What’s Wrong with Typical Hospital Labor Management?

by | Mar 15, 2024 | Labor and Birth Care

I was considering what topic to choose for this month’s blog post when I ran across an article I wrote back in 1985. At the time, I was five years into my work as a Lamaze instructor and a doula, and I was involved with a community group that had opened a pregnancy and childbirth resource center and started a freestanding birth center.

In background to the times in which I wrote it, the cesarean rate had soared from 5 percent to the unprecedented height of 15 percent in the previous decade and was continuing to climb. The burgeoning use of continuous fetal monitoring and the increased use of cesarean surgery were being touted as sure to reduce infant morbidity—especially cerebral palsy—and mortality, assumptions that weren’t evidence based. Research had begun disproving those theories (“Just Say ‘No’ to Routine Continuous Fetal Monitoring” and “What Should the Cesarean Rate Be?”) without in the least altering the trajectory of their use.

As I read over the article, I realized its message is as relevant today as it was when I wrote it. If you want a parable on what’s wrong with typical hospital labor management, read my story of Dotty, who wanted the best care at her dog’s whelping, and, as they say, weep.

Oh, and not to worry that I’ll leave you in the lurch with a problem and no strategies for dealing with it. As usual, there’ll be a “takeaway” section at the end of this post.

Dotty and Her Dog: A Parable of Modern Labor Management
Henci Goer © 1985

Once upon a time there was a nice woman named Dotty. She had a beautiful golden retriever named Sunshine whom she loved more than anything else on earth. When she had Sunshine bred, she was naturally most concerned that her dog have the best care possible, so she was delighted to hear of a veterinarian who provided the same kind of care as obstetricians give human women. As soon as she could, Dotty made an appointment with the vet, a Dr. Smith.

“Yes,” said Dr. Smith, “I don’t hold with the old-fashioned notion of allowing the dog to give birth on an old blanket in a box in a closet. I have a unit in my animal hospital as well equipped as any human labor and delivery ward. Of course, you realize that it will be more expensive.”

“Hang the expense,” said Dotty, “I want only the best for my Sunshine!”

“Excellent,” said Dr. Smith. I wish more people had your attitude toward their pets. Now you be sure and bring her in as soon as you think she is in labor. Oh, by the way, don’t let her eat or drink anything once you think labor has begun.”

“Why not?” asked Dotty.

“Well you never can tell what will happen. If we need to do surgery, I wouldn’t want anything in Sunshine’s stomach. It could be dangerous.”

“You mean you can even do a cesarean? Why, that’s remarkable!”

“Oh, yes,” agreed the doctor. “I told you my labor and delivery unit is the equal of any human hospital.”

When Sunshine’s labor began, Dotty did just as Dr. Smith had asked. She brought her into the animal hospital. Sunshine didn’t like being made to get into the car. Dotty hated to see her dog unhappy, but she reminded herself that Sunshine would get all the care a human mother would get in Dr. Smith’s hospital, and what could be better than that? On the way up the walk to the clinic, Sunshine tried to get to a puddle made by a leaking faucet, but Dotty, remembering the doctor’s orders, kept her from getting to the water.

Dr. Smith showed Dotty and Sunshine into a clean, brightly lit enclosure with a concrete floor and wire mesh walls. Various pieces of equipment were stowed neatly around the walls. A firm, vinyl-covered pallet with straps attached lay in one corner. Dotty felt reassured by the bright, clean surroundings and the efficient look of the equipment. “Why, it’s just as you said, Doctor. It’s quite the equivalent of a human labor and delivery ward!”

Sunshine didn’t like the enclosure. She paced around restlessly, whining, looking for an escape from the bright light and somewhere soft to lie down.

Dotty told Dr. Smith that Sunshine had seemed thirsty.

“No problem,” he replied. “We’ll just start an IV. That will make sure Sunshine doesn’t get dehydrated. We’ll have to restrain her,” he went on as he laid Sunshine on the pallet and strapped her down. “We don’t want her to dislodge the IV.”

Sunshine struggled quite a bit, and her soft whining took on a frantic note especially during her contractions.

“Poor Sunshine,” said Dotty. “I wish we could explain to her that this is all for her own good.”

“You know,” said the doctor, “She needn’t suffer this pain. I can put some medication into her IV. It will take the edge off her contractions and help her relax. As I said before, I can provide the same advantages any human mother in labor can have.” After Dr. Smith injected the pain-relief medication, Sunshine lay quieter. [Today, it would be an epidural.]

Time passed, and although Sunshine seemed to be having good contractions, the birth was no nearer. Dr. Smith explained that he could inject some medication that would strengthen Sunshine’s contractions. He could also connect a fetal monitor to make sure the puppies were doing all right.

“This is marvelous!” said Dotty. “It’s a miracle what modern technology can do. I certainly couldn’t do any of this for her at home.”

Later still, Dr. Smith shook his head sadly and said, “I just don’t think Sunshine is going to be able to deliver those puppies. I think I had better take her back and do a cesarean.”

Dotty was very concerned. “Will she and the puppies be all right?”

“Of course,” said Dr. Smith. “Don’t worry about a thing. She’ll get all the care any human mother would get under the same circumstances, and she’ll be just fine.”

Sunshine hardly protested at all when they lifted her onto a gurney and wheeled her away.

Despite Dr. Smith’s reassurance, Dotty waited anxiously. Dr. Smith came out less than an hour later to announce that Sunshine had five healthy puppies. She was fine and resting in a recovery area.

“I don’t know how to thank you, Doctor, for saving Sunshine and her puppies,” said Dotty, sighing with relief.

Unfortunately, Sunshine couldn’t go home when first expected. She had developed an infection. “No problem,” reassured Dr. Smith, “A few days of antibiotic treatment, and Sunshine will be as good as new.”

On the day Sunshine was due to go home, Dotty had a last consultation with Dr. Smith. “I’m sorry that you will have to bottle feed those puppies. What with the recovery from the surgery and the infection she just wasn’t able to nurse them.”

“Never mind,” said Dotty. “I’m just so happy to have Sunshine and her beautiful puppies safe and well, and I know I have you and your wonderful care to thank for that.”

It’s a strange thing,” mused Dr. Smith. “These modern purebreds just don’t seem to be able to deliver their puppies. Overbreeding is making their pelvises too small.”

Some days later Dotty sat feeding one of the puppies and watching the others play around Sunshine as she lay on the floor. Sunshine had the saddest expression on her face.

“Don’t be sad, dear,” said Dotty. “The important thing is that you have five healthy puppies, isn’t it?”

The short answer to the question posed in the post’s title, as my parable makes clear, is that what’s wrong with typical hospital management is that management is very different from care.

“Care” works to support and facilitate the natural process, only resorting to intervening medically when complications arise that can’t be resolved with simple measures and patience. “Care” has repeatedly been shown to achieve better outcomes with much less use of medical intervention (Goer 2012). “Management” views labor as a problem to be solved by manipulation and control, and when that ends by breaking what wasn’t broken, blames the process and concludes even more intervention is the remedy. Case in point: sweeping obstetric practice today is the notion that the best way to reduce cesareans, now one in three deliveries and has been since 2009 (Hamilton 2010), and improve birth outcomes is to induce everyone at 39 weeks, an idea as wrongheaded now as the belief that routine continuous fetal monitoring and increased cesareans would improve outcomes was back then. Unfortunately for all of us, there’s even less chance of proponents of “management” to see the light on this issue, which brings us to what you can do to protect yourself and your baby.

Your Takeaway

So, what can you do to avoid routine management practices and policies that do you and your baby no good and can do harm?  Here are some ways to ensure that you receive care and not management:

Choose a place of birth:

  • Questions to ask:
    • What is the hospital cesarean rate?
    • What is the general opinion of doulas?
    • What is the hospital’s fetal monitoring policy? What if I want the nurse to listen intermittently?
    • What’s the percentage who have epidurals? What comfort measures and assistance are available if I want to avoid pain medication?
    • How do you facilitate mobility and positioning in labor?
    • What is your policy around eating and drinking in labor?
    • What is your policy for IVs?
  • If your pregnancy is uncomplicated, consider planning a birth center or home birth.

Choose a care provider:

  • Questions to ask:
    • Will you or someone in your practice be attending my birth?
    • Under what circumstances would you recommend a cesarean?
    • What percentage of the women in your care have a cesarean?
    • How do your practices and policies promote vaginal birth?
    • Do all doctors/midwives in your practice have similar policies and practices to yours? If not, how can I ensure that I will be attended by someone who does or that the person who attends me will abide by agreements that we may make?
  • Consider choosing a midwife over an obstetrician.

Take a childbirth education class:

  • Choose a class that:
    • is independent from the hospital
    • is taught by a certified teacher
    • trains you to cope with labor using non-drug strategies
    • prepares you to be a full participant in decisions about your care
    • has something on the order of 10 to 12 hours of classes spread out over several weeks
    • has 4 to 10 couples

Consider hiring a doula:

  • Choose a doula who:
    • is independent from the hospital
    • is certified
    • aligns with your views on epidurals
    • is non-judgmental
    • has good chemistry with you and your intimate partner

References

Goer H, Romano A. Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle, WA: Classic Day Publishing; 2012.

Hamilton BE, Martin JA, Ventura SJ. Births: preliminary data for 2009. Natl Vital Stat Rep 2010;59(3):1-29.

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