Bonnie Lawrence gave birth to her first child at George Washington University Medical Center in the District last January. It was, she said, one of the more satisfying experiences of her life.
"It was very exciting for both my husband and myself to be awake and aware and with it during the delivery - to know everything that was going on was fantastic. My husband was the first to hold our daughter, and he was very thrilled about that," Lawrence said.
Having a baby does not have to be the cold, lonely hospital experience it once was. Pressure for change has come from health providers who are more aware of the parents' psychological needs during childbirth and from couples like the Lawrences who want the benefits, aesthetic and otherwise, of a family-centered childbirth in which both parents share in the birth experience.
Ten years ago, a natural or awake childbirth with the father in the delivery room was rare. According to Dr. Donald Meek, an obstetrician on the staff and faculty of Georgetown University and Sibley hospitals, most deliveries at District hospitals were done with the mother completely asleep and the father pacing the waiting room floor. After the birth, the baby was place in a nursery where the parents could admire their newborn from afar.
"Ninety per cent of the women giving birth are awake during delivery. Where only three District hospitals allowed fathers in the delivery room 10 years ago, all hospitals today not only allow but encourage father's participation," Meek said. After the birth, the baby can remain with the mother during her hospital stay, and the father, when he visits, can hold his newborn child.
"Parents today have some very legitimate aspirations about the childbirth process. They want to normalize it as much as possible and de-emphasize the medicated, illness aspect, and that's a very positive objective - so long as their wishes don't interfere with the health and safety of the mother or baby," said Dr. Allan Weingold, professor and chairman of the department of obstetrics and gynecology at George Washington University Medical Center.
Toward this end, some providers and parents are turning to home births, or are trying to establish birthing centers - a facility that has the emergency equipment of a hospital but the ambiance of a home. Others are overcoming the impersonal nature of a hospital delivery through more individualized and supportive care.
As an aid to expectant parents, the District Weekly looks at the options available to expectant parents - medicated, non-medicated and Laboyer deliveries, obstetrician and midwife care, hospital and home settings - and at the supportive and educational groups which provide information and guidance for the expectant woman and her family.
The Delivery Options
In a general anesthesia delivery, a woman is anesthetized during delivery in much the way she would be for major surgery. With the aid of analgesics and other medications during labor, she feels a minimum of pain or discomfort. Neither she nor the father plays a conscious role in the moment of birth.
General anesthesia is no longer preferred for delivery, however, because medications given to the mother are often passed on to the fetus, producing sleepy or less alert babies.
"The minimizing of suffering of the patient has to be weighed against the risk of medication to the baby. Everything in medicine has an advantage-disadvantage ratio. The obstetrician is in a unique position, treating two patients at once," said Dr. Cyril Crocker, chairman of the department of obstetrics and gynecology at Howard University Hospital.
"There is no question that excessive use of anesthesia retarded post partum healing and certainly any kid of maternal-infant bonding," said Dr. Joseph Giere, assistant professor of obstetrics and gynecology at Georgetown University Hospital.
"A woman who delivers and immediately perceived her child doesn't have go through stages of, who is this? The child becomes a person rather than an it. There's a lot of joy and confidence. The old way, that feeling used to take two or three days," he said.
A regional anesthesia, such as an epidural, attempts to numb the sensory nerve fibers but not the motor nerve fibers.
"It gives a moderate to good degree of relief of pain without impeding contractions, so the mother is awake and aware, and the delivery is effected before her eyes," Giere said. In addition, fathers who wish to be part of the birth process can be in the delivery room.
A regional anesthesia, however, may slow down the progress of labor, or cause a temporary drop in the mother's blood pressure. In addition, medication may still be passed to the fetus.
"Although we can handle any of the problems we cause through medication, medication shouldn't be used automatically; only when necessary," Meek said.
Local anesthesia is sometimes used. "It doesn't have any adverse effect on the baby or on the labor, but it gives relatively little relief for the discomfort of labor," said Meek.
For the woman who wants an alternative to anesthesia, there is prepared childbirth. A woman trained in prepared childbirth techniques, such as the Lamaze method - the best known of the breathing-exercise techniques for childbirth - can be awake and aware during labor and delivery and, by utilizing, minimize the discomforts of labor and delivery contractions. The father - or another family member such as a mother or sister - is in the delivery room, coaching on breathing exercises and offering emotional support. If the father or another close person is not available at birth, It is often possible to find a substitute coach on the nursing staff at the hospital or through childbirth education groups.
"Labor in well-relaxed, prepared patient seems to look forward to the labor and delivery. If we have to interfere with the delivery, she's more able to understand and cope with what we tell her," Meek said.
There is generally a shorter recovery time and more alert baby with a non-medicated childbirth.
"There is better bonding and a shorter hospital stay. The mother is functioning better because she was never dulled or diminished by medication," Geire said.
Although he sees some advantages, Giere suggests that non-medicated prepared childbirth is not for everyone.
"Everyone functions differently. A woman who is well rested and having a small baby under ideal conditions is a far cry from a woman with a large baby who's been up all night, whose husband is not there or who's facing family problems. You can't freeze people into a standard way. The tyranny of the old shouldn't be replaced with a tryanny of the new," he said.
Crocker also pointed out that "pain is a subjective thing and what's unbearable to one is okay to another."
"There are trends but there are also pressures," Weingold added. "Some people are pulled along not so enthusiastically. When it doesn't work out, they feel less whole and that's wrong. The process is designed to achieve a simple objective: a healthy mother and baby. The mother should look back on it as a positive experience, not one in which she was tormented."
To participate in prepared childbirth, expectant parents attend a series of training sessions. Four non-profit groups offer training courses at several District locations. In addition, District hospitals with obstetric services and other public and private institutions provide information or courses on childbirth.
"It's important for prospective parents to take childbirth education courses even in they are not planning a non-medicated birth. Contrary to popular opinion, these courses after more than natural childbirth classes. They educate people about the childbirth experiences. The teachers do a good job of dispelling unfounded fears and old wives' tales," Meek said.
"The childbirth classes help patients understand the process of childbirth and that eliminates anxiety that aggravates pain," Crocker added.
The Laboyer method is named for the French obstetrician Frederick Laboyer who wrote a book a few years ago advocating "birth without violence." Designed to ease the baby's transition into the world, his method has four basic steps: The intense lights of the delivery room are dimmed and no one speaks above a whisper; the infant, as soon as it is born, is placed on the mother's abdomen; the umbilical cord is left intact for six minutes while doctor and mother massage the baby; after the cord is cut, the baby is bathed in water similar in temperature to its familiar environment inside the mother. Laboyer was adamant in his belief that the practice of holding a baby by its heel and spanking it during the first moment of life is barbaric.
His message has appealed to many prospective parents. Several obstetricians in the District now deliver a la Laboyer, although both those who do and those who don't claim that what Laboyer advocates is not particularly new.
"Laboyer didn't write a scientific treatise but an emotional appeal for non-violent childbirth. It suggests that other methods are violent and that's not true at all. Few obstetricians today dangle a baby by its heels and use sharp stimulation. Most of us cradle the baby in our arms," Meek said.
"What Laboyer stressed that we should take is a sense of calmness and order and caring, a relaxed steadiness," Giere said.
A Laboyer delivery, as practiced in this area, usually includes turning off or deflecting the lights except for a spotlight, handing the baby to the mother rahter than to a nurse as soon as the obstetrician is sure the baby is breathing well.
"How soon the cord is clamped depends on the mother's blood type, but the baby goes to the mother and is wrapped in a blanket and kept warm," Meek said. "While the lights are off to tone down the harshness of the operating room, with a flip of the switch the life support systems are step away if you need them. If you don't need them, you can de-clinicalize a hospital delivery."
Obstetricians involved in Laboyer deliveries say the babies appear calmer and stay quiet until some procedure begins, such as weighing or inserting eye drops.
"It's a very gentle transition," Meek said. "Does it have long lasing benefits? Not to my knowledge because there have not been any controlled studies to prove it. Subjective obsevations make us suspect that it may be true. In any case, it's beautiful for the adults and as long as it's not harmful to the baby, there's no reason not to do it."
Hypnosis is another alternative to anesthesia. It "utilizes positive, constructive and healthy conditioning to neutralize negative, destructive and harmful conditioning to reverse faulty thinking patterns. It is a scientific 'power of positive thinking' that works through theimaginative process rather than the will," Dr. William Kroger wrote in his book, "Childbirth with Hypnosis."
Hypnosis alleviates both pain and fear of pain without medication.
"I don't see why childbirth should be painful - it's not a pathological process. Our culture has associated pain with it, but having been a hypno-anesthetist, it's awesome to see a woman deliver a child alert and with it instead of knocked out or not feeling anything," said Dr. Milton Gravitz, a clinical psychologist and president-elect of the American Society of Clinical Hypnosis.
Gravitz points out that classical hypnosis abd the Lamaze method of prepared childbirth have many elements in common.
"The concentration on breathing in Lamaze is like concentrating on something for hypnotic induction," he noted.
Women interested in using hypnosis for childbirth usually start training with a professional - a physician, psychiatrist or phsychologist trained in hypno-therapy - during the last trimester of pregnancy. Gravitz suggested that a woman first discuss the option with her obstetrician. If he or she agrees that it is a viable alternative, the patient can then call the American Psychological Association, D.C. Medical Association for referral of a qualified professional who practcies hypnosis.
A Cesarean delivery, one in which the baby is removed from the uterus by means of a surgical incision, is an option obstetricians consider when they believe the fetus or the mother will be endangered by a normal, vaginal delivery.
The medical indications are fetal distress; a baby's head too big or mother's pelvis too small for safe delivery; brow, breech or transverse presentation (the baby is not in an ideal position); detached placenta; umbilical cord that slips down before the baby. Cesareans also are used when the mother has a medical problem such as diabetes, chronic heart disease or toxemia of pregnancy, or has a history of losing babies during difficult labor.
Cesareans, which were once viewed as a last resort, account for 15 to 20 per cent of births. This figure is roughly twice that of 10 years ago. According to the September-October issue of Ob-Gyn Observor, a periodical written for gynecologists and obstetricians, the increase has been accompanied by a decrease in mortality and morbidity rates of infants during childbirth. The increase-decrease phenomenon, they say, is due in large measure to new diagnostic tools, notably fetal heart monitors, which can detect fetal distress ealier.
"Loss of a baby during the birth process is a very crude measurement of obstetrical care. There are many morbidities which can occur short of death which result in a sub-optimal baby. With fetal heart monitors we can now learn earlier and earlier when to intercede on behalf of the baby. That has a cost and it is the rising incidence of Cesarean deliveries," Weingold reported.
A few years ago fetal heart monitors were used only on high risk deliveries. Now most women are monitored.
"You can predict those with problems during labor with reasonable accuracy, but by no means with 100 per cent accuracy. Some women have no risk factors and they get into trouble. If that can happen, they deserve the same degree of intensive care as the risk patient," Weingold said.
Even though Cesareans are a surgical rather than natural procedure, there is a trend towards making it a family-centered experience. It is sometimes possible to use regional rather than general anesthesia for the delivery and to permit the father in the delivery room to witness the birth. The Cesarean Families Association is a group of Washington area families who inform expectant parents about Cesarean deliveries and how to make the birth as family oriented as circumstances allow.
According to the association, four area hospitals allow fathers in a Cesarean delivery room, at the obstetrician's discretion: Washington Adventist in Maryland, Arlington Hospital, Washington Hospital Center and Columbia Hospital for Women. The association said one other facility, Alexandria Hospital, is seriously considering such a policy.
While it is important for expectant parents to know their options and choose one that most suits their emotional and psychological needs, any final decision must be made in concert with a physician or certified nurse midwife who practices under the direction of a physician.