The Birthing “Understanding”

A birthing understanding is a kinder, gentler overture to your doctor, serving as an educational device for you. The difference between a birthing contract, or birth plan, and a birthing understanding is that the birthing contract challenges your doctor's judgement, but a birthing understanding allows you to partner with him.

Here is a list of typical questions patients have asked me over the years, along with my typical responses. Please know that you may have your own unique questions and that these responses are mine, not a universal answer sheet.

Will I need an episiotomy? Can I get by without one?

Maybe and maybe not. I don't do automatic episiotomies, and I can't tell if you'll need one until the very moment when I should cut one. I will only cut one if it looks like you're going to tear. And you have the right to refuse the episiotomy. But a bad tear is a lot harder to recover from than a cleanly cut episiotomy. On the other hand, if it looks like you're not going to tear, I won't cut one, because it's a lot less work for me and a much smoother recovery for you if I don't.

Will I need to be shaved?

No. Automatic shaving and enemas went out with the Ford Pinto. Shaving was once thought to protect you from infection that might complicate episiotomies, vaginal tears, or even your baby. We now know that any bacteria unique to hair aren't a particular threat, especially with the routine antiseptic cleansing done at the time of delivery.

Also, there is something particularly immunologic about this whole area. Consider this: there is damage to the vaginal tissue with every delivery. There doesn't have to be a laceration or episiotomy if there's enough damage from the extreme pressures of your baby's head against this delicate tissue. So with the milking of feces or bacteria from your rectum that accompanies the bulldozing effect of delivery against your rectum, why aren't there more infections? If there's one place and one situation in which the amount of infection to damaged tissue is so much less than it should be, it's your perineum (vaginal floor and tissue down to your rectum) during a delivery. If you rubbed feces or rectal bacteria into even a brush burn on your arm (and I'm not advocating this), it would probably get infected. When you consider how seemingly invulnerable the perineal and vaginal tissues are to infection during such a gumbo of exposure to bacteria, it's hard to worry about pubic hair with a straight face.

Will I need an enema?

Same answer. Enemas have never been shown to stop infection. In fact, the many trips to the bathroom associated with the watery expulsion of the enema may pose more of an infection risk, especially if your water bag has broken or has been broken, allowing a route in for bacteria.

Will you break my water bag? I'd prefer you don't.

The water bag is the collection of fetal membranes (chorioamnion) that holds in the amniotic fluid and keeps bacteria out. In fact, this is the reasoning behind induction at term if the water bag pops, so that delivery can be accomplished before any chance of serious infection. This question, however, refers to the procedure of artificially popping the membranes (amniotomy), instead of allowing them to burst spontaneously. The routine use of amniotomy is for the purpose of jump-starting an induction or enhancing the progress of a labor. It is felt that this flimsy bag won't make as good a dilating wedge against your cervix as your baby's hard head. Studies have shown that any increase in the efficiency of labor is when amniotomy is performed before you're six centimeters dilated.

When is amniotomy indicated and not just a trick to speed up labor?

First of all, sometimes speeding up labor is a really good idea. If your labor begins too slowly, this can pose some hazards for your baby (lengthier labors are lengthier ordeals) or for you (increased chances of needing a C-section). Besides pitocin, amniotomy can help in the mix of remedies. Secondly, if there's any doubt about your baby's status, amniotomy is very useful. A non-reassuring heart rate can be directly monitored with a scalp electrode, only possible with direct access to your baby's scalp. Examination of the amniotic fluid at amniotomy can be diagnostic of fetal distress (meconium). Bloody amniotic fluid could be the first warning about placental abruption. Foul-smelling fluid will indicate infection. Amniotomy isn't just a pop and a splash, but a true diagnostic tool when indicated.

I'd like to avoid a scalp electrode.

The scalp electrode is a very flimsy attachment of a very shallow corkscrew metal, the depth of which won't go any further than the needle you use on the dead skin around a splinter in your finger. Like anything in medicine, if used properly, it really poses no danger to your baby. But if you're upset about the little pinch it causes, you're going to be even more upset if you were to need an unnecessary C-section.

The non-invasive ultrasound monitor on your abdomen that records the fetal heart rate also picks up bowel sounds, fetal movements, and even the sudden abdominal crunches that accompany coughs and sneezes.

The scalp electrode tells no lies. What you see is what you have. It is an actual EKG of your baby's heart. In fact, this was even one of my questions on my oral board exam. I was given a hypothetical situation in which there was a non-reassuring heart rate recording on a fetal monitor.

"What's the first thing you do?" asked my inquisitor. I wondered should I prepare for immediate emergency C-section?

"I perform an amniotomy and apply an internal scalp electrode," I answered. He looked at me with a poker face for the longest time.

"Next question," he announced, with no indication as to whether my answer was right or wrong. It was right. Oral boards. Boy, ya gotta love 'em, right?

I don't want to be strapped down to a monitor the whole time. I'd like to be able to walk around.

This type of thinking is crucial to the success of Lamaze or the Bradley method. All of those wires and tubes are the bondage that is so symbolic of the distortion of the natural process of labor and delivery. But all of this stuff isn't just a collection of balls and chains. They are useful devices that represent the advances in obstetrics over the generations. Since labor and delivery is a natural process, not everyone will benefit from them. But the ones who will, really will. The nice thing about delivering in a hospital or a properly accredited birthing center is that you can have the natural freedom to roam, but if bad situations arise, you can take advantage of all of those tubes and wires.

The minimum monitoring necessary by standards of the American College of Obstetricians and Gynecologists is determination of a reassuring fetal heart rate by stethoscope or monitor at least every five minutes, or more frequently if indicated. Internal monitoring with a scalp electrode is indicated if there are any questions about the well-being of your baby.