I have been giving birth for 50 years. What exactly is a “normal birth”? | Health

When I was a medical student and young doctor, the terms most commonly used to describe vaginal birth without the use of instruments such as forceps or an aspirator were SVB (spontaneous vaginal birth) or SVD (spontaneous birth) vertex – the vertex is the top of the baby’s head).

Gradually, at the end of the 1980s and in the 1990s, the words “normal birth” appeared in the lexicon. It was part of the backlash against perceived high rates of interventions during pregnancy and labor, and women’s desire to gain more control over their own bodies, which I support.

“Normal Vaginal Birth” has been so polite and praised that it shines like a beacon in most current obstetrics and midwifery publications. But what exactly is a “normal vaginal birth”?

Often used interchangeably with “natural birth” or “physiological birth”, normal birth is defined by the World Health Organization as birth that is “spontaneous onset, low risk in onset of labor and remaining that way. throughout labor and delivery. The child is born spontaneously [without help] in the vertex position between 37 and 42 completed weeks of pregnancy. After birth, mother and baby are in good condition.

Great. Seems like if pesky doctors and midwives just left women alone, they’d be okay with it. The lambs would frolic in the green fields and Judy Garland would sing Over the Rainbow as the baby’s head gently crowns itself, without any tearing to the perineum. The concept is being adopted by maternity service groups in many countries, including Australia, particularly following the UK’s 2005 campaign for a normal birth launched by the Royal College of Midwives.

For example, the NSW Health Towards Normal Birth project provides goals to reduce the number of cesarean sections, inductions of labor and other interventions, and to increase the number of “normal” deliveries, while making care more patient-centered. happier women and medical staff.

Let’s take a moment to think about the implications of the WHO statement. Pregnant women, to be eligible, must not go into labor spontaneously for 37 weeks or undergo induced labor or cesarean section for any reason. Their babies should have a head-first presentation and should not be too large to pass safely through the mother’s birth canal. No instrument can be used to assist vaginal delivery, as has happened with countless women I have delivered with vacuum, forceps, or by Caesar. They should not bleed excessively either.

Did all these women have “abnormal” births?

Human pregnancy and childbirth have evolved over millions of years to allow the perpetuation of our species. As we have been transformed from our primate ancestors, we have switched to walking on two instead of four limbs; in the process, our ability to deliver has been reshaped and its effectiveness compromised. Our pelvis got narrower to accommodate standing walking, and the human fetus, especially the fetal head, got bigger, as our brains got (potentially) more sophisticated.

During the last weeks of pregnancy and in the first stage of labor, this fetal head should slowly descend into the mother’s pelvis, molding and gradually turning forward so that the widest diameter of the head passes by the widest pelvic diameter.

At the end of the first stage, the cervix should be fully dilated – wide open – so that labor contractions and mother’s efforts can deliver. According to the WHO definition, all of this should take place without any outside help. The WHO definition does not mention a woman’s pelvic floor or perineum, but from the last sentence it appears that these must remain intact for the birth to be considered “normal”.

However, evolution itself, if viewed as a process of ensuring the survival of the fittest, has left in its wake a significant number of dead or injured women and babies. For thousands of years, childbirth was a very high-risk activity – for the ancient Egyptians, Romans, inhabitants of medieval Europe, and much later – and, without really effective contraception until very recently. , it was not a choice for women.

It was not until the 17th century that significant advances were made in reducing the waste of “natural” childbirth, with the arrival of forceps and ergot. There was no real progress until the advent of anesthesia and antisepsis barely 150 years ago. The technical expertise developed over these 150 years – antibiotics, anti-D, ultrasound, safe surgery, oxytocics and many more – has now turned childbirth, at least in high-income countries, into a process inherently very safe for mother and child. There is also a wide availability of safe and effective contraception and safe legal abortion, so that women can choose widely whether and when they want to have children.

This security, however, has been achieved by the massive displacement of births from home to hospitals and the increasing “medicalization” of pregnancy and childbirth. In the mid-20th century, women found themselves marginalized in a hierarchical and patriarchal system that gave them little autonomy from their own bodies. Part of their response has been a demand for more voice in decision-making and fewer medical interventions, during pregnancy and childbirth. The naturalistic and holistic aspects of childbirth, often in places far from hospitals and doctors, have been emphasized by some women and many midwives.

The physiological and psychological benefits of WHO’s “normal childbirth”, if they can be achieved, are indisputable. However, childbirth can start normally but then very quickly become “non-normal”. And even “normal” deliveries can stretch and damage the pelvic floor or perineum so much that it results in long-term incontinence and prolapse.

Excessive pursuit of a “normal” delivery has, in some cases, compromised the safety and care of mother and baby, with serious consequences for the provision of maternity care in general. This certainly happened in the historic British case of Nadine Montgomery of Lanarkshire.

Montgomery’s son, Sam, was born in 1999 with cerebral palsy. Montgomery received £ 5.25million in compensation because doctors failed to explain the risk associated with a normal birth in her case – she is small and has type 1 diabetes. Mothers with diabetes can give birth to children. bigger babies and one of the risks is shoulder dystocia, when the baby gets stuck in labor and may be deprived of oxygen and suffer brain damage, which has happened in Sam’s case. Her obstetrician did not discuss this risk and did not offer a Caesarean section. This was a case which established that, rather than being within the clinical judgment of the physician, patients should be informed all they want to know, not what the doctor thought they should know.

We must now ask ourselves the question: do caregivers – midwives and doctors – have the right to promote “normal” childbirth when informing and counseling women about their birthing options? Judges in the Montgomery case felt that this should be balanced with objective information about all alternatives to “normal” birth. And their decision to support Nadine Montgomery’s claim means that doctors and midwives must now tell women, objectively, all sides of the story.

Medicine has come to compensate for some of the apparent shortcomings when birth is left entirely to nature. We now have several types of birth. Let’s embrace them all.

This is an edited excerpt from The Women’s Doc by Caroline de Costa, Allen and Unwin, $ 32.99

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