Ina May Gaskin looks at how obstetrical knowledge and medical hierarchy has undermined and ignored uterine capability
I learned a new Spanish word while lecturing in New York City on a book promotion tour during the spring of 2003. The Puerto Rican nurse who explained it to me said that in the countryside where she grew up it is used like this:
One woman might say: “I heard that your sister was in labour. Has she had the baby yet?”
She might get this answer: “She went to the hospital, but when she got there, she went into pasmo and they sent her home.”
Pasmo is a word with no English equivalent. It means the reversal of labour once it has already started. It may mean that uterine contractions, once started, come to a stop, and sometimes it is characterised by a significant reduction in cervical dilatation. Assuming that this uterine capability is real, we might be justified in asking why no word for the arrest or reversal of labour exists in everyday English. I don’t know that we’ll find any answers.
In US English medical language, though, there are some words or phrases that describe this phenomenon, but these aren’t in everyday use among women. For instance, we have ‘uterine dysfunction’ and ‘uterine inertia’ – both terms that point to a supposed defect in the uterus. Nowadays, once this diagnosis is made after a labour has begun or a woman has been admitted to hospital, several courses of action are common. They include amniotomy; induction or augmentation of labour, or caesarean section. In times past, women whose labours stopped or slowed significantly after admission were sent home or advised to walk the halls of the labour ward in an attempt to stimulate stronger contractions. Now, elective induction is considered acceptable in a majority of US hospitals. Elective caesarean, too, has gained acceptance in a growing number, despite the clear evidence pointing to an elevation of risk in terms of maternal morbidity and mortality.
I was fascinated to know that the concept of pasmo has survived in Puerto Rican culture, even though more than 99 per cent of women there give birth in hospital—approximately the same percentage as in the US. However, the phenomenon that it describes exists wherever there are childbearing women.
An experience of ‘pasmo’
I first became aware of the phenomenon of pasmo in 1973—my third year of attending births—while attending a friend’s first labour. Her cervix dilated to 8cm in just a few hours. At this point, though, her manner changed noticeably. Whereas before she had been light-hearted, laughing and joking with her partner, my assistant and me, her emotional state changed considerably as she approached transition. No longer did she laugh, and she seemed afraid even to clear her throat in her usual manner. Because her uterine contractions had greatly lessened in their intensity and I was scheduled to leave on a bus trip within a few hours, I asked her if I could do a vaginal exam. She gave her consent. I was astounded to find that her cervical dilation was now only 4cm.
I was certain that I had correctly assessed her dilation at 8cm only 20 minutes or so earlier, so I guessed that it might be a good idea for her to reactivate her sense of humour during the next few contractions, in hopes that her cervix might reopen. “Laugh at our jokes like you did before,” I suggested. “It just might work.” And it did. Her baby was born within two hours.
That experience sent me to the medical library for a deeper search about the (to me) unusual phenomenon I had just observed. Never before had I observed any reduction in cervical dilatation in a particular woman. I had observed stalled labours that were resolved by mere words and described these in my first book, Spiritual Midwifery , but I had never before observed someone going backwards in labour.
I hadn’t spent very long reading in the medical library before I saw that I was not going to find any mention of pasmo or anything like it in a midwifery or medical textbook in English. And yet I knew that my friend’s cervix closed from 8cm to 4cm without her even moving her body in any significant or visible way besides a change in facial expression.
The medical viewpoint
During this same period, I occasionally lectured to groups of US midwives, nurses or physicians, and I asked them if they had ever observed the reversal of cervical dilation in a labouring woman. All of the midwives and nurses had. I soon learned from them that this phenomenon probably took place more often in their hospital-based practices than my partners and I saw in our homebirth practice. But I met no physicians who were aware of the capacity to reverse labour. When I asked nurses and midwives about this difference, I was told that whenever they documented a lesser dilation on a woman’s chart, they were told they had made a mistake. I realised that physicians and medical students almost never have the chance to observe women’s labours from start to finish, so it became obvious to me that they were not in a good position to know about the true physical capacities of women in labour. They were actually far less qualified to comment on the behaviour of women in labour than the lower-ranking professionals, whether midwives or nurses, who spent more time in the labouring woman’s presence than they did. I knew then that the lack of mention of pasmo in labour has much to do with the nature of medical hierarchy. Physicians outrank midwives and nurses in status and in income, and this higher status gives their perceptions of labour phenomena a higher value when it comes to formulating the accepted knowledge of how women’s bodies work than the observations made by midwives.
A historical perspective
My documentation of a case of labour reversal in Spiritual Midwifery more than 25 years ago has made no difference in this state of medical and midwifery knowledge. As far as the textbooks are concerned, human females lack the capacity to close their cervices during labour. If such a thing happens, the assumption is that the uterus itself is defective, and medical intervention is warranted. But my research at the medical library did yield some interesting information and evidence having relevance to the pasmo phenomenon. In the library’s rare books collection, I found the following excerpts in medical textbooks published between 1837 and 1901:
…it is to be understood, the fact of there being a continuance of regular pains, for it sometimes happens that, after regular pains have commenced, the agitation of the patient, or the mismanagement of the attendants, occasions a suspension of some hours. (James Hamilton, Hamilton’s Practical Observations , 1837)
As soon as you arrive, let the husband, or some familiar friend, inform the lady, and then you should remain in the antechamber till she requests your presence. A sudden surprise, especially if attended with the fear of severe treatment, will greatly retard the process, and, in many cases, cause the foetus to retract. VVhen you enter the room, let your mind be calm and collected, and your feelings kindly sympathize with those of the patient. (A. Curtis, Lectures on Midwifery , 1846)
In 1792, I was called to attend a Mrs. C, in consequence of her midwife being engaged. As I approached the house, I was most earnestly solicited to hasten in, as not a moment was to be lost. I was suddenly shown into Mrs. C’s chamber. and my appearance there was explained, by stating that her midwife was engaged. As I entered the room, Mrs. C was just recovering from a pain – and it was the last she had at that time. After waiting an hour in the expectation of a return of labour. I took my leave, and was not again summoned to her for precisely two weeks. And Dr. Lyall says, ‘we have been informed by a respectable practitioner. of a labour that had nearly arrived at its apparent termination, suspended for more than two days, in consequence of a gentleman having been sent to the patient, against whom she had taken a prejudice.’ Every accoucheur has experienced a temporary suspension of pain upon his first appearance in the sick chamber; but so long a period as two weeks is very rare.” (Dewees’ System of Midwifery , 1847)
Uterine action, and therefore labour-pains, may be suspended or removed by many causes … The disappointment occasioned by a stranger entering the room when the patient expected her own attendant, has been known to stop a labour. In the midst of its most active operation, and to suspend it for many hours. It is principally on this account that we are careful to prevent a woman in labour becoming suddenly acquainted with any news that is likely to shock her.
…On arriving at the patient’s residence it is better not abruptly to obtrude one’s-self into her presence, unless there be some immediate necessity for our attendance. Information should be sought from the nurse, on such points as will enable us to judge whether labour has actually commenced. On being ushered into her chamber, we may engage her in some general conversation, which will give us an opportunity of observing the frequency, duration, strength, and character of the pains; and our conduct must be framed accordingly. (Francis H. Ramsbotham, The Principles and Practice of Obstetric Medicine and Surgery , 1861)
P. Cazeaux also had much to say on the subject in his well-known text pubiished in 1884:
I am well aware that books furnish some cases of women who had the power of suspending the contractions at will; but if the facts have even been well observed, they have failed perhaps to receive the most rational interpretation. In the cases related by Baudelocque and Velpeau, in which the labour ceased when the students were summoned to witness it and began again when these numerous observers retired, the will had probably less to do than the imagination and modesty, with the alternations of retardation and acceleration; for though the influence of the will may be reasonably doubled, it cannot be denied that moral disturbances appear to affect the contractilty of the uterus; thus, a violent emotion has often sufficed to arouse it long before the ordinary term of gestation, and it is not at all uncommon for the contraction to diminish or disappear for several hours, or even days, under the operation of such causes. [Cazeaux then quotes Betschler, who cited a case 'in which the pains were suddenly suspended by a violent tempest, so that the neck, though widely dilated, closed again, nor did the labour recommence until nineteen days had elapsed.']
Every day, indeed, we witness a suspension of the pains for half an hour. and sometimes even for several hours, upon visiting women whose modesty is shocked by our presence. The exercise of this function is seldom of long duration, lasting for a few seconds only – rarely beyond one or two minutes, and then the organ which was so strongly contracted and hardened gradually regains its primitive state, and remains in repose, until under the influence of the same stimulus, it is again thrown into action. The organic contractility, like all muscular power; is expended by a prolonged exercise, and hence we can understand why the pains so often become at once more slow and feeble or even cease altogether after a prolonged labour.
Any vivid moral impressions operating during the labour; any unexpected news or sharp discussions, the announcement of a child of an unwished-for sex, and the arrival or presence of persons disagreeable to the lying-in woman, may determine a cessation of the pains; and in these cases the removal of the cause is the only remedy. But, unfortunately, it is not always an easy matter to ascertain what that cause may be.
On arriving at the house the practitioner should have his visit announced to the patient, and he will vel}’ often find that the first effect of his presence is to arrest the pains that have been hitherto progressing rapidly, thereby affording a very conclusive proof of the influence of mental impressions on the progress of labour. If the pains be not already propulsive, it is well that he should occupy himself at first in general inquiries from the [female] attendants as to the progress of labour; and in seeing that all the necessary arrangements are satisfactorily carried out, so as to allow the patient time to get accustomed to his presence. (Playfair’s System of Midwifery, 1889)
Just so long as there is no evidence of maternal or foetal exhaustion, andjust so long as the clinical course of labor is proceeding after the normal fashion, the physician ‘s policy is a waiting one, and his immediate attendance is not requisite; on the contrary, his presence in the lying-in room simply excites the anxiety of the woman. (Egbert Grandin and George Jarman, Pregnancy, Labor; and the Puerperal State , 1895)
On The ‘Pains’ or Uterine Contractions… Mental emotion of any kind will temporarily diminish their intensity or even absolutely suppress them; the entrance of the physician into the lying-in room may have the same effect. (W A Newman Dorland, Modern Obstetrics , 1901)
Taken together, the above excerpts constitute strong evidence that until relatively recently there was an operating consensus that women’s labours could be stopped or slowed down by the mere presence of a strange male—the doctor himself (doctors a century ago were virtually always male). In fact, in textbooks published previous to the time when institutionalisation became the norm for childbirth, virtually all texts contained some mention of the sensitivity of labouring women and the need to avoid upsetting them if labour was to continue its normal course.
We know that throughout the world since time immemorial when women have given birth they have most often been assisted by other women. While in some societies, husbands traditionally assisted the birth of their children, in most, men have been excluded from participating in birth except in extraordinary circumstances. Up until the beginning of the 20th century, the birth room was still the domain of the labouring mother and her female attendants. These most likely included her mother, her sisters, her cousins or close friends.
‘Pasmo’ in the animal kingdom
Now, let’s consider for a minute the behaviour during labour of mammals other than us humans. Is the phenomenon of pasmo unknown to them? Of course not. One has only to watch film or video of wildlife to know that gazelle, giraffes, antelope and wildebeest, among others, all have the ability, given the sudden presence of a predator, to discontinue labour and suck the fetus back inside their wombs, even when birth is imminent. Those who raise animals know that various species share something in common: labour at term is most likely to take place when the pregnant female has maximum privacy. Farm animals may be shocked out of labour by the sudden presence of a stranger or predator. Such behaviour is well known to anyone who has any familiarity with the reproductive lives of animals. Considering this, how likely is it that the human female would be the only mammal to lack the capacity to reverse labour once it is well established?
In the US and the UK, as well as in many other countries around the world, caesarean section rates are rising. Some of this rise can surely be attributed to the fact that maternity ward policy at many hospitals is more likely now than formerly to call for induction or augmentation in case of pasmo than to send a woman home to await the eventual onset of labour. The higher incidence of caesarean section after a failed induction or augmentation of labour is well documented.
How would hospitals and maternity clinics differ if the true physiology of labouring women were understood and taken into account? I believe that they would be organised in much the way that Michel Odent outlined in his early book Birth Reborn . Women would give birth in quiet, dimly lit rooms furnished simply with mats on the floor and a good-sized tub of water. There might be ropes or ladders attached to the wall to for the labouring woman to pull on. And if there is a double bed in the room, it is a double bed large enough to accommodate her partner. If a caregiver who has not been in the room needs to check on the woman’s progress, she or he would knock on the door and enter quietly enough not to destroy the mood and the atmosphere in the room. What I have described is the best way to reduce the occurrence of pasmo in modern, high-tech hospitals. I am sure that redesigning hospital maternity wards and altering maternity care policies with the goal of preventing pasmo would significantly lower current rates of unnecessary caesarean section for ‘failed’ labour. How good it would be to see hospitals do this during my lifetime.
Cazeaux P. (1884). Obstetrics in Theory and Practice: Including the Diseases of Pregnancy and Parturition, Obstetrical Operations, Etc ., Philadelphia: P. Blackiston.
Curtis A. (1846). Lectures on Midwifery and the Forms of Disease Peculiar to Women and Children Delivered to the Members of the Botanico-Medical College of the State of Ohio , Cincinnati, Ohio: C. Nagle.
Dewees WP: (1847). A Compendious System of Midwifery , Philadelphia: Lea & Blanchard.
Dorland WA and Newman. (1901). Modern Obstetrics: General and Operative , Philadelphia: WB Saunders & Company.
Gaskin IM. (2002). Spiritual Midwifery (Fourth Edition) , Summertown, Tennessee: The Book Publishing Company.
Grandin E and Jarman G. (1895). Pregnancy; Labor, and the Puerperal State , Philadelphia: F. A. Davis Company.
Hamilton, J. (1837), Hamilton’s Practical Observations on Various Subjects Relating to Midwifery , Philadelphia: A. Waldie The Dunglison’s American Medical Library.
Odent M. (1984). Birth Reborn , New York: Pantheon Books.
Playfair WS. (1889). A Treatise on the Science and Practice of Midwifery , Philadelphia: Lea Brothers & Co.
Ramsbotham FH. (1861). The Principles and Practice of Obstetric Medicine and Surgery in Reference to the Process of Parturition (Third Edition) , Philadelphia: Lea & Blanchard.
Ina May Gaskin, CPM
The Practicing Midwife. Volume 6 Number 8