Caroline and Joseph Roberts of Arlington watched the birth.
"We could see her head appear and then I gave one more push and there she was. The emotion of seeing her born, holding her right there and then, and counting her little fingers and toes. It meant so much for us to be together, sharing in the birth of our baby," Caroline Roberts said.
Having a baby today does not have to be the cold, lonely hospital experience of the past. Pressure for change has come from health providers who are more aware of parents' psychological needs during childbirth and from couples like the Robertses who want the benefits, aesthetntered childbrith in which both parents share in the birth experience.
Ten Years A go, a natural or awake childbirth with the father in the delivery room was rare. According to Dr. Thomas McGavin, chief of obstetrics and gynecology at Arlington Hospital, most deliveries at Arlington were done with the mother completely asleep and the father pacing the waiting room floor. After the birth, the baby was placed in a nursery where the parents could admire their newborn from afar.
Ninety per cent or more of the uncomplicated deliveries are now done with the mother awake and the father in the delivery room, McGavin reported. 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 legiitmate aspirations about the childbright process. The wasnt to normalize if 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 mother of babay," said Dr. Allan Weingold, prefessor and obstetics and gynecology at George Washington 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 Virginia Weekly looks at the options available to expectant parents - medicated, nonmedicated and Laboyer deliveries, obstetrician and midwife care, hospital and home settings - and at the supportive and educational groups who provide information and guidance for the expectant woman and her family.
The Delivery Options
In a general anesthetized during delivery in much the way she would be for major surgeny. With the aid of analgesics and other medications during labor, she feels a minimum of pain or discomfor. Neither she nor the fathes plays a conscious role in the moment of birth.
General anesthesia if no longer preferred for delivery, however, because medications given to the mother are often passed on the fetus, producing sleepy or less alert babies.
"There is no question that excessive use of anesthesia retarded post partum healing and certainly and kind of maternal-infant bonding," said Dr. Joseph Giere, assistant professor of obstetrics and gynecology at Georgetown University Hospital.
"A woman who delivers and immediately perceives her child doesn't have to go through stages of, who is this? The child becomes a person rather than an it. There's a lot of joy and sense of 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," said Dr. Donald Meek, an obstetrician on the staff and faculty at Georgetown University and Sibley hospitals.
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," Meek said.
For the woman who wants an alternative to anesthesia, there is prepared childbirth. A woman trained in prepared childbirth, such as the Lamaze method - the most popular of the breathing-exercise techniques - can be awake and aware during labor and delivery and, by utilizing breathing and exercise techniques, minimize the discomforts of labor and delivery contractions. Women who have experienced prepared childbirth talk of the excitement and sense of accomplishment and of the warm family feeling surrounding the birth. 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.
When the mother was alone, she transferred her feelings to the physician, but it's more natural to transfer them to her husband. It helps to solidify the family unit and the fathers are thrilled - even though some pass out," McGavin said. 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 a well-relaxed, prepared patient seems to go faster; she isn't as anxious about what's happening to her and 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 a more alert baby, he said.
"There is better bonding and a shorter hospital stay. The mother is functioning better because she was never dulled or diminished by medication," Giere said.
Although he sees some advantages, Giere suggests that non-medicated prepared childbirth is not for everyone.
"Everybody 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 inot a standard way. The tyranny of the old shouldn't be replaced with a tyranny of the new," he said.
"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 baby and mother. 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 nonprofit groups offer training courses at several Northern Virginia locations. In addition, Arlington, Alexandria and Fairfax hospitals and other public and private institutions provide information on courses in childbirth.
"It's important for prospective parents to take childbirth education couses even if they are not planning a non-medicated birth. Contrary to popular opinion, these courses offer more than natural childbirth classes. They educate people about the childbirth experience. The teachers do a good job of dispelling unfounded fears and old wives tales," Meek said.
"Whatever way my patients want to deliver, I encourage them to take the courses. That way, they're more a part of what's going on," McGavin said.
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 upside down by its heels and spanking it during the first moment of life is barbaric.
His message has appealed to many prospective parents. Several obstetricians now deliver a la Laboyer, although both those who do and those who don't claim that what Laboyer advocates is not particularly new.
"I've never held a baby upside down. I always put the baby on the mother's abdomen so I don't drop it," McGavin said.
"What Laboyer stresses that we should take is a sense of calmness and order and caring: a relaxed steadness," Giere said.
A Laboyer delivery as practiced in this area includes turning off or deflecting the lights except for a spotlight, handing the baby to the mother rather 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," Meed said. "While the lights are off to tone down the harshness of an operating room, with the flip of a switch the life support systems are a 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 lasting benefits? Not to my knowledge because there have not been any controlled studies to prove it. Subjective observations 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 the imaginative process rather than the will," Dr. William Kroger of California wrote in his book, "Childbirth with Hypnosis."
Hypnosis can alleviate 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 and the Lamaze method have many elements in common.
"The concentration on breathing in Lamaze is like concentrating on something for hypnotic induction," he said.
Women interested in using hypnosis for childbirth usually start training with a professional - a physician, psychiatrist or psychologist - 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 in the District or a state or local medical society for referral to a trained professional.
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 for delivery); 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 at area hospitals. This is roughly twice that of 10 years ago. According to the September-October issue of the Ob-Gyn Observor, a periodical written for obstetricians and gynecologists, 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 such as fetal heart monitors, which can detect fetal distress earlier.
"Loss of a baby during the birth process is a very crude measurement of obstetrical care. There are many morbidites that 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 said.
A few years ago, fetal heart monitors were used only on high risk deliveries. Now, according to McGavin, most women are monitored.
Even though Cesarean deliveries are a surgical rather than natural procedure, there is a trend toward 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 Casarean 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 choose the type of childbirth that most suits their 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.
Nexk Week: A report on home and hospital births.