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Archive for the ‘childbirth’ Category

A cutting comic

One of my favourite comedians is Dara O’Briain. I love his forthright take on issues and his ability to spin off on a fantasy tangent, so imagine my joy when I was watching recently and he began talking about antenatal classes, both NCT and NHS. My ears perked up in rediness for some insightful side-swipes at the presentations he had sat through. It started well, the tone of voice we (some of us) use and the way midwives voice their opinions about doctors being over involved (true). It was during this second observation that my ears pricked up and I started shouting at the TV, something that only usually happens during One Born Every Minute. Mr O’Briain began talking about how the facilitator of the class exhorted the attendees not to let ‘the doctor near them with a knife’, it may have been scissors, or it may have been to cut them, but basically ‘Don’t let a doctor do an episiotomy’. The person went on to say that it was better to tear rather than to be cut, and it was this aspect which Dara went on to disect, using the fact that his wife is a surgeon to support his jocular comments which were ridiculing this attitude.

Tears versus cuts. Research has shown that the use of episiotomy should be restricted, for various reasons, but the one I shall highlight here is healing. As the person presenting Mr and Mrs O’Briain’s classes said, ‘a tear generally heals better than a cut’, this is especially true with muscle. During a caesarean section the surgeons tear the muscle. Why do they perpetrate this violence? If you tear a muscle it generally separates in the direction of the fibres, the fibres can then knit together better following surgery. Move from the abdomen to the perineum and the same logic must apply, with an episiotomy you just cut in a straight line, with a tear it is more likely to follow the fibres, therefore the chances are that it will heal quicker and with less pain. My final thought on this is that an episiotomy ‘may produce a larger wound to heal than would have been produced without intervention‘.

Less pain, better healing and a smaller wound? I know which option I would choose.

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I know, during all the newspaper coverage regarding the state of the maternity services I have been silent. The truth, I’ve given up hoping that things will change for the better, am so disillusioned and demotivated that I cannot be bothered to rant, report or rue the erosion of a service I entered with passion in my belly and will leave with an extremely sour taste in my mouth. Fingers crossed, one year now until I retire.

In the absence of an urge to blog I have been reading The 19th Wife by David Ebershoff, food for thought in this 600+ page book about The Church of the Latter Day Saints and in particular polygamy or, as the church calls it, celestial marriage. I have many, many thoughts on this practise, I suspect tat my outlook as a female would be quite different to that of a male. However, feeling benevolent toward Joseph Smith, I will say that he hit upon an excellent way to rapidly increase the membership of his church, after all a couple are likely to only manage one child a year, and let’s not forget how high infant mortality was back then so only around 35% would reach their fifth birthday, but if a man takes several wives then the family increases at a rapid rate and the population surges. All the more faithful for the church and all the more power for a community. Brilliant wheeze. The book is one of those set in two time frames, one historical and the other contemporary, I sometimes find this a distraction and spend loads of time flicking back to see where the story had been, or who a character was, I didn’t with this one, which must be a tribute to the author for ensuring appropriate breaks in the narrative.

A few years ago I read ‘Call the Midwife’ by Jennifer Worth, very interesting, especially as my Mother was a district midwife in East London in the late 50’s, the time covered in the book, and I have patchy memories of accompanying her on the back of her bike and waiting in front rooms with a man, and sometimes other children. Then I would hear a baby crying and a red-faced, smiling mother would open the door and call the man out. Anyway, daughter bought the trilogy ‘Tales from a Midwife’ around the other day and having refreshed myself on the first part I am now reading the two new sections. Crikey, if I as a midwife or child-bearing women think things are bad now this book certainly brings us up short, the working day for midwives was long and hard, with terrible conditions but their lot was nothing in comparison to what the women and their families endured. I hear that the BBC have serialised it and that there will be 6 episodes shown sometime this year, can’t wait.

Talking of childbirth/midwifery on TV brings me to ‘One born every minute’, channel 4’s look at the realities of giving birth. This weeks was great, I hardly shouted at the telly at all. The couples shown were brilliant, the births were uplifting and the midwives a credit to the profession. I had stopped watching it last series as I found I was getting so cross with the midwives, and their love of confining women to the bed and strapping monitors on for no apparent reason, that it was increasing my despondency, full marks this week though, nearly made me feel enthusiastic.

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I’m about to write an assignment centred around the perspectives of childbearing women, and I could really do with some input from the ‘other side of the fence’. I know what I believe is important, and the area where I think the maternity services should focus but I would really appreciate an honest snap-shot of ‘consumer’ opinion. Where it says ‘Other’ then I hope that voters express themselves and perhaps explain why they rate one aspect more highly than another. If it doesn’t have enough space, or anyone has loads to say then please leave a comment.

It doesn’t matter when, where or if you had a baby. It would be useful though if you could identify your gender in the spare box as then I can identify if perspectives are affected by this. 

Thank you for your time.

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I would like everyone who reads this to remember that on two seperate occasions I  have expressed my concerns to the doctors about the size of the baby and DIL’s ability to give birth to a baby bigger than Evie.

DIL’s waters broke at 16.45. They bought Evie around to us at 17.30 and, since there were only tightenings, they went off to the hospital whilst I stayed at home and gave Evie her dinner. At 18.20 son phoned and said that I should get over there soon as the contractions had started. Off I flew and, of course, encountered every super-cautious driver ( the ones who need an all clear from 2 miles away before they will pull out at a junction) I got to the hospital just before 19.00 hours.

I walked in to hear the midwife encouraging DIL to push, whilst the labouring Mum was inhaling deeply on the entonox. Gosh that was fast, nothing to pushing in an hour! Baby was moving down slowly, very slowly. The midwife and I exchanged glances. Baby’s head started to appear, and then stopped. Much encouragement and his head was born, just. Another contraction and baby didn’t advance at all. The midwife pulled him, he didn’t shift. Whilst the midwives lifted DIL legs back (McRoberts) I dropped the back of the bed and pulled the emergency buzzer, we had a shoulder dystocia.

Within 20 seconds the room had filled with midwives, obstetricians and paediatricians. After a tense few minutes, felt like 10, was really only 3, out came my new grandson, very shocked but after a minute he opened his mouth and let us know that he was fine. DIL didn’t seem to realise anything much untoward had happened, son was quite stunned.

Labour ward was full to bursting, 18 rooms of women in labour or who had recently given birth. Both the on-call community midwives had been called in but even so staffing was not covering the influx so I got on with weighing baby, 8lbs 9ozs, and measuring his head circumference, 37 cms. When DIL started bleeding rather more than we would wish I was left to observe and react. The bleeding slowed down to normal levels by 22.30, DIL was fine and baby had breastfed almost constantly since he was born. I bid them all farewell and returned home.

At 23.30 son texted to let us know that our grandson now had a name, William Joseph, and that Mother and son were doing well.

Evie had gone off to sleep well for grandad and didn’t wake until 5.45am. Unfortunately I had not gone to sleep well, my brain was churning over the evenings events, alternately thanking god for a positive outcome and plotting retribution on the doctors who had dismissed my concerns, so I had managed about 2 hours sleep before Evie woke me from my slumbers.

It is Thursday, so round came the boys to join Evie in the chaos of my sleep-deprived home. Son came and collected his first born at 11 so they could introduce her to her brother, who was now called Joshua William. Unfortunately I had spent the previous 5 hours teaching her to say ‘William,’ so there is definitely going to be some confusion there! The staff had advised DIL that she would not be able to leave until Joshua had been thoroughly checked by the paediatricians to ensure that there was no nerve damage or fractures resulting from his dramatic birth but they were hoping to be home by mid-afternoon.

At 16.30 son phoned to say that the docs had checked baby and he had not suffered any damage, but he does have a heart murmur so they can’t go home. I contacted Hubby who abandoned the golf course in favour of visiting his new grandson, I was stuck at home with the boys and Amy, tired and weepy, me not them!

At 18.30 Hubby arrived home, with Evie, her Mummy and Daddy were waiting for Joshua to be reviewed again. Thankfully I had been blessed with a second wind so we had a lovely time, dinner, bath and much chatting. Then the phone rang, it was son saying that the paediatricians had reviewed baby and……..he was fine so they would be leaving the hospital imminently and would pick Evie up on the way home.

That’s it then, the birth and first 24 hours in the life of my seventh grandchild. DIL appears well and oblivious to how much of a scare she and Joshua gave us. Her coccyx has been displaced again so sitting is painful and it’s very early, pre-baby blues days but presently she regards this labour as a better experience and ‘less traumatic’ than Evie’s labour and birth!

Joshua William, born at 19.19 hours on 23.06.2010

Joshua William – born at 19.19 hours on 23.06.2010

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Next grandchild appears to be making preparations for it’s birth. DIL has been tightening for 24 hours, the cervix is 3 cms dilated and she is now looking distinctly uncomfortable. I’ve asked that baby slows down a bit until after my clinic  but then they will have my undivided attention.

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A while ago a reader, Alice, asked what the -3 measurement related to when midwives* describe baby’s position and so, hopefully, I’m just about to explain the concept of assessing descent of the presenting part of baby, generally the presenting part being it’s head. Any midwives etc. reading this may well have apolexy reading my explanations which will be accuate, but not couched in medical terminology, also I have personally illustrated what I’m talking about but I am by no means an artist!

There are two ways that midwives estimate how far down baby’s head has gone. The first is how it’s done in both in pregnancy and during labour and is discovered by abdominal palpation, or having a feel of the woman’s bump. When the midwife concentrates her hands just above the pubic area, and possibly asks the woman to breathe in and then relax as she exhales, the midwife is trying to determine how much of baby’s head she can feel. This may be slightly uncomfortable as the lower part of the uterus, bump, can be a bit tender toward the end of pregnancy. The midwife will then record her findings in terms of fifths. If she can still feel all of baby’s head then she will write 5/5ths palpable (palp), look at my drawings below and the 5 drawings on the left side illustrate the gradual descent into the pelvis as felt abdominally. Basically, the less of the head felt the the lower the number of fifths palpable. Sometimes a midwife will write ‘Engaged’ (eng) rather than a fraction, when this is writen it means that, in her estimation, the widest part of baby’s head has gone through the brim of the pelvis. (In the photo the brim is the top of the inner circle).

Below is a photo of a female pelvis. The angle is such that if this were a real woman the photographer would be standing at the woman’s feet whilst the woman was lying on her back with her bottom tilted upwards.If you look at the inner circle of the pelvis you can see that I have stuck blue stars on little bony protruberances, these little lumps are called the ischial spines, the gap between them is about 10.5- 11 cms, and these are the landmarks that an estimation of descent, or station, of the presenting part is based upon when an internal examination is performed.

 

 

S0, the spines are 0 (nought) in a midwife’s world. When a vaginal examination is performed the midwife will hope to be able to feel these small bony protruberances  and then note where baby’s head is in relation to them. The spines are 0 and whether the head is above or below is expressed in centimetres, minus ( – ) if it is still above, plus ( + ) if below or, if it is level with them, then a midwife will often write ‘at spines’. My drawing shows the gradual descent through the pelvis, sort of!

This is a simplistic explanation of how estimations of descent are conducted and expressed, below are a couple of on-line resources which are well worth reading.

Liverpool University

Pelvic anatomy

* I’ve written ‘midwife’. It could be a G.P or obstetrician.

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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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