take a stand, the caesarean section rate in the Netherlands will likely be 25% in ten years. 

Back to the topic at hand: the consequences we are left with. 
There is not a single word in our current guidelines that mentions the caregiver as a risk factor. 
Does this mean we are convinced that, no matter what happens, the caregiver plays no part in the problem? 
Does it mean that legal proceedings, when initiated, are understandable, at best, though unjustified? 
Could that also be the reason, as is heard so often, for why shoulder dystocia is persistently presented as a ‘given’ and the consequences for the baby as ‘inevitable’? Is this why we fill the NVOG guidelines with possible prediction signs? In order to exclusively discuss factors that are about mother or baby?

This only leads to off the record conversations in the hallways about: 
- The differences between caregivers. These differences are not mentioned in any textbook I know of. And yet ask a midwifery student (with considerable internship experience) about the differences she perceived between various midwives she observed, in action. There is a very big difference in what midwives (or doctors) ‘do’ during a birth. Some keep their hands away from the baby until its shoulders become visible spontaneously and then they ‘catch’ the baby (at the most). Others ‘help’ the front shoulder. And others, in the event of a more complicated second stage, set everything up and ready themselves for complementary maneuvers.
- The fact that reported incidences of shoulder dystocia differ among countries and among professions. This could be due to more than just a confusion of names (shoulder dystocia, difficult birth of the shoulder, for example) for the same thing, a confusion often invoked when trying to explain away varying reports of incidences.
But isn’t that a backwards argument? It seems to me that, if the definition is not clear, then we have not clarified the problem.
And if we continue on in this way, we will never clarify it either. And we will not be able to ascertain the reason for why defining shoulder dystocia is proving so hard to do.

So, holding on to the phenomenon of shoulder dystocia as a ‘known fact’, something that cannot be prevented nor changed, is a decision that carries consequences.

Are we simply at peace with this?
The truth is that, at this time, many women who experienced shoulder dystocia with a prior birth are given a ‘recommendation for place of birth’, the so-called plaatsindicatie. That is, they are told they can no longer give birth at home. Midwives fear shoulder dystocia in a homebirth setting and voilà, arrangements are made without even the tiniest shred of evidence in support of this advice making the upcoming birth safer. You could even ask yourself whether the a priori probability of having shoulder dystocia happen is increased by assigning this plaatsindicatie. (A number of arguments for why this could be the case are presented in the upcoming paragraphs.)
And then it gets even trickier. It becomes more and more common to consult a gynecologist about the best course of action for a woman with a previous shoulder dystocia. And more and more the consulted gynecologist recommends a primary caesarean section. This boils down to a 100% defensive policy.
The whole baby is thrown out with the bathwater, meaning a permanent end to an ideal opportunity to reflect on our own blind spots. 
This is how it went with breech births as well.
Midwives, don’t fall asleep at the wheel!

When we work defensively the unintended negative consequence is not only that we increasingly miss out on opportunities to retain skills. We also relinquish opportunities to learn (or unlearn) something. 
The price is high, for women especially. 
Isn’t our caesarean section high enough as it is?


4. 
Where a little more is said about Erb’s palsy and about being aware of what it is that you are pulling on.

“The assertion of obstetrics, that it has conquered death, making childbirth safe for women, requires careful examination because the medicalisation of childbirth has not been an unqualified success and has not given to women all the benefits it claims to have done.”
(Jo Murphy-Lawless, ‘Reading Birth and Death’)


Damage to the baby’s brachial nerve is one consequence of the maneuvers we perform to resolve shoulder dystocia. This is known as Erb’s palsy (link).

There are those that claim that Erb’s palsy is a birth trauma that occurs spontaneously, independent of a provider’s intervention. (See, for example, this PubMed article titled ‘Are all brachial plexus injuries caused by shoulder dystocia?’). 

Do you believe that? I don’t.

The arguments put forth in the NVOG guidelines support the theory that an Erb’s palsy may occur spontaneously:
- Half of the reported cases of Erb’s palsy do not mention shoulder dystocia. 
But that doesn’t really tell us anything, does it? It might as well be that this means that for some caregivers the standard way they pull at the baby’s head is that firm, that they pull an Erb’s palsy to the child in a situation they themselves would not describe as ‘shoulder dystocia’. Sometimes there is a fine line between what is ‘delivering’ and what is ‘pulling’.
- Subsequently the possibility is left open that plexus injury can occur by way of 'maternal expulsive power'.
Yeah, right. As if it’s possible to ‘push’ an Erb’s palsy.
I have yet to see a case of Erb’s palsy reported after an ‘unmanaged’ birth (from when contractions start and until the toes emerge), where the baby was not touched by anyone except by its own mother. Where the baby’s completely healthy.
- The incidence of Erb’s palsy after caesarean section is the last argument used to demonstrate the ‘spontaneous’ occurrence of Erb’s palsy.
Yeah, duuh.

Photo ©2013 Patti Ramos Photography
http://www.facebook.com/doulapattiramos




















Now, I can quite understand how difficult it is to take hold of such a slippery baby when doing a caesarean. And I understand that this is an extreme picture. But what this picture does show is a bizarre move that, no matter how you look at it, can cause serious damage to a baby.
And, what’s more, I have seen a lot of vaginal deliveries in which this pulling happened in nearly the same way. Unfortunately, I have done such things myself. It is very easy to have a grip on the baby’s head.

But let’s get to the meat of the matter. How on earth did we ever come up with the idea that it’s suitable to maneuver the baby via the baby’s head? 
And not just holding by the head comfortably above water for a bit while the baby is floating in the tummy tub. Oh no, this is more like if I were to pick the baby out of its crib by its head during a postpartum visit. My career would be finished!

Let’s suppose it’s possible to lower the incidence of Erb’s palsy. Then we need to stop pushing aside the real issue: Erb’s palsy is caused by pulling. It is iatrogenic damage.


5. 
In which it is demonstrated that the current definition of shoulder dystocia allows for a glimpse of a persistent misconception.

“What you don’t watch, you cannot see.”
(unknown)


The definition of shoulder dystocia according to the NVOG guideline is: 

‘The term shoulder dystocia refers to when, after the birth of the head and its movement towards the sacrum, additional obstetric maneuvers are needed to birth the shoulders.' 

I mentioned earlier that a ‘vague’ definition is a potential indication of a poorly understood problem. By now you probably won’t be surprised that I think we have not understood the problem because it is, indeed, vague.

For starters, a portion of the NOVG’s definition could be read in two ways, namely:
- the baby’s head moves towards the sacrum or
- the caregiver directs the baby’s head towards the sacrum.

If the definition is trying to say that the head moves towards the sacrum, then we have an observational problem here. From the moment the head is born, it moves away from the sacrum, not towards it. If the caregiver refrains from ‘delivering’ the baby (and he/she should refrain from that anyway – more on that later), then the head follows the movement of the body. That might be towards the sacrum in the event that the front shoulder comes first, but it is much more likely to continue straight downwards or towards the symphysis, because the rear shoulder comes first. 
You will discover this only when you start dissuading women from lying in bed and when you stop ‘delivering’.*

If this is what the definition is trying to say – that the head moves towards the sacrum after it is born – is it any surprise that an adherent to this theory would assume that the front shoulder be the one born first? 
And what if that leads the caregiver to try to help the front shoulder so that it is the one born first? 
And, what if the rear shoulder would have been the one to be born first if the caregiver hadn’t done any ‘delivering’? What would result?

Now for the other interpretation, where one assumes that obstetric management would be needed for the shoulders to be born (see my post ‘lege artis ontwikkelen’, not yet translated into English.)
I think there is an observational problem in this case too. Anyone working in this field and who sometimes just lets nature take its course know this is not true. Birth dynamics ensure the spontaneous birth of the shoulders.
In otherwords, no one else, beside the woman and the baby, is needed. No one, period. The word ‘additional’ in the NVOG definition suggests that in the case of ‘delivering’ something ‘extra’ above and beyond ‘delivering’ is needed. Which that is not correct. Normally, nothing – not even ‘delivering’ - is needed.

Here is an issue that, I believe, contributes to a fundamental lack of understanding about how a baby is born safely. 
How often do our hands really add something important? 
Or do they undermine that safety?

In other words, you cannot see what you don’t watch. 
Do we observe ourselves enough? Do we observe what we do? What do we take for granted?


* (By the way, and this is also relevant later on: it is obviously clear that there is a substantial difference between a woman who chooses herself to lie down and a caregiver who expects her to lie down.)

6.
In which the ‘time’ factor contributes to a better definition of shoulder dystocia and we take a look at all the things we don’t know.

“When you are in a hurry, take your time.”
(Teacher Amsterdam midwifery school, 2000-2004)


External assistance is basically unnecessary in a spontaneous birth, but, given our cultural habit of ‘catching’ babies, we’ve lost sight of this, considerably.

There is much more to say about that, and I will say it. But first I would like to make clear that ‘delivery lege artis’ is nonsense. This doesn’t mean I think that there isn’t a single situation where outside help is desirable. One of these situations could even be described as ‘shoulder dystocia’. 
But what is shoulder dystocia?

It might be stating the obvious, but it is worth reminding ourselves that three players are needed to perform ‘obstetric maneuvers’:
1. the mother, 2. the baby and 3. the midwife / doctor.

Suppose the third is not present. Suppose, too, that both mother and baby are in good condition. Under those conditions, I can imagine that it might take more time for the baby to be born completely. And I can also imagine that this has something to do with the shoulders needing to rotate. But what I cannot imagine is that, in 0.2 – 3 percent of the birth, this would lead to the baby not being born.

We are assuming it could take too long for the baby to be born completely, causing the baby to become asfyctic (link), or to even die. 

And that means that the reason a caregiver turns to ‘obstetric maneuvers’ is not because the maneuvers themselves are necessary, but because he/she does not want to lose more time. 

Or, to define it more clearly (my proposal for a more precise description of the problem):

“Shoulder dystocia presents when, in the estimation of the caregiver present, too much time passes between the birth of the head and the birth of the body, at which point he/she proceeds to additional obstetric maneuvers.”

The introduction of the ‘time’ factor leads to several additional differences in the presentation of shoulder dystocia. 
There is difference among individuals: To be seen in countless YouTube videos where (mostly American) OB/GYNS or midwives start delivering the shoulders immediately after the head is born, as if they didn’t have any time to lose. 
But I’ve also seen videos where a provider waited two contractions before acting on the urge to intervene. 
There is also a difference among countries: In Great Britain it is quite normal to wait after the birth of the head. It’s not a question of ‘whether’ you do that; it’s just done. The reported incidence of Erb’s palsy (i.e. unintended consequence of obstetrical maneuvers) in Britain is lower than in the Netherlands. Could these two things be interrelated?

There is, apparently, quite a difference in the perception of how much time we actually have. 
And the tricky part is that we don’t actually know how much time we have exactly nor what it depends on. Four minutes? Six minutes? Ten minutes? 
And, what’s more, this is a really difficult question to answer with research. To be able to answer the question 'Is it true that...’ is hard because we are afraid of consequences we are convinced will happen and so we don’t dare wait longer.

But what if there is a link between the time you have and whether you have (or have not) already manipulated the baby? 
Does the baby’s muscle tone change with the maneuvers? Does that act positively or negatively to ‘resolve’ the situation? 
And what about checking whether or not the umbilical cord is around the baby’s neck? What influence is that if the umbilical cord is handled? And what if an attempt is made to slip the cord over the head? Does that influence the functioning of the umbilical blood vessels? Negatively? Making asfyxia more likely? 
Or do we just assume that it’s not a problem? How do we know that? And can we be sure?

A prolonged pushing stage and shoulder dystocia seem to be related; this also applies to instrumental deliveries and epidurals. 
But why?

And is there then a difference between a prolonged second stage where the woman was actively coached (to take a deep breath, to push, push, push – that’s it – to exhale, to take another deep breath, and so on and so on), compared to where she labored independently?
In other words: couldn’t that ‘long duration’, combined with the increased incidence of shoulder dystocia, be due to the increase of ‘intervention’ of the caregiver present at the birth? Is there any research out there that looks into the outcome differences between births where the caregiver delivered ‘lege artis’ and where the caregiver did not?

I think we do not know the answers to these questions.
So is it possible to state that ‘in dubio abstine’ doesn’t count here? Why not?


7.
Where a bit of practical advice is given and an introduction to the sequel, for those who’d love to dig deeper.

‘People become the product of the culture that feeds them.’


Let’s summarize:

Shoulder dystocia is a traumatic event for everyone involved. 
It is, moreover, a complication that leads to working defensively because iatrogenic damage (such as Erb’s palsy) can occur. 
Working defensively deals a fatal blow to reflection on what we do and, for me, is a definition of bad care.

A close reading of the definition of shoulder dystocia, as it now stands, proves unsustatinable because:
- it demonstrates a misunderstanding of the physiology of ‘normal’ birth;
- it does not involve the caregiver as a possible risk factor.
The moment the caregiver and his/her motive to intervene (i.e. time constraints) are involved, what we mean with shoulder dystocia becomes clearer.

So, how to proceed?

I would first like to return to the argument that reducing the number of Erb’s palsy cases should be well within reach. 

And I would like to look at the prevention of shoulder dystocia, with a new attempt at seeing beyond our cultural ballast.

The related question of ‘What is the better way?’ will also be discussed. 
As a side note: my writings do not intend to exchange one technique for another because I don’t think much will change if we solely abandon one for another. Understanding the reason for why we do the things the way we do is so much more interesting!

So, Erb’s palsy. 
I do not mean to imply, with what I’m about to say, that you are an idiot if you helped a baby out by the head last week. Or if you put the mother in the McRoberts position. 
And, although I still kick myself (regularly) for prying children loose in this position, it has helped me understand that I’m part of a culture. We do things because we’ve learned to do it that way. Things are ‘true’ because we’ve learned they are ‘true’.

This is especially the case with how we deal with shoulder dystocia, in which it is all too clear that the outdated estimation of women as the weaker sex persists. Time might have passed this concept by, but the obstetric foundation has not.











I mean: why on earth do we think we could learn anything whatsoever with the table and the mannequin set so as it is?
We mean very well, but we actually do stupid things.
And allow me to be blunt: one of the foolish things we do is the McRoberts maneuver (link to short video) on the delivery bed. 
Whatever you may think of all my theorizing, set fire to that intervention. Burn it!

The idea is nice – changing the pelvic passage by putting the womans legs in her neck. But it renders her (immobile already, on her back) even more powerless. Furthermore, there are much more effective ways of encouraging a woman to change the diameter of her pelvis with movement. 
The only outcome of the McRoberts maneuver is that caregivers feel more inclined to ‘deliver’ the baby and to exert traction on the baby’s head – whether you want to call this ‘pulling’ or not – and that the associated risks are incurred.
If you think you need to intervene;
If the mother does not solve the situation herself (and you would call the situation ‘shoulder dystocia’);
then simply stop using the baby’s head in your actions meant to resolve the situation. And that is something you will be prepared to do only when you are prepared to stop doing anything with the baby’s head. 
It is not a handle. Not even a little bit. Period. 
There are alternatives which carry a much lower risk of Erb’s palsy.
And (spoiler alert: section 8), if you reach a point where you’re considering a McRoberts, it means you’ve been off-track for a while. 
To which you say: ‘but what else is there to do when she’s lying on a half-bed?’. I completely agree, but what was she doing there in the first place?


8.
Where I pick up where I left off and where the passive woman is discussed.
“How much of obstetric practice has been about learning without discernment?”
(Jo Murphy-Lawless, ‘Reading Birth and Death’)

“I suppose it [skill] comes from experience, but it feels they’re actually not getting the experience”
(citaat van een vrouw, in ‘Birthing Autonomy’ van Nadine Edwards)


We know that giving birth is an active process. We still immerse ourselves (I hope) in learning about the brilliant turn of the baby through the woman’s pelvis by way of the combined action of factors having to do with both mother and baby.

We really do know about the ‘dynamics’ of the process. And yet, somehow, something has gone wrong. 
Earlier I mentioned the myth of ‘delivering lege artis’, a myth that probably stems from the inquiries made by those who laid the foundation for what we know. Laying a woman down in bed was considered a compassionate act, and it also ensured visibility of (and access to) the perineum. This, in turn, allowed a provider to then lend a helping hand at any time (with instruments, if necessary). That was why she was on the half bed in the first place.
So, I need to go back to this picture:

This is a ‘patient simulator’.
By using the patient simulator, multiple caregivers are able to learn how to cooperate in a coordinated way once rare complications present (thereby making fewer mistakes, as pilots have a ‘flight simulator’).
I cannot object to having access to a rubber baby simulator for CPR training. By the time resuscitation is needed, there is little movement in our ‘object at hand’ – the mannequin acts real enough, in that scenario. But, when the model represents a birthing woman? One who is not unconscious? Or fully anesthetized?
Such a model is clearly intended for practicing skills, but certainly not for gaining insight into our question of shoulder dystocia. 
For that, I ask: who is piloting the plane lying there?

A striking feature of the stories told by women with previous birth where shoulder dystocia was present is that they had no idea of what exactly happened – this in spite of having the single task of ‘listening very carefully’ to what was being asked of them. At best it was assumed the caregiver had to urge them to take action, but never that they would do that by themselves. Let alone take the steering wheel. 
We caregivers have all be taught that we are the ones who need to sit in the driver’s seat. But what would happen if you decided, just once, to refrain from doing that and just waited? 
Is the thought of ‘I cannot get this baby out’ one that should actually be in the birthing woman’s mind instead of the caregiver’s? And should we make our appearance only when she calls for us? And would she have laid down like this by that time?

Is nature that cruel or are we that urbane as to make all this ‘necessary’?

From my own ‘basic knowledge’ in midwifery, I know that the mere asking of these questions would seem reckless and irresponsible. 

But I would like to ask another, an even trickier, question: Isn’t it, in fact, totally inappropriate to immobilize a fellow human being in this way?

‘Well, yeah’, you might reply, ‘but I meet so many women who are fully willing to put their fate in my hands’. 
Do you think that it’s strange? That after generations of input, they are now supposed to do that?
The ‘time’ factor from section 6, in combination with the woman forced into passivity, leads one, in my opinion, into troubling and murky waters. 

When you, as a caregiver, are willing to work systematically ‘hands-off’ (and that means that you literally keep your hands to yourself), only then will you get the chance to observe how closely a woman’s body and a baby’s body work together during the whole duration of the birth. You disrupt this process completely when you put a ‘time’ on the moment the baby’s head is born, thus leading you to have the shoulders born immediately after. And yes, who knows, maybe you did prevent a disaster from happening. But how can you be so sure that, when you started to act, you were not the source of equally as many potential disasters? 

Two suggestions for now:
The first is for women who have experienced shoulder dystocia. If you, even slightly, felt doubts about whether it was really true that it didn’t ‘fit’ or if you can’t remember exactly what went ‘wrong’ in your situation, then think about who the ‘pilot’ was in your labor, think about whether that could have influenced events.
And if you had to or wanted to relinquish control, then be very, very careful with making plans for your next birth. The chance for a repetition of events might be much lower than what is usually assumed. And indeed, a caregiver’s anxiety about the risks for a repetition of events can influence how big that chance ends up being. So, in your search for an environment that will promote a safe birth, please look for a caregiver that does not fear shoulder dystocia.
The second is for caregivers. Watch out for this trap: ‘Since a shoulder dystocia with a woman’s prior birth was resolved in a position other than 'that where she was lying in bed', then it could be a good idea to ask her to push in that position during a subsequent birth.’ This is still you – and not the woman – with the hands at the wheel!


9.
Where it turns out that what you can’t see is rather worth looking at.
“Except for being hanged by the feet, the supine position is the worst conceivable position for labor and delivery.”
(Roberto Caldeyro-Barcia, gynecologist, 1975)


In 2011 85% of Dutch women gave birth lying on their backs (percentage taken from the Deliver study).
I still get worked up about this topic, though I know that’s not so productive.
But only a small percentage of women will give birth ‘on their own’ in a supine position. Of course they will sometimes, and ‘whatever she is used to’ is a factor that’s fair enough. But it is astonishing that in our era of ‘evidence-based midwifery/medicine’ a tradition totally lacking any scientific foundation persists, despite its numerous disadvantages. 
In addition, there is evidence to suggest that it could sometimes even be dangerous to give birth in a supine position. There is a potential higher chance of hypoxia for the baby. And for the mother, an increased chance of having an instrumental delivery. These are only two of the potential risks. So, it is not only about giving birth comfortably, it is also about safety.

If women can find a beneficial position by themselves, then that will seldom be the supine position. A woman who stays upright is pretty much spontaneously active and inclined to be in charge. There’s a lot to say in favor of that, even if it’s to cope with everything that is going on in her body. 
This is not only my opinion; it is a fact, a fact that more and more takes root in the caregiver realm.

When it’s about ‘being in charge’ and about ‘coping’ and things like this, we, as caregivers, tend to say: ‘Yeah, sometimes you just need to temporarily accept that there is no other way, that someone takes charge for a moment. See it as a sacrifice a mother does for the well-being of her child.’

Because that is the way we have been taught to see it.

I really hit the ceiling a few years ago when I received the KNOV leaflet: ‘Which position suits you (link)?’

Unfortunately, it contained one short sentence too much: ‘If medically safe, your midwife will support you in your choice.’ 

A commonsensical enough sentence. On the one hand we all know that the supine position is an intervention with no benefits for mother nor baby. On the other hand, the same supine position does benefit actions of the one responsible or in charge. That is how we were trained; we see virtually nothing else, it feels familiar to us....
Yes, we have made a potentially unsafe mode of delivery (there is only one that is even worse) the current norm. And that is what we call ‘medically safe’.

Maybe we can come to terms more easily with our conscience if we do adress te topic, after all decades of evidence cannot be ignored, but bury it under a heaping serving of medical gravy? 
If we tell ourselves it’s only a ‘bonus’: nice and desirable when all goes well, but (oh well, too bad) not supportable when it becomes ‘medically unsafe’? 
But isn't it true that the available evidence for an ‘active birth’ shows that it should be exactly the other way around? 
One would think that, if there is mention of ‘increased risk’ or of something ‘medical’, then it would be especially important to choose the most favorable position?

In that case, it would be more logical if the aforementioned sentence read: ‘Giving birth in a supine position is also fine, as long as it is medically safe’.

I’ve mentioned it before – we are left to pick up the pieces. All the research we have from the last 100 years, let’s say, consists of 95% of the births in a supine position.

















Have you ever watched a woman’s bum when the baby is actually ‘on its way’? I’m not referring to the red strip in this picture, though there is a lot to say about that (it’s not always visible, but when it’s visible, it is at its longest shortly before the baby arrives). What I’m pointing out is the woman’s sacrum. It looks completely different than how it looks when she is not giving birth. At the place where the two parts of her buttocks lie against each other (also when she’s kneeling), you can see a ‘wedge’. It seems like her sacrum bends outwards and sideways. 
This is the place where the all-important space is created.
Sometimes it seems like the whole baby sinks toward this space before it comes out, and the bigger the baby, the more time it sometimes needs. 

I paid pretty close attention during my training, and yet I wasn’t taught anything about this. 
That’s not strange, of course, because what you cannot see, you cannot look at either.

But since hearing about it and since being able to look at it with my own eyes, I have begun to worry about our ‘knowledge’. To ask a woman to lie down on this highly important dynamic part of her body? And then to watch and see how she handles it? 

I’m not trying to suggest that you would be able to prevent all shoulder dystocia if women were able to give birth in every position they felt like. 
But what on earth do we do with all the evidence collected with the help of women who managed to birth their child in the second worst conceivable birth position?


10.
Where we again point out how complex the topic of shoulder dystocia has become.
“The promotion of the conditions for physiological birth is best achieved by the recognition of flexible definitions of normality, understood in the context of uncertainty, non-linearity and complexity. We believe that this recognition of the ‘unique normality’ of each woman should be a fundamental midwifery skill.”
“It may even imply that if systems such as labour are not allowed to progress to the edge of chaos, the body cannot make the dynamic change necessary to accomplish essential phase transitions.”

“Without this understanding of the complexity of birth, the uncertainty of our knowledge in the area and the salutogenic potential of childbearing, we approach normality with very limited vision.”
(Alle citaten: Soo Downe et.al, ‘Normal Childbirth’)


So here we are. 

We, the midwives, and those working with midwifery, have become the ‘experts’; the birthing woman is the ‘laywoman’. 

We are the ones responsible for a good outcome; the birthing woman has to trust us. 

We monitor progression. 
We monitor the condition of mother and child.

But it seems we have defined what is ‘normal’ from a perspective of what, down to a fundamental concept that is, is incohesive at best. 
The woman gets a passive, physically deactivated role at the exact moment it is most relevant. 
Lying flat on exactly that part of her pelvis where the dynamics are taking place, surrounded by senseless rituals in which we ‘help’ the baby. 
And accompanied by the ticking time clock, for how long no one exactly knows. And we hold onto that as a foundation for our theoretical knowledge.

To put it bluntly: it is quite a bit worse than ‘incohesive’. It is wrong and it results in mismanagement. 
And the most serious error is that we fail, from the start, to derive insights from our own role in the matter.

Once more, I don’t think I know it all. 
But since I stopped looking at births in that unsuitable linear way, I haven’t once been afraid of shoulder dystocia. 
And I especially haven’t been afraid of it since becoming aware that my feeling of ‘being responsible’ and the persistent impulse to take control, to pilot, are not founded in science. 

That feeling of responsibility and the persistent impulse to take control is only founded on cultural habits, habits by which I am horrified in any other context.

Women are not damsels in distress. 
And women are everything but lay people when it concerns their own body. Women instinctively know exactly what to do. 
Or, perhaps it could be phrased better as: they could know what to do if they were able to occupy the space needed for that to happen.

No, not all births go smoothly. 
And sometimes interventions are needed. 
But something has to change with the way it is currently taught and the way we currently teach it to others, because otherwise we just keep going. 
We keep on practicing maneuvers to resolve shoulder dystocia without questioning where it came from in the first place. 
Or in other words, how the h#@% we got ourselves into this situation?!


11.
In which questions are listed and practical advice for everyone is given.
“Do bees bee? Do bears bear?”
(Bruce Willis in ‘Moonlighting’)

“I trust birth and the woman who owns it.”
(Carla Hartley)


Well, did I discuss everything I wanted to?
Not quite.
I still have a list of questions, and that list keeps growing.

Things like: what is the influence of vaginal exams?
Should we actually do those?
By default? Or on indication? Which indication?
Push away a cervical lip?
How long do we wait for the urge to push?
Does coached pushing ever makes sense?
Is a fast birth safer than a long one?
Why?

What would happen if you adopted the basic assumption that the woman is the one who ‘owns the problem’ at birth? And that she is, in most cases, by far the one completely equipped to resolve this ‘problem’? Just like with any other of her bodily functions? 
What would happen if you worked from the basic assumption that this is not only ‘empowering’ but, plain and simple, safe? (Just like with any other of her bodily functions?...)

There is so much more that we don’t know than what we do know.

As far as that is concerned, we might be better off laughing occasionally at our ‘own’ expertise.

I'll finish with a few suggestions.

1. Wait.
Caregivers: If there is still a possibility to do nothing - then do nothing.
In any case wait for the next contraction (unless the birth of the head was preceded by a cascade of interventions). And certainly wait until the birthing woman asks for your help.
Birthing woman: When the head is born and the body does not follow (yet), follow your impulse. MOVE. If you were sitting or kneeling - stand up. If you were standing, squat deeply.
There is time for this.

2. Caregivers, practice waiting, because we are not used to it.
There are very educative videos to be found about what I mean by that. This one, Jaimes Birth (link) is an absolute ‘must’. (Please note, this video contains very graphic images of a birth).

3. Never, and I really mean NEVER, cut and clamp the umbilical cord in vulva.
Not only is this completely unnecessary, it is life-threatening.

4. I already said it, but I can’t say it often enough: if you think you need to intervene, in any case don’t touch the baby’s head.  The place you need to be is the sacral cavity. But to be honest I think that when you apply suggestion #1, chances are small you will ever do this.

5. Dare, whether you are a caregiver or not, to be honest about fear.
Fear is the worst advisor imaginable.

Fear is also one of the most contagious emotions imaginable.
When you’re pregnant and your caregiver expresses doubts about risks that concern your body or your baby, without being frank about his or her own fear, please be careful.

Better no caregiver at all than one who does not know his/her own fear.

6. Reflect, as caregiver, about the things you do and don’t do - your mere presence influences the process. If you want to know whether the physiological process is ‘safe’ or not, you will have a problem when you are not aware of the effect of your own presence.
To give an comparable example: if you try to find out at what time a herd of deer drinks water and you sit by the water’s edge and wait, you might conclude that they never drink.

7. Meet other colleagues to exchange thoughts about this topic.

In conclusion:
If something is not done soon, it may soon be too late for midwifery, as a profession. Maybe we have been focusing a bit too much on ‘delivering’. But I am hopeful as well and refuse to give up, because there are plenty of women willing to teach us the trade.



Thank you:
I feel deeply grateful to both Marjolein Faber and Margie Franzen for their assistance with this translation. Vrouwen, zonder jullie had dit stuk er heel anders uitgezien! 


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