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The Active Management of Labor

The above link takes you to an excellent article written by Marsden Wagner. He started out as a neonatologist and is now a consultant for WHO. He fully supports natural birth, midwives and midwifery and you may have seen him in birth movies - he's the over-educated elfin guy who is fun to listen to.

I've jotted some highlights from the article and added my own thoughts on it.

From my own personal experience, I agree that most health care providers no longer know what a non-medicalized birth is. Their training rarely covers natural hospital births and almost never brings the medical student into a free-standing birth center or home to observe birth.

As a result of lack of exposure to natural birth, hospital staff often believe that labor is something that happens to women rather than something women do that can be empowering and a rite of passage. Because labor is involuntary and unpredictable, many doctors and nurses interpret that as birth being out of control.

It’s sad to read the example of a hospital considering birth normal even if it includes an amniotomy, induction, augmentation, epidural or episiotomy. I feel that the list can go on to include continuous fetal monitoring, IV, withholding of food, drink and privacy, numerous cervical checks and disregard to birth preferences. What is even sadder is that most women today have accepted those same standards and also believe that birth with serious intervention is normal.

I found it interesting to read how the clock has quickened. Marsden states that the definition of the normal upper limit to labor has been reduced from 36 hours in the 1950s to 24 hours in the 60s and now holds steady at 12 hours since 1972, when active management was introduced. He also mentions that these random times were based on clinical concerns and not scientific evidence. With this scenario on hand, women adjust to the hospital and not the other way around.

My head was shaking when Marsden compared active management to inventing cars that can be driven too fast and then when the speed causes accidents, rather than change the cars, we invent speed bumps and as a result of the speed bumps people hit their heads on the car ceiling and we give them pain medication.

I think a better comparison would be the creation of entire task forces whose job is to monitor speeders and catch them in the act so they can then ticket them and make money from their speeding. That feels similar to hospitals making money from highly medicalized births.

Marsden concludes that hospital staff can never tell a woman that a certain procedure is safe because that person is not taking chances. A safety determination can only be made by the one accepting the procedure and that is the woman taking the chance.

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