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Archive for the ‘Birth’ Category

breech

There seems to be a positive epidemic of babies wanting to be born bottom first at the moment, and in today’s maternity services that invariably means a caesarean section. There is a procedure which can be offered if the baby is discovered to be breech at 36 weeks, an ECV (external cephalic version). This very much depends upon the hospital she is booked at, her previous obstetric history, medical history and factors affecting this pregnancy and there is quite a variation in success rates, but the average appears to be 50 – 60% if the turning is attempted at 37 weeks.

As the result of an (in)famous study conducted by Hannah the preferred mode of birth for all babes presenting in the breech position is C Section. Prior to, and since the Hannah study several other researchers have concluded that planned caesarean section does not improve outcomes when compared to planned vaginal births for the breech baby when the birth is conducted by a well-trained, EXPERIENCED clinician. This is the crux of the matter, experienced, how does a doctor or midwife gain this experience if all women are being advised, encouraged to opt for a caesarean?

I can empathise with women who decide to take their obstetricians advice as when one of my daughters decided that she wanted a vaginal birth for her baby who as breech I was panic struck, who did I believe could expertly help a bottom-first baby enter the world safely, very few was the answer. I know, and trust, an independent midwife Jane Evans who is experienced in breech births, but when I spoke to the head of midwifery about the possibility of Jane coming into the hospital to deliver baby I was told that the Trust wouldn’t allow it. The consultant that daughter was seeing referred her for an ECV, thank heavens it worked as, although the doctor had offered to be on call for the birth should the ECV fail, I knew that his recent experience of breech births was negligible.

These are babies who are known to be breech before their mothers go into labour, what about undiagnosed breech? I have a confession to make, I failed to realise that one of my women, W, had a baby lying bottom first. I take some comfort from the fact that the G.P and the hospital registrar and the midwife inducing the labour and the midwife who examined her in labour also failed to discover the correct position. It was found, luckily, when the monitor was failing to detect baby’s heartbeat so they decided to use a fetal scalp electrode, at this point W’s cervix was 6cms dilated and W had been in labour for 4 hours. Although W’s labour had been induced using a prostin pessary her waters had broken by themselves and her labour was not being augmented in any way, and she had only just stared using entonox.  A portable scanner was rushed in, an extended beech was visualised and W was immediately taken to theatre where baby was born by caesarean section. Mum and baby girl are both well but Mum is questioning the decision to get baby out via the ‘sun-roof’. I wouldn’t say anything to her but I wonder if the decision was taken for the right reason. The labour was progressing normally, it wasn’t slow, the contractions were well-co-ordinated and W was coping well with entonox, all positive signs indicating that there were no problems with baby versus W’s pelvis.

This is not unusual, in fact it is almost the norm however far labour has progressed, I have known several babies whose bottoms were visible but were then born by a caesarean section. A little voice inside suggests to me that this may be happening due to clinicians feeling de-skilled with regard to breech births, and who can blame them, if you’ve never seen one how can you have the confidence to support a woman through a vaginal, breech birth?

What’s the answer? I don’t know. We have all been brain-washed into believing that caesarean section is safest for the breech baby courtesy of the Hannah trial and, even though many professional organisations and researchers are now beginning to argue against her conclusions and recommend a more judicious use of the scalpel, I don’t think we will see a rapid increase in obstetricians supporting or encouraging women in having a vaginal birth for their breech baby.

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Over the last two weeks 3 of my women were due to give birth – at home.

A is a 30 year old who was having her first baby. She wanted a homebirth as she is frightened of hospitals.

B is a 31 year old, also having her first baby. B decided on a homebirth after having an entirely normal, ‘easy’ (her words) pregnancy.

C is a 34 year old, she already has a 2 year old who was born in hospital following ‘an awful experience’, with a cascade of intervention and a ‘control freak of a midwife’.

A’s story

At 41 weeks pregnant, with the birthing pool up and waiting in the sitting room, A had a stretch and sweep. The examination discovered that the cervix was central, effacing and 2 cms dilated with baby’s head -2 above the ischial spines. For a few hours afterwards A reported that she was feeling sightly uncomfortable, but then everything settled back down. 2 days later a second stretch and sweep was performed, with very similar findings except that the baby’s head had descended to the level of the spines. A was now 9 days past her due date, so a date was made for an induction of labour when she would be 40 weeks + 12 days.

At 11am on the scheduled day A, tearfully, made her way to the maternity unit. On admission a cardiotocograph (CTG) was performed to assess the wellbeing of baby. Once it was demonstrated that baby was doing okay a vaginal examination was performed, a Bishops Score estimated and a prostin pessary inserted, it was 1pm. Following a second CTG A went for a walk and tried to relax, nothing was happening. At 7pm the whole procedure was repeated, her partner and Mother stayed with her until 10pm and then left (hospital policy) to await a phonecall. By 2am A was experiencing regular contractions but was coping well using a TENs machine and wobbling on an activity ball. 6am saw A no longer coping with contractions, a vaginal examination discovered that the cervix was now 6ms dilated and baby’s head was now -1 below the ischial spines, an artificial rupture of membranes was performed and A as given pethidine.  At 10am a vaginal examination was performed, hospital guidelines indicate that 4 hourly vaginal examinations should be performed during induction of labour to assess progress, at this time the findings were the same as 4 hours previously. A was very upset by the lack of progress, despite regular contractions, and when told that the next move would be to start a syntocinon infusion she requested an epidural, after an hours wait for the anaesthetist, he was in theatre, an epidural was sited and then the synto was started. 3pm, a vaginal examination by a doctor estimated that the cervix was now 9cms dilated but he detected that baby was trying to come out with it’s back to Mum’s back, direct occipito-posterior, he also believed that baby’s head was not tucked down with it’s chin on it’s chest, instead it’s head was deflexed. He decided that baby was not going to succeed in being born vaginally and so A gave birth to her baby boy, weighing 8lbs 12ozs, by caesarian section.

B’s story   

41 weeks pregnant and the super, heated, filtering birthing pool had been inflated and filled for a week. A stretch and sweep was performed and the findings suggested that labour was not imminent, the cervix was posterior, long and only 1cm dilated, baby’s head was -3 above the spines. An induction was scheduled for 2 days later and all started as with A. The first prostin worked wonders though and 6 hours after it was inserted B was taken to labour ward to have her waters broken (ARM). Within the hour her contractions had started and her TENs was pulsing away, 5 hours later, after much marching, she gave birth to her son who weighed in at 8lbs 10z and 6 hours later they went home.

C’s story

At nearly 36 weeks I couldn’t be sure that baby was coming head first so A went to hospital for a scan, baby was head down so her homebirth was booked. 4 days later A experienced sharp pain in her uterus so self-referred to the maternity unit where they performed a CTG. The doctor who reviewed it felt that it was non-reactive and believed that baby was small-for-dates so, as a result of these two findings, suspected intra-uterine growth retardation (IUGR), an USS and doppler was arranged for 2 days later. C was on tenterhooks. The scan and doppler were performed, plus a repeat CTG, and all was reassuring, baby wasn’t huge but was estimated to currently weigh about 5lbs 8ozs. C was now 37 weeks pregnant, it was all systems go for a homebirth and so…..the pool was inflated.

2 days later and C experienced a few trickles of fluid.  A community midwife visited, performed a speculum examination to try and assess if her membranes had broken, they had, and a vaginal swab was taken to exclude the presence of infection. The following morning the on-call midwife contacted C, there were no contractions and the membranes had now been ruptured for nearly 24 hours so C was asked to make her way into the maternity unit for augmentation of labour by syntocinon infusion plus the administration of intravenous antibiotics as once the membranes have broken there is a risk of infection to the baby. C refused, but did agree to attend the hospital a have a CTG to check that baby was okay. The risk of prolonged rupture of membranes was explained to C, but she opted to return home and await events.

36 hours after her membranes had first started leaking C’s contractions started. She contacted the on-call midwife who came round to assess the situation. It was 4am and when C was examined the midwife found that the cervix was 2cms dilated and long, C was advised that labour was not yet established. The midwife stayed for an hour and, believing that C was only in early labour, went back to bed. C was finding the contractions difficult to cope with so had a warm bath. Within half an hour she decided that, if this was early labour and that there were still hours to go (as the midwife had told her), then there was no way she could do it without an epidural so she, her husband and their 2 year-old son set off for the hospital, 20 minutes away. Halfway there C realised that baby was coming, quickly and told her husband to pull over. He told her to hang on as they were nearly there, with that C felt the baby’s head being born so screamed at her other half to stop, NOW! He did, and their son, weighing 5lbs 7ozs, was born in a lay-by. An ambulance took C and baby to hospital for a quick check over, all was well, and 4 hours later they were driving back past the lay-by where baby entered the world.

Why write about these 3 births. Well, all were booked homebirths, but not one actually gave birth at home. None of the examinations before labour gave any indications of when, or if, labour might start. In fact the examination which appeared to give the most positive sign of readiness to labour was A, who ended up with a caesarian section. What does this show?  That there are no rules, patterns or predictive measures as far as labour and birth is concerned and that birthing pools are very popular!

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What man would be brave enough to suggest that the pain of labour is ‘a good thing’? Dr Denis Walsh, that’s who. Now the doctor title may be slightly misleading as, rather than being a medical ‘doctor’ the title is a PhD, he is actually a midwife, admittedly an extremely senior practitioner, but midwifery is his profession, even if he is ‘not able to provide midwifery care at this time’ (NMC register). He is now also the cause of huge discussions everywhere, ranging from a well-constructed defence of his opinion by Feminist Philosophers to a series of expletives, tempered with some thoughtful comments, on the Mumsnet forum.

What do I think? I think that epidurals are over-used. That they do adversely affect the progress of labour. That they change, what for 70% of women is a normal, physiological process, into a medical event. That the use of epidural anaesthesia increases the risk of an instrumental delivery. That the opiate used in the epidural passes into the woman’s blood stream and so across the placenta to the baby and may affect breastfeeding.

So now I have stated my thoughts about epidurals BUT I would never deny a woman her choice of an epidural, in fact there are times when I actually advocate the use of epidurals in labour. What I do attempt to do is support the woman in normal labour, to encourage her to accept that the pain of the contractions is not a sign that something is abnormal but, if she still wants the epidural, then she gets one.

I get annoyed when I hear women say that they don’t want pethidine because ‘it affects the baby but an epidural doesn’t’. Rubbish. Even before I read the research suggesting that epidurals adversely affect breastfeeding I was only too aware that having an epidural increased the chance that baby would be delivered by a ventouse or forceps, both of which are capable of causing severe physical damage to baby. How about the woman? Yes she will probably have a pain-free labour (not all epidurals work though). Labour will be longer, but that’s not a problem, for her, if she can’t feel anything, might distress baby though. She may not be able  pass urine, her bladder may become overful and obstruct baby’s head descending, no bother though as she can always have a cathater, but that does run the risk of giving her a urinary tract infection (cystitis). It’s more likely that she will need an episiotomy, but at least she won’t feel it, or the stitches, until the epidural wears off. The epidural may cause her blood pressure to fall dramatically, but her feeling faint and sick as a result, like the fall in baby’s heartrate, will be sorted out quickly by the intravenous fluids being increased and rolling her onto her left-side. The woman’s temperature may well rise as a result of the drug used in the epidural, but the staff can’t say definitely that the drug is the cause so the treatment has to be as if there is an infection present. The woman having a raised body temperature may also cause the unborn baby to demonstrate an increase in heartrate, if this persists then the medics will wish to investigate further and fetal blood sampling may be required. Following the birth the baby may well have to undergo investigations to rule out infection or, there may be a decision to use intravenous antibiotics prophylactically.

There it is then. If you hear, or have heard, of a midwife refusing a woman an epidural it wasn’t me, but if the story entailed a midwife trying to encourage a woman to cope without one it may well have been me as I have seen all of the above too many times to believe that epidurals are the innocent pain reliever many would like you to believe they are.

If anyone would like to read more from Denis Walsh about epidurals this  ‘Zephrina Veitch Lecture’ is great.

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Life has been super busy recently, hence no posts. I have had 2 weeks without having the boys so you would think that I’d have an excess of time for relaxation, well that would be the case, if it weren’t for Son moving house last Friday so, as I couldn’t help on the moving day because I was working, I offered to look after Evie on the days prior to the move, those excessively hot days. Their move went well, however since they both have a desire for perfection they concentrate on a specific, wonderful in their work life but rather limiting when moving house and needing to set it up quickly for an 8 month old who is crawling , cruising and into everything. As a result, by Monday the house was still full of boxes, mirrors propped up against walls and totally unsafe for an adventurous bundle of mischief so, I abducted her for the day. Thankfully it worked the trick and by the time I returned her the house resembled a home, rather than a junk yard.

On Sunday Amy, the boys and their Mummy and Daddy came round for dinner as they had only returned from Majorca the previous evening. We were lucky to still have Amy as, on their first day there, she jumped into the deep end of the swimming pool while her Mummy and Daddy were attempting to control her brothers. By the time they had realised that she was not with them she was bobbing up and down underwater. Daddy leapt into the water and dragged her out, blue and, eventually, spluttering. She recovered well, unlike Daddy’s camera and wallet which were in his pockets when he jumped into the pool.

I’ve been having a clutter clear-out and am now a huge fan of ‘Freecycle’ . I have always been a terrible hoarder, mainly because I hate throwing out something which is still ‘fit for purpose’, so having a system whereby you can pass things on to people who want them is brilliant.

Whilst I’ve been on annual leave one of my women who I had booked for a homebirth had her baby, in a lay-by! Whilst I was discussing homebirth with D and her partner she asked me what would happen if she decided that she wasn’t coping well labouring at home, I reassured her that if that were the case then we would transfer her in to hospital. I did point out though that as this was her second baby, and if she were progressing well in labour, the chances were that by the time we had got her to the maternity unit the baby would be very close to putting in an appearance, and it may well be too late for the epidural. I’m so glad that I said this as what happened proved my point. Apparently a midwife had been called out early in the morning, examined D, found that it was still early labour, stayed for an hour observing irregular contractions and then left, leaving D with her phone number for when labour kicked off. Labour did kick off, and D decided that she wasn’t going to bother the midwife as she was finding contractions too much to cope with, so decided to go straight to the maternity unit by car, only they didn’t get that far before baby decided that car travel was interesting and so he would get a better look by being born, in a lay by, on a dual carriageway. Thankfully everyone is well, the car does need valeting though!

For the past 5 weeks I’ve been on-call for a family friend who was having a homebirth. Needless to say this 1st baby was reluctant to start the being born process by himself, so off went his Mummy for an induction on Thursday. Boy was this an awkward little boy, so, so near to being born normally, but, after 14 hours on the syntocinon drip, Mum’s cervix nearly fully dilated, a doctor discovered that baby was trying to come out brow first and so a CS was the method by which the not-so-little – 8lbs 11ozs, baby boy came into the world. Once again though, Mum and baby doing well.

I’ve just managed to get 2 days much needed gardening in, the borders are looking so much better now and the risk from errant brambles has been contained. I must be stronger than I thought as I succeeded in snapping a tine off a garden fork, only 3 months old and with a 10 year guarantee. When I returned it to the store the assistant told me that they had never had one returned, broken, before. Don’t mess with me, I’m obviously a force to be reckoned with.

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Two days ago I received a Google alert regarding Independent Midwives, the link provided was to the Nursing Times, and the precis supplied indicated that a recent study had found that there were increased risks of stillbirth or neonatal death in pregnancies and births booked with Independent Midwives. I started reading the article ‘ Stillbirth more likely with independent midwives, says study’ and immediately realised that either the study was intrinsically flawed, or that the author of the NT article, Clare Lomas, had not interpreted the study correctly.  I was certain that IM would have something to say about the study so I made them my next click. As I started reading their response to the study I began to suspect that the sensationalist headline in the Nursing Times had been just that, and that the detail of the study was revealing more than the increased stillbirth rate being associated solely with the care provided by IM’s.

My next click was to the study in the BMJ, “Outcomes for births booked under an Independent midwife and births in NHS maternity units: matched comparison study”. When I read the title I began to argue, how on earth could you do a ‘matched comparison’ and why not compare like with like, NHS homebirths and IM homebirths? As I pondered this I realised that the reason it was NHS hospital was because NHS homebirths are generally low-risk, whereas IMs have a high proportion of women who have been refused homebirth by the NHS due to being considered high risk. An editorial, also in BMJ, points out the shortfalls in the research study eloquently without detracting from the positive aspects.

So, what were the outcomes? If a woman employs an IM for her low-risk pregnancy and birth is she placing her unborn baby at higher risk of mortality? No, there is not a significant difference in perinatal mortality. However, if the pregnancy is a twin or breech birth then there is a higher perinatal mortality rate. There are other factors which were discovered in the study; “Women attended by an independent midwife were more likely to go into labour spontaneously, less likely to require pharmacological analgesia, more likely to achieve unassisted vaginal birth, less likely to give birth prematurely, and more likely to breast feed”.

Sounds pretty positive to me, if you are low-risk, but if you read the title of  The Times report of the study findings “Risk of stillbirth ‘tripled for women who have their babies at home'” you wouldn’t think that, and then just see how the article starts – ‘Women who give birth at home with an independent midwife are nearly three times more likely to have a stillbirth than those who give birth in hospital, a study has found’. The reporting does become slightly more balanced after that but the sound bite has happened and what some will inevitably take from this is that 1) Homebirth is dangerous 2) Independent midwives are especially dangerous. Is this biased or just sensationalist headlining as it’s certainly not balanced or accurate?

Yes, I’m annoyed by Nursing Times and their cheap swipe at IM’s, and I’m saddened that The Times should resort to cherry-picking findings to lure readers. What these publications should have done was to disseminate the findings and realise that accuracy would advise a title like Nursing in Practice’s ‘Study calls for urgent review of  NHS and independent birth care’  or the  BBC’s ‘Urgent’ birth care review needed’. They are honest titles which both report the conclusion the study leads the reader to arrive at.

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Labour coming?

Oh Lordy, lordy I’ve just read this article, and I really wish that I hadn’t, it is about childbirth as an orgasmic experience. For the record, I have known 1 woman who told me that she had experienced orgasm at the moment of birth, this was 32 years ago, she had just had her 2nd baby, and I was 7 months pregnant, I thought that she was just trying to make me believe that birth was nothing to fear. As a midwife, at countless births, I have known women be silent, groan, shout, swear and scream, expressing their birth experience in many different ways but I have never suspected that any one of them were in the throws of ecstasy.

I’m going to speak here as a midwife.  ‘A romantic atmosphere is important’, a contributer to the documentary Orgasmic Birth, says. Well, he has my argeement there in that research has shown that a relaxed environment, low-lighting, soft music, contributes to labour progressing well but passionate kissing, what is the midwife supposed to do, hum to herself whilst lookng at her feet? I know that it’s not about what makes me feel comfortable, but how many couples are going to feel relaxed about displaying intimate behaviour in front of strangers? The concerns I have are about women’s expectations. Pregnant women read a lot about labour and many set themselves objectives about how it will proceed, how they will behave and then have this ideal of how they will feel afterwards. If they see this documentary, or read associated articles they may believe that if all goes well they may well experience a climax during labour. Some will be disappointed when this doesn’t happen, others may well go into childbirth with even more of a fear of ‘losing control’ (a common theme when discussing women’s concerns about labour), and a horror that they may behave sexually during the birth and obviously have an orgasm. For some women childbirth is degrading, they feel they are losing their dignity and hate the intimate nature of the examinations which are undertaken. They enter labour ‘uptight, anticipating ‘violations’, vaginal examinations, on a regular basis by complete strangers, is this documentary going to make these examinations appear sexual and more like a violation? I feel that this documentary may cause women to feel more unease about childbirth than eagerly anticipate it.

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That well known purveyor of non-sensational news stories, The Daily Mail, has an attention drawing headline today ‘Babies crippled as midwives bungle births’, I started reading with a sense of dread, what is my profession being blamed for now?

The article is about an obstetric emergency, shoulder dystocia, and how it has affected 3 babies. A true shoulder dystocia is an absolutely horrific occurrence, which can lead to the death of a baby. Early on in my midwifery training I met a woman who had just experienced the death of her baby due to shoulder dystocia, I had never heard of this before and I asked the midwife I was working with what it was, her answer chilled me, ‘Every midwife’s nightmare’, she then went on to explain what happens. Basically, the baby’s head is born, but that’s as far as it gets. There is no further progress as the shoulders, generally the anterior, become stuck above the brim of the pelvis. I was terrified, I wanted to find out everything I could about it, why, how, is there anything you can do to avoid it and, most importantly, what can you do if it does happen. I read a huge amount of literature, I found out about the maneuvers recommended, the factors which may lead a midwife to believe a woman may have a large baby and the signs during birth which may indicate that a baby may be having problems sliding it’s shoulders through the pelvic brim.  The video below shows anatomically what happens when shoulder dystocia occurs, and the damage it may wreak on the baby. 

3D Medical Animation: Shoulder Dystocia Birth Injury

There are drills we have to practice on the sequence of events which should happen if we are caring for a women who has a shoulder dystocia, the first element is ‘call for help’. That ‘help’ is not solely another midwife, it is also an obstetric registrar. What happens in practice is, that when the emergency buzzer is pressed, every senior member of staff responds. Did the midwife ‘bungle’ as The Mail says, or did the team fail to respond appropriately? I think the latter, as the article says that the woman had been told that she needed a caesarean section, but that never happened. Instead,  ‘Penelope was at the mercy of an overstretched obstetric team which did not seem to have the skills to deliver the baby without injury’. Whatever happened the woman went through an horrific experience, and her child is left with  a possibly permanent disability, Erb’s palsy.

Back in 1955 W.I.C Morris wrote a description of shoulder dystocia. I read it as a student midwife, and have never forgotten it, the extract below starts from when the baby’s head has been delivered 

‘Time passes. The child’s face becomes suffused. It endeavors unsuccessfully to breathe. Abdominal efforts by the mother and by her attendants produce no advance.

Gentle head traction is equally unavailing. Usually equanimity forsakes the attendants — they push, they pull.

Alarm increases. Eventually, “by greater strength of muscle or by some infernal juggle,” the difficulty appears to be overcome, and the shoulder and trunk of a goodly child are delivered. The pallor of its body contrasts with the plum-colored cyanosis of the face, and the small quantity of freshly expelled meconium about the buttocks.

It dawns upon the attendants that their anxiety was not ill founded, the baby lies limp and voiceless, and only too often remains so despite all efforts at resuscitation.’

 

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