We’ve all heard it, and many of us have said it. In most contexts the advice to ‘go with the flow’ during labour usually comes from well-intentioned friends and family or midwives. But professional care providers who are navigating a complex hospital system fraught with patriarchy, policy and threat of litigation, whilst they want to be providing ‘women-centred care’, are, in my opinion, in danger of managing first-time mums towards labours with unwanted medical interventions with unhelpful advice such as ‘go with the flow’. And here’s the sucker-punch; we’re permitting it. We are handing over our bodily autonomy to someone else, someone we trust – often blindly – whose motives and desired outcomes may be wildly different to our own. No one can take your power, only you can give it away so why give it away at a time when you are at your most vulnerable?
Picture the seen:
First time mum, low-risk pregnancy (let’s call her Esme), full of excitement to greet her new baby. Esme has no direct experience of childbirth and not much therefore to go on in terms of creating a Birth Plan. She’s heard birth-horror stories from her girlfriends (which wisely she’s chosen to tune-out from) and watched One Born, of course, but she’s into clean eating and yoga and so thinks she might prefer a natural delivery, maybe with some Gas and Air.
Overwhelmed by the amount of pregnancy/ labour literature available, Esme hasn’t done much of her own research preferring instead to chat it all through with her midwife – someone she trusts who she believes will guide her to what’s best. She heads into her 36 week antenatal appointment where she expects to discuss her birthing options with the midwife, only the midwife clinic is full to overflowing and the midwife is flustered, stressed and pressed for time. After routine antenatal checks on mum and baby, the midwife asks “Have you thought about a birth plan?” “A little. I think I’d like a natural birth – if I’m allowed – but I’m not really sure. What do you think is best”, Esme replies.
And then Esme takes it, the best(?!) advice a midwife can give… “Well, its probably best to go with the flow. See how you feel on the day. You can always transfer from the Birth Centre to the Labour Ward if you change your mind about an Epidural…And maybe you should keep an open mind – labour rarely turns out the way you plan”
Esme feels reassured and yet leaves without a real birth plan and without having discussed any of the actions/ decisions she might take to help promote a natural delivery or any of the benefits, risks or alternatives associated with the medical interventions such as the Epidural the midwife implies might feature in Esme’s labour.
So what’s going on here? Why is this ‘advice’ so bad, in my opinion?
Let’s start by unpacking the midwives suggestions. ‘Going with the flow’ suggests that one ought not to be fixed on a particular outcome, perhaps to protect oneself from disappointment (statistics tell us that when a women’s labour doesn’t go to plan, she can be at an increased risk of postnatal depression). Given that labours can progress differently and not always as we intend or expect, keeping an open mind to all possible outcomes may actually be sensible – but knowing what those outcomes might be ahead of time is equally important for reasons I’ll explain shortly.
‘Going with the flow’ also suggests a surrendering of maternal autonomy – going with the flow implies a powerlessness against it, that Esme ought to submit to the flow. So, if Esme is not directing or leading the flow then who (or what) is? For sure, nature, and nature will run it’s course but labour is a collaboration between the pregnant Mama, nature (or biology/physiology), the baby and the care providers. Nature can definitely lead, but nature can also be guided in both optimal and sub-optimal directions.
‘Normal’ physiology of labour can be inhibited if the care provided is not satisfactory to a labouring woman, if drugs have been administered, if the environment inhibits oxytocin release or if the labouring women feels disturbed, frightened or ‘out of control’ (a well documented contributing factor for Birth Trauma) and this can diminish Esme’s chance of a natural birth.
The opposite is also true; when a labouring women works in harmony with her body and her physiology to labour optimally, is supported by the attending care providers, in a safe environment with minimal disturbance, then labour can progress really well and Esme’s chance of a natural, vaginal delivery is promoted (which is why homebirths for women at low risk of complications are now encouraged). But how can Esme achieve this if she is not in charge of her labour?
Perhaps, Esme is being advised to follow the lead of the attending midwife, who may direct ‘the flow’ using partograms to measure and predict dilation of the cervix and therefore assess how well labour is progressing or not. But how reliable are partograms? Not very, is the short answer. So then what? The midwife makes an assessment that labour ought to be ramped up a bit, suggests a transfer to an obstetric unit for augmentation with a syntocinon drip, which Esme goes along without real discussion or prior consideration of the associated benefits, risks or alternatives. Are these discussions appropriately timed whilst in active labour when chances are, they may slow contractions by triggering a state of stress? I’d say, probably not, probably best had way before labour begins, rather than ‘seeing how you feel on the day’!
And what of consent? It is paramount that consent is gained for any medical intervention or care plan. I would question the validity of any consent gained from a labouring women who is in a compromised frame of mind (ie distracted or frightened by pain) or has not had time to fully consider the pros and cons of any medical intervention. During my time as a Student Midwife and Birth Doula I have listened to many women share with me their realisations post-birth that they did not fully understand to what it was that they were consenting.
One of my postnatal clients consented to undergoing a number vaginal examinations (VE), antenatally, to help her overcome her fear of internal exams in labour without any discussion about the risks associated with vaginal exams or alternative methods of evaluating progress of labour. The antennal VE’s didn’t help, quite the contrary, and she was, of course, very upset to later learn the VE sought only to serve the interests of her attending obstetrician and potentially put the wellbeing of her baby at risk.
Another woman I spoke to regretted deeply consenting to an episiotomy and Forceps delivery, during labour, without fully understanding the risks of 3rdand 4thdegree perineal tearing. Later she described the experience as being raped and brutalised. She is currently seeing a Psychotherapist for Birth Trauma.
Pregnancy and childbirth are wonderfully complex experiences. On one hand you can feel immeasurably powerful and on the other inconceivably vulnerable. Surely, surrendering ones autonomy during a time of great vulnerability can only lead to feelings of disempowerment.
Now let’s address that part about transferring for an epidural and labour not turning out the way you plan..
In the Birthplace study of 2011 – a summery of which you can find here– the birthing outcomes of nulliparous women (women who have not previously given birth) with a low risk of developing complications in labour, planned to deliver in Midwifery-led Birthing Centres were reviewed. The study found that over 78.8% of first-time mums achieved a normal, vaginal delivery. 5% of all women were transferred to the obstetric unit for an epidural and 10.8% of women were transferred for an instrumental (Vontose or Forceps) delivery. 6.7% of women were transferred for an emergency Caesarean Section.
Are these figures significantly high enough that Esme should be discouraged from believing an unmedicated, vaginal delivery is achievable? Personally, I don’t think so. I think Esme has every chance for being one of the 78% that achieve the vaginal delivery aimed for. And if Esme needs to be transferred for whatever reason, or her baby needs assistance in being delivered, then Esme could empower herself by ensuring she understand the benefits, risks and alternatives associated with epidural, instrumental and caesarean delivery ahead of her labour starting to ensure she (and her partner) are clear on their preferences under those circumstance. This way they mitigate their chances of going (with the flow!) in a direction they never knew they didn’t want to go until it was too late!