Has the Over-medicalization of Childbirth robbed Moms of a Magical Experience? An Anesthesiologist's POV

The gradual decline in perinatal deaths has stalled as birth through Cesarean section, labor inductions and epidural anesthesia has been on the rise.

Photo Credit: BirthKalamazoo.com

This essay is about my personal experience as an anesthesiologist caring for mothers in the perinatal period as well as my research into the body of evidence that guide perinatal care in this country.

I had been planning to write this piece for several years. Then last week one my favorite authors on this platform, A Midwestern Doctor, published this piece, “The Hidden Dangers of Hospital Births & How to Protect Your Family” on their newsletter, “The Forgotten Side of Medicine”:

The Hidden Dangers of Hospital Births & How to Protect Your Family

The author touched on many of the concerns I have had regarding medical interventions in the perinatal period thought to be necessary and beneficial but are, in fact, based in conflicting bodies of evidence. Some of them are thus plausibly responsible, in part, for poor outcomes and the increasing incidence of C-sections.

CDC data indicate that in 1970 the annual rate of primary C-sections in the United States was just over 4% and nearly quadrupled by 1993. By 2024, the primary C-section rate, per CDC provisional data hovers just under 23%.

Even more stunning is that C-Section rate for the lowest risk pregnancies (Nulliparous, Term, Singleton, Vertex) in 2024 is 25.3%. In other words, more than 1 in 4 first-time moms who carry their pregnancy to term and have a confirmed fetal position optimal for a vaginal birth deliver their baby through a major abdominal operation.

Beyond acute risks to the mother (infection, prolonged recovery) and baby (a 1.5-1.9% risk of lacerations and a three times greater risk of developing respiratory distress syndrome), babies delivered through a C-Section have an associated increased risk of

• asthma

• gastrointestinal afflictions like irritable bowel syndrome and Crohn’s disease

• Type II diabetes and obesity

• Lower standardized test scores

• ADHD

Obstetrical Anesthesia

Obstetrical anesthesia can often be rewarding and can also, in extremely urgent and emergent situations, be exceedingly challenging.

Anesthetists are in the business of minimizing the risk to our patients. This involves medically optimizing the health of our patients undergoing elective procedures. In situations that are exigent, where an operation is required to prevent the loss of life or limb, we try to prepare for every contingency as best we can.

One of the most challenging situations we encounter is an obstetrical emergency, when an unplanned Cesarean section needs to be performed within minutes to save the life of a baby. There is no time for preoperative laboratory testing or even standard cleansing of the intended incision site which requires several minutes of drying time for maximum effectiveness.

There is no time to perform a spinal anesthetic, the safest form of rendering the mother adequately anesthetized for a large incision in her lower abdomen, the dissection of deeper layers of muscle and eventually a hysterotomy, the opening of the highly vascular gravid uterus so that the infant can be extracted.

In those situations the often panicked and bewildered mother must receive a general anesthetic, where she is given rapidly acting medications intravenously which render her unconscious and paralyze her vocal chords so that a tube can be inserted into her trachea which protects her from aspirating stomach contents and allows us to institute mechanical ventilation of her lungs with oxygen and a standard concentration of anesthetic gases.

The obstetric patient offers more challenges. The physiology of pregnancy results in limited pulmonary reserve. In other words, the mother’s relatively greater demand for oxygen combined with the compression of lower lung fields from a gravid uterus results in a far more rapid decrease in blood oxygenation during the period after she is rendered unconscious and before ventilation can be initiated mechanically. In other words, we are afforded significantly less time to place the breathing tube.

To make matters even worse, large studies have established that pregnancy is associated with a 2 to 3 times greater risk of a “difficult intubation”. Anesthetists must act swiftly and successfully under circumstances where there is not one but two lives in the balance. It is always an extremely risky and chaotic situation—something we train to avoid whenever possible.

On the other hand, obstetrical anesthesia can also be very rewarding. Over the years I have received a handful marriage proposals after placing an epidural to mitigate a laboring mother’s pains of contraction. Far more often we receive unspoken gratitude from the expectant mother’s family who are astonished to see her snooze through contractions after helplessly witnessing her scream and plea for some form of relief for hours.

The placement of an epidural during labor is by far the most common anesthetic intervention in pregnancy. Approximately 2.5 million epidural anesthetics are administered every year in the U.S. and over three quarters of nulliparous women receive them. However epidurals come with risks too.

“Epidural” refers to a potential space between the ligamentum flavum and the dura mater (the outer protective membrane of the spinal cord). The space is accessed through a fairly large needle which is carefully advanced into the epidural space so that a tiny catheter can be threaded into it. The procedure can be done in under five minutes in the best of circumstances. Sometimes it takes much longer depending on maternal obesity, scoliosis or the inability of the patient to assume the optimal position for placement. Hence, the anesthetist must contend with screams and unavoidable, unintentional movement during contractions.

Once placed and tested, a mixture of local anesthetic and narcotic can be continuously infused through the epidural catheter so that the nerves which convey sensation of labor pain can be blocked thus providing unmatched relief of the pain of labor.

Epidural anesthesia comes with unavoidable risks. If the epidural needle is inadvertently advanced too far, the protective sheath surrounding the spinal cord will be punctured and that often results in a devastating headache and occasionally other neurological symptoms. Even in the best of hands the incidence of a dural puncture headache is approximately 1:200. The symptoms usually resolve gradually after a few days or weeks, but the negative impact of this complication upon the new mother’s experience cannot be overstated.

While mothers are assured that epidural anesthesia is safe during pregnancy, the evidence supporting this claim is questionable. Local anesthesia in the epidural space can lower mom’s blood pressure which can lead to fetal distress. Nearly 42% of women in this study involving over 400 parturients had significant adverse reactions to epidural anesthesia including a severe drop in blood pressure. Epidural placement in this cohort was associated with an increased rate of an unplanned C-section.

Rapid and profound drops in blood pressure during epidural anesthesia is so common that Labor and Delivery Nurses usually have a standing order to administer a powerful and rapidly acting medicine called ephedrine intravenously. Maternal blood pressure directly affects the fetus. Though we may be able to rapidly intervene if necessary, the idea that epidural anesthesia is “completely safe in pregnancy” is a myth.

Yet a Cochrane study from 2000, considered to be the gold standard for medical evidence, found that there was no significant increased risk of C-section for mothers receiving epidural anesthesia for labor. It is this finding which serves as the basis of our commonly held belief that epidural anesthesia for labor harbors no increased risk for an unplanned delivery through C-section.

However other studies, like this one have shown the opposite. The author of this study notes that the Cochrane meta-analysis found no evidence of an increased risk of C-section because of a single, large study which skewed the results toward an “absence of risk” conclusion. That study by Sharma et al was conducted at Parkland Hospital in Dallas, TX when at the time their C-section rate was very low (12%) compared to national averages. The author further notes:

“Most importantly, the subjects in the trial were randomized at more than 4-cm cervical dilation—the active phase of labour.”

And

“According to the Cochrane data, the rate of CS for both groups in the study by Sharma and colleagues was only 5%”

In other words, it is entirely likely that the risk of C-section after epidural anesthesia has been ignored or hidden by a single very large study which has little relevance to how obstetrical anesthesia is actually practiced in most of the country.

As noted above, epidural anesthesia in the study by Sharma et al was offered only after the patient achieved a cervical dilation of 4 cm and was considered to be in active labor. This is by no means achieved in my own facility (and others where I have worked) where obstetricians routinely give the okay for epidural anesthesia before their patients are in active labor.

Labor and Delivery nurses who seek to offer their patients relief as early as possible thus advocate for epidural placement if the obstetric service has approved it. More than once a mom at our facility who was expected to enter the active phase and received an epidural never progressed and was sent home, still pregnant. The patient exposed themselves to the risk of a catheter placement only to have it pulled.

At least several times a month our department is asked to place an epidural in a patient in active labor who ends up delivering upon our arrival, or worse, ends up delivering shortly after epidural placement having received no benefit and only risk from the intervention.

Beyond that, patients having received an epidural are often surprised to discover that they will be restricted to their beds until they deliver because their legs are too weak to allow them to get out of bed safely and that their bladder will have to be continually drained through an indwelling catheter. These are more reasons to withhold epidural anesthesia until the active phase of labor.

HYPNOBIRTHING

Like most doctors in other fields, I never questioned the culture and evidence which supported our approach for some time. And then, eighteen years ago when my wife was pregnant with our son she informed me that she had reservations around standard perinatal care in this country.

She had given birth five years earlier to my step-daughter at Beth Israel Hospital in Boston, MA after her obstetrician had warned her in her second trimester that there was a significant chance that she would not carry the pregnancy to term due to various clinical markers. She ignored the assessment and trusted her intuition that everything would turn out fine.

Everything did turn out fine, despite the treatment she received when she arrived at the Labor & Delivery unit a few weeks before her expected delivery date. Her “water”, the fluid inside the amniotic sac, had “broken” hours before, but she hadn’t rushed to the hospital to be evaluated. Her nonchalance wasn’t viewed kindly by the staff when she arrived and announced that she was ready to give birth.

Though she was having frequent and painful contractions, they quickly assessed her and coldly informed her that she was still early in labor and needed to put on a hospital gown and expect a visit from the anesthetist who would place an epidural when the contraction pains became intolerable. Jill wasn’t interested in wearing a gown. She wanted to be in her birthday suit when her daughter arrived in her own.

And neither was she interested in an epidural.

The nurses rolled their eyes. “You think it hurts now? Just wait!”, they told her.

I wasn’t there, but I knew exactly what the staff was thinking: another naive, first-time mother who thinks she knows about the realities of childbirth.

The anesthetist was summoned anyway. Racked with the pain of a powerful contraction and unable to think clearly, she allowed herself to be placed in a sitting position for the epidural while a nurse tried to insert an IV into her arm and place a gown over her shoulders. She pushed everyone aside and much to their shock and dismay, gave birth to my step daughter then and there, completely naked twenty minutes after arriving at the world-renowned medical center.

This time around things would be different. Jill was training her body and her psyche to expect a smooth and tolerable labor using a method called Hypnobirthing, a technique developed by Marie “Mickey” Mongan who used it herself after researching the conditions many mothers endure during childbirth in this country.

I had never heard of this approach and was completely open to it as long as the delivery would take place in a hospital with an obstetrician in attendance. Though I am of the opinion that childbirth is over medicalized I am well aware that the need for urgent, life saving intervention can never be predicted.

Halfway into her second trimester we would fall asleep listening to hypnotic scripts which encouraged her to visualize herself in a birthing position, relaxed and confident of the process and the innate intelligence of her own body which would know exactly what to do when the time came. We never spoke about the risk of complications and avoided talking about our “birth plan” to our friends. Four months later (on September 11, 2008) my wife peacefully gave birth to our son in a birthing tub with no continuous Fetal Heart Monitoring or epidural while I strummed a guitar and sang while the hospital doula harmonized.

I was impressed. A few years later I attended a four day seminar given by Ms. Mongan offered to people who were interested in becoming “certified” Hypnobirthing coaches. I arrived at the small conference room at a modest hotel in greater Boston to find about 15 women seated in a circle casually chatting. Mongan started by asking us each to share our name, what we did and why we were there.

Everyone was either a birthing doula or a mother who had an amazing birthing experience using the Hypnobirthing approach and wanted to help other mothers to experience what they did.

I let them know that I was an anesthesiologist and was questioning the establishment’s approach to childbirth even before witnessing the peaceful birth of my son. Having regularly been in situations where immediate interventions were required to save the life of a mother, her baby or both I knew that modern medicine offered essential care that could never be replaced by visualizations or hypnotic suggestions. But were we robbing mothers of the full depth and beauty of perhaps the most magical experience our human condition offers?

Mickey Mongan’s eyes welled up. She quietly said that in her decades of spreading her perspective I was the first physician who was seriously interested in what she was offering.

Mongan gave birth to her first two children in the 1950’s when it was common to give a mother in labor a brain-scrambling drug called scopolamine and/or ether and physically restraining them until the baby was delivered. She was traumatized. Surely there must be a better way to approach the most natural part of being alive? Do other mammals have the kinds of problems we have?

She recalls contemplating the birthing process of a cat, living on a farm. The pregnant feline will find a quiet, dark, warm and safe place when the time came and would simply let her body take over. However, if the pregnant cat hears someone approaching or becomes aware of any potential threat, her labor immediately arrests and she will scurry away to find a different secure place and labor naturally resumes.

She hypothesized that the fear humans have about childbirth may be the source of our difficulties. In order to push a pregnant woman’s body into birthing against its natural response to fear powerful drugs are required.

She was right. Often, mothers who are due but not in labor need to have their cervix mechanically opened with a balloon catheter and “ripened” with the direct application of Prostaglandins to substitute for a natural hormonal response. Though effective they can also lead to uterine hyper-stimulation where contractions are unnaturally strong or long.

Mongan speculated that the contraction pain was exaggerated by chemical stimulation, especially if the cervix wasn’t ripe or “favorable”. If that wasn’t enough, modern obstetric practice routinely “augments” contractions with pitocin, a synthetic version of oxytocin, the hormone which stimulates uterine contractions. All of this, she believed, would be unnecessary if a mother’s body and mind were ready to have a baby and was allowed to progress at her own pace.

She noted that women in child bearing years at the time understandably regarded childbirth as dangerous and painful, a situation where they would have to surrender control of their own bodies to a medical machine that insisted their approach was better and safer. Horror stories abounded. No one had heard of a painfree childbirth let alone a pleasant labor. She was determined to undo her own programming. She refused to listen to the rampant accounts of harsh treatment. She noticed the negative connotation of the terms used by convention around childbirth: “contractions”, “rupture of membranes”, “delivery”, “complication”, “failure to progress”, “pushing” and yes, even “pain of labor”. Why were we doing this?

Hypnobirthing isn’t about hypnotizing mothers into pretending that a horrible, painful experience was pleasant; she was arguing that we were a population which has already been hypnotized to believe that giving birth must always be agonizing. Using her own revised mentality she fiercely advocated for the birth experience of her third child devoid of the practices that were in vogue at the time and gave birth happily, calmly and with little discomfort.

Armed with her own experience as proof she spent the rest of her life promoting this radical approach called “Hypnobirthing: The Mongan Method” which is now practiced around the world. As I mentioned above, the method involves visualization and imagination. She introduced different terms to describe the process. She insisted that we refer to “Contractions” as “Surges”, “Rupture of Membranes” as “Releases”, “Pushing” as “Breathing Down”, “Pain” as “Sensation”, “Dilation” as “Opening” and “Labor” as “Birthing".

Perhaps, most importantly, Mickey taught her clients how to advocate for themselves when their obstetrician began to insist that things weren’t going exactly as planned. She saw that the obvious consequence of more monitoring and interventions was more monitoring and interventions.

For example, if progress is deemed “inadequate” frequent manual exams of the cervix will be deemed necessary. This is known to increase the risk of an infection, chorioamnionitis, an indication for a C-Section.

If “contractions” were judged to be “inadequate” augmentation with pitocin would be suggested. The sensation of a uterus contracting under the influence of exogenous oxytocin against a cervix that isn’t open is significantly more painful. This often leads to the request of an anesthetic, i.e. epidural anesthesia, which requires, at the very least, continuous fetal heart monitoring and bed restriction as well as rare risks of serious adverse effects.

Another extremely common intervention used to “speed things along” is the intentional rupture of the amniotic sac, the bag of fluid surrounding the fetus which is extremely vital in protecting the developing baby from mechanical stressors, allowing space for limb mobility, providing thermoregulation and protection from infection. Why, you may ask, would an obstetrician wish to rupture such a structure with a long hook like instrument during a vaginal exam? The answer is that it is thought to increase the strength of uterine contractions and speed the whole process along.

Once again a Cochrane meta-analysis of 15 studies, the best evidence we have, tells us the opposite:

“Evidence does not support routinely breaking the waters for women in normally progressing spontaneous labour or where labours have become prolonged.

“The evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended as part of standard labour management and care.”

So why is it a part of standard labor management and care, especially when labors have become prolonged? I don’t know. This is another reason why I am writing about it. If there are any obstetricians, mid-level providers or Labor & Delivery nurses reading this and have an answer please share it in the comments.

Despite having no proven benefit, once the amniotic sac has been ruptured, the stop watch has started. In this country, guidelines indicate that if a baby hasn’t been delivered within 24 hours of membrane rupture, it is at risk for other complications. This guideline is often used as an indication for an unplanned C-Section.

Elective Inductions

Two years ago I became aware that some of the obstetricians at my facility were electively inducing their nulliparous, low-risk patients when several Labor & Delivery nurses came to me privately and asked me to look into the data that supported this practice. It seemed to them that these patients were ending up in the operating room more often than they should.

In layman’s terms induction of labor is a pharmacologic and mechanical means of getting a woman’s body that is not ready to go into labor to go into labor. There are legitimate indications for the induction of labor:

• Pre-eclampsia (a non-physiologic response to pregnancy which can put Mom in serious danger)

• Gestational Diabetes

• Chorioamnionitis (infection of the sac surrounding the fetus)

• Chronic, pre-existing maternal conditions which are exacerbated by pregnancy

• Fetal Growth Restriction (Fetus isn’t thriving)

• Oligohydramnios (insufficient fluid in the amniotic sac)

• Premature Rupture of Membranes (as stated above, the membrane sac is crucial for the fetus’ survival)

• Post-term Pregnancy

In these situations, continuing the pregnancy is either dangerous to the mother, the baby or both. The induction of labor offers a way to deliver without the risks of a C-Section.

An Elective Induction is, like the term indicates, stimulating labor and delivery for no medical reason. It is elective, i.e. by choice. This flies in the face of the Mongan approach which advocates for the innate intelligence of Mom’s body, which will automatically know when the time is right.

The evidence for offering an elective induction to nulliparous women stems from a 2018 trial (the “ARRIVE” trial) which compared two matched cohorts of low risk nulliparous pregnant women in their 39th week of pregnancy to elective induction vs “expectant management” with regard to a primary endpoint of perinatal death or severe complications. A secondary endpoint was the incidence of delivery via C-section.

There was no statistically significant difference between the two groups with respect to the primary endpoint. Interestingly the incidence of C-sections was 3.6% lower in the elective induction cohort (18.6%) vs (22.2%).

Note that the “expectant management” C-section rate, unlike the Sharma et al study, was in alignment with national C-section rates. Why would the artificial induction of labor involving all the interventions listed above result in a lower rate of C-sections?

The answer is that the higher rate of C-sections in the “expectant” group is largely due to the fact that a subgroup of them (17%) did not deliver spontaneously by 41+ weeks and received a medically indicated induction for either post-dates or another condition (no patient was allowed to continue their pregnancy beyond 42wks and 2 days). Induction late in pregnancy is well established to be associated with a significantly higher rate of failed induction, i.e., need for a C-section. Indeed, 37.5% of this subgroup received one.

In other words, electively inducing labor at 39 weeks eliminates any pregnancy which could have extended into the period when the C-section rate increases dramatically. The trade off is that there was a higher percentage of C-sections in the first week in those induced (18.6%) compared to those that weren’t (17.3%). Though the overall risk of a C-section was 3.6% lower in the elective induction cohort, it is entirely possible that a number of elective inductees could have avoided a section if their pregnancies were expectantly managed. We simply do not know.

However, labor induction usually requires the artificial rupture of membranes (AROM), administration of pitocin and continuous fetal heart monitoring. Uterine contractions with escalating doses of pitocin are excruciatingly painful and epidural anesthesia becomes necessary most of the time.

The “laboring” mother will have probes attached to her abdomen which record the heart rate of her baby and detects uterine contractions, a machine which pumps local anesthetic into a catheter in her spine, a pump infusing fluids and pitocin into an IV in her arm and a catheter in her bladder to drain her urine. She will also be subjected to regular vaginal exams to monitor the state of her cervix. Mothers getting epidural anesthesia will be confined to their bed and in most facilities will not be allowed to eat solid food until the baby arrives.

I can say with reasonable confidence that those who consent to an elective induction are not adequately informed about the nuances of the data or how their birthing experience will be affected by an induction of labor, which will be much different than my wife’s. It’s the difference between “labor” and “birthing”.

On the other hand, AROM (artificial rupture of membranes) and labor augmentation with pitocin is very common in my facility, so for all intents and purposes their experience would be similar to “expectant management”.

“Traditional” births have now become distinctly “Non-Traditional”.

While I do not find any issues with ARRIVE trial’s methodology or the interpretation of the data, I do think that its results cannot be replicated at most facilities, including mine. This concern has been expressed by others too. The induction protocol in the study was very strict. Lack of adherence will undoubtedly result in different outcomes. I trust the observation of the nurses on our Labor & Delivery unit who are strong advocates for their patients. If they brought it to my attention they must have well-founded concerns.

So, what is the C-section rate among elective inductions at my hospital? I brought the question to the administration. Astonishingly I was told that they have no idea. They’ve never run the numbers.