Labor Options – What the Research Says
Childbirth is intense: emotionally, physically and spiritually. It’s a miraculous, life-altering experience, and transformative every single time. Not only is a baby born, but a new mother, stronger and more confident than she was before. It’s a once-in-a-lifetime event, and it’s only natural that you are seeking a birthing that is safe, satisfying, and naturally comfortable for you and your baby as possible.
For some women, an elective C-section in a maternity ward feels like the most empowering choice, and the prospect of being medically unsupported in case of an emergency is terrifying. But for other women, a hospital birth may seem impersonal, intimidating, and even traumatic. They can only envision their ideal birth in one place: home.
No two women, children, or pregnancies are the same. This means that there isn’t a one-size-fits-all answer to the question, “should I have an unmedicated birth?” Instead, it’s about understanding your needs, exploring options, gathering information, and proactively making choices that will support the kind of safe, meaningful birth experience you desire and deserve. It’s the first step in your journey as a deliberate, intentional mother.
While this post is written as a jumping off point for the 95% of births which fall into the normal, low-risk, or no-risk categories, I also want to acknowledge and hold space for the the difficulty that surrounds birth when it does not go as planned, or a mother feels they don’t have the privilege of making the birth choices they desire. ❤️
“It is not only that we want to bring about an easy labor, without risking injury to the mother or child; we must go further. We must understand that childbirth is fundamentally a spiritual, as well as a physical, achievement...The birth of a child is the ultimate perfection of human love.”
Labor Options – What the Research Says
THE PROS & CONS OF PAIN RELIEF
Women have been birthing babies unmedicated for hundreds of thousands of years. It wasn’t until the 1960s that medications during labor have became popular.
A 2018 study in the journal Anesthesiology found that 71% of American women opt to receive the pain relief of epidurals, which is 10% more than in 2008. Although many women have perfectly healthy deliveries with epidurals, the full risks are seldom discussed.
Epidurals and other spinal anesthetics block nerve signals from both the sensory and motor nerves, which relieves pain but also immobilizes the lower part of the body. Instead of riding the contraction rollercoaster, a mother can sleep or relax through birth or a C-section. The pain is numbed, but so is overall sensation, and the mind-body connection is temporarily severed.
Though epidurals are generally proven safe, they can sometimes fail to work or work in patchy, unpredictable ways. Because they dampen the natural urge to push, there is a threefold increase in likelihood of perineal tearing and risk of forceps delivery. There is also an increased risk that labor slows down. Unable to easily walk or change positions, her blood pressure may plummet. There’s also an elevated risk of developing urinary, anal and sexual disorders after birth, and in very rare cases, epidurals can cause permanent paralysis, nerve damage, respiratory depression, brain damage, and even death. 23% of women will go on to develop temporary “epidural fever.”
WHAT ABOUT THE CHILD?
All obstetrical painkillers have been proven to reach the unborn baby, and because infant’s immune systems are not fully developed, their bodies are slower to eliminate the drug. Epidurals can affect fetal blood oxygen supply, as well as their position – this in turn can decrease the chances of a natural spontaneous birth, simultaneously increasing the chances of a C-section.
Many women also report sleepy babies after epidurals. Epidural babies may present with difficulty rooting and suckling, low responsiveness, distress and neurobehavioral effects that last for weeks after delivery. Finally, epidural drugs can interfere with a baby’s heart rate, with one study finding that 11% of children exposed to epidural drugs develop bradycardia. It’s not hard to imagine how those precious post-birth hours could be lost to recovering from complications, rather than mom and baby resting, bonding and breastfeeding.
UNDERSTANDING THE PAIN CYCLE
Though the list of potential dangers is overwhelming, it’s worth taking a step back and investigating what causes pain during childbirth in the first place. After all, our bodies were designed for childbirth.
Pain starts in the brain. Fear of the unknown, unresolved past traumas, or anxiety about being in an unsafe and unsupportive environment can all trigger the release of stress hormones in the body. When a mother approaches labor with fear and stress, the hormone catecholamine is triggered. Blood and oxygen are directed away from the uterus.
Ultimately, when the body is tightening and tensing against the birth process, pain results. This pain confirms the original fear (for example, “something is wrong”), which is now amplified, further increasing tension, and so on, sending the body spiraling…and in the case of birth, this fear-tension-pain cycle slows things down!
Fear causes tension causes pain… which then creates more fear.
This cycle can be exacerbated by the panicked interference of others, but also by the mother’s fatigue, anxious breathing patterns, or discouraging thoughts.
Pain relief medication steps in only once the fear-tension-pain cycle is well underway. But there is always the choice to consciously tackle pain earlier, at the fear and tension stage. Obviously, some pain is inevitable, but women can manage it mindfully by:
Using relaxation and mindful breathing techniques
Ensuring they are well-informed and educated, reducing fear of the unknown
Pre-emptively choosing coping strategies that help them feel empowered and in control
Having trusted support nearby so they feel safe and supported
Your body has a hormonal blueprint that is designed to work to bring about labor, protect mother and baby, and even block pain receptors. You can learn more about these hormones in Dr. Buckley’s Ecstatic Birth.
Oxytocin - brings about labor, blocks pain receptors, dilates the cervix, releases endorphins in labor, and helps milk production and bonding with baby.
Endorphins - neuropeptides in the brain and pituitary gland have an effect 200 times that of morphine.
“There is a secret in our culture, and it is not that birth is painful, but that women are strong.”
CHOSING TO INDUCE
Induction is the process of artificially stimulating uterine contractions to trigger labor before it would naturally start on its own. During induction, the cervix is prepared for labor with artificial prostaglandins (prostin E2 or cervidil), which help it open and relax. Sometimes, the waters will also be artificially broken before administering artificial oxytocin to induce labor.
There are a number of health conditions that call for an induced labor, including post-term pregnancies, complications, or problems with the placenta. Induction is also common with big babies, i.e. those with macrosomia. Most often, women are induced at 41 weeks and no later, based on studies that show the risks of death are higher after this time (however, as is so often the case in obstetrics, the accuracy of these studies is debated). The traditional way of calculating the estimated due date (40 weeks after the last menstrual period) is not evidence-based. In a 2001 study of 1,514 healthy women, 50% of all women giving birth for the first time gave birth by 40 weeks and 5 days, while 75% gave birth by 41 weeks and 2 days.
Though induction can be lifesaving in some cases, it’s not without significant hazards, especially for healthy, low-risk pregnancies. This is because of how incredibly important the final weeks of pregnancy are. During this time, the baby is gaining in weight and strength, with the respiratory system, immune response, brain, muscle coordination, and metabolism maturing.
The final weeks of pregnancy also trigger a cascade of hormonal changes in the mother, which prepare her body for birth. According to Judith Lothian in a 2006 Journal of Perinatal Education paper, “Contractions in the last weeks may start the effacement and dilation of the cervix. A burst of energy helps pregnant women make final preparations, and insomnia prepares them for the start of round-the-clock parenting.” Interruptions during these final weeks can understandably prove distressing for a baby that is physiologically not yet ready to be born… as well as for a mother who is not quite ready to be a mother!
Despite the risks, 2014 data shows that 23% of American women are induced – with up to 10% induced for entirely non-medical reasons. Are the risks worth it? That depends. Truthfully, everything in life carries risks. Though doctors can provide the data, risk is ultimately a very personal concept, and each woman needs to assess for herself the options, the alternatives, the risk she’s willing to take, and why.
We know that artificial prostaglandins can lead to hyperstimulation, resulting in fetal distress and potentially a C-section. Likewise, artificially rupturing the membrane can stress the fetus and increase the risk of complications. The use of syntocinon or Pitocin can cause postpartum hemorrhage or the metabolic condition called water intoxication. In rare cases, complications can even lead to convulsions, coma and/or death. For the baby, such interventions are associated with hypoxic brain damage, neonatal jaundice, and neonatal retinal hemorrhage. Interestingly, there is now research suggesting a link between the use of induction drugs and ADHD.
While these extreme outcomes are undoubtedly quite rare, fetal distress and increased risk of C-section are sadly commonplace when mothers are induced.
DO YOU NEED VAGINAL EXAMS?
Simply put, vaginal exams are done to monitor labor and ensure that it’s progressing as expected. Routine vaginal examinations are done at intervals to find out how dilated the cervix is, but exams can also help determine the baby’s position, effacement, and station during labor.
These exams are not the only way to monitor progress, though, and they can often be painful and distressing for mothers. The trouble is when such exams provide misleading information, causing doctors to intervene in slow, but otherwise healthy labors or for mothers to become discouraged.
One study found that pelvic examinations increased the risk of PROM (premature rupture of membranes), and others have suggested increased risk of infection, discomfort and C-section. But for the most part the jury is still out and the research inconclusive, with most investigations finding that vaginal exams have little effect either way.
CAESAREAN SECTIONS
There is absolutely no question that C-sections can save lives in emergency situations, and I am truly grateful for these advances in medical care. However, in recent years, the rates of elective C-sections have drastically increased.
The World Health Organization has said that “Caesarean sections are effective in saving maternal and infant lives, but only when they are required for medically indicated reasons […] At population level, caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates.” In fact, unless medically necessary, C-sections can create serious and sometimes permanent complications, disability or even death.
So it’s alarming that, according to 2019 data from the CDC, a full 31.7% of all American births are C-sections, with 25.6% of the low-risk population electing for a C-section. What explains this high rate?
Some research suggests that from 2002 to 2008, approximately 10% of first-time American mothers were given a C-section due to being diagnosed with “failure to progress” i.e. labor not moving fast enough. However, the definition of a “normal” labor has changed significantly since the 1950s, and today there is mounting evidence that labor should be classified normal as long as mother and baby are well, and labor is not arrested. Allowing enough time – especially during induced labors – means fewer C-sections and the complications they come with.
Over-diagnosing “failure to progress” is not the only contributor to increased C-sections rates, however. In the 1970s, electronic fetal monitoring (EFM) became popular even though randomized trials found no evidence for its efficacy. This kind of monitoring is simply not medically necessary for low-risk, normal pregnancies, and in fact may lead to unnecessary C-sections – not to mention additional stress for the mother. Today, a more low-tech and hands-on approach is preferable for low-risk births
Caesarean section is associated with the development of an imbalance of the infant gut microbiome. The correct colonization and the establishment of this microbiome are linked to the early and future health status of the individual.
“It should be taken into account that when antibiotics are administered before the clamping of the umbilical cord, an exposure of the newborn to the antibiotic occurs due to its passing through the placenta. Breast milk can also be a way by which antibiotics pass from the mother to the infant. We do not currently know the consequences of this exposition in the neonate [8]. It could affect the correct establishment of the intestinal microbiota and increase the antibiotic resistance on gut microorganisms and even the correct immune system development, with transitional but not depreciable effects [8].”
According to a review by Karger (2018), “Differences between C-Section (CS) and Vaginal Delivery (VD) babies are already obvious and observable from the very early moments of life, as underlined by the differences found in the Apgar scores, which is a widely used measure of neonatal health [20]. Later on, a higher risk of different non-communicable diseases has also been observed in CS-delivered subjects, including allergic diseases [21, 22], celiac disease [23], obesity [24, 25], type-1 diabetes [26] and even hypertension in young adults [27].
YOU HAVE THE RIGHT TO BODILY AUTONOMY
At the end of the day, a woman is her own authority when it comes to deciding about the kind of care she receives. Our understanding of the risks and benefits of medical approaches is constantly evolving, but what never changes is a woman’s right to appraise this information, and choose for herself. There has seemingly always been contention around women’s birthing choices, but ultimately it is your birth, and a doctor or nurse cannot do anything without your permission.
Bodily autonomy means the right to make informed choices given the data. However, what statisticians uncover on a population level may nevertheless be irrelevant for an individual woman on a personal level. What’s more, though doctors deal in risk probabilities, they cannot tell any individual how to act on this risk. Finally, we can’t forget that in childbirth, nothing is ever 100% guaranteed or predictable, no matter how solid the data – we can only do our best with the knowledge we have.
The more that women can inform and prepare themselves, the more empowered they will feel in their ability to have a positive birth experience. One way to do this is to look for practical evidence-based information and ask how this knowledge squares up with your own values, principles, situation, and aspirations as a mother. Another way is simply to ask questions:
“Tell me more about this drug or procedure. How does it work? What are the side effects?”
“Are there other options?”
“How do the benefits weigh up against the risks?”
“What is the risk to me and my baby if I don’t take it or have it done? Can we wait a while longer before deciding?”
Don’t be afraid to take your time, seek second opinions, weigh up your options and voice your concerns. Have courage to make choices that are right for you and your baby… even if they are not the choices others would make. Childbirth is always a little scary, a little messy, and a little unpredictable. But if you can take charge of your birthing experience, and compassionately explore your expectations and fears, your confidence in your own abilities will only grow. With that confidence, you can embrace the life-changing experience of childbirth – no matter how it unfolds for you.
“To all mothers in every circumstance, including those who struggle, I say, ‘Be peaceful. Believe in God and yourself. You are doing better than you think you are.”
