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Birth Day

So many of the posts on this blog are critical and deal with examples of poor science or other problems. I’d like to offer a breath of fresh air in the form of a book by Mark Sloan, MD: Birth Day: A Pediatrician Explores the Science, the History, and the Wonder of Childbirth.

It is a very positive book. Sloan has attended over 3000 deliveries but he has not lost his sense of wonder. He tells us what life is like in the womb – how much the fetus can see and hear – and smell! He explains the labor process. He explains how a fetus has to rapidly adapt to life outside the womb with a number of physiologic changes. He reflects the joy of bringing a new life into a family, and the experience of becoming a father. He delves into the history of childbirth, with fascinating anecdotes about “salting” newborns, Queen Victoria’s influence on obstetric analgesia, and the attempt to keep forceps a proprietary secret of one family.

He shows the many contributions science has made to childbirth, some of the mistakes it made along the way, and how it corrected those mistakes.

He covers the history of medical interventions in childbirth both from a scientific and a sympathetic human viewpoint. Twilight sleep, epidurals, fetal monitors, C-sections, birthing positions, attendance by doulas, etc. He makes a strong case for having someone, anyone, stay with the mother throughout the process; there is evidence that this improves outcome. He covers the pros and cons of various types of analgesia and suggests that nitrous oxide could be used more often. He discusses the reasons for the rising C-section rate and carefully considers the risks and benefits of surgical deliveries, including physiology-based arguments I had not heard before. He covers the alarming new trend of elective primary C-sections by mothers who just don’t want to go through childbirth. He discusses circumcision from a neutral standpoint – he doesn’t recommend it, but he does it at parents’ request and he recognizes that there are medical benefits although they are far from compelling.

He explains the newborn reflexes like “stepping” and the Moro reflex in terms of evolution: primate babies needed to grab onto Mom and pull themselves to a nipple; and he says if left undisturbed on its mother’s abdomen, a human baby’s neonatal reflexes allow it to little by little inch itself up to the breast and find the nipple over the course of half an hour. I didn’t know that. I find it fascinating. I’d love to see a video of the process.

The book is full of interesting facts and anecdotes. A human birth takes 30 times as long as a gorilla birth: he discusses the anatomical changes in humans that prolong the process, and possible evolutionary explanations for them. He discusses cord care. The umbilical cord stump can take a long time to fall off – Dr. Sloan’s personal record was “88 parent-torturing days”! He tells about an embarrassing incident from his medical school days when he thought something looked funny about the fetal head but failed to recognize it was a breech presentation. He tells about Apgar Guy – a father who harassed him, wanting him to alter the medical record to show that his baby’s Apgar was really a 10 rather than a 9, as if that would somehow improve his child’s prospects. He tells about the expectant father who ran all the way to the hospital, slipped on the floor, knocked himself out, and woke up to find out his wife was at another hospital.

A fascinating book by a science-based doctor, a wise clinician, and a loving father. An example of what the scientific approach to medicine is all about, showing that it need not be cold and impersonal.

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18 thoughts on “Birth Day

  1. Nice review! I plan to read the book. There’s a lot to know about childbirth, and about all I know is my experience of my partner’s delivery of our daughter. Of course, I was born, but no amount of regression therapy will cause me to remember it.

  2. sowellfan says:

    The Apgar thing is interesting. From my discussions with friends who were Labor & Delivery nurses, they almost never gave Apgar scores of 10 and 10 to babies. To hear them talk, they were kind of superstitious about it – like, to say that this baby is as healthy and active as it could be, would be to almost invite some kind of crisis.

  3. SF Mom and Scientist says:

    I’ll put this on my list of books to read. I am curious about the elective C-section rate. What my doctor told me (and everything I have read) suggests that this is overblown. That is, it is still such a small percentage of women who choose a C-section (about 2%) vs. the number of women who get C-sections on the advice of their physician (about 29%), yet the elective C-sections get much more press.

  4. Amy Romano says:

    It’s nice to see a birth-related post on this blog. I am also happy to see that this book – which I was not yet familiar with – talks about obstetric science in the context of normal physiology. The physiology of normal newborn transition and the self-attachment that you describe (which is indeed breathtaking to see in real life or on video) are remarkabe, as is the normal process of birth itself. So much of obstetric research is focused on rooting out disease and solving the most vexing problems of complicated childbirth (preterm birth, preeclampsia, etc.) While we absolutely need more science to better diagnose and manage these problems, we need a different toolbox and a change in our perspective to effectively study physiologic birth, to optimize health outcomes in uncomplicated pregnancies, and to understand the effects of obstetric interventions on the normal physiologic processes (which, in turn, would help us better identify circumstances when benefits outweigh these negative effects). I keep a blog that is focused on science-based birth, and my most recent post talks about some of the problems of studying physiologic newborn transition within the context of “medical model” care systems and using “medical model” research. The blog is called Science & Sensibility and is at http://www.scienceandsensibility.org.

  5. Calli Arcale says:

    That does sound like a very interesting book!

    The elective c-section rate is difficult to study, because where exactly is the line between “birth is hard, I want to avoid it (or schedule it more conveniently)” and “birth will be risky for me, I want to mitigate that risk?” There are probably a lot of edge cases.

    One place that would be interesting to study is Iran. Contrary to what many in the American public think, Iran is actually one of the most progressive Muslim nations, particularly in terms of women’s lib. Indeed, they have the same problem in their universities that we do — women now outnumber men in the universities. One curious factoid about Iran is the way births tend to happen. While in its neighboring country of Afghanistan, women die in terrifying numbers while giving birth, usually unassisted and usually at home in unsanitary conditions, in Iran women usually give birth not just at a hospital but in an operating room. This is because the preferred birth method in Iran is the c-section. Many Iranian women cannot understand why any woman would want to undergo a vaginal birth, and use their influence to insist upon the most medical form of birth possible. They have good reasons; the c-section is more controlled, which can mitigate certain risks (while introducing others, of course), and they feel that the mother will be less stressed if she doesn’t have to undergo labor and will be better able to bond with her baby. Oddly, these are very similar arguments to those many homebirth advocates use, and to those used for twilight birth and, well, probably just about every birth practice in history.

    Anyway, it would be interesting to study outcomes in Iran because there is such a large cohort of truly elective c-sections where the patients feel no shame or other reason to hide their motives.

  6. Fred Dagg says:

    Nice review Harriet

  7. wertys says:

    You read some really interesting books Harriet ! thankyou for these book reviews, as I don’t have heaps of time to read for pleasure so I find it helpful to be pointed in the direction of books I am likely to enjoy. Keep it up !

  8. magra178 says:

    oh, thank you so much! how I wish I had this book available to me a year ago when I was pregnant! I was looking for a science based, neutral pregnancy and childbirth book, but all I could find were people taking sides and promoting an agenda (the mayo clinic guide was good, but lacking any heart that this book sounds like it has). I will be certain to read this book!

  9. Danio says:

    @sowellfan,
    I had this experience when my daughter was born. The nurse inquired of my midwife: “She scored a 10–should I write down 9 1/2?”

    This sounds like a wonderful book, Harriet. I’ve gotten a lot out of the other books you’ve favorably reviewed, and this one will go onto my library list straightaway. Thanks!

  10. Dash says:

    Here’s a link for a breast crawl video, they truly are amazing. http://breastcrawl.org/

    On the ‘elective’ caesar – in Australia, anything that isn’t emergency is classed as elective (I don’t know if this is universal). But from talking to mothers a lot of them feel that it certainly wasn’t the course they would have chosen in an ideal world and dislike that terminology. A lot of them use ‘planned’ instead, and that sort of distinction might make it easier to study reasons behind birth choices.

    Risk perception is always a difficult one – we all have a different idea of what is an acceptable risk and different priorities, especially in something as emotionally fraught as birthing! It sounds like a great book.

  11. Versus says:

    Nice post — this book sounds like a perfect shower/new parents gift.

    Another knocked-out father story: My friend, a radiologist, was well into labor when her husband keeled over in a dead faint and hit his head on the floor, as men will sometimes do in such situations. Despite being really preoccupied with giving birth, my friend managed to order that he be taken to the X-Ray department and listed the views of his head she wanted taken.

    Dr. Hall: Another interesting birth related post suggestion: the chiropractic “Webster technique” which purports to release the fetus from “intrauterine constraint” allowing it to turn from a breach position. In other words, the chiropractic version of a version, although I think they don’t want to call it that because chiropractors cannot practice obstetrics in most states.

  12. Harriet Hall says:

    Dash,
    Thanks for the link to the breast crawl video – fascinating!

  13. Harriet Hall says:

    Versus,

    According to this review, only external cephalic version has been shown to work:

    http://www.ncbi.nlm.nih.gov/pubmed/17927112?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

    The natural rate of spontaneous conversion of breech to head-down presentation is 50%, so effective methods must produce a greater response than that and the correction must persist. The methods they compared included hypnosis, acupuncture, chiropractic and special exercises. Only conventional medical external cephalic version worked.

  14. Regarding Apgar scores of 9 vs. 10, and why ’10′ is almost never a reality:

    Here is the scoring system:

    Activity (muscle tone)
    0 — Limp; no movement
    1 — Some flexion of arms and legs
    2 — Active motion

    Pulse (heart rate)
    0 — No heart rate
    1 — Fewer than 100 beats per minute
    2 — At least 100 beats per minute

    Grimace (reflex response)
    0 — No response to airways being suctioned
    1 — Grimace during suctioning
    2 — Grimace and pull away, cough, or sneeze during suctioning

    Appearance (color)
    0 — The baby’s whole body is completely bluish-gray or pale
    1 — Good color in body with bluish hands or feet
    2 — Good color all over

    Respiration (breathing)
    0 — Not breathing
    1 — Weak cry; may sound like whimpering, slow or irregular breathing
    2 — Good, strong cry; normal rate and effort of breathing

    Almost all babies who get a ’9′ have lost one point for color, because newborns normally have ‘bluish’ hands and feet. I’ve been present at thousands of births, and can’t remember ever having seen a baby who truly rated a ’10′ at either one or five minutes after birth.

  15. Harriet Hall says:

    And the Apgar was designed for use in studies determining the success of obstetric interventions. It was not meant to assess the prognosis of an individual baby.

  16. arationalmom says:

    Thank you for this post. My first child is due July 30, and I’m a little nervous about the birth. I went out and read this book as soon as I saw the post and it’s helped me feel more comfortable about everything.

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