A Passion for Birth

by Sheila Kitzinger

  Women felt they must be on their guard against being seen to be ‘knowledgeable’ or ‘demanding’: ‘The most delicately worded questions were interpreted as sinister threats’. A midwife exclaimed, ‘You’ve been reading books!’ or asked sarcastically ‘Who put those ideas in your head?’ There were striking exceptions to this in a few hospitals. A woman who was in pain asked for pethidine and ‘Sister said, “Do you really want it? I don’t think you have much longer to go”.’ And the mother delivered happily shortly after. Another asked for an epidural, though she had said beforehand that she hoped to be able to manage without one. In this case the anaesthetist suggested that she was doing so well that she probably did not really need it and stayed with her, helping her with her breathing and relaxation during every contraction. She looked back on what was obviously an ordeal at the time as a very positive experience. But it is clear that drugs for pain relief were often used in place of emotional support, and that some caregivers were adept at undermining confidence: ‘She said, “You don’t know how painful it is going to be. You haven’t any idea”.’ The midwife said, ‘“I’ve never seen relaxation work yet.’”I was greeted with, “So you are another of those huffers and puffers”.’

  Continuity Of Care

  Contributors to the research set high value on continuity of care and being able to get to know well those people who looked after them through pregnancy, labour and the postpartum period. Those with GP/midwife care saw fewer professionals than those who had consultant care.

  But even where care was given by a large number of professionals, women appreciated being greeted by name and welcomed by members of staff introducing themselves. This acknowledgement of individuality, being treated as more than just one more bulging abdomen, was important. Antenatal clinics provided for most of these women their introduction to the worst aspects of fragmented care. Clinics were described as ‘badly organised’ and even ‘a shambles’. Women told of long waits, sometimes exceeding two hours, being moved from queue to queue, and coming away from the clinic frightened, depressed and humiliated. Even in units where care in labour was personal and intimate, in the antenatal clinic work tended to be task-centred, not woman-centred, and ‘the only continuity was that of written notes’. There were several accounts of notes being lost.

  Women wanted to be remembered in the antenatal clinic and to meet the same people in labour whom they had already encountered in the clinic, and liked the midwife who delivered the baby visiting the postpartum ward to see how the mother and baby were getting on. During labour shift changes sometimes caused confusion and distress and a woman had to work at establishing a link with a different midwife and to redefine her wishes with members of staff whom she may never have met before, often when contractions were coming thick and fast in the late first stage.

  In some hospitals women were left alone for long periods and described members of staff popping into the room to ask rhetorical questions such as ‘Everything OK?’ and passing on before they could answer. They also described people ‘wandering in and out’ sometime when the mother was in the shower, on a bedpan, or physically exposed in the second stage. They said they did not know who most of these people were, but it included ‘tea ladies’ and other ancillary hospital personnel. ‘I felt like an animal with so many people present during a vaginal examination’ one woman said, and another, ‘There was a succession of nurses and midwives, none of whom I had ever seen before or saw again after the birth’. One woman even laboured with a window cleaner clinging like a limpet to the delivery room windows, apparently fascinated by the view of her perineum.

  Satisfying personal contact was most likely to be remarked on by women who had GP unit deliveries and continuing care from a community midwife through pregnancy, labour and the immediate postpartum period. This was sometimes stated as the reason they chose GP/midwife care in the first place.

  Information

  Women stressed the importance of being able to get accurate and unrestricted information. Nearly every account contained references to the ease or difficulty with which information was obtained about, for example, the progress of labour, alternative courses of action, the side effects of treatment and such things as the measurement of blood pressure and the outcome of a scan. Where women had free access to information they said things like, ‘All my questions were answered fully’, ‘They explained everything they were doing and asked if I consented’ or ‘The midwife consulted us over every issue’. There were other women, however, who felt taken over as if they had been sucked into a complicated machine. This process of feeling treated like an object acted on by doctors and nurses started for many women in the antenatal clinic. Care in the labour ward and delivery suite was sometimes more intimate and personal than in the antenatal clinic at the same hospital.

  A woman’s satisfaction with the information which she was given and being asked to share in all decision-making was only indirectly related to the degree of obstetric intervention. Though in high-tech hospitals women said they felt manipulated even in some very straightforward labours, in some complicated labours other women felt free to make informed choices between alternatives, and said they were consulted and their views respected. One woman who had a forceps delivery, for example, said, ‘The doctors explained what they were doing in such a gentle, respectful way that it was as if they were suggesting what they would do.’

  Autonomy

  Support for personal autonomy was important in every account. ‘It was a team effort, with me as Captain’ one woman stressed. ‘It was my labour and they were there to help if needed’, another said. Their autonomy was supported where the system was flexible and the woman’s needs and wishes recognised, and caregivers made it clear to mothers that they had freedom of choice and could ask for what they wanted and staff co-operated to adapt to the wishes of the individual. In those hospitals a woman felt that it was she who was having the baby, not the staff. One woman said that after lifting her baby out of her body, she turned to the doctor as she was cuddling her daughter and asked if the baby was all right, ‘He replied that he hadn’t seen her yet and then we all realised that he had just stood in the background and let us get on with it.’

  Yet in many hospitals the mother’s freedom to decide what she wanted and to act spontaneously depended on whoever happened to be on duty and it was impossible to know in advance if she would find allies or whether it would be an uphill battle.

  Clockwatching

  Time was also a central issue, time given for discussion with the mother, and time for her to feel that she could work with her body instead of battling against it to get the baby born.

  When women praised the birth environment they often said it was ‘a relaxed atmosphere’. ‘I never felt rushed’, ‘I could ask him anything, however trivial, and would always get a patient answer.’ One woman wrote, ‘When I asked about the size of the baby in relation to the pelvis the doctor disappeared and returned with a bright blue rubber pelvis and a doll and delivered the child several times, this during a particularly busy afternoon.’

  Some women discovered that an intravenous oxytocin drip was set up as part of the admission procedure, often without asking permission or explanation other than a comment such as, ‘We’ll just help you along. You don’t want a long labour, do you?’ It was common practice to do an amniotomy (the artificial rupture of the membranes), fix an electrode on the fetal head and set up a drip to stimulate the uterus shortly following admission. These women felt taken over by a baby-producing institution. They said things like, ‘I felt like a tin of beans on a conveyor belt.’

  In the second stage some had time to find their own rhythms without being commanded or coaxed to push, but many said they were ‘rushed’, ‘harried’ and urged to push harder and longer. ‘I was hectored by a jolly midwife who seemed to have done her training on the lacrosse fields of some girls’ public school’. Women were sometimes told it was the rule that they could be in the second stage no longer than o
ne hour, and then it must be forceps. Occasionally this was restricted to 45 minutes. They described the anxiety, desperation or sheer panic this caused.

  Time was also of primary importance following birth and most women referred to time with their partner and baby. They valued having unlimited and undisturbed time together and where it was restricted to a statutory ‘ten minutes bonding time’, after which the partner was told to leave and the baby often ‘whisked away’, said they felt ‘frustrated’, ‘cheated’, ‘sad’, ‘lonely’ and even ‘disoriented’.

  Technology

  Whereas some women felt trapped and immobilised by electrodes and catheters, a small number felt more secure when the fetal heart was monitored continuously and many used the monitor to help them prepare for contractions, watching the print-out to see when they should start using breathing and other techniques learnt at antenatal classes.

  But most described how it made them anxious, distracted them from concentrating on relaxation and breathing, or restricted movement. They often said that the staff took no notice of the print-out and there were frequent descriptions of monitors not working properly or breaking down completely: ‘Various members of staff came in and kicked it. They said to ignore it. It was always doing that.’; ‘It was on the blink and emitting a piercing whine.’; ‘They left us alone with the monitor for an hour. I couldn’t see the point of it, since no-one even looked at it.’; ‘It wasn’t recording anything properly. It seemed futile to have the electrode on the baby’s head and to have to lie still when it wasn’t registering anything.’; ‘A doctor came in and pointed out that the belt was monitoring my heart rate, not the baby’s.’

  Technology often prevented a woman’s spontaneous behaviour. It was difficult or impossible to move or get into a comfortable position. ‘I sat up to see the head and was told off for disturbing the drip.’ Some women said they were instructed to lie on their backs so that the monitor could more accurately register the fetal heart, so they had to adopt a position which tended to put pressure on the inferior vena cava and reduce the flow of oxygenated blood to the fetus. Women often acknowledged the skills of obstetricians in dealing with the abnormal, but in many high tech units felt the constant threat of intervention in normal labours.

  Ritual Interventions

  I learned that shaving of pubic hair, a practice that started in hospitals created for the indigent poor to eradicate pubic lice, together with the routine enema, were still seen as part of ‘clean midwifery’. Women were often told that the shave was done to have a bald area for episiotomy and suturing the perineum. A few years later midwifery research showed that shaving did not reduce infection, but increased bruising and caused multiple abrasions around the hair follicles. Though the enema had become an almost sacrosanct element in the management of birth, research was to show that it, too, was of no benefit, and if a woman had an enema she was more likely to pass liquid faeces as she gave birth.

  In the 70s Active Management was the norm, membranes were routinely ruptured on admission, and other interventions, dictated by the clock, took place from then on.33 In some hospitals it was possible, provided she made it clear that this mattered to her, for a woman to try to deliver without an episiotomy, but most women were cut in the end because staff had no idea of how to help them give birth so that they didn’t need one, and they were urged to push harder even though they didn’t want to.

  Continuous fetal monitoring, with monitors located centrally at the nursing station without having to stand at the patient’s bed, and management of labour to last not more than six hours from six centimetres dilatation in women having second and later babies and 11 hours in those having first babies, were more or less routine. Membranes were ruptured artificially early in labour, often when the woman was admitted, when she might be only two to three centimetres dilated. Then an electrode was attached to the fetal scalp so that continuous monitoring could take place. Unruptured membranes were thought of as getting in the way of the progress of labour. But early amniotomy exposes the baby and the uterus to invading pathogens. Infection is directly related to the length of time between amniotomy and birth.

  Iain Chalmers wrote, ‘Thousands of existing questions have not yet been investigated in systematic reviews, and thousands of systematic reviews have shown that the existing evidence does not answer important questions about the effects of many treatments. This challenge will not go away – indeed, resolving one uncertainty almost always results in the recognition of additional uncertainties…

  ‘The consequences for patients of acquiescing in therapeutic ignorance can be disastrous, yet, perversely, current attitudes to, and restrictions on, therapeutic research are powerful disincentives to people who wish to confront uncertainties about the effects of treatments. It is up to clinicians, patients, and the public in general to decide whether they wish to continue tolerating this bizarre state of affairs.’34

  Fathers

  I campaigned for acknowledgement of a father’s role in childbirth. In those days a male partner was allowed in the birth room only in the role of voyeur, and back in the 60s, the first man to be with his partner in a big American teaching hospital had to handcuff himself to the delivery table before he was allowed to stay.

  Fathers couldn’t be turned out at home, and the midwife often depended on a man to learn the geography of the house and where she could find things she needed.

  In hospital men often had to wear gowns, masks, caps and overshoes. As an anthropologist I could see that protective garments play a ritual role denoting status in the hospital hierarchy, and the lower down in it an individual is, the more protective clothing he has to wear. This produced a barrier between the woman and her partner. For one thing, they couldn’t kiss each other. A mask used for 15 minutes is no longer sterile anyway. It has only a ritual function. One hospital that undertook bacterial counts when overshoes were used found that there was no statistically significant difference, so discarded them. Caps rarely covered the hair, so they had a ritual function, too.

  The father was treated as an optional extra. Most women wanted their partners or some other companion with them. Hospitals usually allowed a single labour partner, but sometimes only for the second stage to witness the delivery, because first-stage wards opened onto each other and were inadequately screened. In many when a woman was admitted in early labour, or having labour induced, the partner was sent away because ‘It’ll be hours yet’, or was told to eat or have a smoke because ‘Nothing’s happening’. He was only there on sufferance.

  If he was present he might be told to watch the monitor print-out to tell the woman a contraction was coming. His eyes were focused on the machines. Occasionally a midwife tried to form a feminine bond with the mother by saying, ‘We women understand each other. Men can’t know’, or something of this kind. In a disturbing number of hospitals the man was asked to wait outside during minor nursing and obstetric procedures. This included admission procedures, amniotomy, the insertion of an IV, when she was using a bed pan, and vaginal examinations. Staff often forgot to invite him in again. Sometimes drugs for pain relief or an oxytocin drip to accelerate labour were given without him being told. He then came back to find there was no room beside her because a machine had taken his place, or that she was drowsy with pethidine and he could no longer help her handle contractions with techniques they had practiced together. He was barred from attending a forceps delivery or Caesarean section, just when she was most likely to need him.

  Drugs For Pain Relief

  Freedom of choice with knowledge of alternatives was especially important when it came to drugs. In some hospitals women were persuaded to have pethidine or an epidural and nurses stood over them asking, at the height of each contraction, ‘Don’t you want something to take away the pain?’ or words to that effect. When staff gave warm approval to a woman’s determination to cope without drugs and supported her in her decision, the way was opened for an almost conspiratorial collaboration which boosted moral
e and made it much more likely that she did not, in fact, need analgesics or anaesthesia. This mutual aim formed a strong bond between a woman and her caregivers; ‘I said I didn’t want pethidine. I wanted a natural birth and the midwife was delighted’. They worked together with a sense of common purpose and it gave spice to the relationship.

  Writers referred often to ways in which midwives offered pain relief through strong emotional support and in the words they used rather than through drugs. Non-pharmacological relief of pain was provided by touch and holding, eye contact, massage, changes in position, moving around, and unswerving praise. A good midwife gives of herself, not only of techniques.

  Women were also told that they had a ‘long way to go’ in labour when, in fact, they were almost fully dilated, and in some cases given a high dose of pethidine, and when they asked what was being injected, were told, ‘Never you mind. We know what we are doing’, or words to that effect. It was possible to ask for a mini dose of the drug, but difficult when a junior midwife felt that she couldn’t give a lower dose than one that was normally prescribed, and sometimes a woman had to choose between not having pethidine and having a dose of 150mg. That is enough to cause extreme drowsiness, nausea and vomiting, confusion, amnesia, visual disturbances and hallucinations. It makes the baby less likely to breathe spontaneously at birth, especially if given close to delivery, may make it sleepy in the days following birth, be slow at sucking, and interferes with the interaction between mother and father.