Lying down once, sitting up on the edge of the bed (things were moving quickly) once. Lying down, they did an episotomy, and were getting kind of concerned about the baby (who was also breech). Sitting up, everything happened very, very quickly.

Makes sense, I think you could get a lot more success with barely legal neonates with this strategy.

It's only recommended if there was vertical conception.

This is the traditional Navajo way of giving birth. It seems to work for them.

My only knowledge of the subject comes from The Business of Being Born which seemed to think that a more vertical position was good.

Seems entirely logical, though I have a hard time in my memory of the blessed event conceiving that I could possible have managed to stand up at go time. I'm guessing the idea is a squat?

I will say that I found that liberal and very loud cursing helps things along quite a bit. YMMV.

I do not recommend the film linked in 5.

I've actually read a fair amount on this (not all from the 1970s), and vertically does seem to be the way to go. But I don't even think that's silly hippy-talk anymore (as it probably was 30 years ago); unless you elect to have an epidural (or other medication that might make the vertical position dangerous), most hospitals these days are happy to let you give birth that way. I think plenty of ob's encourage it.

I do not recommend the film linked in 5.

I've actually read a fair amount on this (not all from the 1970s), and vertically does seem to be the way to go. But I don't even think that's silly hippy-talk anymore (as it probably was 30 years ago); unless you elect to have an epidural (or other medication that might make the vertical position dangerous), most hospitals these days are happy to let you give birth that way. I think plenty of ob's encourage it.

The arguments for vertical birth seem similar to those for squat toilets.

One of my friends had some sort of non-medicalized birth at a birth facility. I'm not sure what the position was for actually deliverinng, but most of labor was either sitting, or walking around the room. Afterward, she took a shower and then went home. But walking around was supposed to help keep things going.

In the 70s, the superiority of vertical birth was something that still needed to be argued for, but had plenty of people willing to argue for it. It may be that publications on this matter have dropped off simply because the idea is accepted now.

Luddites, the lot of you. This seems like it will clearly be at least part of the answer.

I'm glad ben broached the baby - turd thing. Seems to me the biomechanics are pretty similar. I'm a big fan of the squat toilet, so...

Just make sure there's someone to catch the little bugger. Wouldn't want to drop it on its head.

Friends who have given birth recommend staying on your feet, in motion, as long as possible. My sister walked round the room for twelve hours and swore at the only doctor who tried to get her to lie down. (He beat a retreat. Her boyfriend says he hadn't realised she could swear like that.) Several close friends say this is a perfect opportunity to do the ironing. (They weren't kidding, either. One midwife offered to run home and get her pile of stuff waiting to be ironed.)

Of course walking is good for the early and middle parts of labor. I have two different delivery positions. The first, in a sitting up in bed, propped up with pillows, was not as close to lying down as one might think, the pushing only lasted 20-30 minutes, and I didn't feel it at all, because the baby's head was pressing down on my nerve center, basically providing a natural anesthetic. The down side to this was some tearing. My second delivery position was on my side. I wanted to try squatting or some sort of vertical position, but I could not force my body to squat. This did not feel like a mental block, but that I physically just could not assume that position (although I'd had no problem in late pregnancy squatting, it wasn't that my belly was in the way or anything, I'm not sure if I can explain, but I guess it felt like being forced to swallow when your stomach is completely full). I could deal with standing up, but my midwife did not want the baby to fall on the floor, and standing on the hospital bed seemed, well, untenable. So I ended up on my left side. That time I felt the baby's head come out distinctly. Some people consider this feeling to be a privilege.

My impression is that delivery personnel will let you deliver in any position you want, but some will make it clear that they are more open to being asked than others.

For our first birth on The Farm Molly was encouraged to try whatever position worked for her, and there was a lot of switching around. The delivery finally occurred vertically, on a sort of birthing stool.

(Somehow this is all sounding really sexual.)

Our second hospital birth was in a semi-reclined hospital bed. I don't recall Molly asking for something else, but the staff didn't give off that receptive vibe.

Ben, yes, it is almost exactly like the squat toilet argument. And, while you might think "regular toilets seem to work just fine to me", if you had to take a watermelon-sized shit one day, you might be interested in finding the best position for doing so.

wife-pwned.

Also trust her memory on these issues over mine.

wife-pwned.

Also trust her memory on these issues over mine.

For maximum symbolic value, you should give birth standing astride a grave (see Beckett, Samuel), as long as that's cool with your midwife.

Obstetrics means "to stand by" in Latin, which is what the doctor does. They don't want to change the name to "stand next to" or "squat by".

4: Also, "it works for indigenous population X" is kind of a tragically hilarious argument.

9: Objections to the squat toilet fall away once you recognize the profound power of grabbing on to a small tree. This correlates pretty well with the level of outdoor expertise at which boy scout camping trips become tolerable.

16: your wife gave birth at the farm? Mine would be jealous; she'd have loved to, but never really considered it an option since we're halfway across the country. For some reason I didn't realize you lived near there.

We lived in Alabama at the time, and it was the nearest place we could go where midwifery was legal. We live outside of Cleveland now.

I don't want to say anything else about the experience, because I'm afraid of being wrong again.

And, while you might think "regular toilets seem to work just fine to me", if you had to take a watermelon-sized shit one day, you might be interested in finding the best position for doing so.

I didn't adduce the similarity by way of aspersing
Upright birthing.

9: Objections to the squat toilet fall away once you recognize the profound power of grabbing on to a small tree.

I wasn't objecting to anything!

I recommend a modern medical solution: forceps.

Just be sure to be careful about the nose.

I find that nose-woes can be ameliorated by proper naming practices.

28: So long as one remains careful about poorly maintained window sashes.

I'm somewhat amused that the birthing thread is thus far male-dominated.

Why? We were all born, weren't we?

Sure, but to offer any sort of comparative analysis, you'll need to get born again.

My impression is the same as Rob's in 11 -- that it isn't a big deal anymore, though not particularly common, I expect, in the U.S. In my experience (experience of reading and talking, that is), it falls into the same category as birthing tubs -- slightly alternative but not controversial or wacko. I've never heard, nor can I imagine, an argument against it. The birthing stool seems eminently sensible to me.

Mostly I've heard from other women that it's good to go in with a plan and a clear understanding with your doctor/midwife, but that the plan is as likely to go to hell as not.

30: We've all taken a dump, and it's not *that* different, is it?

Birthing a tub is definitely unusual in my neck of the woods.

Apart from ease of access for the physician, I think there's fetal monitoring has something to do with the supine position.

It's worth noting that Shanley is not exactly without opinion on childbirth.

34: You are lucky there is no suitable emoticon to represent my icy glare of death.

My second-hand (watching but not doing) knowledge is from four births at Mayo, so YMMV. A lot.

Walking before epidural - sure, if you want.
Epidurals - yes!
Standing - can't do it with edidural.

Body position at birth, kind of a squat, but on the edge of a special bed.

The best advice I can give is to find a medical practitioner you can trust and make an informed decision.

I heard about some wacko idea of giving birth in the ocean assisted by dolphins and that is just crazy talk. What if, God forbid, there is a problem? It wasn't all that long ago that death during childbirth was a significant cause of female mortality.

I heard about some wacko idea of giving birth in the ocean assisted by dolphins and that is just crazy talk. What if, God forbid, there is a problem?

Isn't that what the dolphins are there for?

Apart from ease of access for the physician, I think there's fetal monitoring has something to do with the supine position.

The ease of access thing is annoying. Of my two births, I had one where everything was going fine, and I could birth however I wanted, and one where the baby was breech and everyone was worried. And of course the one where everyone was worried meant that I had to be flat on my back on an operating table, and things went slower, which meant everyone got more worried.

I don't know if the positioning had anything to do with how fast things transpired in my specific case, but if lying down slows pushing, it seems like the sort of thing that would be particularly counterproductive where there was concern.

I agree "ease of access" seems a little odd or silly, especially when access is actually needed 5 or 10 minutes out of the hour during early or mid-labor.

I suspect that part of the problem is that it's extraordinarily difficult to do a definitive study on these sorts of things. So, you're left with anecdata.

The dolphins are there to eat the placenta. And the child.

41: True. I've got an anecdote, which is not even a data point.

41: I suspect that part of the problem is that it's extraordinarily difficult to do a definitive study on these sorts of things.

Huh? I mean, you can't do double-blind randomized trials, no, but there are enough births (and enough data collected about many of them) to do plenty of studies of all sorts. There's volumes of research literature on childbirth.

I don't think I understand the post update at all.

44: Meaning that 1) it's hard to get people to experiment 2) childbirth seems to be a very fluid process where a lot of variables change and 3) it's difficult to quantify pain, ease of childbirth, etc. IANAO, so I could be just talking out of my butt.

But you're right, I don't doubt there's a ton of unorganized data out there.

I vote for hanging by the feet. A no-brainer, really. Heebie will be famous.

42 is the answer.

46: Well, right. I suspect that my first birth would have been easier, pleasanter, and less risky for Sally if I had been allowed to get up, but I'm not sure what easily collectible data would show that.

AB was very interested in vertical birth for Kai, but instead went with a more potato gun-style method of popping him out of there in a matter of minutes.

With Iris, she had to get in bed after about an hour of serious laboring spent on a yoga ball, leaning on windowsills, etc. She was utterly unable to get up - or even move - again.

Upshot: the advice you read seems like one of those slightly disconnected things like "keep your back straight when lifting a couch from the floor." Just because it's physiologically optimal doesn't make it practicable. You should definitely keep it in your bag of tricks, but don't feel like if you end up on your back, little Heebie-Jammies won't make it out.

That last bit applies to every single piece of advice you get during this pregnancy, and afterwards.

37: I assumed 34 was in response to "The birthing stool seems eminently sensible to me."

they say women have this urge to walk a lot before giving birth which is physiological and results in the gradual opening of the birth canal
so in the olden times women would wander away, give birth by themselves and bring babies wrapped in their skirts, tough ladies
and washing the floors on your knees in the last trimester is also good for that with double benefits of clean floors and easy birth
but i think i wrote it before, forgot, maybe not here

49: Wouldn't a simple survey show a lot? What was your plan for the birth? How was baby actually born? Breech? Epidural? Did you tear? Same or different from previous births? What would you do if you could do it again? Anecdata, but very useful anecdata once collated. This assumes we're talking about the mother's experience, of course, as opposed to outcomes for the baby. The latter would require follow up to be meaningful.

I think birthing tubs are more uncommon than positions other than lying down (if you mean actually delivering the baby in the water, as opposed to having a tub available during other parts of labor for pain relief, relaxation, etc.) I think the idea of different positions as a way to keep things moving & help deal with contractions & push more efficiently is widely accepted--but, incompatible with an epidural or internal fetal monitoring, & epidurals and internal monitoring are pretty damn common.

General impression, based on people I speak to, is that having an epidural & being immobile can really slow things down--in a couple cases people stopped dilating entirely and ended up with a c-section--but it's a bit tricky knowing for certain that the epidural was the cause, and there's also a possibility that: (1) the slowing can be mild & worth it for the pain relief (2) if you're just really exhausted & at the end of your rope/in serious fight or flight mode, the epidural can actually speed things along.

I do think there's more risk of tearing if you push on your back. But I've read natural childbirth literature that I think fearmongers a bit about some of the medical interventions & soft-sells the difficulty of labor, even though I'm generally sympathetic to the idea that the c-section rate is way, way too high, the "cascade of interventions" fear, etc.

All of this is secondhand anecdata, of course....I'm using a midwife & a doula & a hospital that is supposed to be relatively natural-childbirth friendly as hospitals go--tubs or showers in all the rooms, birthing balls, monitors that allow you to walk around if at all possible--and plan to labor at home for a while (the hospital actively encourages this), try every natural trick in the birth before opting for an epidural, etc.. But, I don't know that I have the proper birth-is-natural-and-empowering attitude that I feel I ought to. There's some limited possibility that I won't be eligible for an epidural due to a low-ish platelet count, & that really freaked me out when I first heard it.

washing the floors on your knees in the last trimester is also good for that with double benefits of clean floors and easy birth

Makes sense, but I don't think my wife would've bought it. Pity.

But, I don't know that I have the proper birth-is-natural-and-empowering attitude that I feel I ought to.

I'm not much with the natural-and-empowering; I went natural out of a combination of concern over the 'cascade of interventions', dislike of harrassing medical care, and three separate people I knew vigorously recommending the same midwife service, and everything went great. I don't think the perfectly sproutsy attitude is necessary, regardless of what you decide to do -- as long as you've made a plan that makes you happy, and you're prepared for whatever is going to happen to happen, you should be fine.

I suspect that my first birth would have been easier, pleasanter, and less risky for Sally if I had been allowed to get up, but I'm not sure what easily collectible data would show that.

Aggregate data from thousands (hundreds of thousands? millions?) of births showing faster, less painful (a subjective judgment, but again, we're aggregating), and fewer complications from deliveries where woman are free to get up (vs. required to stay flat)?

When your n is as high as it is for "births in America" (a great many of which have useful data collected), your "study" doesn't have to be especially well designed to give fairly compelling results.

57: But the data you'd need to affect me would have to be data aggregated from breech births after fast labors, not all births, and that's a much smaller n -- the doctor was making me lie on my back because there was something particular going on, not because of a belief that it was a generally superior position. And pretty much any birth is going to have some special circumstance that is going to affect the doctors' clinical judgment.

breech births after fast labors, not all births, and that's a much smaller n

Much smaller, sure, but I bet it's not all that small. There are a lot of people born.

All this talk of labor and delivery and contractions etc. is re-activating my "I-want-another-baby" instincts. I want to try vertical birthing! Or the thing with the dolphins!

I don't think I understand the post update at all.

Oh, I just didn't like the phrasing of the first attempt. It sounded more negative than I actually feel.

I do not recommend the film linked in 5.

Out of curiosity, why not? It is definitely partisan but, adjusting for that, it seemed okay based on my limited information.

Weird--the update seems much more negative than the original, to me.

62: it was boring. And didn't strike me as especially compelling (even though I more or less agreed with its premises).

56: there's "perfectly sproutsy" & there's the "sobbing in terror after hearing graphic descriptions of labor"...

The hospital I use also has mentioned pushing while lying on your side as an option that might work better physiologically than on your back, but isn't as physically demanding as some of the others. I think they also said that squatting can almost make things too fast & increase the likelihood of tearing if it's your first birth.

I am all for modern medicine & think romanticizing traditional birth is a little ridiculous given the maternal & infant mortality statistics. OTOH, it seems like c-sections have kept increasing even though gains in preventing awful outcomes have not, and we may be at a point where we're trading a very slight reduction in the risk of something disastrous for worse experiences & more not-strictly-necessary c-sections for a lot of women. I come from hardy peasant stock--my grandmother had six kids with average labors about 2-3 hours and once told me she "didn't see what the big deal was" about it all; my mother had 4 kids averaging about 9 pounds & topping out at 10'4 without pain relief, the latter two at home--whereas my sisters seem to have 24 hour labors, epidurals, pitocin, & in one case a c-section--and it feels like half the people I know have had a similar experience.

There are medical studies of birth, but I do think it's tricky--there are a ton of variables & they potentially interact with one another, so it's not always clear what you should be controlling for & what you shouldn't.

62: it was boring. And didn't strike me as especially compelling (even though I more or less agreed with its premises).

Oh, okay.

I admit to not finding Ricki Lake compelling, but I was worried that you objected to the information being presented.

I like it, but I came in not knowing that much about the issues, and had it been any longer I probably would have objected.

66: yes. And to be clear, I didn't saying I wouldn't recommend it. Under the right circumstances I probably would. I just said do not recommend it. As a matter or course, in my day-to-day dealings.

whereas my sisters seem to have 24 hour labors, epidurals, pitocin, & in one case a c-section

Yeah, I've heard of a couple total horror stories lately of excruciatingly long births.

My self-protective story is that I'll be protected from a worst case scenario if I stay in shape.

internal fetal monitoring

I really pissed of one of the myriad nurses who came in during AB's labor at Pittsburgh Industrial Baby Production and Uterus Removal Center, who tried to hook her up to a fetal monitor. We had the Birth Plan, we'd been very clear, and we'd also been begging someone - anyone - to call her fucking doctor (they waited 25 minutes to do so). But this nurse wanted to hook her up to a machine, the thing she wanted least. I was about 6dB shy of yelling at the nurse, after which she left in a huff and didn't return.

If you go to a hospital, you basically need 2 strong advocates if you want to control anything about your birth - a doctor/midwife who understands what you want and supports it, and a support person who can remind everyone (including you) what it was that you had in mind, and can help offer some clear-mindedness.

56: there's "perfectly sproutsy" & there's the "sobbing in terror after hearing graphic descriptions of labor"...

If it helps any, my graphic description of unmedicated labor would be that it was certainly painful, and awfully impressive, but really not that bad overall. Like, twenty minutes after the birth, I was sitting in a room waiting for my husband to reappear with the baby from whereever they'd whisked her off to, and I was mostly cross that the TV in the room wasn't working and I had nothing to read. Or eat -- I was starving, and it took an hour or so before Buck could find takeout. (And then of course there was the charging around looking for someone with a bottle opener for the beer.)

OTOH, it seems like c-sections have kept increasing even though gains in preventing awful outcomes have not, and we may be at a point where we're trading a very slight reduction in the risk of something disastrous for worse experiences & more not-strictly-necessary c-sections for a lot of women.

It's very clear to me that a huge proportion of c-sections have nothing whatsoever to do with medical necessity, and everything to do with convenience for various parties.

69: Good for you! Buck didn't have occasion to run interference like that, but that was exactly why I wanted him there, just in case.

I am using a kind of small town hospital that's less likely to have many options. I work the opposite direction away from Austin, and can't get to a doctor's appointment in Austin during a normal work day.

Also Texas has a lovely law that midwives are not allowed in hospitals. So we're looking for doulas, but they're very hard to find in this area, (short of cold-calling, which I'll probably end up doing. No one seems to have any recommendations.)

It's very clear to me that a huge proportion of c-sections have nothing whatsoever to do with medical necessity, and everything to do with convenience for various parties.

God, c-sections sound horrible. The whole slicing your stomach muscles part gives me the willies.

73: Eh, whatever happens, the overwhelming odds are you'll be absolutely fine.

75: No, yeah, I have a healthy dose of invincibility about this. But I am really annoyed about the midwives part. There are tons of midwife recs floating around.

75: While I'm negative on c's myself, I'm pretty sure that they normally don't cut your abdominal muscles -- they cut the skin, pull the two sides of your abs apart, and then cut the uterus. Not so bad.

Also Texas has a lovely law that midwives are not allowed in hospitals.

Have you considered just doing it at home?

It's very clear to me that a huge proportion of c-sections have nothing whatsoever to do with medical necessity,

Yeah, this is crazy.

77: Oh. Well, that's good. But you're still pretty incapacitated for a couple weeks, no?

Have you considered just doing it at home?

Yeah, but I don't want to. Because of the tiny chance that things can go very wrong, very quickly.

Also I picture the cats being like WHAT'S THIS? WHAT'S THIS? PET ME. PET ME. WHAT'S THIS?

69/72: yeah, first time I didn't run any interference, because my wife and I sort of both assumed that, since we'd carefully gone over the birth plan with everyone, and they'd all smiled and nodded and said "sounds great", that must mean there was some medical reason why they did more or less the opposite on everything as soon as the action started. And it was frustrating that no one would explain to us why, but would instead just say "we really need to do "x" now", but in the excitement and confusion we didn't push back much. Later we learned there weren't medical issues, they just didn't give a shit whatsoever. (Which, believe it or not, I'd have been much more okay with if someone had just said that upfront. As in, when we talked through the birth plan, jsut saying "okay, points 2, 4 and 7 are against our standard protocol, so they'll be difficult to accomodate." But instead they acted like everything sounded great and then just ignored it.)

I was fully prepped and geared up to run aggressive interference for #2, but we were somewhere else where it proved to be entirely unecessary, since they respected our wishes. It was almost disappointing, in a way.

79: yeah. you do actually cut through the abdominal wall a bit (obviously), but they're pretty good about placing it where it will be least likely to cause long term problems. Still, no lifting anything for a while.

I have it on good authority that this is much more of an issue with later kids if you have a small one around that is used to being picked up.

80 - I recently had a flareup of back pain so bad I couldn't get out of bed without crawling across the floor and climbing up the door frame. The whole experience was made infinitely more interesting by the cats obsessively checking me out the whole time, including climbing on top of me when I paused to let the spasms subside. I think they might have been trying to figure out what I was hunting for down on the floor. The tension between love and murderous hostility would have been quite entertaining if it had been happening to someone else.

I think they might have been trying to figure outwhat I was hunting for down on the floor. if you were about to become a food source.

Di,

All this talk of labor and delivery and contractions etc. is re-activating my "I-want-another-baby" instincts. I want to try vertical birthing! Or the thing with the dolphins!

Heh heh. Kinda like the commercials for feminine 'products' when I was a kid. They made it sound like so much fun (swimming, horseback riding) I was disapointed when I found out I couldn't have a period.

Yeah, I was a gullible lad. For awhile I really thought Ked's sneakers would really make you run faster and jump higher.

81: Yeah, the positioning stuff I was bitching about upthread was like that. In retrospect, I can't see why it could possibly have been necessary for me to be lying on a table throughout the pushing stage, except that the OB didn't want some annoying pregnant woman lurching around and making noises like an angry bobcat. But given the semi-emergency nature of the whole thing, it didn't even occur to me to do anything but follow orders.

73: Not so. Individual hospitals make up their own policies. My SIL was involved in the fight to get hospitals in Austin (of all places) to reverse a policy change to bar midwives. At least one of them has allowed midwives back in.

togolosh,

I certainly know how difficult it is to do situps with friendly dogs around. All the buggers want to do is lick my face.

Bumper sticker from Texans for Midwifery: Midwives help people out.

I'm currently an L & D nurse but had home births: one squatting, one hands and knees, and one lying on my side. The vertical positions are eat for learning how to push, but hands and knees and side-lying are better for the perineum at the last moment.

With an epidural, most women end up in lithotomy doing Valsalva pushing, despite all of the evidence against it, and end up tearing or cut. Most of the doctors at my hospital (Upper East Side, manhattan) have never seen any other position. And don't want to. No kidding.

About not calling your doctor when told to: your doctor probably gave clear instructions to get a 20 minute strip, examine your wife, and THEN call him. If he wanted to evaluate her himself, he'd be there, wouldn't he?

About the abdominal muscles: they are very much between your skin and your uterus, and therefore get cut.

Also, I think one on my birth stories is still on Laura Shanley's site. She's a bit nutty, but giving birth is glorious if you allow it to be.

(Upper East Side, manhattan)

St L/R? I was in their birthing center (or, aimed for it the first time but ended up on the L&D floor, and delivered in it the second time). The nurses were great.

The wording in 87 is somewhat ambiguous. Two hospitals that had allowed midwives barred them because of internal hospital rules requiring a physician to be present in addition to the midwife, which was expensive.

All the buggers want to do is lick my face.

Bunch of mollycoddlers and whelps in today's Royal Navy, certainly not the kind of buggery we had in my day.

Naw, LH. St L/R is for sure your best bet at a natural birth in Manhattan.

Gawdawful food, though. Luckily, there's plenty of takeout around.

About the abdominal muscles: they are very much between your skin and your uterus, and therefore get cut.

Right, but positioning the cut matters a lot in terms of recovery time, etc. or at least so I've been told.

95 to 93, sad to say. Where are the expert chef-johnnies of yore, masters of blood puddings and kidneys? A man cannot survive on canned vindaloo alone.

Not to mention the spotted dick!

It's very clear to me that a huge proportion of c-sections have nothing whatsoever to do with medical necessity

I too have all sorts of very strongly held opinions about professions about which I know less than fuck-all. (If anyone wants to confirm this, try looking on Unfogged for my helpful suggestions to college lecturers).

H-G: The Cochrane Commission has done a lot of work on childbirth, and Cochrane reviews are basically the ultimate standard of evidence based medicine. Here is the link to the actual science; I'm not going to add any of my own spin here, but you're entirely capable of reading through a dozen or so metastudies, and they're going to be as good advice as you're going to get (I am not by any means a 100% supporter of the "evidence-based medicine" cult, but for this purpose it seems to me suited). Don't listen to anyone who either disagrees with or hasn't heard of the Cochrane evidence.

What kind of freakish Royal Navy did you serve in, Winny? In my day sailors lived on salt beef, hard biscuit, and any rats slow enough to catch, and they throve on it.

And maggots.

Not maggots, weevils. The lesser, of course.

God, c-sections sound horrible.

Wasn't that bad for me.

positioning the cut
the most cosmetically progressive one is along the bikini line

re 99:

The US rate is about double WHO recommendations, iirc.

It's a tricky thing to sort out though; is the high US rate unneccessary, or is it correlating to some other issue (higher average weight, say).

The convenience issue is also unclear. It is clear that some of the high rate of induction in the US is for convenience. It's less obvious if the c-section rate is increased due to inducitons, etc.

99 - yep, dsquared gets it right. I loved A Guide to Effective Care in Pregnancy and Childbirth.

Anecdata: first time, in hospital, when I told the midwife I wanted to push, she asked me to "hop up on the bed" so she could check. And then I was stuck on this high, narrow bed, sitting up and couldn't move. Was ok, but not great. Tore a bit. Last 3, home births so could do what I wanted - one on hands and knees, two standing. No tearing.

When I was hanging about on pregnancy newsgroups, there was this bloke who used to post constant trollish messages about how sitting or lying reduces the cross-sectional area (not the term he used, but you know what I mean) of the birth canal by UP TO 30% ! ! ! !! He's probably right (or close), but he was a knob about it.

From Dsquared's link. In my search I didn't find anything about childbirth with and without anesthesia, but the site is not terribly user-friendly and maybe someone else will spot it.

1.

The review concluded that all women should be offered midwife-led models of care. Link

2.

Water immersion during the first stage of labour significantly reduces epidural/spinal analgesia requirements and reported maternal pain, without adversely affecting labour duration, operative delivery rates, or neonatal wellbeing. Immersion in water during the second stage of labour increased women's reported satisfaction with pushing. Further research is needed to assess the effect of immersion in water on neonatal and maternal morbidity. No trials could be located that assessed the immersion of women in water during pregnancy or the third stage of labour. Link

3.

Home-like birth settings are intended for women who prefer to avoid medical intervention during labour and birth, but who either do not wish or cannot have a home birth. The results of six trials suggest modest benefits, including decreased medical intervention and higher rates of spontaneous vaginal birth, breastfeeding, and maternal satisfaction. However, there may be an added risk of perinatal mortality. Link A BIG "HOWEVER", NO?

4.

In some countries almost all births happen in hospital, whereas in other countries home birth is considered the first choice for healthy and otherwise low-risk women. The change to planned hospital birth for low-risk pregnant women in many countries during this century was not supported by good evidence. Planned hospital birth may even increase unnecessary interventions and complications without any benefit for low-risk women. The review found only one small trial, which provided no strong evidence to favour either planned hospital birth or planned home birth for low-risk pregnant women. Link (It would seem that further study is in order. Given the amount of popular interest in this question, the scarcity of studies strikes me as pretty good evidence for the idea that medical research has scientifically unjustifiable blind spots.)

I've been looking through these Cochrane Reviews, and I have yet to see one that contradicts my own uninformed biases. Thank you, dsquared! I can now confidently assert that my opinions have the patina of Science!

I've never heard of the Cochrane Reviews before. I wonder if they're better known in the UK?

Thanks, Dsquared. I bookmarked that link.

Nah Walt, most people in the UK prefer to get random childbirth advice from their friends, family, neighbours and strangers on buses, just like the rest of the world. I've heard of them because the UK branch is in Oxford and I knew people who worked with them.

The important thing to me about your position when giving birth, is not so much what it actually is, but that you are free to find whatever is the right, most comfortable one for you. Not being coerced into something just because someone can see up your vagina better that way.

Yeah, make 'em work for it, I say.

Seriously, you're absolutely right. Being able to move around to get, um, comfortable isn't the right word, was huge.

105: When I was doing fetal monitoring research we noted an increase in C-sections because of (alleged) fetal distress. In the US there is (was?) a strong presumption that all babies would be perfect if not for someone screwing up; a few late deceleration dips in the strip chart + a damaged baby sets one up for a lawsuit.

Near as I can tell from some quick reading, things haven't changed all that much. Most deliveries go fine and could well be done at home. Sometimes they should go fine but suddenly go bad. That's when it's nice to have some capable medical facilities easily available.

I refer to the experience in ports of call, when ingredients could be had. Obviously in mid-ocean, conditions were dire, but we never stooped to foreign sweetmeats and titbits.

Kickshaws, I believe you mean.

112: I've read that continuous fetal monitoring corresponds with an increase in c-sections, without a corresponding change in the percentage of good outcomes. Maybe that Cochrane page has something.

Yep, that's what I remembered.

116: That's the one I was just going to post. There's also this one.

It's not much different from what we were seeing forty years ago.

I've read that continuous fetal monitoring corresponds with an increase in c-sections, without a corresponding change in the percentage of good outcomes.

A c-section is the least-risky procedure a doctor can do, from a liability perspective. If anything goes wrong in a vaginal delivery, and there was any potential hint along the way that suggested something might have gone wrong, the doctor is likely to be sued. "Why didn't you do something to prevent this?" If they do the c-section, even if a problem with the baby materializes, it's easy for the doctor to claim "look, emergency c-section--we did everything we could do!" You can't sue your doctor for performing an unnecessary c-section, so the incentives flow one-way. (This is a common problem in US medical care, of course, and isn't limited to childbirth.)

Dsquared's link, which I spent some time on, was valuable and seemingly well-intended, but I can't help wondering where the snark and bluster are.

It just doesn't seem like Dsquared. Maybe Asilon could go check in on him.

You all are making me consider not having kids ever.

Just take in some street urchins, Cala.

My sister has had four babies, 1 at a birth center, 2 at home with midwives, and 1 with her husband catching the baby while the midwives were on their way.

I think she had 2 of them vertically, the one that showed up before the midwives did and her last one (at home). The last one was breech too.

She has said the one that was caught by her husband was one of the easiest births, her body just took over (while her husband was saying "Wait! Wait!").

I did learn that if the if the baby shows up before the professionals do, make sure she's warm. Stick some towels in the dryer and warm them up before you wrap her in them. Or at least make sure the towels are dry.

OT: Why can't all Texans be more Heebie-like? Bastards.

Did you have a bad experience with a Texan lately?

Was it M/tch M/lls?

Heebie is not a real Texan. She started chewing snoose in Florida.

I am having a bad experience with a Texan RIGHT NOW. I hold you and M/tch jointly responsible.

most people in the UK prefer to get random childbirth advice from their friends, family, neighbours and strangers on buses, just like the rest of the world

this is true, but we get our medicine from the NHS, which makes policy based on the National Institute for Clinical Excellence, which is the other big world centre for evidence-based medicine. As I say, I'm not wholly convinced by the EBM trend (if anyone gives a crap, I had a real argument with Steven Poole about this on his blog) but it's good science within the meaning of the term.

For what it's worth, I had one midwife who basically refused to co-operate with my wife's ideas about how she wanted to lie down on the bed, citing some health & safety rules relating to back strain, and while I spent a short while taking these occupational hazards seriously, I ended up being glad that I am basically not a nice person.

128: I figured Napoleon Adolph came charging out in the direction of Russia before realizing that was a bad idea.

The good thing about a really long, painkiller-free labor is that it's like running a marathon. Yes, it's hell, but when you're finished, you're completely high on endorphins and oxytocin and extremely pre-disposed to fall madly in love with the next thing you see, which happens to be the kid. It's kind of handy that way.

I can say this with some sort of authority, because my water broke on Wednesday night and my son was born on Sunday morning, which takes an extremely high level of...well, stubbornness, combined with a lack of real understanding of the risks. But vertical delivery would only have worked about two days earlier, in my experience. I was sleeping between pushes by the end, which wouldn't have worked while standing up.

because my water broke on Wednesday night and my son was born on Sunday morning,

Holy crappity crap crap.

Evidence that I spend too much time in the Internet: I am well-aware of dsquared's critique of evidence-based medicine. As well as dsquared's opinions on: Freakonomics, Lancet, the Iraq War, Darfur, and blood diamonds.

Heebie, my wife's water broke about a half hour before she had the baby.

That sounds much more appropriate.

my ex's water started leaking on Dec 1 and our son was born on Dec 31. Until then, she was flat on her back.

fun times

I was a month and half late and then 36 hours of labor. But don't worry, heebie. I'm pretty sure I'm still not ready for the harsh and bitter realities of contemporary life.

You were a month and a half late? You were born at 46 weeks, for realz?

137: Due date of January 1; born mid-February. I guess they may have been less accurate with their due-date predictions in the early 1980s, perhaps?

Anecdata: my wife's OB told us she didn't cut the abdominal muscles, presumably because they had separated. While she's definitely a bit tender in the midsection, I'd say she was only really "incapacitated" for a few days. Still no heavy lifting or carrying, of course.

See, that freaks me out. Separated from what? We should invent storks.

Rumor has it that childbirth can do a job on one's body.

We should make the men do it.

142: I'm afraid there's no way around this one. One should wish for the most optimal circumstances, then, health-wise and otherwise. And there's the stuff about just knowing that you're not going to be the same as you ever were. I haven't had kids, but it seems similar to growing older, really.

See, that freaks me out. Separated from what?

Each other. Your abdominal muscles run in bands, hence the look of a `six pack'. The process of pregnancy loosens tendons and spreads these muscles, so if the alignment is right you can cut through to the uterus without damaging much muscle.

The fuck that the fuck. I like my abs where they are.

138: I didn't want to be the one to tell you this, Stanley, but you were due in mid-February all along. Your parents didn't tell you this because then you'd realize your the mailman's son. Don't feel bad. When I learned that my parents stole me from circus folk as revenge for the circus folk stealing their real child, I was pretty upset, but I've grown to accept that about myself.

Why can't all Texans be more Heebie-like? Bastards.

Are any of the `Texans' here actual home-grown artisinal Texans? Bob maybe?

145: Cala, thought experiment: Imagine looking at a very (final days) pregnant woman from the side. Now imagine what her abdomen looked like pre-baby. Roughly same amount of abdominal muscle there ... but it's got to be really spread out (relatively)>

148: You're trying to drive Cala to self-administer a tubal ligation, aren't you?

That would be damaging to the abdominal muscles, Walt.

You could always birth a child from the top of your head, like Zeus.

148: Look, I get the miracle of life and the stretchy abdomen the muscles loosening and all of that. It's more the 'oh, and part of this deal is that there's enough room to take the baby out in between your abs' part that's hard to stomach. (heh.)

Cala have you considered a robot baby?

How's the robot coming along, anyway, Sifu?

I might be able to handle a tamagotchi.

Evidence that I spend too much time in the Internet: I am well-aware of dsquared's critique of evidence-based medicine. As well as dsquared's opinions on: Freakonomics, Lancet, the Iraq War, Darfur, and blood diamonds.

And Budweiser!

Are any of the `Texans' here actual home-grown artisinal Texans? Bob maybe?

If you mean McManus, no, he's from somewhere in the midwest, I think. I actually can't think of any born-and-raised Texans at Unfogged, although I'm sure there are some. Which is odd, because Texas is huge.

Armsmasher and susan (PBUH) are Texans.

That's right, many of the DC people here are actually Texans. Thanks; I don't know how I forgot that.

Your parents didn't tell you this because then you'd realize your the mailman's son.

Creepy. My grandpa was a mailman. Not our mailman, but still. Ew. And funny.

154: well, instead of the robot, I've lately been building an enormous-pile-of-homework buddy, but we're going to learn about the algorithm I intend to use to control the thing in one of my classes this quarter, so assuming less craziness next spring, it might be at the wedding, wearing a tux.

Fuck, I forgot about the Budweiser one. His stirring defense got me to try a Budweiser again. Still didn't like it.

Miller High Life > Budweiser

but if you have Yuengling where you are, that trumps all.

161: you also forgot analytic philosophy. Oh, and the value of home ownership.

God, if I lived in Yuengling country, I would be a happy man. Where I live, it's Bud or Miller. I haven't even Pabst on tap anywhere.

164: Wow. Not even Nouveau Pauvre. Sad, really.

162 speaks the truth. No Yuengling for me, which is quite unfortunate.

On the other hand, here they sell Fat Tire at gas stations, so it's not all bad.

132. Walt, I don't know D^2's objections to EBM: what does he prefer? Witchcraft? Guesswork? Can you give us a 25 word summary so I don't have to give Steven Poole traffic.

21: based on long-forgotten schoolkid latin and google, obstetrics should (from now on) be called:
a: CONQUECTRICS (from "conquinisco", i squat or possibly bend over for sex), or
b: SUBSESSICS (from "subsideo", i crouch down or otherwise lurk in an insurgent-style manner), or
c: INCOXATRICS (from "incoxo", i en-hip myself)

sadly c is not from "incoquo", i dye, or i boil, i seethe, which would otherwise allow the best of all renaming options: "incoctrics"

wondering why it was obstetrics and not eg obstetics, i discovered that it is of course from the female form "obstetrix", viz a midwife who is actually an actual lady not just some bloke with a degree

I cannot decide whether i squat or possibly bend over for sex or i crouch down or otherwise lurk in an insurgent-style manner would delight me more as a mouseover.

Smooches to 28, 29.

I attended many home births as a child. I grew up thinking it was relatively normal.

"Is that your kid that keeps showing up at birthings?"

"No, I thought that was your kid?"

167: the clue is that "evidence-based" is Unspeak.

you also forgot analytic philosophy. Oh, and the value of home ownership

And "dumb" bankers and simple machines. (The latter was actually on of my favorite Unfogged threads ever.)

Subsideo i crouch down or otherwise lurk in an insurgent-style manner

That would be a good pseud. Next time someone shows up calling himself Lurker or Ex-lurker or similar s/he should be asked to pick from a list:
Subsideo
Insidiator:one lying in ambush/wait (attack/rob); lurker; who plots/sets traps;
Latebricola: lurker; brothel-frequenter;

When those positions are filled we can move on to another language.

Sussudio.

Walt, I don't know D^2's objections to EBM: what does he prefer?

Darkwave.

145: My abdominal muscles separated -- while weird, it was no big deal. The only after effect was that for a couple of years after the kids were born, if you poked me in the belly right on the center line, there was nothing there -- I could tense my abs as much as I liked, but you could poke inbetween them. But no visible cosmetic effect or loss of strength; situps worked just fine.

I should look up the d-squared EBM critique -- I've only heard the positive side from my sister, who grumbles about doctors who kill people relying on their clinical judgment rather than looking at the research. I gather there's some narrow meaning of 'EBM' that's objectionable, but have no idea what it is.

Basically, it's the colonisation of medicine by statisticians, with all of their myriad personality flaws and with their insistence that there's only one way to do things. Added to that, it's "government science" - there is definitely a Goodhart's Law effect on the medical statistics literature, that the quality of it gets much worse as it becomes more important, because people begin to realise that if they want to push their pet theory, they'd better get some "evidence based" statistical work to support it. Basically, the "evidence based" approach to economic policy gave us the efficient markets doctrine.

Yeah, I just read the Poole thread. My family-gossip-based sense is that there's an awful lot of good research out there still being ignored in favor of outdated 'clinical judgment'; that if the worry is that EBM will go too far, the profession, at least in the US, isn't near that line yet. But I can see your concerns being more of an issue in a more centralized system.

Here I thought the efficient markets doctrine was a bunch of a priori hooey.

179: EBM is fine for the initial or public health approaches to any treatment. From my experiences it starts to break down when the only "E" the doc will consider is from some published study.

I'm well aware there are patients who get every side effect listed as soon as they read about it on the net but there are also lots who complain about something quite real and are blown off because some study didn't find any significant incidence.

But my real problem with the evidence-based medicine community and their appropriation of the term "evidence" to mean their kind of statistical study is that they're trying to treat the average patient when no such entity exists. It makes a bit of sense in social and economic contexts to reify a statistical aggregate as a "representative agent", but not to try and treat his gout. There's an implicit assumption of homogeneity among human beings that is very unsupported by the evidence indeed

Woot! (whatever that means) I got to agree with D**2 before I read his comment! I'm going to take a nap now.

shorter EM probles: Making a good prior isn't making a good posterior.

erm, `EBM' and `problems'

making a good posterior.

Are we talking about Heebie, here?

I suspect Daniel is attacking a bit of a straw doctor here. There may be instances of doctors here and there who regard their patients as the medical equivalent of homo economicus, but I don't know anybody who's ever encountered one. Anecdotally, whenever I've presented with something not easy to diagnose, I've always found the doctors very happy to keep testing, and trying different treatments on the basis of their judgment, and I've supposed that this was a matter of professional pride plus the fact that they get paid for them. I've never been shoehorned into a statistical curve.

On the other hand, I'm very anxious that any treatment I might receive has been properly trialled, that the numbers have been run on those trials and that they have been published in readily available journals where they can be used in ongoing meta-analysis by people like the Cochrane Collaboration. That is evidence-based medicine to me, and if you think it's all obvious stuff, read up on Thalidomide.

Another thing is that a lot of advances in treatment these days come not from ab init. innovations, but from ongoing assessment of tweaks to protocols. This is the bread and butter of what, e.g. cancer research groups do, and they get results.I do want my outcomes to go into those databases, because I want those protocols to be better next time I'm sick.

Questioning these approaches (unless you have a better idea, in which case go for it) strikes me as dangerous, because it can be misrepresented by RFK jr. and those of his kidney. If Daniel is tempted to question them, I can only say he's been very unlucky with his doctors.

188: To the extent that I understand his point in the Poole thread, there's something to it. It's the "lies, damn lies, and statistics problem"; you can do a bad study that produces a spurious result, but that doesn't have flaws immediately apparent to the statistical layperson (which includes almost all doctors). Slavish adherence to EBM would allow the results of such a study to compel doctors to act in accordance with its results, even if their (in this case more reliable) clinical judgment suggested otherwise.

The "patients differ" thing strikes me as a bit of a red herring, as you say. I can't imagine anyone saying that a doctor should follow the course of treatment that's best for all patients on average where they have some quantifiable reason for believing that it wouldn't be advisable for the patient in front of them. And if the doctor can't figure out why he thinks the conventional best practices are a bad idea in a given instance, that seems like a reasonable basis for going ahead with them anyway.

you can do a bad study that produces a spurious result, but that doesn't have flaws immediately apparent to the statistical layperson (which includes almost all doctors)

That would be Andrew Wakefield. The fact that he is discredited, and the lives of thousands of children may thereby be saved, is attributable to the careful evaluation of evidence by his colleagues.

Nobody I know of advocates slavish adherence to anything.

Yeah, my sense is that genuinely difficult statistics comes into play when you're talking about really small effects, so spurious results will either be easily debunked or will be not particularly harmful. The main point of EBM is to make sure that the medical profession has actually gathered all the low-hanging fruit out there; protocols which can be clearly shown to be preferable, but aren't yet universal.

I'd be surprised to find an otherwise good doctor that insisted a certain procedure or drug had worked if it was against the evidence of her own eyes, and I'd believe it less in the case of good nurses. I don't have a whole lot of experience with the medical profession generally, but almost every time I have had a prescription, if it hasn't worked, the doctor has been more than willing to listen.

Are any of the `Texans' here actual home-grown artisinal Texans?

Armsmasher and susan (PBUH) are Texans.

M/tch, too.

I'd be surprised to find an otherwise good doctor that insisted a certain procedure or drug had worked if it was against the evidence of her own eyes, and I'd believe it less in the case of good nurses.

Is the trouble more with what options doctors are willing to consider, or with what, oh, say, insurance companies are willing to cover? Also, the trouble with fetishizing certain kinds of evidence is multiplied, I think, when applied to decisions about standards of care (when to do early screenings, for example, how to apply preventative care, and what tests to run under which circumstances) as well as decisions about pharmaceuticals.

you can do a bad study that produces a spurious result, but that doesn't have flaws immediately apparent to the statistical layperson

This, too.

almost every time I have had a prescription, if it hasn't worked, the doctor has been more than willing to listen.

And that's good, but it's not so good if your insurance requires the doctor to put you through a month's trial of each of six different medications in a prescribed order before getting to the one that works for you. Or if the medication that works for you is discontinued because a poorly designed study shows that it's not effective (because, say, they failed to isolate results for patients with whatever special circumstances make it work really well for you).

Not that I object to studies that attempt to test the efficacy of various medical interventions, by any means.

Aren't the problems you're talking about more about purportedly evidence-based cost-control measure than about evidence based medicine itself? Like, trying six medications in turn before getting to the one that works for you -- if you don't know which one is going to work, I can't see what's wrong with having a set order for trying them out; if you do already know because you've had success before, a protocol requiring you to ignore that knowledge and go through the process again is insane, but isn't dictated by EBM.

Aren't the problems you're talking about more about purportedly evidence-based cost-control measure than about evidence based medicine itself?

Right, that's why the studies themselves aren't (necessarily) a problem; it's consequences of investing them with too much significance or seizing on them as an excuse to enforce more uniformity of care than is actually justified.

I suspect Daniel is attacking a bit of a straw doctor here. There may be instances of doctors here and there who regard their patients as the medical equivalent of homo economicus, but I don't know anybody who's ever encountered one. Anecdotally, whenever I've presented with something not easy to diagnose, I've always found the doctors very happy to keep testing, and trying different treatments on the basis of their judgment, and I've supposed that this was a matter of professional pride plus the fact that they get paid for them. I've never been shoehorned into a statistical curve.

If you presented to an NHS psychiatrist with mild (in the clinical sense, ie still fucking nasty) depression, and told him that you didn't want CBT but would like to be prescribed Prozac, then you probably would be shoehorned into a statistical curve, because if your psychiatrist agreed with you that you weren't the right personality type for CBT and the drugs would be better for you, then he would be prescribing against a NICE guideline, and if he did this too often it probably would cause trouble for him. (I've obviously cherrypicked the single most controversial NICE guideline here, but only to show that this isn't a strawman).

I'm in general in favour of the correct use of science (it was me that linked to the Cochrane site above). But I'm also in favour of paying careful attention to the sociology of science (which is also a science), and what the sociology of science tells us is that movements which loudly characterise themselves as value-neutral, usually aren't. And my general view of the evidence-based medicine movement is that it's beginning to develop quite a few careerists and over-reachers. Having a balance between the scientists and the practitioners is healthy because it reduces the danger of either side inflicting their personality quirks on medicine.

And in the long term (I didn't make enough of this point on Steven's site), if one were to mandate that everything had to be done on the basis of evidence-based medicine, that would definitely have an effect on the kind of scientific studies which we got, and not necessarily either a predictable or favourable one.

Aren't the problems you're talking about more about purportedly evidence-based cost-control measure than about evidence based medicine itself?

time to get all Bruno Latour here I think. There's no such thing as "evidence based medicine in itself", just as there's no "physics in itself". The only way in which sciences exist is in the real world, carried out by real people, and therefore as sociological entities. This matters less in physics than in medicine, because medicine's much more politically important, but even in physics, there are plenty of examples of research programs going to all sorts of strange places for basically science-political reasons. Evidence-based medicine exists in a particular social context, and that social context is one (in OECD countries at least) in which one of the biggest issues in medicine is how to pay for it. I think it's really dangerous to pretend that a definite line between "evidence based medicine" and "evidence based medical cost control" can be drawn, and my biggest worry about the EBM crowd (who I reiterate, I generally like and respect when they're doing science at the further edge of their profession from clinical practice) is that they really do tend to sweep these complicated and vital sociological issues under the mat.

My theory is either that sciences studying value-laden questions should never be value-neutral, or else that discussions of value-laden questions should never be purely scientific.

For example, would you want medicine to be neutral about cholera? You really want your doctor to be strongly and unambiguously anti-cholera. You don't want even-handedness on his part.

You may respond: economic and social questions are not normatively unambiguous the way medical questions often or usually are.

Heh. Indeed.

If you presented to an NHS psychiatrist with mild (in the clinical sense, ie still fucking nasty) depression, and told him that you didn't want CBT but would like to be prescribed Prozac

I think learning to ride a motorcycle is great, but I'm not sure that I'd recommend it as treatment for depression. Why does the NHS think that's a good idea?

if one were to mandate that everything had to be done on the basis of evidence-based medicine,

It's not clear exactly what this means. Presumably there are always going to be individual situations on which no research has been done (like, a patient with an idiosyncratic problem with the conventional best practices treatment), or people with ideas for new treatment protocols that have not yet been tested. In the first case, the doctor's going to have to do something, and in the second case, presumably we're not planning to freeze medicine as of some given date, so variations and innovations in practice would have to remain possible.

But certainly, you describe ways that EBM could lead to problems -- nothing's perfect. It still seems, as a general rule, better than the alternatives.