Adapted from: Optimal Birth: The What, The Why & The How by Sylvie Donna

Of course, your own institution will have its own protocols and guidelines, probably including a decision tree for watchful waiting, and these should all be informed by NICE guidelines. However, since there is enormous scope for variation it’s important to consider what’s important and also what’s possible, so as to optimise in-labour care.

The importance of non-disturbance

I get the impression many people think that nothing much constitutes a disturbance when it comes to birth. All kinds of people are invited along to watch a labour and birth, cameras and even camcorders are used, and medical personnel pop in and out, frequently with no respect for the woman’s privacy. People freely talk to the labouring woman, unaware that this might have a profoundly negative effect. Midwives and consultants interrupt the labouring woman whenever they perform vaginal examinations or listen to the fetal heartbeat and they sometimes suggest hooking her up to an electronic fetal monitor, which usually limits her movements. Many midwives issue commands or make suggestions, they offer drugs and other options for pain relief and if they actually administer any they completely change the woman’s internal chemistry. They touch the woman and usually catch the baby, they offer comments and information without being asked (e.g. on the baby’s gender) and they often interrupt early mother-baby interactions. All these things are done without any real concern that disturbance is a possibility. Insensitivity on top of—or instead of—all this disturbance can also result in poorer outcomes because a mother’s negative reactions can severely affect bonding.

Although at times there are excellent safety reasons for stepping in, sometimes carers, relatives or friends disturb things out of impatience. Sometimes their speech or actions are prompted by worry or fear; sometimes carers are not really following protocols at all, but doing things out of habit.   At times it may even be a desire to control a seemingly wild experience which prompts someone to cause a disturbance. And, of course, very often the processes of labour and birth are disturbed by attempts to alleviate pain. The idea that a woman is entirely capable of giving birth without anyone else’s help is shocking to many people… and the idea that it’s possible to help prompts many people to action.

However, it does seem that the processes of birth are so delicate that many things can disturb a labouring woman and consequently make her labour slower and more dangerous. Just as one small jolt changes the pattern in a kaleidoscope or one mistake at work might have enormous repercussions, affecting numerous people, even one inappropriate action, comment, intervention or therapy can have a dramatic effect.

If you personally question this, please remember the link between emotions and hormonal production… It may cause a dramatic chain of negative developments. The link between speech and the ‘wrong’—non-instinctual—state of mind explains why even simple one-word interventions can be very disruptive. Furthermore, disturbance is particularly likely because of the sexual nature of birth. As you may know, even a mistimed comment or wrong movement during a sexual experience can take a person ‘out’ of the mood. If a person outside the experience should also come along… well that might really change outcomes.

States of mind are very important and things seem to proceed most smoothly if the labouring woman is allowed to drift off into a different, totally absorbed state of mind. To do this, a feeling of privacy and security is necessary… It’s worth noting that first of all, as a midwife, you are the person who can create both a sense of privacy and security for the labouring woman. You have enormous power in this respect, even if it may seem rather Zen-like! (It’s not exactly inaction but considered action or refraining from action from a standpoint of wisdom.) It’s also worth noting that in not disturbing the labouring woman you’re not handing over all control to her. As one experienced antenatal teacher (with first-hand experience of physiological birth) pointed out to me, it’s not a question of handing control to the labouring woman, it’s a question of not controlling her. As you know, while she’s in labour and giving birth physiologically, she’s going to seem well and truly out of control—totally wild!—so the issue of control seems a pretty irrelevant one really.

Disturbance vs. negligence

It’s important to note that I’m not advocating a completely laissez-faire attitude here. As we know, things do sometimes go wrong during labour and birth and things can be done to prevent maternal or fetal mortality or morbidity. That’s where the decision tree comes in... along with your years of experience, which will help you interpret it, and your sensitivity, which will help you relate to the labouring  woman entirely silently and without disturbance.

In the text on the previous page Michel Odent is talking about a complete lack of disturbance, not a situation in which there is a lack of care or inappropriate care—where a woman’s labour is disrupted, neglected or mismanaged.

I remember once speaking to a very bitter German woman who’d given birth in Japan. Not speaking any Japanese, she’d nevertheless communicated her wish to have a natural labour. After three days in labour, she gave birth to a brain-damaged baby. I listened carefully to what she said and it was only after much reflection that I realised that there were various things that were odd about her account. Certain comments she’d made indicated clearly that her birth had not been at all ‘natural’. For example, she’d mentioned in passing that she’d had to drag her drip, on its stand, to the pay phone, and had said what a nuisance this had been. This must have meant either that she was being denied all food and drink and had therefore been put on a glucose drip, or—a more likely scenario—that she was being administered pitocin in order to accelerate  or induce her labour. It’s very sad that she insisted on continuing in this situation for a full three days, before finally giving birth. She’d clearly had interventions, so the natural processes had been disturbed. Her labour was then neglected at her own insistence.

Perhaps this is not such an uncommon scenario, not because of the communication difficulties which were obviously a factor in this birth story, but because lack of understanding on the part of women or care givers as to what really constitutes disturbance. Very often, midwives will talk about or suggest procedures which disturb the labouring woman, without realising that they are doing anything disruptive. The labouring woman will then insist on continuing in a disturbed situation because of a misguided view about natural birth. This is sad because really we have a choice between leaving nature alone completely, or disturbing it and having a very ‘managed’ labour. Unless we are extremely lucky, there is usually no middle road.

The prevalence of accidental disturbance

I’ve often come across cases where women have told me they wanted a natural birth, but it didn’t work out. After listening to them I usually found it easy to pinpoint the disturbance which occurred in their labour and in almost all the cases I’ve come across it was a disturbance which wasn’t at all necessary from a safety point of view. I have been amazed by the predictability of this element in ‘failed’ natural births.

What has saddened me is people’s apparent unawareness of disturbance. Again and again, the assumption that nothing can possibly ‘disturb’ birthing processes emerges. In one article I read in a popular women’s magazine, a woman expressed disappointment and sadness at not having the natural birth she’d wished  for after being induced. What did she expect? Induction is an enormous intervention! In the same way, I’ve been repeatedly amazed that women who’ve had epidurals have then expected the natural processes to proceed smoothly. After any major intervention, such as induction or the use   of pain relief, medical management is essential for the sake of safety. In his book Birth Reborn (Souvenir Press 1994) Michel Odent commented that the more medicine gets involved with childbirth, the more complex and difficult everything becomes.

It’s no wonder that the phenomenon of the ‘cascade of interventions’ has become so well-known. Very often what started out seeming ‘helpful’ ends up being a trigger for another problem and another intervention. By definition, disturbing things means changing them in some way, and this is particularly the case with birth.   

Does this all surprise you? It’s true that sometimes things do proceed towards a happy conclusion despite any number of disturbances… but usually they don’t. We can only be sure women will produce all the right hormones at the right moment if we leave the processes of pregnancy, labour and birth undisturbed.