In some hospitals epidurals were ‘pushed’. Women offered a package deal of an epidural and induction were told that even if they didn’t have pain relief at that point, they were bound to need it later, so they might as well have the epidural now while the anaesthetist was around. They were not told about possible side-effects and were surprised when their blood pressure suddenly plummeted, they felt weak and faint, and their bladders had to be emptied with a catheter. They also didn’t realise that an epidural increased the risk of a forceps delivery.
Spreadeagled And Harpooned
While I was researching material for The Good Birth Guide I also did a small study into opportunities to move around in labour. This was based on detailed birth reports from 48 women. I found that many birth attendants assumed that women would be in bed. They were expected to lie down or sit propped up. Pillows kept slipping, and any foam wedge was often not high enough to give good back support. Women in labour were often in acute pain when lying or sitting, but were given no help to kneel or get on all fours, and there were often not enough big cushions on which to crouch forward and rest between contractions. Beds were too high to get on and off, and there was no stool. Beds were too hard, too. This was commented on especially by women who were immobilised with an intravenous drip and/or a fetal monitor. Midwives and doctors palpating the uterus and doing vaginal examinations expected the woman to lie flat on her back. This increased the pain.
They took it for granted that she must deliver on the delivery table or bed. All but five hospitals assumed that a woman would deliver on her back. These five offered the choice of lying on her left side. After a vaginal examination many women found it too exhausting to turn into a more comfortable position, so remained supine. Even those who had enough pillows in the first stage often felt they had insufficient in the second stage. When they were moved to a delivery table some were not permitted to take their pillows with them, and were left with only one or two. The delivery table was too narrow and they felt suspended in space. They worried that they would fall off, and when the lower end of the table was removed, that they would push the baby out with no-one ready to catch it. They were particularly anxious if the birth attendant turned away or was talking to anyone else and not concentrating on them. In some hospitals a midwife got the mother to lie with her feet on her hips, in a simulated lithotomy position. But if the midwife twisted away she was lying with one foot supported and the other suspended in air. Women were often told to put their hands on their thighs and pull their heads and shoulders up when they pushed. Many found this very tiring. Though most described the baby being placed on their tummies, some wanted to watch and help lift their babies out, but could not because they were lying too far back. When they asked if they could be more upright caregivers refused to allow them to change position.
In the early 70s the John Radcliffe hospital in Oxford was the first to use a foam support, shaped like the back of an easy chair but with the bottom part, behind the lower spine, bulging outward. ‘The Kitzinger Cushion’ was designed by an architect/interior decorator friend of mine, Martin Sylvester. This hospital also introduced polystyrene-granule filled bean-bags for women who wanted other positions and to lean or crouch forward. Meanwhile discussion had started about the dangers of the supine position because of reduced blood flow to the fetus, and an obstetric chair was invented in Sweden that enabled a woman to sit up.
Change was in the air, but women needed courage to ask for what they wanted.
Caesareans
With the explosion of technology Caesarean rates were rising. The lowest rates were in the Netherlands and some of the Nordic countries where around 10 in every 100 women had Caesareans; in the United States and Canada Caesarean rates were much higher and in some countries (Brazil and Mexico) 30 to 40 percent of all women are given Caesareans. In British hospitals Caesareans were often performed because labour was exceeding the time limits. Women were told that they would not be allowed to labour beyond 12 hours, for example, and many felt the whole thing was a race against time, with the threat of intervention hanging over them.
Following a Caesarean, babies routinely went straight to the nursery. Some remained there for no other reason than that everyone was busy, postnatal wards were understaffed, and ward routines took precedence over responding to mothers’ and babies’ needs. Communication between postnatal wards and the special care baby unit was very poor. A mother felt trapped on a ward far from the unit where her baby was cared for and reluctant to interrupt busy nurses with requests to see her baby. When she did get there she might find the baby had been fed, though she had wanted to breastfeed.
Staff encouraged breastfeeding, and sometimes were enthusiastic about it. Unfortunately, advice and assistance did not always match up to enthusiasm, and the biggest problem was conflicting advice which led to confusion, and at times despair, and resulted in the mother losing confidence and giving up breastfeeding.
The night after delivery was an ordeal for many women because of rules that the baby must be in the nursery. I believe that a mother and baby belong together. This can be arranged safely if clip-on cribs are provided. I would like to see the day when all hospitals have large double beds in which mother and father can be together with the baby in a crib attached to the side. Hospitals, even those which say they offer ‘family-centred care’ are usually highly unsuitable places in which a family can be born.
Bonding
Towards the end of the 70s, as a result of research in the United States by paediatricians Marshall Klaus and John Kennell – both colleagues and friends of mine – the word ‘attachment’ used by John Bowlby to describe the close relationship between mother and baby was changed to ‘bonding’.35
I was happy about this new emphasis on falling in love with your baby. Yet I had trouble with the word ‘bonding’ because it was commonly seen as a magic glue that makes the mother and baby stick together. Hospitals started to advertise and promote bonding. In some of them caregivers turned into bonding sleuths who watched new mothers to see if they responded to their babies in the correct way. If they didn’t, they might be reported to the social services. I went back to the hospital administrators to ask them about their policies. In many of the letters from managers there were statements such as, ‘Time for bonding is allowed in the delivery room’, ‘Staff understand bonding’ and ‘Bonding is encouraged.’
I wondered if this was another imposition on women. It often happens that after a birth in a hospital setting a woman needs time to find herself. That is a normal phase in the moments after birth in an alien environment. I believe she should be able to follow her own feelings.
Breastfeeding
In the 70s it became generally agreed that women should be encouraged to breastfeed their babies for the first months of life and that feeding whenever the baby wanted it was better than a strict schedule. This was largely the result of the Oppe Report of 1974.36 Yet in many hospitals babies were still being given additional fluids, especially at night, with the intention of letting the mothers sleep, sometimes even if they were awake and listening for their babies. In some paediatricians insisted on babies being given water before they went to the breast to rule out oesophageal atresia (obstruction in the upper digestive tract). There was no evidence that observing a feed with water was safer than observing one when the baby was getting colostrum.
Some mothers felt bludgeoned into trying to breastfeed. One said she was handed her baby for a feed and the nurse said, ‘Poor little baby, your mother doesn’t want to feed you herself. You’re only getting a bottle.’ On the other hand, some nurses who were concerned a woman did not have enough milk were pleased when the baby was given a bottle and said things like, ‘It’ll be all right now.’
In many hospitals women said that nurses and midwives did not know how to help. Different ones tried different ways and women were subjected to conflicting advice. One nurse came up and positioned the mother with the baby’s head in the crook of her arm. An
other came and moved it so that she could control it with her hand. Another came and suggested that the baby’s legs would be best tucked under her arm. A fourth placed the baby on a pillow. So women had to keep a look-out to see who was approaching and quickly switch the baby round to the ‘correct’ position. This made an athletic exercise of even the simplest feed. This was later corroborated by Jo Garcia in the Community Health Councils Surveys on Maternity Care.37 She pointed out that rules about feeding were too numerous to be described. One was that a mother must feed her baby in the nursery at night, so as not to disturb other patients who were sleeping. Women had to sit on hard, straight-backed chairs set in a row, lights glaring, sometimes with pop music playing non-stop. Occasionally there was even a queue for the chairs.
Another rule was that women had to fill in the baby’s sucking time on a chart. This occurred where the hospital had moved on from schedules to ‘demand’ feeding, but staff had such little confidence that it could work that it was necessary to record the length of each feed or nibble. Women often made these times up, partly because they found it difficult to be sure when a baby was sucking and swallowing or simply enjoying sucking without swallowing, and partly because the more experienced mothers realised that according to hospital rules the babies were supposed to feed for three minutes on the first day; five, seven and 10 on the second, third and fourth days, and not more than 10 minutes each side after that.
The worst problem for most women was the constant stream of staff requiring information or wanting to do something to them, which made their stay exhausting. Some sent detailed diaries of events during the 24 hours. It was a kind of torture.
Day And Night
Care at night was dramatically reduced and created problems for breastfeeding mothers who wanted to feed their babies as soon as they woke. A completely different system was often introduced when the nightshift came on, which was made up of agency nurses, often unaware of the unit’s ethos concerning breastfeeding. In some hospitals people were walking around, chattering, and waking mothers, while babies were left to cry. Women left these hospitals exhausted.
They were not supposed to labour at night in some hospitals. Labour had to be at the right time, which was in office hours. In one hospital a woman in an antenatal ward with rapidly escalating contractions was told, ‘Go back to sleep and stop imagining things’. The night staff must have realised she was in labour because when they handed over to the day shift they passed on this information, and a midwife examined her and found her in the second stage.
In some hospitals, too, if a woman was admitted during the night she was sedated, her partner was directed to go home, and she was put in a darkened room and told to sleep. For some women this meant that they were deprived of their partners’ support, and of help from staff, when they most needed it, and either passed hours in anxiety and pain until the hospital started up again, or had a sudden dash to the delivery room in the early hours of the morning, while being ordered to stop pushing. Occasionally their partners missed the birth.
Certain methods of managing labour, notably the use of an oxytocin drip or regional anaesthesic, often depended on the time of day, too. A woman labouring at night was unlikely to have drugs to stimulate her uterus, or have an epidural. On the other hand, if she went into labour in the daytime, laboured through the night, and was still in the first stage when activities started in the morning and doctors’ rounds took place, she would automatically be put on an oxytocin drip. Active management related to social divisions of time, rather than the progress of that particular labour.
At night, too, a woman was less likely to be allowed out of bed and to move around. Her spontaneous urge to rock her pelvis, stand up, or go on all fours, might have produced more effective contractions, but an oxytocin drip was used in place of simpler methods of stimulating labour.
There was wholesale distribution of sleeping pills at night time. One mother said that they were ‘handed out like candy’ and staff lacked sympathy and understanding for women who said that they wanted to be alert to respond to their babies, or were concerned about contamination of breast milk with sedatives.
Rigid routines meant that all mothers were woken at 5.30 or 6.00 a.m. to feed their babies, regardless of the fact that some had been feeding during the night and had just dropped off to sleep again.
Cosmetic Changes
Putting up curtains and hanging pictures improved the look of wards, but creating a positive environment is a matter of people. On the other hand, women don’t like having to give birth in boxes. I was appalled when I was taken to see the labour and delivery rooms in a large American hospital. We went down to the basement. There, with all the plumbing, birth took place underground without daylight.
Women appreciate being able to see living, growing things through the window. Many hospitals have been built in which labour and delivery rooms have no windows. There were detailed descriptions of ceilings. When women are in bed the view may be restricted to a wall and a clock. Ceilings were often cracked and stained. One woman encountered a blood-stained ceiling over the delivery table, but luckily had already been warned about it by a friend who had a baby there two years previously!
Many women had lights shining directly in their eyes. It is difficult to surrender to a natural psycho-sexual process with your whole body and mind in such surroundings, and labour has been turned into a clinical event.
The Good Birth Guide was originally published in 1979, the first time anyone had asked patients what they thought about the care they received and published the results. It was a daring venture and bound to attract criticism – even outrage. But my book stimulated a range of enquiries and what amounted to a fresh approach to birth. I can be proud of that.
CHAPTER NINE
THE EIGHTIES:
INSTITUTIONS OR INITIATIVES
The University
One of my few experiences of a ‘proper job’, working in an institution, was in 1981 when I enthusiastically joined a university as a lecturer and Team Chairperson to create materials for community education. Perhaps I’d better not identify the university I worked for given what I am about to say about the experience. I expected social idealism expressed in practice, a shared spirit of adventure, and a stimulating environment. Working there was a shock because they seemed to me cut off from other vigorous organisations that were shaping the way women thought about pregnancy, birth and motherhood.
Our team was supposed to revise an existing course. This tied our hands, and it was difficult working with the original authors, who had set ideas about how their material could be updated.
My main concerns about writing fresh courses on birth and parenthood were that we should draw widely on all the help we could get from professionals and parents, and that materials should be made readily accessible to a much wider public than in the past. They should attract those who would not normally think of doing a university course, be written in an easy, flowing, warm style, starting from readers’ own experiences and the challenges facing them in their everyday lives.
Film was an essential part of the course material and the BBC gave me speed training in the basic skills of video-making.
When Esther Rantzen came to film it was a high spot. She arrived wearing a capacious leopardskin coat, heavily made-up for TV, and with her new baby. She and I went out to a pub for lunch and the baby got hungry. Already the men in the pub were eyeing and talking about her. She just pushed back her fur coat, pulled out a breast, and fed the baby, who nestled under the pelt like a baby cub sucking from its mother. It was a superb demonstration of the ease of breastfeeding and how to incorporate it into a busy life.
I had a lively and excellent secretary, Helen, and became very fond of her. She was pregnant, resigned when I did, had her baby, and died of cancer of the cervix when her daughter was just over a year old. Her mother had disapproved of her choice of partner, especially when she became pregnant. In her last letter to me Helen wrote: ‘My mum still won�
��t talk to me. I was shopping last week and saw her and she totally ignored me. She didn’t even look at the baby. Never mind. I rang her to try and make peace and asked her if she’d like to come and meet the baby. She told me she didn’t want any “intruders” in her family. Oh well – at least I tried.’
I was informed that all work in the department should be done with doors open so that there was easy access. Nobody worked in isolation. In fact, everything took place by committee, and I was very bad at working this way. It was very slow. I felt sucked into a machine which ground up everything I wrote and spilled it out as slobber, and confronted ingrained smugness which was resistant to ideas coming from outside the building. Committee language was churned out, drafted and redrafted, then redrafted again. Decisions were delayed until everyone agreed, sometimes out of sheer exhaustion. The custom was to write everything and then look to external organisations to rubberstamp the material.
Topics were put into second draft stage by a small group on which I was not represented. They were written in a pseudo-academic, patronising style, mixed with jerky, short and disconnected statements. Many vital educational points were thrown out or ignored, without any reason being given although some of my phrases were included in this general indigestible pudding. Finally, discussion on the course team was terminated by the Project Co-ordinator concluding that the whole course should be ‘put on ice’ and that I must get on with writing yet another set of first drafts for the second course – more work to be fed into the sausage machine.
A Passion for Birth Page 22