Normal Birth: Do We Believe? Can We Remember?
by Valerie El Halta

[Editor's note: This article first appeared in Midwifery Today Issue 47, Autumn 1998.]

When a woman is considering having a homebirth and we meet for an interview, she often asks, "What is the difference between a midwife and an obstetrician?" Although I can think of many differences both in philosophy and in practice between us, I have simplified my answer to explain what I believe to be a very basic difference in perspective. The obstetrician may say to the pregnant woman, through attitude, words or continual reliance on technology, "You have to prove to me that you can give birth to a baby." The midwife, on the other hand, with her attitude that birth is, in most instances, a reliable event, says to this same woman, "You have to prove to me that you cannot have a baby!"

The midwife is (or should be) an expert in normal birth, while the obstetrician must be an expert in pathology. This is exactly the way it should be. For it is that expert to whom we must turn when we do encounter the abnormal. I believe that oftentimes, the midwife is more likely to recognize situations which demand attention than the caregiver who sees all pregnancy and labor as a potentially dangerous and lethal process.

How have midwives developed such a positive attitude toward the birthing process? Is it that after watching birth and birthing women through countless generations, we know that "babies come out?" Of course, we have also seen birth tragedy, and yet after less than perfect outcomes, we are able to go on to the next labor with our belief in the process intact.

The first factor paramount to maintaining normalcy in birth and obtaining an optimum outcome for mother and her baby is our ability to provide both constancy and continuity of care. As the relationship between midwife and mother develops during the course of prenatal care, a mutual trust between the caregiver and cared for brings a sense of safety and security. Communication becomes forthright and honest, and words and ideas flow easily between them. When it comes to the time of birth, rarely must we deal with psychological issues, which may stall or impede labor, since specters of the past have been met, dealt with and put in their proper place. The midwife has said to the mother through her manner, her touch and even with her words through the preceding months: "I will never lie to you." This is great comfort to the woman with so many questions, meeting birth for the first time. So many times I have sat with a young woman who is having her first baby. When her eyes gaze into mine, when I feel her contractions crashing through her body like tumultuous waves against the rock, and I know she is doubting her strength to go forward despite her great desire to complete her task, I say to her, "OK, Suzy, now you will have to walk on water." She grasps my hand a little harder and replies, "How far do you want me to walk?" Then, we walk together.

The amount of time spent during prenatal visits as well as honing our powers of observation to a fine edge are the second factor impacting a normal outcome. A hurried assembly line prenatal visit may be worse than no visit at all. This is particularly true when a woman has a condition that requires more frequent visits. The routine prenatal exam in which urine is tested for protein, glucose and so forth, the blood pressure is taken, fundus measured and fetal heart tones quickly found, in reality may have little relevance in determining the normalcy of this woman's pregnancy. Of course, I will continue to do all these things at each visit, lest I be accused of offering less than "the standard of care." However, I am much more interested in how the woman carries herself. Does her back hurt (should we check for kidney problems?); how's her energy level (is she anemic or depressed?); her self-esteem (is she being taunted because she has put on weight?); her mood and her general appearance (is she too tired to wash her hair? Is she working too hard? Is she worried about family or finances?) How is her appetite? Is she able to sleep well at night? (Is she having nightmares, are there unresolved psychological issues of abuse or previous birth trauma?)

Is she happy about the pregnancy? (Does she feel that this baby is breaking the camel's back?) Is she getting along well with her partner? (The nosy person I am, I have even asked a couple right in front of me, "Do you love each other?") Then, when I am allowed to place my hands on her belly, I try to see how the baby responds to my touch and am very encouraged by the baby who "plays with me!" I even do silly things like sing to the baby. Fundal height? How about feeling how much fat is on the baby's back? Is it one centimeter less than last week? Before we run off for an ultrasound to determine intrauterine growth retardation (IUGR), let's make sure it hasn't become transverse, or isn't simply deeply engaged in the pelvis. I take time to assess the position and attitude of the fetus at each visit, and may offer the mother ideas to assist with optimum positioning when the baby is not lined up just right. All in all, it takes time to "tune in" with this pregnancy—to talk about nutrition, that strained ligament on her left side, the things that she is being told by her neighbor who has had two "emergency" cesareans, how she can get her husband to be more involved, how she can wean the two year old and many, many other things that don't have squares on the chart to check.

Case# Parity Date 1st stage 2nd stage Total Weight of baby VBAC?
1 2 12/97 1hr 17m 17m 2hr 4m 9lb 2oz  
2 1 1/98 1hr 1m 9m 1hr 20m 7lb 10oz  
3 1 2/98 1hr 15m 15m 1hr 30m 7lb yes
4 4 3/98 45m 3m 57m 8lb 14oz  
5 3 4/98 1hr 7m 21m 1hr 53m 8lb  
6 0 4/98 2hr 40m 19m 3hr 5m 8lb 4oz  
7 0 4/98 1hr 50m 30m 2hr 30m 8lb 14oz  

This young woman came to her prenatal visit at my house, had her baby and went home!

8 2 4/98 2hr 30m 17m 2hr 47m 7lb 2oz  
9 2 4/98 35m 10m 55m 6lb  
10 6 5/98 ? 6m ? 10lb  

More called me saying, "I think this baby wants to be born." I felt no contractions, I went to her very quickly, arrived to find her complete, and waited until she felt like pushing!

11 0 6/98 1hr 30m 15m 2hr 5m 7lb 8ox  
12 0 4/98 3hr 30m 15m 4hr 7lb 6oz  
13 7 5/98 55m 18m 1hr 20m 8lb 20z  

Thank heavens, this mom's water broke to give me time to get to her before her labor began. She had 8 contractions, nuchal cord x3!

14 4 5/98 3hr 30m 38m 4hr 20m 12lb yes

History: Two Cs for "failure to progress, CPD (posterior)," two births with us at the Birth Center. This was her first homebirth. 16 in. head, no laceration.

15 1 5/98 3hr 40m 35m 4hr 23m 7lb 4oz yes

She experienced almost no pain during dilation. When told she was complete, she said to her friend, "Why would she lie to me?" I had her touch her baby's head, waited until she wanted to have her baby and helped her get him out. She had been told she could never have a vaginal birth.

16 0 5/98 2hr 34m 35m 3hr 9m 6lb 4oz & 6lb 8oz
term twins
17 0 6/98 7hr 40m 8hr   8lb
compound arm
18 2 6/98 7hr 1hr 35m 8hr 35m 8lb yes
(2 Cs for CPD!)
19 1 6/98 3hr 30m 19m 3hr 59m 9lb 3oz  

I want to be known as the world's laziest midwife; to achieve this I try to spend the bulk of my energy during the prenatal period so that when it comes time for the labor and birth, all I have to do is smile encouragingly and make chicken soup!

Now we come to the third very important factor in assuring the birth will proceed normally. This is a matter of environment. Where does the mother feel safe? With whom does she feel confident? Recently I was talking with a young dad who had just finished his college degree and felt pretty exhausted after taking some of his final exams. He had studied very hard and felt that he had a good grasp of the subject matter, yet when it came time for the actual tests, he had been hampered by great feelings of fear and anxiety. Although he did well on all the exams, he felt he should have done better and that the grades did not reflect his knowledge of the subject fairly. As he was talking, my mind opened into a big "A-HA." I asked him to describe the testing site, and he told me it was a room he had not been in before, and full of equipment with which he was not familiar. There were about twenty others being tested whom he did not know, and the proctor was a stranger. The room was a dull shade of green (not his favorite color), and it was very cold. To me, this sounded like a woman going to a hospital to have a baby! No wonder so many women have "failure to progress" when exposed to an unfamiliar environment.

It has been my experience that when the mother is able to labor in an environment of her choice, with people surrounding her who make her feel respected, loved and safe, she is free to give birth to her baby, rather than be delivered. Some time ago, I was watching a video of Dr. Chilton Pearce describing what he considers to be "normal birth." To my astonishment, I heard him say "normal labor ought to take about twenty minutes!" Although I laughed at his remark, I have had time since to seriously consider his premise, and I am coming to believe that he just might have a point. Belief is a very strong universal force, and faith, I am told in the scriptures, can "move mountains!" I wonder how much effect the belief of the caregiver has upon birth outcome? The more I believe that "babies come out" and that it is not necessary that it be a lengthy nor painful ordeal, the more I am witnessing short, almost painless labors. For all of you who just stopped reading this because "Auntie Val" is being a little crazy again, I am going to offer you some evidence to sustain your belief in "evidence based practice."

What is normal birth? I wonder if we really know anymore. The modern birth has been so managed, arranged, choreographed, augmented, drugged, sliced and diced that many of us have forgotten its very nature. What I do know is that when we free ourselves to love women unconditionally, establish relationships of trust, learn everything we can about the physiological process, take care to ensure the prenatal course runs smoothly, pay attention (by our physical presence) to situations before they become complications or emergencies, and relearn to use our hands to calm, massage, encourage (and sometimes adjust those little heads), our minds and hearts may once again remember that birth itself is a normal event. Birth is truth.

Valerie El Halta, CPM, has been practicing midwifery for twenty-four years. She co-directed The Birth Center in Dearborn, Michigan with Rahima Baldwin Dancy for nine years. She now enjoys a busy homebirth practice and continues to write and teach.

If you enjoyed this article, you'll enjoy Midwifery Today magazine! Subscribe now!