Maternity a la mode Maternity a la mode (July 11, 2003)

By Diana Reynolds Roome

Even giving birth -- the ultimate constant -- is subject to fashion, and the current demand in Silicon Valley is for high-tech and painless. At El Camino Hospital, 80 percent of women request an epidural for labor and delivery -- a total anesthetic block of the pelvic area that used to be reserved for Caesarian sections or unusually difficult deliveries.

"Professional women are used to controlling everything in their lives, and birth is overwhelming, both physically and emotionally," says Olga Libova, an ex-engineer turned midwife, who was recently granted privileges to practice midwifery at El Camino Hospital. At the same time, she points out, there are many women who still want to push their babies out themselves and participate fully in a natural experience, despite the exhaustion and pain.

The arrival this year of two midwives -- the first was Lin Lee, -- may make it easier for women to have it all: a natural experience of giving birth with the help of a highly supportive and skilled birth expert, with all the safety of a well-equipped hospital, including an anesthesiologist constantly on hand.

"A lot of people are torn between home birth and hospital birth, and a midwife practicing in a hospital setting is the perfect answer," says Lee, a nurse-midwife trained in Britain, where midwives not only routinely deliver the babies, but physicians do not deliver without midwives present.

Lee also teaches childbirth education along with Libova, and says that she encounters a whole range of attitudes, from those who say, "I want my epidural in the parking lot" to others who would like to keep the whole event as natural as possible.

Opinions on these issues have always been sharply divided. Twenty years ago, midwives in the U.S. were reluctantly tolerated by the medical community, and a state-of-the art birthing center in Menlo Park eventually closed due to lack of physician support.

More recently the natural birth lobby has criticized the medical community for performing unnecessary procedures and administering drugs that carry risks for both mother and child. When birth is treated as a medical event, with continuous fetal monitoring, there is a higher likelihood of episiotomies and even Caesarian sections.

Midwives, by contrast, use a variety of techniques -- some of them ages old -- that help ease the birthing process along rather than hurrying it. Having looked after the mother throughout the pregnancy, they also stay with their patient during the entire birthing process, thus providing an extraordinary continuity of care.

The result is a closer and subtler interaction between practitioner and mother.

"You can observe changes on her face," says Lee. "I don't always need to check her cervix to see what the dilation is. The sounds she makes, and her expression will tell me whether it's four or ten centimeters. I can tell when she is entering the transition phase by the way her toes curl."

Instead of increasing drugs, the midwife offers back rubs, cool washcloths with calming lavender oil, hot compresses, and help with breathing techniques. She also offers the opportunity to get up and walk or take a hot shower or bath between contractions. A large gym ball can help ease the pelvis back and forth, which helps progress the labor.

Movement is an important factor which is prevented by anesthetics, as well the conventional fixed birthing position with stirrups.

Midwifery has its roots in the ancient practice of experienced women helping younger ones in an interaction that approaches birth as fundamentally normal and healthy rather than pathological and risky. The tradition is still alive and well in many of America's cultures, and is well accepted in most other parts of the world. Lin and Libova both have children of their own. "While I was on call during my training, my parents were on call to look after my kids," said Libova.

Today, a midwife requires training as an RN and has the authority to administer certain drugs, and perform minor surgical procedures such as episiotomies. But there is always an element of intuition involved, and part of the midwife's role is closer to that of a doula, or birthing coach and supporter.

Libova, who is a qualified doula as well as midwife, quotes one pilot study from Washington University Medical School showing that continuous labor support resulted in significant reductions in Caesarians, medications, episiotomies, postpartum depression, and more successful bonding and breastfeeding.

Midwives as well as doulas give support before, during and after the birth. They do the early pregnancy exams, as well as ultrasound, and the prospective mother then meets with one obstetrics specialist -- in this case from the Altos Oaks Medical Group in Mountain View, where Lee and Libova both practice.

Women with risk factors, such as severe hypertension or cardiac disease, diabetes (on insulin), or previous problems with childbirth, or multiple pregnancy, would be referred to a physician or co-managed by doctor and midwife. A baby in breech position which cannot be turned is usually delivered by Caesarian. But for most situations, the midwife remains the chief coach, manager, and supporter, only calling in the physician in case of complications.

"One important thing is talking to the parents," says Lee, who has been told her voice is so soothing it acts as an anesthetic. During labor "we remind them that they're safe and their baby is safe. We encourage the husbands to help and to take part."

Lyja Bautista's husband Joe was able to help deliver their baby by putting his hands under the baby's armpits and later cutting the cord.

"We felt so involved the whole time," said Bautista, whose son Cooper was born just over two weeks ago. "It was so different from our first baby's birth, when the on-call doctor was in and out, and there for the final seconds to deliver. We felt very removed then."

Bautista also had an epidural anesthetic, which can now be ordered by a midwife without referral to the on-call physician.

"People say, 'We want your care, but we also want an epidural,' and we're open to that," says Lee. About 50 percent of the midwives' patients end up having one, though in some other parts of the country it is as low as 10 percent, with a few hospitals only offering them for Caesarian sections.

"We're in a time when many mothers make the decision for an epidural early in pregnancy," says Marilyn Swarts, clinical manager for labor and delivery. "But I also have couples who come to me and say, 'We're going to see if we can do it without [the drugs].' I teach all the options -- it's not just either-or."

Swarts teaches birth preparation classes, including the Lamaze and Bradley natural birthing techniques, both here and at Stanford Hospital, where midwives have practiced for years. In putting their faith in midwives, El Camino will be joining the other hospitals in the Bay Area.

The important thing, says Swarts, is to achieve "a healthy baby and a healthy mum who feels good about the experience."

Information

Lin Lee and Olga Libova are members of: Altos Oaks Medical Group Orchard Pavilion, 2485 Hospital Drive, Suite 330, Mountain View 988-7470