Ina May's Guide to Childbirth (the *real* girlfriend's guide)

* Now, obviously I am a natural/normal birth advocate, so it's obvious that I'd be more likely to pan some books over others. I'll admit my bias and yet try not to get caught up in too much "woo." Just putting that out there. :)


In light of my last post on pregnancy/birth books, I decided this is the book a true girlfriend would give you if she really loved you. I first discovered this book when I was on the verge of delivering my second child. I was attempting a VBAC, and don't even remember where or how I heard about it - but once I started reading it I was immediately interested. Ina May Gaskin, much like The Navelgazing Midwife, Barbara Herrera, sounds like the kind of midwife you could trust to be open, loving, and more importantly - honest. Infallible and perfect; no - no midwife is. But someone you could trust to completely care for you to the best of her ability, yet call it as she sees it.

Before I even get into the book, take a look at Ina May's website - which has some impressive stats of the births she's attended while at The Farm, her "birth center" in Tennessee. Apparently she is well-esteemed within her local birthing community, even by obstetricians - which for a midwife is saying a lot. (I know there are lots of good doctor-midwife relationships in the medical world, but all things considered, most OB's will look at midwives disparagingly - even excluding them from their practices or at hospitals altogether.)

Ina May's stats - and her book - tell me that she must be doing something right, and has faith in the laboring woman! Among low-risk women over a thirty-year period, her rate of cesareans was ridiculously low. What hospital can say that? Obviously this is a picture that illustrates one thing: normal birth can work. It's clear that Ina May's insights into birth provide a glimpse that few other pregnancy and birth books outside the NCB circle provide - especially one that's not based on fear of birth.


Ina May's Guide has some amazing, empowering birth stories, which are always a fascinating read. Many of the mothers, I feel, give accounts that seem to show how inwardly focused they are, concentrating on their births and the process that is happening within them. It's often said that when a woman gets into the "zone" of labor that she should not be bothered, and yet some books seem to categorize this phase of labor as negative and a sign of the laboring mother losing control. Much like people who have witnessed animal births know that animal mothers don't like to be touched, moved or approached in any way, I think of it in kind of the same way with some laboring women: they need to be left alone, unless they request something else, to just go inside themselves and focus on getting the baby out, a process that ideally shouldn't be met with cries of "Push! Push!" and idle talk and chatter from attendants.

Interestingly enough, in probably every story, the women mention vaginal exams from the midwives. Not excessive ones, but one or two during the course of labor to determine progress. But obviously nothing about it suggests repeat checks every hour on the hour, and no harshness or disrespect that sometimes accompany a hospital birth. Many of the women mention the loving, caring atmosphere from the birth attendants, and being in strong, capable hands of people they knew they could trust implicitly.

Some of Ina May's ideas greatly impressed me when I first read this book, namely how much our fear (or lack thereof) can sometimes dictate our actions in childbirth. I thought back to my first birth, and how I knew I was going to have a cesarean anyway, but was scared something would happen before then (my baby was breech). I was breathing uncontrollably and my husband was busying himself at the monitor by telling me "that was a big one!" when the contractions showed up, which didn't help in the slightest. I was letting the pain and fear take over.

Ina May recounts the story of a woman laboring in a hospital under the care of a resident, who is horrified when her baby presents face-first:

"...[the resident] was not good at hiding his horrified expression when her baby's head parted the lips of her vulva. It seems that the baby was coming face-first, and it was the first time the resident had seen this (usually the top of the baby's head comes first). He imagined that he was seeing some horrible defect. His facial expression terrified the mother, who instantly felt her baby retract inside her body with such force that one of her ribs cracked."

I don't doubt it. When most of us are trained to see doctors as bastions of calm and collectiveness, it can be unsettling to see through their body language that something might be wrong (even when it isn't).

Ina May's Sphincter Law is a popular theme in the book, explaining how some women can literally clam up when a rough care provider is examining them. Not only are the frequent hospital examinations excessive, but are often done in a less-than-gentle way, especially if mom is already uncomfortable with the idea of a strange doctor delivering her.

She mentions this in relation to directed pushing, when the mother is literally ordered to start bearing down simply because she is dilated. If there is one thing I wish I could change about my VBAC delivery, this would be it: I would push when I was ready to, not when they are.

"Those who have never felt what it is like to give birth while being shouted at can better understand how this can interfere when they try to imagine what it might be like to poop while a stranger stationed a few feet away yells at them how to do it."

Kind of puts that whole thing in perspective: no, pushing out a baby is not like having a bowel movement. You know what's going to happen when you try to go and don't have the urge, right? Why should this be any different?

Ina May also mentions something very important: that a rough exam performed by someone with a less-than-pleasant demeanor (say, an OB who is ready to go home for dinner or is impatient to catch his flight) can actually cause reverse dilation of the cervix. Ina May recounts the story of a patient who was transferred to the hospital because of a bladder infection that was keeping her cervix from dilating past seven centimeters. Upon a rough examination by "an obstetrician who was rather sullen and unfriendly in his manner," he noted that the patient was only four centimeters. Ina May noted that after that encounter, the mother's labor "never reestablished itself after this obstetrician's rude internal examination, so this mother's baby was born by cesarean."

There is a very informative section on pushing positions, as well as illustrations that depict women of various cultures in different positions while birthing. Not surprisingly, few, if any, of the other books I've read so far mention anything about changes in position to either aid in the baby's descent or birth the child. In fact, as far as alternatives to the typical lithotomy position, I don't think they mention it at all. (With one exception: What to Expect does mention changes in positioning, but doesn't really elaborate much on them, that I remember.)

Pushing in the lithotomy position, or flat on your back, has been in fashion for probably a few centuries, at least in Western cultures. While most people think it's necessary, really the only reason it's used is for the convenience of the physician. "By the end of the nineteenth century," Ina May notes, "birth chairs were rarely used any longer." She adds that squatting in labor, which actually helps to open the pelvic outlet, was something considered "low-class."

She includes a passage from physician George Engelmann, written in 1882:

"At every pain she made violent efforts, and would bring her chest forward. I had determined to use the forceps, but just then, in one of the violent pains, she raised herself up in bed and assumed a squatting position, when the most magic effect was produced. It seemed to aid in completing the delivery in the most remarkable manner..."

It sounds like this lady was prompted by sheer instinct. As Ina May says about a patient who flipped to the all-fours position while laboring, "women often make this choice spontaneously." If they're allowed to.

Even Engelmann realized this, in his now-obsolete book Labor Among primitive Peoples. He, too, realized the importance of positioning during a mother's labor:

"If we wish to obtain an idea of the natural position we must look to the woman who is governed by instinct, not by prudery." 

(He does go on to mention women of "savage races," who we can assume are too uneducated or "tribal" to be worried about how their hair looks or if they look "lady-like." While it sounds blatantly discriminatory, I've often thought poorer, less educated laboring women I've read about in birth cultures were luckier than they realized: they were left alone to labor, and often chose medication less often because of physician distrust. Because of their lack of social standing and inadherence to societal customs of the day, they probably had easier labors than their elite counterparts.)

If you're interested in normal birth - not even completely "natural" birth, which can be defined in many, many ways - you need to read this book. Not only to see that yes, it is possible, but that there is definitely something different out there that's worth exploring. So much of the innately beautiful physiological aspects of birth are ignored, covered up with medication and interventions, when they don't even need to be.