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I have received a request from an organisation in America who are running a contest looking for a short, about 4 – 7 minutes, video about an aspect of birth choices which is “factual, informational, educational, inspirational”.

The organisation is Birth Matters and if you would like to find out about the contest, which has a prize of $1,000, click on this link

They state their goal as increasing awareness of the evidence-based choices and options available for childbirth. They hope to ” appeal to and inspire new audiences that may not have previously been exposed to any model of childbirth other than the version we see on television and in movies: dangerous, uncertain, excruciating, and usually in need of extensive and often emergency medical interventions.” Using these videos they believe that they will show ” Birth doesn’t have to be this scary, and people need good information in order to make good choices.”

Unfortunately the competition is aimed at an American audience, shame really I would have loved to contribute! Will it work? Well, with a caesarean section rate there approaching 30%, anything is worth a try.

Perhaps a pressure group here in the UK would like to run a competition along the same lines and with the same aim, after all our CS rate is rapidly approaching that in the USA. The recommendation from the World Health organisation is for a section rate of no more than 10-15%. The NHS Institute for Innovation and Improvement produced a ‘toolkit’ to assist maternity units in reducing the section rate, this doesn’t seem to have worked, perhaps short videos would? I would love to believe this, but sadly I believe that the ‘problem’ of the high CS rate is too multi-facetted for a media vignette to lower the rate by 0ver 10%. Fear of litigation influences clinical decisions, below optimum staffing levels effects both the clinicians, and the labouring womens actions and choices. I could ramble on about other factors like epidurals, unrealistic expectations and ‘control’ issues but these are purely personal, observational conclusions and so have no place in my musings which, although personal, are published on the web.

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“Hi just found your blog on google as I am doing a research project on free birthing and if the NHS should offer help to these people to make it safer, (paedeatric first aid and signs of when its going wrong etc). I was wondering if you knew what the NHS’ stance on this practice is (do they offer any help? etc), as I am finding it dificult to find information on this subject in England, it all seems to be Laura Shanley in America.
I am doing an access course and have aplied to uni’s, so will hopefully start my training as a midwife this sept. yay! Thank you Emily”

I received this e-mail today and I really am not sure of the answer. I have replied to Emily, pointing out that if people wish to be instructed on resuscitation then local Red Cross associations run courses for the public. I notice that Emily has focused on ‘paedeatric‘ [sic] first aid, I should have pointed out that adult first aid should definitely not be ignored (I have assumed that Emily means resuscitation when she says first aid). What I should have said was ‘ Would offering help, in the form of instruction, really make freebirthing/unassisted childbirth safer? I would imagine that any woman seriously considering freebirthing would have read and watched everything possible about labour and birth, what can go wrong, and especially what to do if things do go wrong.’

Emily asks what the NHS’ stance is on unassisted birth? Not too easy to answer that one,  the NMC have issued a guidance for midwives in which we are told we ‘should support the woman and her family’! RCOG are equally non-specific in their 1st statement  saying that they ‘are aware of it………obstetricians and midwives are concerned with the safety of both patients, mother and child…….little research exists regarding its safety and success’ but then are perhaps coming off the fence more in their 2nd statement by saying they ‘are concerned about the practice.’ With regard to the NHS, well neither NHS Choices or Direct give any web space to freebirthing that I could find. Logically though why would the NHS expend any energy on the subject?  Those who wish to freebirth want to avoid any input from those employed by the NHS, so surely they would not desire any ‘medicalised’ input?

I am torn as to whether the NHS should give advice to those intending to freebirth. It would perhaps make people more aware of when, and how to summon help but it may also encourage people to go ahead with it and, if they do go ahead, and something does go wrong, it may be me who has to respond to their summons. So…….no, I don’t think that the NHS should publish a manual. 

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A month ago I received an E-Mail from a reader. Life has been quite busy so I haven’t got round to answering, apologies to the author. One of the reasons I have taken so long to reply is that I wanted to use the E-Mail as the basis for a blog entry as there are so many interesting points contained in it. Here I go then –

Copy of the E-Mail

Hi there,
 I have just read your article which I found very interesting. I am currently pregnant and had twins 8 years ago, and am trying to find information on home birth after having a pph with the twins. I certainly wouldn’t go for the option of freebirthing but can you suggest a way that I can take control of my situation and find out what my actual risk is of having a pph again are.
 
I desperately feel like the area I am in is lacking in caring midwives, the first one I had was very abrupt with me and frightened me a lot, as when I asked at what stage would be best to discuss my birth options she asked me why and I explained that I hadn’t made up my mind but if at all possible wanted to go for a home birth, to which she replied oh they won’t let you do that as you will hemorrhage again. This comment coming without knowing any of my history or what happened in my twin birth as I was in a different county when they were born. I have since then changed midwives and have sent of for my old notes but I am still having major problems with disorganized staff as the midwife I have been seeing has my old notes to read but yet the midwife I can’t stand turned up for my appointment last week, and lol she didn’t even bring her stuff to monitor baby or me (blood pressure heart rate monitor etc).
 
The main problem I have is that I don’t believe that my twin birth would have ended up the way it did had they not looked at me as being a young mum that didn’t have a clue and bullied me into lying back when all I wanted to do was sit up as I wasn’t having proper contractions and was in constant pain (which they also didn’t believe until it came to feeling them to tell me to push as I had given in and let them give me an epidural)  but could deal with that fine as long as I stayed upright . My instincts are telling me that I can give birth this time really well as long as I stay in a clam and relaxed environment, which would mean staying at home as every time I even go to the hospital just for a general appointment I tense up and start feeling unwell and just wana get out of there asap. Which I don’t think is going to be particularly good for going into hospital to give birth, I also really wanted the option to have my children with me if I feel good enough as they are very interested in childbirth and have watches a lot of births on TV with me over the years (graphic and not so and they still end up jumping up and down for joy when the baby arrives either way, lol).
 
I really didn’t think that almost 10 years on that I would feel so out of my depth, last time right up until the birth itself I felt so empowered as had done so much research and had spoken to so many midwives and doctors that I really felt I could give birth in a really good way. I have also wondered if my risk is so high for having a pph again why hasn’t someone spoken to me about having elective c section as I have known a couple of women who lost around the same amount of blood as myself and they were offered it to avoid the same trauma happening again as were equally effected as myself by the fact they were told they almost died.
 
Sorry for such a long email, should you want to ask me anything please feel free to contact me.
I look forward to your reply

As I observed before, lots of points here. The first question I ask myself is ‘ where does Sarah live’? I’m not talking the UK here as I feel confident about my ability to give advise about how to request a homebirth and what the criteria is in the UK for a homebirth request which won’t freak out the midwives. Anywhere else in the world and I have no idea!

PPH. Post-partum haemorrhage. Bleeding in excess of 500mls following birth. A major obstetric emergency. There are many risk factors and causes.

Twins. For me this is a major fact which makes me wonder the relevance of the previous history with regard to this pregnancy and any risk assessment. A twin pregnancy is a high-risk pregnancy and birth, with one of the associated risk factors being PPH. It is obvious really that if a uterus has been over-stretched during pregnancy it is more likely that it will fail to contract down quickly and efficiently following the birth, so making a haemorrhage far more likely. Also, there will be either 2 placental sites or 1 large one so the area where bleeding is likely is larger. As a precaution against haemorrhage the synthetic hormone syntocinon is routinely infused following the birth of twins to ensure that the uterus contacts well.

8 years ago. When I was a student I was told that if it were more than 5 years since the last pregnancy then it should be viewed as if it were the woman’s first. If this ‘rule’ is used in this case then this provides another reason why the previous history should be ignored.

Lack of caring midwives. Difficult one! All  can suggest is that Sarah discusses this with the manager responsible for community midwives. It may be that there is a clash of personalities, if this is the case then another midwife should be offered.

They won’t let you. The truth is that they can’t stop you. They can make it extremely difficult for you to have a homebirth but if you are persistent, involve the manager, the head of midwifery services and a supervisor of midwives a plan will be implemented. HOWEVER, there are constraints on the system and there can be uncontrollable circumstances which would mean that you getting your homebirth deprives other women of safe care. In many areas there are only 2 midwives on-call for homebirths so if they are already at another homebirth there would be no midwives available to come to you. Many units use the on-call midwives to cover busy times, low-staffing levels in the obstetric unit. If you demanded that they attend you at home the unit would be dramatically understaffed, the women there would receive limited care and the unit may have to turn away women. This is the way life in the maternity services goes, it does need a radical re-think, especially in light of the governments desire to increase the homebirth rate, but at the present time resources are seriously limited and so women arranging a homebirth should be aware of this and accept that their choice can/should not be guaranteed.

Elective caesarian section. Wow, talk about a sledge-hammer to crack a nut! CS it’s self carries a four-fold increase for the risk of PPH. I’m reluctant to comment on this as there may be medical problems, history which make birth by elective caesarian a more ‘manageable’ option.

So what would I say to Sarah? Chase up your old notes. Once you have them make an appointment to see the midwifery manager, take your partner or a friend with you. Go through your notes with the manager and ask him/her what the risk-factors are. If s/he says that you are at increased risk of PPH you should be under consultant care for the birth, request that you see the consultant and talk it through with him/her. If you are still unhappy then request a meeting with a supervisor of midwives, they are there for you. If the advise is still that you are high-risk but you are determined to go ahead then there are 2 options; tell the manager that you intend to have a homebirth anyway or employ an Independent Midwife

I cannot say whether you are low-risk, therefore I should not, and will not say whether you should push for a homebirth but I will say to speak personally to as many well-informed professionals as possible and to be guided by them.

I will say please do not freebirth, especially not with your children present. If you did haemorrhage again no amount of watching videos or discovery health would have prepared them for the reality of a collapsed Mother and litres of blood.

Reading this through I don’t think that I have been of much help but for me to judge risk-factors without reading your medical and obstetric history would be foolhardy.

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Hello baby

 

Evie Louise arrived 31st October at 13.50hrs, weighing in at 7lbs 13ozs.

 

and here’s how it all went……………………………….

Her expedition into the outside world was encouraged yesterday at 12 noon when DIL had her first, and as it turned out, only prostin pessary. Before the pessary was inserted she and baby were monitored for half hour, ensuring that all was well before the stress of induction of labour. Following an internal examination, to assess if it would be possible to rupture the membranes without using prostin, the pessary was inserted high in the vagina, monitoring was then recommenced for an hour. At this point all was well so DIL was released from the monitor and encouraged to mobilise. At 3pm frequent ‘prostin’ pains started. They caused the uterus to contract, frequently, causing Mum and baby to become distressed. Monitoring was recommenced, increasing DIL’s distress as it made mobilizing more problematic. At 6pm a repeat internal examination was performed, there was no intention to repeat the prostin as would normally be the case if it were needed due to the intensity of the uterine activity. Unfortunately there was no change in the cervix, unsurprisingly DIL was disheartened and after that it was taking a huge amount of support and encouragement to cope with each contraction. By 10pm it was all too much, TEN’s was ineffective and so pharmaceutical pain-relief was offered in the form of pethidine, this was given by injection. The opiod helped her to relax for a couple of hours but after 3 hours she had used up all her, and our (!), reserves and was extremely distressed. Another internal examination was performed and……..hurrah, the cervix had opened enough for the membranes to be broken (ARM). For this to happen we had to transfer to delivery suite, and unfortunately there were no beds and we had to wait another hour and by the time there were beds DIL was demanding an epidural prior to the ARM. This was nearly a problem as there are restrictions upon the number of women with epidurals on labour ward, in the end the fact that I was there saved the day. Oh well, I do have my uses!

Once the epidural was sited, and working, all became super calm, the waters were broken and two hours later the syntocinon infusion was started. DIL and Son settled down for a well-earned sleep, whilst I kept watch, labour ward was super-busy so their midwife was caring for three women in labour, totally unacceptable but par for the course in today’s under-resourced maternity services.

When the day staff came on they had their own midwife so I decided to come home, have a power nap and return rejuvenated, or at least refreshed, just after the next scheduled examination at 11am. On the way home I nipped to the bakers and bought some sausage rolls for son’s lunch and some iced doughnuts for after the birth. At 9.30 I flopped into bed, and at 10. 30 I was awakened by son phoning to say that it was all systems go, DIL was going to start pushing at 11am. Thank heavens the roads were clear and there was a parking place at the hospital!

By 1pm it was starting to become obvious that baby was not going to make an entry into the world by just it’s Mummy’s efforts. So frustrating as it was so nearly there but, push as hard as she could, there was no further advancement, a Doc was asked to review. After much encouragement, and a very exacting assessment of how baby was lying, doc explained that baby was trying to come out without flexing her head, so a larger diameter is attempting to deliver, something which causes delay. Baby was, by now, becoming tired, after every contraction the heart-rate was dropping from a baseline of 130 beat per minute to 70, and staying down there for a minute, action was necessary, a ventouse was decided upon.

At 13.50, after one pull of the ventouse, baby was born with with her hand up by her cheek and and a real cone-head. Whilst the Doc was stitching DIL up she started to bleed, he estimated about 1 litre. The IV syntocinon was increased, bi-manual compression was used and ergometrine was given, the bleeding stopped quickly, and DIL appears to have tolerated the blood loss.

As you can imagine it was all quite emotional, I think that all of us had been keeping our angst’s under wraps and the wonderful arrival of Evie has released our feelings, the relief is palpable.

Photos tomorrow when I’ve had a long nights sleep.

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I lay in bed last night listening to the wind whistling outside and blowing the rain against the windows, I snuggled down and hoped that no one would go into labour. Fatal, as almost immediately the phone rang, it was labour ward ‘ Hi, we’ve got a lady for you.’ As usual I phoned the woman to find out what was happening so I could assess how quickly I should make my way there. R was quite relaxed and said that she didn’t think that she needed me yet, her ‘waters’ had gone (SROM, spontaneous rupture of membranes) half an hour earlier and she was having mild contractions. I told her that I would have a cup of coffee and then would make my way over, this was her 4th baby, things could happen quickly.

I braved the elements and went off to see what was happening and 45 minutes after labour ward phoned I arrived at R’s house. She was in bed, semi-recumbant and having what appeared to be mild, but regular, contractions. I introduced myself and sat and had a chat with R and her husband. Was she comfortable in that position? What had her other births been like? Just chit chat really to put her at her ease but to supply me with useful information. I looked through her notes, retained placenta with last baby, haemaglobin lowish but otherwise all well. After about half an hour I did all the routine observations, all within normal limits, contractions about every 2 to 3 minutes and R breathing quietly through them. As I was writing my notes R asked if I would examine her to assess how labour was progressing, I said that I would but cautioned her not  be disapponted if it was still early on. Well, I need not have bothered as baby was very low and the cervix was disappearing as I attempted to estimate how dilated it was! I relayed the findings to R and her husband and congratulated them on how well everything was going. My next move was to ask labour ward to send he 2nd on-call and then suggest to R that she get up so that I could put some sheeting down to protect her bed. After the next contraction she got out of bed and immediately announced that she needed the toilet, hmmm. Her husband helped her into the en-suite, whilst I flung a plastic shee on the bed and then turned to open a pair of gloves, I was suspicious! As I tore open the packaging R said ‘ Baby’s coming’, her husband expressed his doubts whilst helping her back onto the bed, a quick look confirmed that I was right to be suspicious, baby’s head was advancing rapidly. ‘Slow breaths, slow breaths’ I urged as I fumbled to get my gloves on, and bless R, that’s what she did, brilliantly well-controlled. Baby’s head was born slowly, then a long wait until the next contraction, long enough for me to consider if I was about to encounter a shoulder dystocia, I was just starting to plan when R said there was another contraction and, with a little encouragement, out came their 4th baby, their 2nd boy. As I placed baby onto R’s stomach I saw something which had me really counting my blessings, a true knot in the cord –

The true knot, taken on my phone!

Very scary, if that knot had tightened during the birth we would be having a very different experience now. I offered my thanks to whoever had been looking over me and then turned my attention back to R and baby. Labour had been 2 hours 5 minutes from the waters going and contractions starting to the delivery of the placenta, precipitate labour. R was delighted with the birth, she kept thanking me ( I told her that she had done all the hard work) and decreed that everyone should have a homebirth.

I phoned the 2nd on-call to tell her that she could go back to bed, she was nearly at the house so said that she would attend and give me a hand, bless her.

When I was home I lay in bed, the wind had died down but I couldn’t sleep easily, my thoughts were racing – should I have anticipated better, yes, but if I had I may have broken the relaxed and calm atmosphere. It would have been nice to have my birth packs open, but it didn’t cause a problem so I don’t think that I will beat myself up about it. That true knot though has nestled itself in my psyche, yet another thing to worry about!

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Birth Plan

What is a plan? Well, we had an extension built. We employed an architect, we told him what we wanted, he did some lovely drawings, full of measurements, specifications and loadings etc. We spoke to a few builders who looked at all the lovely drawings and few weeks later told us how much it would all cost and how long it would take to do it. Then we sent our drawings to the council, out came a man, he looked around and then wrote us a letter saying we could have what we wanted but due to the soil and how our house, and our neighbours houses looked we would have to make some changes to our plan, not major, we would still end up with the extension but the preparations (footings) and the finishing (rendering) would have to be slightly more intricate. Back to the architect, he made the changes on the drawings, back to the builder, he made adjustments to the costs and the time it would take, both increased. Our plan was ready. Needless to say it took longer and ended up more expensive, both of which we knew would happen. The weather affects the pace of building; third parties like suppliers, sub-contractors and the need for visits at certain times by the building inspector will affect progress if they are late delivering or attending. Did we consider that us or the builder had failed because we hadn’t kept to our plan? No, we were realistic and, most importantly we had the end result that we had desired, our extension.

Back to the eponymous birth plan, I think that that it should be named something different. When my children were younger they had a book called ‘ Would you rather?’ by John Burningham, it posed dilemmas like ‘ would you rather eat spider stew, slug dumplings, mashed worms or drink snail squash?’ ( it is still available but in an updated version ) I think that Birth Plans should be named ‘What I would rather’. It would go along the lines of – I would rather be able to move freely than have to stay on a bed. Or perhaps it should be an informative questionnaire to be filled in by the woman –

  • Do you want to be mobile in labour ? Many women find that this helps them to cope better with contractions and can help labour to progress faster. If your baby needs to be continuously monitored it may be difficult to do this if you are moving around.
  • Do you want to use gas and air? The research suggests that it does not affect baby. When you stop inhaling it the effects wear off immediately. Some women experience nausea/vomiting when using it.
  • Do you want an epidural? The advice is not to have one before you are in active labour. You will need to have a cannula (small plastic tube) put in a vein. Research has shown that they may cause labour to be longer, and make it more likely that you may need help to give birth, but if it works it will get rid of the pain of contractions. Some labour wards have a limit on the number of women on labour ward at any one time who may have an epidural as they need more intensive monitoring. An epidural needs to be put in by an anaesthetist, he may not be immediately available. If the midwives or doctors believe that you may have a longer or more difficult labour they may suggest that you have an epidural.
  • Do you want your ‘waters’ to be broken. There is no proven benefit from this procedure if all is straightforward but it may be necessary if you are having an induction of labour or there is need to monitor baby by putting a clip on to his head……..

and so on.

Why this musing? I really hate it when women feel that they have ‘failed’ because their birth didn’t go the way that they had planned and over the last three days I have spent a lot of time de-briefing women because of this disappointment with themselves and/or the staff. Back to our extension, we got what we wanted in the end, we had to compromise on some choices, we can look back and say that it would have been nice if it had finished earlier, that it had kept within budget, but in the end we had a positive outcome. Our plan was flexible, it was a case of ‘we would rather, but we are content’, I wish that birth plans could be viewed in that way and that women could view the outcome, a healthy Mum and baby, in the same way.

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I have been given an award, by Geepeemum, and it gave me a lovely warm feeling.

The rules of the award are:

  1. The winner can put the logo on his/her blog.
  2. Link the person you received your award from.
  3. Nominate at least seven other blogs.
  4. Put links of those blogs on yours.
  5. Leave a message on the blogs that you’ve nominated.

7 other blogs?

Town Mouse

Punctuation

Flighty

Lisa’a Place

Cartside

Mumof4 (even if she has disappeared)

Mum of 4’s Blog

Something even more stupendous has happened though, the unasked question I’ve had wriggling around in my brain for the last 30 weeks has been answered. Big family meal yesterday and Son and DIL arrived first, complete with a beautiful bouquet of flowers for me, DIL was in need of an antenatal check-up so I went through all the ‘routine’ and as usual asked if there were any questions. There were, what did I think of TENs machines, off I went into my little chat about ‘anything’s worth a try’. Practice putting it on and how the controls work before you’re in labour, make sure that you start using it as soon as you think you may be in labour as it works by ‘tricking’ the brain and reducing the recognition of pain from contractions, it’s called the Gate theory etc. Out came my demonstration pelvis and off I went showing the reason that lying down restricts the possibilities for the joints within the pelvis to move and so allow for an increase of the internal dimensions. Have you thought of using water to help with pain-relief? I was on a roll, then DIL stopped me in my tracks, ‘ You will be there won’t you?’. After checking that they were really asking me to be with them when their first baby, and my 6th grandchild, was born I jumped-up, hugged them both, and burst into tears, so did DIL. I know that I was happy, and I think that my happiness was making her happy. Now all I’ve got to do is discuss it with the powers that be, that will be fun – not.

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