Wednesday, July 16, 2014

Stages of Labor

We now continue with our analysis of the article of interest, "Obstetrics and the Curse of Eve."  The paragraph we took apart in the first post ends with the following statement:
"In fact, before the final stage of labor, no transgressions of the Sabbath were permitted, except for summoning the midwife."
Those readers who have followed this blog from its inception, should be familiar with the Five Principles of Rationalist Medical Halacha.  It should be immediately obvious that the quote above is a gross violation of principle # 2, the "historical corruption principle."  To quote myself, it is of utmost importance when one analyzes a topic in medical halacha, that they "understand how the medical understanding of their predecessors affected the decisions that they made."

They use the term "final stage of labor" which is a modern medical term with a very specific meaning, and they use this term to describe the words of the Shulkhan Arukh.  Their intent in doing this is to emphasize that for most of the process of labor, most transgressions of shabbat were not permitted, other than to summon the midwife.  Only in the "final stage" are we allowed to do anything else if it violates Shabbat.  This further illustrates their contention that the process of childbirth should not warrant as much chillul shabbat as is commonly assumed today.

This is based on a serious misinterpretation of the term used in the sifrei halacha "K'shekora'at leyaled" "when she bends over to give birth".  It is true that one may not violate Shabbat until that time, but when is that time exactly?  Doesn't that sound like the "final stage" of labor?  This seems to support the contention of the authors that only during the "final stage" of labor are we allowed to violate Shabbat.

Nothing could possibly be further from the truth however.  The truth is that the poskim say clearly that we are allowed to violate the shabbat from the time of "Kora'at leyaled", and they describe clearly exactly when that is.  Three examples are given by the gemara in Shabbat 128b-130a, and these examples are repeated in all the sifrei halacha:
  1. When the blood starts to drip
  2. When she sits upon the birthing chair
  3. When her friends are carrying her
I will digress a little to teach you some modern obstetrics, and a little bit about the signs of labor. Every woman experiences labor differently, and there is no one exact way that every labor progresses.  However, there are still some general concepts that can help us understand how labor progresses, and modern medicine is great at dividing things into categories and stages.  

The first stage of labor starts with a closed cervix and ends when the cervix is fully dilated, generally around 10 centimeters.  This is divided for conceptual purposes into two phases, the latent phase and the active phase.  The latent phase is slower, usually less painful, and consists of contractions that are usually farther apart. This phase can last anywhere from two days to just a few hours, and usually is much shorter in women who have had babies before.  This phase usually ends around 4 centimeters when the woman enters into the active phase.  During the active phase of labor, the contractions are much stronger, closer together, and much more uncomfortable.  The cervix dilates quicker, and this phase is usually over in a few hours when the cervix is fully dilated.

The second stage of labor starts when the cervix is fully dilated, and ends when the baby is delivered.  this is often called the pushing stage, as the woman's natural urge to push is very strong, and she will have to work extremely hard to push the baby out.  This can last anywhere from a few minutes to a few hours, depending on all sorts of factors.

It is very important to differentiate between "stages" and "signs" of labor.  Signs of labor include things such as bloody show, the passing of the mucous plug, the "dropping" of the baby, pelvic or low back pressure, and other such symptoms. Stages are what we just described in the previous two paragraphs. The important difference between stages and signs is that not every woman experiences all the signs of labor, and sometimes the presence of those signs doesn't necessarily mean that someone is in labor.  However, every woman does go through the stages of labor, although it could happen at way different speeds, and way different levels of intensity, but the stages always happen.

During the time of chazal, they needed to define the signs of labor that meant the woman is in sakanah.  This was important in order to provide guidance as to when chillul shabbat was permitted. In those days labor was not described in stages like we do today in modern medicine.  Chazal knew very well that there were soft signs that meant labor was imminent, but that the woman was not yet in danger when they happened. They also knew that at some point in time, she transitioned into a stage of sakanah.

When I was a resident, the nurses and residents came up with what we called was the "visual labor check".  We used to joke about how one could usually tell when a couple walked off the elevator towards the front desk whether or not she passed the "visual" test to be admitted.  If her partner (be it a friend, mother, doula, or husband) was holding her as she breathed through her contractions, that was a positive visual test. If she was wet with blood and water, that was a positive visual test.  If she was in such discomfort that the security guard had to wheel her in, that was a positive visual test.  No exam was really necessary to confirm that she was in labor.

The "positive visual test" usually correlates well with the active phase of the first stage of labor, also known as "active labor".  This was of course confirmed when we examined the woman and found out how far dilated her cervix was.  If she was in latent labor, we may send her home, or may send her for a nice walk around the hospital for a few hours, but she did not require admission.  Why? because in the early stages of labor it is commonly understood that there is no serious risk to the health of the Mom or the baby.  However in the active phase, there is risk.  What risks are more common in the active phase? Some examples (but there are certainly many more) include:

  1. Hemorrhage due to abruption (separation of the placenta) or vasa previa (a condition where the umbilical cord can tear)
  2. infection (especially in cases where the labor lasts a long time and the membranes have been broken)
  3. fetal intolerance of labor (the baby may not tolerate the contractions well - which is why we monitor the baby during active labor)
  4. seizures due to blood pressure abnormalities
Now remember that all of these problems are rare, but also recall what we said in the first post on this topic. We explained that although the overwhelming majority of women make it through labor just fine without any medical interventions, the Halacha still paskens that they are all considered pikuach nefesh, so that we can intervene in order to prevent the few deaths that would occur if we didn't intervene.

For example.  We monitor the heart rates of every baby on Shabbat, even though the vast majority of babies would do just fine without a monitor.  Why? because we want to save the one in a thousand that we can find abnormalities in the heart rate.  Another example: We check every woman's blood pressure and temperature, why? because we need to find the one in a hundred that have problems that we can treat! and so on.

Let's go back to the "visual test" from my residency days.  Even though they didn't use the same terminology to describe the stages and phases of labor, Chazal absolutely knew about all the signs of the latent phase of the first stage of labor.  They knew it because it was common knowledge, and everyone knew that it wasn't yet a dangerous time.  But they also knew that when she transitioned into active labor, she was in danger? They knew this as well because it is something that has been observed for as long as human beings have been having babies! What were the signs that she had entered this phase, the signs that any observant person can see? When the blood is flowing, when her friends need to help her walk, and when she lies or sits down in the birthing bed (see Arukh Hashulchan OC 330:4 who explains that sitting on the "Mishbar" does not mean sitting in the bed to push the baby out, but it means when she lies down due to the pain of the contractions).  This fact is so obvious to anyone that has ever seen a woman in labor that one need not even bother explaining it further.

The authors of our article wrote that "before the final stage of labor" violations of shabbat were not permitted.  They assumed that one may not violate the shabbat until the second stage, when the woman is pushing the baby out.  But this is patently wrong.  One may clearly violate Shabbat at the onset of active labor, during the first stage of labor.  Chazal were extremely clear about this, as they observed in nature the same phenomena that we observe today, that the really risky time is the active phase of the first stage of labor.  Just like modern hospitals usually won't admit a patient in the latent phase of labor, chazal also knew that chillul shabbat was inappropriate as well.  It is not necessary to be a modern scientist to know these obvious facts.

"except for summoning the midwife" - of course one may summon the midwife before the onset of active labor.  Because we don't want to wait until the woman is in potential danger before we summon her! She needs to be there before that stage begins!

In short, our authors used a modern medical term, the "final stage" of labor, and assumed that this is what Chazal meant when they said K'shekora'at leyaled".  They therefore concluded that the poskim only permitted chillul shabbat during the final stage of labor, except for summoning the midwife.  This is a mistake. Chazal were referring to the active phase of the first stage of labor.  This is exactly the time when everyone agrees the time of potential danger has begun, and this agreement spans the entire history of humanity, up to and including in modern hospitals.  The modern poskim all agree with what I just wrote, and correctly so. But the authors of our article, not surprisingly, proceed to criticize the modern poskim for this, but that will be coming up soon in an upcoming post...

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