When The Door Closes

Abnormal labor patterns. Dysfunctional labors. Failure to progress. If you are a professional in the childbirth industry long enough, you will hear these words.


Abnormal

Dysfunctional

Failure

Such harsh and condemning words. And of course, the blame is put on the mother and her bodies inability to birth.

Now, I am not talking about the woman who goes in at 39 weeks with a Bishop's Score of 3 who has a failed induction 'necessitating' a cesarean..

I am talking about the woman who is laboring beautifully, begins getting really juicy and birthy, starts transitioning, is checked to be 8... and then, for some reason, either stops dilation, or even goes backward in dilation.

"Uterine action, and therefore labour-pains, may be suspended or removed by many causes ... The disappointment occasioned by a stranger entering the room when the patient expected her own attendant, has been known to stop a labour. In the midst of its most active operation, and to suspend it for many hours. It is principally on this account that we are careful to prevent a woman in labour becoming suddenly acquainted with any news that is likely to shock her. 

...On arriving at the patient's residence it is better not abruptly to obtrude one's-self into her presence, unless there be some immediate necessity for our attendance. Information should be sought from the nurse, on such points as will enable us." - Dr. F.H. Ramsbotham, The London Medical Gazette

This can be from a transport to the hospital (midwife transfers for some reason when mom is checked to be 7cm... when she gets to the hospital, the OB checks mom and she is closed up to 3 cm - then, of course, the OB looks at the midwife like she has no idea what she is feeling).

This can be from a mom who is opening nice and gently and easily, and then a hostile or combative presence (usually a care provider, can be a mother or mother-in-law or other disturbing presence) enters the room and suddenly moms dilation stalls... within a few hours, she is rechecked by another hand (nurse to OB, or OB to shift-change OB) and deemed 'less than' before. 

Wait, you say... the door can close during labor?

Yes, you read that right, she UNdilates.

Of course, medical texts now refuse to document this very normal and natural phenomenon. Instead it is chalked up to the nurses error, the residents error, or the woman's bodies fault.

"MANA's first report was on 9,000 births (MANA, 1998). Cervical reversal was reported by 107 midwives and occurred in 234 women (2.6%). Midwives found that the most common factors associated with reversal were: home to hospital transfers; a swelling anterior lip; an ill fitting presenting part; following membrane rupture; anxiety; lack of continuity of carer; and contractions stopping. We are all aware that all the above may affect a woman's progress in labour, but we do not seem to accept that they can be associated with a cervix closing down."  - www.birthworks.co.az

Think about it for a moment: the cervix is slippery, sinewy 70% collagen, yes.. but about 25% muscle - which directly responds to catecholamine (adrenaline).

"Cervical dilation and effacement are produced from vertical fibers in a relaxed woman.  Stress causes horizontal and vertical fibers to contract, creating non-productive first stage labor."  - Osborne-Sheets, C. Pre-and Perinatal Massage Therapy.  Body Therapy Associates, 1998.

Catecholamines are produced when a woman is frightened, stressed, or otherwise emotionally upset. They are also produced when one feels threatened or cornered. Just like when animals clamp down on their labors until they can get to a place where they don't feel threatened by predators and can re-initiate labor.

Or, in simplest terms, as Ina May states:

Sphincter Law manifests itself in the following ways:

• Sphincter muscles of both anus and vagina do not respond on command.
• Sphincter muscles open more easily in a comfortable intimate atmosphere where a woman feels safe.
• The muscles are more likely to open if the woman feels positive about herself; where she feels inspired and enjoys the birth process.
• Sphincter muscles may suddenly close even if they have already dilated, if the woman feels threatened in any way.

In Ina May’s book Spiritual Midwifery, she recounts the story of Judith, a woman giving birth on The Farm. Judith felt that her labor was out of control and moving too fast.

“Judith…on hearing that she was fully dilated, became very sober, very serious. If someone said something funny, she was the only one who didn’t laugh…She coughed once, a shallow, polite little cough that obviously didn’t get anything done. By this time I was getting curious as to what was going on…So I put on another sterile glove and once again checked Judith’s dilation. She was only four centimeters dilated! I was amazed. I had never known before that a woman could go backwards and undilate herself. When Judith heard what she had done, she admitted that she had been worried that the labor had been coming on so fast that it was getting out of control. I told her that it was supposed to feel like that…She relaxed and in one or two more rushes [contractions] she was fully dilated again and after a few good pushes, Abigail was born.”

In fact, if we were to really look into this phenomenon, it wasn't until just recently when the obstetrical model refuses to acknowledge that the cervix doesn't like to be threatened or put in the spotlight.

"To judge whether labour has actually commenced. On being ushered into her chamber, we may engage her in some general conversation, which will give us an opportunity of observing the frequency, duration, strength, and character of the pains; and our conduct must be framed accordingly." - Francis H. Ramsbotham, The Principles and Practice of Obstetric Medicine and Surgery , 1861

Recently I attended a birth where a doctor thoroughly forgot all of her interpersonal communication skills and simply came in blaring with guns drawn. She was talking down to mom, trying to coerce and push her into making a choice, and using demeaning and belittling terminology.

She would have done well to listen to Dr. Cazeaux:

"I am well aware that books furnish some cases of women who had the power of suspending the contractions at will; but if the facts have even been well observed, they have failed perhaps to receive the most rational interpretation. In the cases related by Baudelocque and Velpeau, in which the labor ceased when the students were summoned to witness it and began again when these numerous observers retired, the will had probably less to do than the imagination and modesty, with the alternations of retardation and acceleration; for though the influence of the will may be reasonably doubled, it cannot be denied that moral disturbances appear to affect the contractilty of the uterus; thus, a violent emotion has often sufficed to arouse it long before the ordinary term of gestation, and it is not at all uncommon for the contraction to diminish or disappear for several hours, or even days, under the operation of such causes. [Cazeaux then quotes Betschler, who cited a case 'in which the pains were suddenly suspended by a violent tempest, so that the neck, though widely dilated, closed again, nor did the labor recommence until nineteen days had elapsed.']" - P. Cazeaux, 1884

Mom was working well with her labor. She was opening slowly, but opening. Doctor came in and immediately began pushing her to 'let her do her job'. She was aggressive and harsh, ridiculing and cruel.

Dad finally had to take the doctor out to the hall and give her a piece of his mind. Her caustic manner was slowing mom's already slow labor down to a crawl.

"Every day, indeed, we witness a suspension of the pains for half an hour. and sometimes even for several hours, upon visiting women whose modesty is shocked by our presence. The exercise of this function is seldom of long duration, lasting for a few seconds only - rarely beyond one or two minutes, and then the organ which was so strongly contracted and hardened gradually regains its primitive state, and remains in repose, until under the influence of the same stimulus, it is again thrown into action. The organic contractility, like all muscular power; is expended by a prolonged exercise, and hence we can understand why the pains so often become at once more slow and feeble or even cease altogether after a prolonged labor. 

Any vivid moral impressions operating during the labor; any unexpected news or sharp discussions, the announcement of a child of an unwished-for sex, and the arrival or presence of persons disagreeable to the lying-in woman, may determine a cessation of the pains; and in these cases the removal of the cause is the only remedy. But, unfortunately, it is not always an easy matter to ascertain what that cause may be. 

On arriving at the house the practitioner should have his visit announced to the patient, and he will vel}' often find that the first effect of his presence is to arrest the pains that have been hitherto progressing rapidly, thereby affording a very conclusive proof of the influence of mental impressions on the progress of labor. If the pains be not already propulsive, it is well that he should occupy himself at first in general inquiries from the [female] attendants as to the progress of labor; and in seeing that all the necessary arrangements are satisfactorily carried out, so as to allow the patient time to get accustomed to his presence." - Playfair's System of Midwifery, 1889

I wish there were a way to get these studies in front of doctors such as that one. A way to remind them of the wisdom of their predecessors:

"Just so long as there is no evidence of maternal or foetal exhaustion, and just so long as the clinical course of labor is proceeding after the normal fashion, the physician 's policy is a waiting one, and his immediate attendance is not requisite; on the contrary, his presence in the lying-in room simply excites the anxiety of the woman."- Egbert Grandin and George Jarman, Pregnancy, Labor; and the Puerperal State , 1895

So, what is our role as doulas? To educate moms to know how important it is to choose a place of birth and a birth professional who will respect the need for peace and gentleness:

"On The 'Pains' or Uterine Contractions... Mental emotion of any kind will temporarily diminish their intensity or even absolutely suppress them; the entrance of the physician into the lying-in room may have the same effect." - W A Newman Dorland, Modern Obstetrics , 1901

What is our role as birth attendants (midwives and doctors)? To remember that there is a way to convey important information, touch the laboring woman, and explain plans of action without interrupting the ebb and flow of birth:

"..it is to be understood, the fact of there being a continuance of regular pains, for it sometimes happens that, after regular pains have commenced, the agitation of the patient, or the mismanagement of the attendants, occasions a suspension of some hours." - James Hamilton, Hamilton's Practical Observations , 1837

What is your role as a mother? To reevaluate your feelings about your birth attendants and their back ups to make sure that you can trust them explicitly to respect your body and yourself enough to treat you with dignity and as a proactive consumer of your own healthcare decisions. If you cannot trust them to do this at your most vulnerable time, labor and birth, then to change providers to one who can.

"As soon as you arrive, let the husband, or some familiar friend, inform the lady, and then you should remain in the antechamber till she requests your presence. A sudden surprise, especially if attended with the fear of severe treatment, will greatly retard the process, and, in many cases, cause the foetus to retract. When you enter the room, let your mind be calm and collected, and your feelings kindly sympathize with those of the patient." - A. Curtis, Lectures on Midwifery , 1846

And finally, what do we do in these situations?

We become patient. Patience is the only real thing to do at this time. Perhaps making judicious and cautious choices regarding the addition of medical help. Perhaps simply waiting on mom and babies own time.

We remind ourselves of our bodies wisdom and the intuitiveness of the process. We trust that, as long as baby and mom are healthy, time will bring things to fullness as long as the space is protected and the mother is not made to feel condemned.

REFERENCES (unless otherwise linked):

• MANA (1998). Report on Cervical Reversal, MANA Newsletter, 16, 2, 16-17, March 1998.
• Michele Odent, Birth Reborn
• Gaskin, Ina May CPM. Going Backwards: The Concept of Pasmo. The Practising Midwife.
• Gaskin, Ina May CPM. Birth Matters: A Midwife's Manifesta.
• Stalled Labor
• Cervical Reversal
• Cervical Regression