Thursday, November 22, 2007

Dysfunctional labor

One of the greatest ironies of homebirth advocacy is that homebirth advocates are so blinkered by their philosophy that they cannot interpret the body's signals.

Early in my internship I worked with a professor of surgery who had a profound influence on my thinking. He would always admonish us that the patient was "telling us the story" if we would only listen. He didn't mean just the patient's words, though that is very important, he meant the patient's body as well. Through signs and symptoms (and lab values, and test results) the patient's body gives us all the information we need to determine what is going on. Yet in our rush to confirm our personal impressions, we often discard information that doesn't fit and thereby ignore the fact that our diagnosis is wrong.

Homebirth midwives are profoundly handicapped in preventing and managing complications because their understanding of the human body and its signals is simplified to the point of meaninglessness. The philosophy of "trusting birth" presumes that the body "knows" what to do. It is a bizarre tautology in which whatever happens must be the right thing because that's what has happened. So if a pregnancy extends beyond 42 weeks, it is because the baby "knows" that's the best time to be born; if labor lasts days, its because the body "knows" best; if the membranes rupture long before labor begins, it's because the baby "needs" them to rupture.

Homebirth midwives, because of their lack of basic knowledge and training, cannot see the wondrous complexity of human birth. For reasons that we do not understand, the body seems to recognize impending childbirth complications and attempts to avoid them. In addition, the body sends signals that a problem is developing. Obstetricians refer to the signals as "dysfunctional labor". Unfortunately, homebirth midwives refuse to listen.

Dysfunctional labor is a SYMPTOM. The uterus does not attempt to tear itself apart by forcing a baby too large to fit against the bones of the pelvis. The uterus often recognizes when a baby is malpositioned and refuses to bang the wrong presenting part up against the cervix over and over again. Dysfunctional labor is NOT a personal insult. It is not a sign that a woman's body is "broken"; it is an early warning system. Because homebirth midwives and homebirth advocates are so hung up on "trusting" birth, they cannot bear to acknowlege that such a system even exists.

There is a thread on MDC that illustrates this perfectly. A midwife describes a situation in which the patient had a 9 hour second stage (!!!) before transfer to the hospital. At the time of C-section, it was found that the baby, although head first, had one leg folded flat up against its body and the other leg beneath it. It was clear that the baby could not have fit through the pelvis in that position. The midwife now believes that there was no possible way for her to have known about this malposition, but she is entirely wrong. The patient's body was telling her about the malposition for 9 HOURS, but she wasn't listening.

The midwife couldn't perceive the very obvious symptoms because reality conflicted with her over simplified view that the woman's body always "knows" the right thing to do. The patient's body was "telling the story" to the midwife and she was completely ignoring it. The contractions in the second stage were weak and desultory, and that's why the midwife encouraged the patient to continue laboring. Yet the weak and desultory contractions (dysfunctional labor) are a SYMPTOM of malposition. The uterus was trying not to kill the baby by repeatedly ramming it against the bones of the pelvis and the uterus was trying not to tear itself apart by repeatedly pushing against a malpositioned baby that could not possibly fit.

One of the most toxic aspects of homebirth advocacy is the bizarre idea that childbirth complications are a personal affront that must not be acknowledged. Complications are not sign that a woman's body isn't "working" or is "broken"; often they are an early warning of a serious underlying problem.

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