WORLD HEALTH ORGANIZATION: Care in Normal Birth: A Practical Guide (1996)

Category B: Birth Practices Which Are Demonstrably Harmful and Should Not Be Done

In 1996, the World Health Organization (WHO) assembled birth experts from around the world to identify common practices in normal birth that were justified, that improved birth outcomes, and that ought to be encouraged for safe care in normal birth.1 At the same time, the WHO identified common birth practices that are known to be harmful, unnecessary, underused as well as those interventions that required further study to determine their merit in the care of child bearing families. In a way, as presented, the listing of intervention by category serves as a “sort of” report card for birthing facilities in that either the intervention is or is not currently practiced. This article “speaks to” the second of the four categories of common birth practices and the rationale of those interventions the WHO identified seventeen years ago. The practices that are known to be harmful and should not be practiced are in bold type and listed below. The rationale for prohibiting these practices accompanies the cited intervention.

Before addressing the specific harmful interventions that are still practiced today, it is important to emphasize that birth is a normal, natural, safe and healthy event. On average, 80%-85% of pregnant women are low-risk both through their prenatal months and during the process of birth. 1 However, normal birth has become intervention intensive because labors are managed and forced, babies are extracted, and childbirth is viewed as an illness from which women must be rescued.2 Sadly, many of the routine practices women endure during labor and birth “are not supported by scientific evidence3 and expose women to avoidable harm.2

Category B: Practices which are Harmful or Ineffective and Should Be Eliminated

1. Routine enemas were once a common practice upon the admission of a laboring woman to the hospital. The belief was that the enema would stimulate the labor (make it go faster), empty the rectum to give more room for the fetal head to pass, and to prevent “contamination” of the perineal area (space between the vaginal outlet and the anus) during birth thereby reducing infections for mothers and babies alike. Those beliefs have been challenged by research findings. Routine enemas do not enhance the progress of labor4, 5 nor do they reduce maternal or fetal infection rates post birth.4, 6, 7 Indeed, post-enema, there tends to be ongoing leakage of fluid from the rectum. Reason alone suggests that the continual leakage of fecal fluid from the rectum throughout labor and during birth does more to “contaminate” an area that should be clean than does a formed stool that is easily removed if and when it is expelled. Common to most research outcomes about the routine use of enemas during labor is the discomfort and embarrassment the intervention causes most women.4, 6, 7 The research evidence is that enemas do nothing beneficial for the progress of labor, mothers or babies and therefore ought not to be done.1, 3

2. Shaving of the pubic hair was believed to prevent infection and to facilitate the repair of episotomies (incision of the perineum… that space between the vagina and anus) or lacerations. “But, there is no evidence to support this” (WHO, p. 8). Not only has research demonstrated that there is no difference in infection rates between shaved and unshaved women, the findings of one study suggests that women who have not been shaved were less likely to have Gram-negative bacterial colonization of the perineum.8 Women report that the after-effects of pubic shaving (redness, irritation, burning, superficial scratches and itching) is more than uncomfortable.1,8 The WHO states that pubic shaving “should not be done except at the request of the woman” (p. 9).

3. Many birthing facilities today continue to require the routine IV (by vein; sometimes called “the drip”) infusion of fluids in labor believing that IV fluids will hydrate sifficiently and reduce the risk of vomiting and aspiration of stomach contents in the event of emergency surgery using general anesthesia (putting the patient to sleep). In reality, no research findings have demonstrated that IV placement improves the outcomes of birth.9, 10 Indeed, if women drink and eat as desired, there ought to be no need for IV fluid replacement. 3, 11 It is the acidity of stomach contents that is the villain of aspiration, not the volume of stomach contents. The residue in a liquid and food deprived stomach, because it is so concentrated, is highly acidic. As long ago as 1984, researchers have known that “it is only since we began to starve our laboring patients … that we have experienced the epidemic of acid-aspiration” (Crawford, p. 926). The energy requirements of labor are much like that of a marathon. If a mother is to birth, she must be hydrated and fed to meet the demanding work of labor and birth.1 What a mother eats and drinks in labor will fuel the demanding process of birth. 13, 14 An important reality about IV drips, is that they restrict maternal movement 15, an important contributor to maternal comfort,1 labor’s progress15 and fetal descent.15

4. The routine placement of hep locks (venous access… just in case) is a painful procedure and suggests to the laboring mother that “complications” are likely and venous access will be required.3 “There is a temptation to treat all births (of which 80 % are uncomplicated) routinely (standardized protocols) with the same high level of intervention required by those who experience complications (20%).1 The WHO maintains that “women and their babies can be harmed by unnecessary practices” (p. 2). If, between 37 and 42 completed weeks of gestation, no risk factors have been identified, the labor ought to be viewed as a low-risk event, which is what most labors and birth are. 1,11 So the question remains, should intravenous access be routine?

5. Supine position (lying on the back) in labor in labor hostile. Freedom of position and movement during labor15 and the use of upright positions in labor (gravity positive)15 are two helpful labor practices that complement each another. Mobility and upright postures enhance the progress of labor1 if only because the activity itself prohibits interventions commonly imposed on normal labors (continuous EFM, intravenous therapy, induction or augmentation of labor, artificial rupture of membranes, epidural use that confine a laboring woman to bed). Recumbent positions is any stage of labor can diminish the effectiveness of uterine contractions thereby slowing labor’s progress.1, 16 Supine positions are more painful for mothers 1, 17 and compromise uterine (hence placental) blood flow because of the compression of aorta and vena cava blood vessels by the heavy uterus.1 This can interfere with adequate oxygenation of the fetus. In the second stage of labor, squatting or kneeling increases pelvic diameters and employs the benefit of gravity to enhance fetal descent.28, 29 The supine position in labor and birth “flattens” the pelvis and requires that the mother push her baby out “uphill” and against gravity. Position changes, upright postures and respect for the maternal choice of position decreases the incidence of instrumental birth, episiotomies (surgical incision of the mother’s bottom),16 lacerations (tears of the perineum provoked by the exaggerated spreading and flexion of a mothers legs), maternal discomfort and backache1 and may shorten the pushing phase of labor (Stage II).17 The lithotomy position for birth is usually the dictate of the healthcare provider rather than that of maternal choice simply because it is a position of convenience for the individual “delivering” the baby. 30, 31, 32 “Knowledge of the advantages and willingness to attend to women in various positions can make a vast difference to labour” (WHO, p. 27). But, this is not how it is. Healthcare provider preference usually dictates the position a mother must assume for birth rather than maternal preference and/or comfort. 17

6. Rectal examination for progress of labor has long been out of favor. Decades ago, physicians believed that rectal examination prevented vaginal contamination1 but research did not affirm that belief. Furthermore, rectal exams were far more uncomfortable for mothers18 than vaginal examinations are and the assessment was far less accurate.19

7. The use of X-ray pelvimetry (X-Ray of the pelvis in labor) became obsolete when ultrasound technology came of age. Because ultrasound examinations can be employed earlier in pregnancy to confirm a gestation, to determine the number of fetuses conceived, to estimate gestational age, to locate placental placement, fetal presentation and position, among many other assessments and without the possible hazards of radiation20, ultrasound has replaced the less sensitive diagnostics of x-ray pelvimetry. Furthermore, X-ray pelvimetry has been associated with an increased incidence of leukemia in babies.21, 22

8. The routine use of oxytocin (syntocinon/pitocin) prior to birth and the use of that “high alert medication”23 that cannot be stopped quickly, is risky business. High-alert medications are those with the potential to cause harm to a patient if not administered with caution and according to protocol. Syntocin (Pitocin) was added to the list of high-alert medications in 2007 by the Institute for Safe Medication Practices.23 It is one of twelve medications labeled as high-alert. Patient injury and the consequences of improper or overuse of high-alert medications may result in more devastating outcomes. In the case of maternity care,23 there are two clients at risk, the mother and her fetus. The more common adverse effects of Pitocin administration are rapid onset of painful contractions that become too many too fast because of overstimulation of the uterus. The consequences of this tachysystole (uterine hyperstimulation), if not addressed appropriately, are uterine rupture, fetal distress (especially if used in gestations less than 39 weeks)23, 24, and possible cervical injury.25 Because induction or augmentation (stimulation) of labor has become a routine elective intervention today (which is wholly other than medical reasons for hastening birth),3 it is not surprising that this high-alert medication is “one of the leading causes of obstetrical liability” (Krenig, p.15).  Adverse outcomes are associated with electively induced labors because the onset of labor is being forced before the fetus is ready to initiate his own birth. Consequently, it is the baby that must be rescued from an environment that has become hostile 3, 27 because of uterine hyperstimulation that gives the fetus too little time between the oxytocin-driven contractions to adequately oxygenate himself. Induced and augmented labors increase the maternal need for analgesia and anesthesia, increase the incidence of instrumental birth (vacuum or forcep extraction), increase the risk for cesarean birth, increase the length of hospital stay and drive up healthcare costs.3 If Pitocin is used, it must be used with caution and careful monitoring of uterine activity (frequency, length and strength of the uterine contractions) and the corresponding fetal response (the fetal heart rate) to those contractions. There must be a way to stop the infusion of the Pitocin laced drip quickly and prompt support of the fetus (oxygen by a tight fitting face mask and changing of maternal position). The WHO, however, questions if “liberal use of oxytocin augmentation (“active management of labor”) is of benefit to women and babies” (p. 23). Indeed, the WHO asks if “labour augmented by oxytocin infusion can still be considered normal” (p. 23).

9. Use of lithotomy position (legs constrained/positioned, and unnaturally spread) with or without stirrups (leg support) is neither mother nor fetus friendly. In the second stage of labor, squatting or kneeling increases pelvic diameters and employs the benefit of gravity to enhance fetal descent.28, 29 In contrast, the supine position in labor and birth “flattens” the pelvis and requires that the mother push her baby out “uphill” and against gravity. Position changes, upright postures and respect for the maternal choice of position decreases the incidence of instrumental birth, episiotomies (surgical incision of the mother’s bottom),16 , lacerations (tears of the perineum provoked by the exaggerated spreading and flexion of a mothers legs) maternal discomfort and backache1 and may shorten the pushing phase of labor (Stage II).17 The lithotomy position for birth is usually the dictate of the healthcare provider rather than that of maternal choice simply because it is a position of convenience for the individual “delivering” the baby. 30, 31, 32

10. Sustained and coached bearing down (Valsalva maneuver also known as “purple pushing”3 and breath holding) in labor to expedite the birth of the baby is harmful to both mother and baby.33 Once the cervix is fully dilated (opened fully), the fetus can begin her descent downward to birth (Stage II). Stage II begins with a period of latency, a brief time of rest for the mother as the fetal head descends passively (known as laboring down).16 The mother usually has no urge to bear down (push) to contribute to fetal descent at this time. Indeed, premature pushing, as encouraged by many healthcare providers puts the mother at risk for exhaustion and the risk of forceps or vacuum extraction.16 As the final active phase of descent begins, a mother will begin to feel perineal pressure as involuntary pushing begins. It is when a mother has the urge to push that she will push effectively, spontaneously and without the maternal exhaustion that accompanies the breath-holding and loud coaching that usually accompanies the less effective and more aggressive Valsalva kind of pushing. Mothers “push best if they are allowed to follow their own intuitive pattern of bearing down.33 As the fetus descends and presses more firmly against the perineum, the mother pushes more forcefully, which is what the birth of the baby’s head will require. She will require no coaching to push effectively at this time but rather prosper from encouragement and praise. Furthermore, birth of the fetal head between contractions, rather than during a contraction, contributes to less genital tract trauma.34, 35

11. Massaging and stretching of the perineum (vaginal outlet) by the hands of the birth attendant, once an accepted practice, is now known to cause more harm than good. When a woman is in a supine position for the birth of her baby, the gravity generated descent of the baby is eliminated. Furthermore, if a mother is being directed to “bear down” prior to her innate urge to do so, she will not push effectively.33 In these situations, the birth attendant, attempting to artificially generate an urge to push, will stretch and pull the vaginal out let as though to “iron it smooth” to make more room for the oncoming head and provoke the mother into pushing effectively. However, if the mother is birthing in an upright position and is pushing involuntarily during and/or between contractions, the artificially and digitally created perineal stretching and pressure is not necessary. The artificial stretching of the skin is laceration-inducing and increases the risk of infection because of the constant presence of a foreign body (healthcare provider’s fingers) in the vagina. A forced stretching of tissue will lack the resilience of tissue that stretches only to the extent it must. Current research suggests that antenatal perineal massage, the application of warm compresses to the perineum (space between the vagina and anus) in the second stage as the head descends and stretches the perineum, and a hands off the perineum and fetal head at birth is associated with reduced perineal trauma.2, 36

12. Oral ergometrine tablets (Methergine) in the third stage of labor (birth of the placenta) to prevent or control postpartum hemorrhage is unwarranted for two reasons. Research findings demonstrate that ingestion of oral ergometrine had “little demonstrable effect on blood loss after childbirth” (WHO, p. 30). When taken by mouth, the onset of action is between 5 to fifteen minutes,37 depending upon the fullness of the stomach at the time of ingestion. The intramuscular route (injection), on the other hand, promotes a more rapid onset of sustained uterine contraction (the treatment for anticipated or actual postpartum hemorrhage) two to five minutes post-injection. Because of the severe side effects associated with intravenous administration of ergometrine, this medication is administered by this route for only the most “severe uterine bleeding”.37 Non-pharmocologic assists to encourage placental separation and control blood loss in the third stage of labor are nipple stimulation either and putting the baby to breast (because of the breast-brain-uterine interactive connection.

13. While once common practice, routine use of parental ergometrine in the third stage of labor (birth of the placenta) is no longer endorsed because the effect of ergometrine is less effective than the oxytoxic syntocinon (pitocin).1 Since Ergometrine cannot be administered intravenously (allows for an almost immediate response to the medication) and pitocin can be administered IV, it makes sense, in the event of heavy third stage bleeding, to administer the medication that will have strongest effect the fastest. The combination of ergometrine and oxytocin (Syntometrine) is a more powerful uterotonic (contraction inducer), however, the maternal side effects of Syntometrine (vomiting, nausea, blood pressure elevation) are unpleasant and discourage the use of this particular contraction inducer.38

14 & 15. Routine lavage (washing) of the uterus after birth is a most harmful practice as is routine manual exploration (examination of the uterine cavity by hand) of the uterus after birth. Once the placenta is delivered, it is essential that the uterine musculature (myometrium) contract tightly and remain that way to prevent circulation to the placental site that is now void of the placenta. Oxytoxic medications, gentle massage of the uterus abdominally, nipple stimulation and putting the baby to breast favor uterine contraction. To fill the uterus with fluid to wash it or to insert the entirety of a hand into the uterus encourages hemorrhage, causes trauma, and is an invitation for a severe postpartum infection.1 The pain of these interventions for the mother is of course obvious. If the placenta is allowed to separate spontaneously (rather than pulled from the uterine wall), and if careful inspection of the placenta to determine the completeness of its birth along with the accompanying amnionic sac membranes, there is no need for such invasive, painful, and hemorrhagic, sepsis-inducing uterine violation.