How Healthy Are We?

This year marks the end of the second “Healthy People” decade. Healthy People is a program that puts together an extensive set of 10-year health goals for our nation with the intention of promoting health for America. Various government agencies, along with outside organizations, have worked together to come up with goals that are of the highest priority for our nations’ health.

Being in the field that I am in, I am always eager to see the goals they set for maternal and infant health, along with how we do in meeting those goals. Of specific concern to me is how they view the rate of cesarean sections.

In the Healthy People 2000 set of goals, a target of a 15% total cesarean rate was set for our nation, with a 12% rate for first time, low risk (full-term, singleton, vertex presentation) moms, and 65% target for repeat cesareans. The actual numbers were an improvement from what they had started at, down to 21.8% for total, 15.7% for first time moms and 66.4% for repeats, but did not meet the intended goals.
For Healthy People 2010, you may notice that the target rate went up. The goal for first time cesarean section was set at 15%, and target repeat cesarean was for 63%. A few points difference, but when you take into account how many thousands of women those points account for, that’s a lot of cesareans. We do not have any comprehensive data on these statistics any more current than 2007, but if we are continuing along the trend we see from that year’s rates, we are far, far, FAR from our goal! Last I heard, our overall cesarean section rate was around 31.8 %.
That’s more than twice the intended rate.

So, what’s going on here? Our health agencies and organizations believe that reducing the rate of cesarean sections is imperative for improving the health of our nation, but we are moving away from our goals in this area.

Why is a low cesarean rate an indication of a healthier nation? Isn’t cesarean a life-saving technique? Yes, it is. Having access to technology that can be used in emergencies is an indication that our country is advanced, but the use of these procedures does not mean that we are healthier because of our advancements. My belief is that we are too quick to use our advanced techniques when low-tech approaches could work just as well, if not better. If our high cesarean rates are a reflection of the number of emergency births that take place, there is something seriously wrong happening. Our women are becoming very unhealthy if one-third are unable to birth their babies. Our babies are becoming very unhealthy if one-third are too distressed to be birthed. Not only is our high cesarean section rate an indication of poor health prior to birth, but it increases health risks following birth, creating a new epidemic of young women with fertility problems, uterine problems and needing hysterectomies. If it is true that one-third of our nation’s births are emergency situations, we need to back WAY up and figure out how we can help women become healthy prior to, and throughout their pregnancies. We need to figure out how to grow healthy babies and promote that.

My question for Healthy People is how they intend for these goals to materialize into action? It’s one thing to set a goal, it’s quite another to make a plan of action and follow it. What is the point in setting these rates when there is no plan also set in place in how to achieve them?

Healthy People states that they are “grounded in the notion that establishing objectives and providing benchmarks to track and monitor progress over time can motivate, guide and focus action” but this is clearly not the case in obstetrical care. Though the “Mother-Friendly” and “Baby-Friendly” stamps of approval were established as an incentive to practice evidence-based, goal-meeting, care in hospitals, in the 14 years that these guidelines have been established, I can only find 86 hospitals in the entire United States that can claim being Baby-Friendly, and have yet to find one Mother-Friendly award.

Do we just not care? On the one hand, we see it important enough to list in our health priorities, but on the other hand, the shows we watch, the organizations that are respected, and the numbers themselves all show us that we really don’t care enough to do anything about it. Instead of it being seen as a medical emergency, cesareans are beginning to be seen as the norm.

Setting a goal without a plan of action is like saying you want to lose ten pounds and then continuing your life as you always have. If you want to lose weight, you need to make an effort and have a plan of what you are and are not going to do. The same goes with the Healthy People goals. Just setting a goal is not inspiring enough to the obstetricians in our nation. They need steps to guide them.
So, let’s look into the cesarean epidemic. Why are our rates so high? Why do they continue to climb when our goal is set for something much lower?




The first thing we need to do is address the top reasons for medically necessary cesarean sections.

1. A Previous Cesarean
Well, the easiest way to avoid this is to avoid the first cesarean! But, since that’s not always an option, we need to look into the reasons why a primary cesarean necessitates a repeat cesarean. Research shows that the risks of a vaginal birth after cesarean are much less than the risks of having another cesarean section.
A previous cesarean should not automatically place a woman in need for a repeat cesarean. The opportunity for women to have a vaginal birth after cesarean (VBAC) needs to be supported and encouraged.

2. The Baby is Too Big
This is a commonly given reason for a truly rare problem. American women, with their access to plenty of nutrition, should not be suffering from debilitating bone growth conditions, such as rickets, which would inhibit their ability to birth a baby. American women, in general, have pelvises that are perfectly suitable for passing a baby.
The problem lies in a misunderstanding of a pregnant woman’s anatomy, physiology, hormone production, and the baby’s role in his exiting.
 A woman’s production of relaxin and hyaluronidase during the last part of
pregnancy and throughout labor loosens up the ligaments of the pelvis, enabling it to stretch and move a lot more than a typical non-pregnant pelvis. As a side note, dehydration can decrease hormone production, so do not restrict access to fluids.
 A woman needs to be able to move in labor in order to allow the baby to navigate its way through the twists and turns of the pelvis. This is best done if a woman is upright and has the use of her legs.
 Squatting during pushing can open the outlet of the pelvis by more than 10% to allow more room for a descending baby.
 Physiological pushing ensures that mom is not wasting energy and only pushing when she and baby are truly ready.
 A well-toned pelvic floor can encourage a proper head flexion of the baby to allow for the smallest diameter of the head to lead the way out.
 Allowing enough time in labor and encouraging movement with the mom will help baby get into a good exit position, rather than rushing a baby down into a more difficult position.
 Not rushing a labor, and letting it progress on its own time will help with the baby’s head molding into a shape that fits through a mother’s pelvis.

3. Breech Baby
Delivering breech babies vaginally has been taboo for so long now, that it has come to the point where there are very, very few doctors who even know how to deliver a breech baby. Preventing breech babies should be the first consideration, followed by more attempts at delivering breech babies vaginally. The best ways to discourage a breech presentation are through the following:
 Have an extensive knowledge of optimal fetal positioning, and practice it throughout the end of pregnancy and in labor.
 Make time for body work such as chiropractic adjustments, craniosacral therapies, myofascial release, massage therapy, acupressure, acupuncture, and physical therapy.
 Have a practitioner who is good at palpating to have an understanding of how the baby lies, or do it yourself through belly mapping.
 If baby is not moving through home techniques and body work, try an external version.
 Allow mom to go into labor and utilize the wide range of movements to allow for baby to turn in labor.

4. Transverse Baby
A transverse baby is a problem indeed. A baby truly cannot come out of his mother shoulder-first. To reduce the likelihood of this position, the guidelines for preventing a breech presentation apply to transverse presentation as well.

5. Placental Problems
We cannot prevent all, but a healthy lifestyle and good nutrition prior to conception and throughout pregnancy, will greatly reduce these issues. Mothers with previous cesareans are at greater risk for placental problems due to the scar tissue acquired from the cesarean.

6. Slow or Arrested Labor
Failure to progress is one of the most common reasons for cesarean sections. The reasons why labors slow down or stop are so various it’s hard to address the issue unless you know all the little details surrounding each woman’s circumstances. But here are some basic things to consider.
 Starting a labor with artificial means increases the chance of a labor stalling out, because sometimes, a body just isn’t ready! Letting moms go into labor on their own will increase the chances of labors happening at a time when both mom and baby are ready.
 Women in labor are incredibly sensitive to what’s going on in their surroundings. Privacy is vital in order for a woman’s body to follow the natural course of labor. If she does not feel safe or respected, her body will shut down the labor process. Being respectful, quiet, and calm around a laboring woman will help to support her through the process.
 Encouraging movement and walking throughout labor can help a labor along. Studies show that it can shorten the length of labor by 25 %. Walking opens the inlet of the pelvis, allowing room for the baby to descend and move into a good position.
 Epidurals are known to slow down labors when given too early, or just as a reaction in some women. Using natural pain coping techniques can be effective in managing labor pain, as well as helping labor progress at a steady rate.
 A body that is well nourished and has the strength and stamina to endure hours of labor will be less likely to wear out and give up. Encouraging good nutrition and exercise throughout pregnancy can give women a better chance of a healthy labor.
 The presence of a supportive birth partner has been shown to shorten labors by 25%. Encourage participation by husbands, partners, and the use of doulas.
 If a woman is not in good active labor, she should not be wasting her time in the hospital! Being admitted at an early stage of labor can cause boredom, stress, excessive use of medication and fear, all of which can slow and stall a labor.
 In about 1/3 of labors there is a phenomenon that occurs called the Natural Alignment Plateau. During this time, contractions may continue but dilation does not happen, or contractions may stop all together. While dilation is not occurring, progress may still be occurring. Muscle revitalization, hormone production, a baby changing position, head molding, the release of fears, colostrum production – these are all ways in which progress can be made while dilation is not occurring. Staying patient while this occurs can lead to a labor which ends in rapid dilation (once all of the unseens are taken care of, things tend to move quickly). To force a labor forward that is experiencing a natural alignment plateau may be interfering with processes that are vital to the mom, baby, or both.

7. Umbilical Cord Prolapse
A cord prolapse is a true emergency situation. The umbilical cord is the baby’s lifeline while it is in utero. If the cord slips down past the baby’s head and gets pinched or compressed, the baby’s oxygen source is cut off.
> One of the ways to avoid a cord prolapse is to not artificially rupture membranes, especially early on in labor. Early ruptures are at a higher risk of cord prolapse because the baby tends to still be high in the mother’s pelvis, allowing more room for the umbilical cord to slip past.
> Avoiding internal exams during pregnancy and excessive exams during labor can help prevent early rupture of membranes. Each time an exam is done, bacteria from the birth canal is pushed up toward the bag of waters. This bacterium can eat away at the membranes and increase the likelihood of an early rupture.
> Healthy diet throughout pregnancy helps to create a strong membrane that is less likely to rupture early on.

8. HIV or Genital Herpes
In this instance, preventing the diseases prior to pregnancy is a must. Continued education on abstinence and safe sex practices needs to be encouraged. Women with genital herpes may still be able to have a vaginal birth if they are able to suppress a herpes outbreak at the time of birth.

9. Multiple Births
Multiple births seem to be on the rise now that infertility treatments have become so readily available. In order to grow healthy multiples, a healthy diet and lifestyle is absolutely necessary. Just because there’s more than one baby growing in the uterus this should not automatically put mom in the cesarean category. Vaginal birth of multiples is possible and should be attempted. Because of the increased likelihood of a breech presentation with multiples, vaginal breech deliveries need to be revived and doctors should relearn this practice.

10. Fetal Distress
The majority of cesarean sections I know of are a result of fetal distress. This is a scary situation. Why are so many babies unable to handle the rigors of labor? If this was the intended way for babies to come out, shouldn’t they be able to endure contractions and birth? While contractions and exiting through the vagina is the way that our bodies and babies are intended to work together, the rest of the labor story tends to stray from the intended course.
While distress can occur even during a completely natural and hands-off labor, it is important to note that any time you interfere with the natural process of labor, you are inviting repercussions. That’s why every single intervention should be weighed in a risks vs. benefits analysis.
One of the most noted side effects of pitocin is fetal distress. Pitocin, which causes unnatural contraction patterns, affect babies differently than normal contractions. Because they are stronger and last longer, they are adding stress to the baby in utero.
Add the epidural. Again, one of the most noted side effects of an epidural is a drop in mother’s blood pressure and decelerated heart rates in babies. And when an epidural is used in conjunction with pitocin, the pitocin is much more likely to be abused. If the mother cannot feel the intensity of the contractions, the medication can be administered in higher doses, without thinking that the baby still is feeling the intensity.
So, to counter the cesarean due to fetal distress, we need to:
 Lower the induction rates! Starting a labor chemically can stress out a baby who isn’t ready for labor, and it can cause stress to a baby due to the intensity of the pitocin-powered contractions.
 Utilize movement in labor! Movement in labor helps a labor to progress, which means less likelihood of having it augmented by pitocin or artificial rupture of membranes. Rupturing the membranes can also increase stress on a baby, as the cushion of water is no longer present and the strength of the uterus squeezing directly on the baby’s head can become harmful after time. Movement also helps to move baby into good positions. Many times women are asked to lie down on the bed and not move in order for the baby’s heart rate to be picked up on the fetal monitor (to ensure that baby is not in distress). The funny thing is, laying down and being still can put baby in a compromising position and cause distress in and of itself! Fetal heart tones can be picked up on a woman upright and moving by holding the monitor to the belly in conjunction to where the baby is during that time.
 Avoid pitocin. Avoid it for induction, avoid it for augmentation. It’s just better to stay away from the stuff.
 Avoid epidural. Having an epidural can slow down contractions which can then lead to augmentation with pitocin. Epidurals in and of themselves can cause fetal heart rate deceleration. Epidurals also prevent a mom from being able to move and when mom lays in one position, babies can get stuck in compromising positions.
 If fetal distress is suspected, fetal scalp sampling can be done to test for true distress in a baby.

11. Maternal Medical Conditions
There are many different medical conditions that cause concern for mothers who are carrying a baby. Some are truly incompatible with labor, some can handle labor if mom is
If there’s a chance for a mom with a medical condition to give birth vaginally, it’s important to keep these in mind:
 healthy eating and a healthy lifestyle prior to conception can make a huge difference in your options once you are pregnant.
 Controlling your medical condition through nutrition, exercise and medications throughout pregnancy can help increase your chances of a normal labor and birth.
 Try labor. See how the mom’s body reacts. Don’t just rule out labor.

12. Baby’s Birth Defects
Some birth defects are incompatible with labor, so cesarean is the best option for these babies. But often times, labor is beneficial for the health and well-being of a baby who has problems, so this is something that a parent needs to really research.
The March of Dimes has gone through a huge effort to help prevent birth defects through education. Good nutrition and a healthy lifestyle prior to conception and throughout pregnancy cuts down on the chances of birth defects, as well as a mother taking the right supplements (i.e. folic acid).


Now that we’ve addressed the top reasons for medically necessary cesareans, we need to figure out the steps to take prior to the cesarean becoming necessary.

1. Nutrition and lifestyle counseling. This should not start *in* pregnancy, this needs to start in infancy! This is a lifelong goal, and not one that should be brought to action only after a woman is pregnant. If a woman is unhealthy when she enters a state of pregnancy, encouraging good health and nutrition still can make a difference, and should occur, but the earlier, the better.
2. Utilize midwifery care. We are seriously lacking in balancing out the specialized practice of obstetrics with practice of caring for normal pregnancy with midwives. The midwifery model of care goes a long way in preventing many of the reasons for cesarean sections, and our nation needs to look seriously at this.
3. Utilize doulas. Because doctors and nurses are kept so busy, doulas are wonderful additions to the labor room. They provide continuous labor support for the mother, father and family. They help the mom with the emotional side of labor and help her through finding her own way. They drastically cut down the medicalized part of labors and help moms get up and moving. Insurance companies would be very, very wise to reimburse families who use doulas. They can greatly reduce the cost of a hospital stay.
4. Train nurses in taking care of laboring women. Because of the high percentage of medicalized births, many nurses do not know the needs of a naturally laboring woman. If cesarean rates are to go down, those who work with laboring mothers need to know how to help them in ways that protect, rather than interfere, with the natural process.

Birth

Watching birth videos always makes me cry. Not because of fear, or thoughts of pain, or sympathy. I cry because watching women bring forth life fills me with an overwhelming feeling of awe. Because women are so beautiful, so strong, so amazing.

Epidurals at the Door

With an over 95% epidural rate in the area I'm currently living in, most people seem shocked at the idea of taking natural childbirth classes. Obviously, childbirth is about pain, and you want to do everything you can to get rid of that pain!

But here's the cold, hard truth, ladies. An epidural is not a guaranteed thing! Sometimes you have a quick labor. Sometimes something holds you up from getting to the hospital early enough on in labor. Sometimes the anesthesiologist is being utlized for someone else's emergency situation. Just because you sign up for an epidural birth does not mean that you will get one!

So, what happens to a woman who is in labor and finds out that the one basket she has put all her eggs in has crashed to the floor? Every labor has to start sometime, somewhere, and I'm pretty sure most will not be in a hospital room with a catheter already in the back. You will have to cope with contractions at some point.

A woman who knows how the body works and how to work with it is a woman who will experience a lot less anxiety, a lot less panic, and a lot less fear about getting to the hospital in time.

Attending childbirth classes that go over plenty of useful pain coping techniques is essential to every pregnant woman. I've had women who have taken my natural childbirth classes who have ended up on pitocin, had an epidural, gone through a cesarean birth, and every single one has come back to tell me that relaxation techniques were vital to their labor, no matter how it turned out.

Learning how to relax, how to calm down the mind, how to create a setting of safety, how to deal with pain - these are all techniques that are useful in various birthing situations as well as situations outside of the labor room! These are life skills!

Working Hard For Normal

Why is it that we must fight so hard for what is normal in birth?

Normal is not what you would find if you took a glimpse into an L&D ward at any hospital around the U.S. Normal is what you'd find if you took a look at birth through history and various cultures around the world.

What is Normal?

Normal is women up and moving in labor.

Normal is women wearing what is comfortable for them in labor.

Normal is women eating when they are hungry and drinking when they are thirsty.

Normal is women being free from wires, lines, pokes, prods, straps, and needles.

Normal is a laboring woman being at the center of the childbearing drama while a group of supporting women surrounds her.

Normal is a woman having instincts and trusting them.

Normal is a familiar room full of peace and love.

Normal is knowing those who are with you in labor.

Normal is a woman knowing that she was made to give birth.

Normal is women rushing with a power that their own bodies provide.

Normal is trusting that birth has a ton of fail-safes set in place.

Normal is understanding that there is a reason for what happens.

Normal is a woman surrendering in labor -- not to others, but to her self.

Normal is knowing that most variances of labor can be handled in a calm and competent manner.

Normal is trusting that mothers are responsible for making decisions for themselves and their babies.

Normal is being touched by loving and caring hands.

Why is this not normal for our country? Because we are all wearing glasses tinted with a film of medical superiority. Instead of normal, we have handed birth over to an atmosphere steeped in danger, fear and pain, where women are martyrs and doctors are saviors.

We need to put on a different set of glasses. We need a shift in paradigm. When viewed in a light that our bodies were made to give birth. That this is something women have done for all time and the human race still exists. That our bodies are capable of growing and delivering a baby into the world. That it is a normal human function. It seems a little ridiculous to create such chaos around every single birth when it is obviously unnecessary.

Fathers at Birth

Because there has been such a long struggle to allow fathers to participate in the birth experience with their partners, it sometimes surprises me when I read or hear someone talking negatively about fathers at birth.

When Dr. Bradley began teaching women how to give birth naturally, fathers’ only participation was pacing in the waiting room, smoking a cigar. It wasn’t until Dr Bradley continued receiving lavish affection from these mothers after their births that he realized what an intimate and bonding experience birth was, and maybe he should invite the fathers to take part in it. I love what Dr. Bradley has to say about the fathers’ role, that it’s not just his job to plant the seed, but to nourish it and remove any weeds of doubts and anxieties.

There is an idea in most Americans’ heads of what labor looks like. Generally, it’s of a woman in pain, screaming at/hitting/or pulling on the man that put them in that situation. In all the Bradley births I’ve attended and heard feedback from, this has never been the case. When a mother is nurtured by a loving husband throughout her pregnancy, when he takes the time to understand what is taking place inside her, when he devotes his time and energy to working with her through the whole process, then birth is not a blaming or hurtful event. It is a bonding and loving event.

I strongly believe that women should be supported by women in labor. But I also believe that there is a crucial role for the father as well. A woman in labor needs to be cared for by other women and her husband. Each of them brings something to the laboring woman that the other can’t, which makes for a more fulfilling experience. While a husband may see his wife in pain and only think of ways he could take away the pain, another woman can look at the difficulty of labor and know that the mom will be okay. At the same time, this husband is also the only one who knows this woman intimately, all her deepest desires, her loves, her passions, is the only one who loves her deeply, and is the only one who makes up part of the baby being born. While a father can never truly understand what a laboring woman is going through, understanding the process, learning tools that help, and being an emotionally strong presence will truly lead to an experience that exceeds all others.

Is this too much pressure on the father? Some (a lot?) think so. While I don’t think fathers should be made to suffer through the laboring experience because their wives are experiencing pain, I do think it’s important for a father to see the process. When he sees the hard work that labor is, when he puts himself to use to help her through, he’s able to see a strength in his wife that he may not have previously seen before. He’s also able to see what great lengths one goes through to bring a child into the world, and experience the sacrifice of parenting from the start – an important concept to learn in the parenting journey.

When a father has an understanding of what’s happening, and is willing to be there with his love and support, birth, no matter what the outcome, becomes an experience of love and relationship. You see the two become three before your eyes. You watch as a family emerges, and you can SEE the love. The father’s love for the mother, the mother’s love for the father, the parents’ love for the baby, and the baby’s love for it’s parents. And it’s astounding.

Got To Go Through It!

We're going on a bear hunt. We're going to catch a big one. What a beautiful day! We're not scared.
Oh-oh! A forest! A big, dark forest. We can't go over it, we can't go under it. Oh, no! We've got to go THROUGH it!

Why am I quoting a children's book on a birthing blog? Well, I was reading the book Baby Catcher by midwife Peggy Vincent this past week and I came across a birth story that brought this children's book to mind. It was Peggy's own birth story, the birth of her third baby.

"I struggled to find a path around the pain. If not around it, then
under it, or over it. I ground my knuckles so deeply into my hip that
bruises remained for a week afterwards. Nothing helped, and I fought the forces of my body...

The next contraction came grinding down on me, but it felt different. A white-hot hole of knowledge opened in my pain. I saw
that in my effort to get around or under the pain, I'd been avoiding that central point of intensity, staying on the brink of the primitive surrender that's required to get a stubborn baby out...

With sudden clarity, I knew it would have to hurt more before it got better. I wouldn't be able to circumvent the pain. I had to go through it, enter willingly into the void, hoding nothing back. I had to jump off the diving board."

The bear hunt book is a great way to visualize the different stages of labor. We start with some long grass. We need to go through it, but it's not too bad. Next, we come to a river. A little more apprehension because we need to get cold and wet, and maybe the force of the river pulling us is a little frightening, but we can make it through. Now, we get to the mud. It sucks at our feet and makes us very dirty. This is getting to be harder. Then the forest, a big, dark forest. Entering into the unknown, tripping and stumbling along, we see how going *through* labor can be scary. Then, a snowstorm! It's whipping us, howling at us, we can't see where we're at, we're lost in the forces around us! And then, we're almost there. The cave. A narrow, gloomy cave. At the other end of the cave is...

In the book, it's a scary bear. But for the laboring mom, the nose, eyes and ears belong to their baby! Their sweet, precious babe that emerges from the cave.

If the mom had not traversed all the different terrain, she would not be at the final place where her baby emerges, ready to meet her.

So, you can't go under labor, over labor, or even around labor. You can't escape and get around the pain. You've got to go THROUGH it, and you'll get to the end much quicker, and be able to relish in the beautiful results of your hard work.

Books used for this post

Baby-Catcher by Peggy Vincent

We're Going on a Bear Hunt by Michael Rosen and Helen Oxenbury

The Law of the 3 P's vs. Sphincter Law

This weekend, I had the privilege of attending a workshop on Pain vs. Suffering presented by Penny Simkin, noted author, doula and one of the founders of DONA (Doulas of North America). During her talk, I kept thinking back to Ina May Gaskin’s discussion of the physical workings of labor, and how emotions and how a woman feels plays even more important a role in how her labor progresses than the strength of contractions, position of baby, and size of a mother’s pelvis. Ms. Simkin brought up how a woman’s past can have a huge affect on her labor. Abuse, trauma, and shame can lead to fear and suffering during an event that should be celebrated. This makes perfect sense, and physicians normally take past history into account when working with a patient. But when it comes to a woman who does not have a past history, physicians rely heavily on the Law of the Three P’s for understanding progress and time of labor.

I first read about the Law of the Three P’s along with Sphincter Law a few years back in the book, Ina May’s Guide to Childbirth. It sparked an interest in me, but not until this year have I really dug deeper into understanding the differences between the two and how they really play out in childbirth.

What is the Law of the Three P’s?
The basics of the law say that:
• A woman’s body, if it is capable of giving birth, should produce a baby in a reasonable amount of time.
• If progress is not apparent, one of the three P’s is dysfunctional, and intervention becomes necessary.
• Strength of uterine contractions (Powers), size and position of baby (Passenger), and/or type and dimension of pelvis (Passage) are the main components in a labor’s progress or dysfunction.


First, let’s look into what a “reasonable amount of time” really amounts to. In the 1950’s an OB resident at Columbia-Presbyterian’s Sloane Hospital for Women in New York took on a project of plotting the progress of labor in each of the laboring women in his ward. With the initial intent of seeing if caudal anesthesia had any impact of the speed of labor, Emanuel Friedman unknowingly changed the course of obstetrics by presenting for the first time an average length of time of the three stages of labor. While he considered the information to be used to help doctors determine if their patient’s progress was well outside of normal, Friedman became frustrated when he saw that doctors used the averages as absolutes, not taking into consideration how many women fall on either side of his asymmetrical bell curve.



In Norwitz and Schorge’s book, Obstetrics and Gynecology at a Glance, a “dysfunctional labor” is diagnosed if, during the active phase of labor, a first time mom is dilating less than 1.2 centimeters per hour and/or baby is descending less than 1 centimeter an hour. In a mom who is having a second (third, fourth, etc.) baby, dysfunction is diagnosed if she is dilating less than 1.5 centimeters an hour, and/or baby is descending less than 2 centimeters an hour. An “arrested” labor is diagnosed if a mother has not progressed in dilation for more than two hours, or progressed in baby’s descent for more than one hour in multiparas and two hours for first time moms.

How limiting! Within only these very narrow margins, a “normal” labor is considered. If a woman falls outside these margins, then the first step is to augment the Powers, the first thought being that the uterus is dysfunctional in being able to produce strong enough contractions to get the baby out. If mom doesn’t get on track with augmentation, then baby or pelvis must be to blame, and cesarean is considered the only way for baby to get out.

Since uterine contractions, baby and pelvis seem to be the main parts of laboring, this law may seem reasonable. But it definitely puts limits on a woman’s abilities and does not take into account that the uterus does not work apart from a woman’s brain.





Understanding the Laboring Brain

From the works of Michel Odent, we are able to see how much the brain is involved in labor. The brain is made of two layers – the primitive brain, and the neocortex. The Neocortex is the newer, rational part of the brain, which plays a role in abstract thought. The Primitive part of the brain, also called the brain stem, governs instinct and is considered to be a gland that releases hormones.

Labor is all about hormones! Oxytocin, endorphins, prolactin, etc. are all released by the primitive part of the brain. Dr. Odent likes to call it a “labor hormone cocktail”. No amount of thought or rationalizing will be able to make more hormones to produce the proper workings of labor. In order for these hormones to be produced, a laboring woman must allow her primitive brain to take over. In natural births, you see this in women who are laboring. You can tell when a woman has gone deep into “laborland”, and is no longer aware of what’s going on around her.

But what happens when we force that woman out of her primitive brain? Stimulating the neocortex by asking a laboring woman to answer questions that require thought, being near her in a way that makes her feel self-conscious, subjecting her to bright light, or failing to protect her privacy can actually inhibit the action of the primitive brain in hormone release. So, in reality, much of what goes on in a hospital room is working against the entire labor process.

How Sphincter Law differs from the Law of the Three P’s
While the Law of the Three P’s takes only three physical parts of the body into account for labor progress, Sphincter Law takes a look at the woman as a whole being, and considers that the cervix and vagina, being sphincter muscles, are highly responsive to fluctuation of maternal emotions.



The basics of Sphincter Law say that:
• excretory, cervical, and vaginal sphincters function best in an atmosphere of intimacy and privacy.
• these sphincters cannot be opened at will and do not respond well to commands
• when a person’s sphincter is in the process of opening, it may suddenly close down if that person becomes upset, frightened, humiliated, or self-concious
• the state of relaxation of the mouth and jaw is directly correlated to the ability of the cervix, the vagina, and the anus to open to full capacity.

Consider what your needs are when having a bowel movement. In order for that sphincter muscle to relax and open fully, most desire a moment of privacy. If, in the midst of a bowel movement, the bathroom door was suddenly thrown open, what would happen? The sphincter muscle would probably tighten back up. It is also necessary to be comfortable and relaxed in order to have a bowel movement. I know people who have a hard time with bowel movements if they can’t take off their shoes. If you are stressed and rushed, bowel movements may not occur. When you consider that the cervix is a sphincter muscle as well, it makes perfect sense that the needs for bowel movements would be similar to the needs of having a baby.

If the Law of the Three P's were truly a law, then it would have to be true in every circumstance. And when we scan the entire U.S., we see many variations in the amount of intervention deemed "necessary" in womens' labors. Cesarean section rates vary from doctor to doctor, hospital to hospital. There is more prevelence of pitocin use in certain areas than others. Women at The Farm, Ina May's village in Tennessee, have consistently had a cesarean rate of less than 2%, while the rest of the country sees more and more cesareans each year, with a national rate of nearly 33%. How can this be if there was truth in the Law of the Three P's?

Even in Lawrence Impey’s textbook, Obstetrics and Gynaecology, right in the middle of discussing the Three P’s, he deviates away from his own writings by saying this:

"General Measures to Maintain Progress
Continuous support during labour is associated with a reduction in operative delivery and length of labor. This should be from the midwife, as well as partner, or from non-medical supporters or “doulas”. The impact of support is seldom remembered, but reflects the importance of psychological well being on obstetric outcomes. Mobility should also be encouraged."

It's very interesting to me to read in the middle of the formula for diagnosing dysfunctional labor, and how to correct them (artificial rupture of membranes, pitocin, then cesarean section), something so simple and so far removed from the medical/pharmacutical mindset. It also seems to counter what the Law of the Three P's deems to be true. That labors don't progress due to insufficient strength of the uterus, too large or malposition of baby, or too small inlet of the pelvis. How is the presence of a partner or doula making a uterus stronger, a baby smaller or better positioned, or the pelvis outlet bigger? While there are certainly things that a doula can do to help with these things, "psychological well being" is what is being pinpointed here. Isn't this what Sphincter Law concludes as well? That feeling loved, supported, protected and safe will help with labor progress?

So why are emotions so discounted in the obstetrical world? Or perhaps its not the emotions, but how to help a woman's emotions in labor that is being brushed aside. When administering pitocin is something that can be done quickly and checked on from time to time, staying with a laboring woman and supporting her seems like a big waste of time.

It just seems to me that obstetrics and hospitals function in a way that sets up a laboring woman to fail.

Information for this article came from

Birth, by Tina Cassidy

Ina May's Guide to Childbirth, by Ina May Gaskin

Obstetrics and Gynecology at a Glance, by Errol R. Norwitz and John O. Schorge

Obstetrics and Gynaecology, by Lawrence Impey