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Archive for the ‘childbirth’ Category

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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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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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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“Why are you doing homebirths, and why is the government promoting them, if no one has any idea whether or not they are safe?” A question asked by Dr Amy on Homebirth Debate.
Hmmm. Well, I’m a Community MIdwife, it’s my job. Stop thinking, if I think too much I could talk myself out of a job. I mean, who in their right mind would do a job that requires them to work all day, then go home and wait all evening, all night to see if the phone rings to summon them to previously uncharted territory, to meet new people, in unknown circumstances, for an unspecified length of time and all for their usual hourly rate, plus one third and, to then go to work the next day?

My response to Dr Amy was so smarmy, real interview speak “I would rather provide women demanding homebirth with trained support than encourage UC. There will always be women who want homebirth and, if this is the case, then it must be preferable that they have care from a trained professional.”  That’s true, and I suppose it is a component of why I facilitate homebirth, although it does not explain why I promote them. I have purely anecdotal, observational ‘data’ to support my belief that homebirth is appropriate and safe for low-risk women, so from my personal perspective I see no reason not to offer homebirth as a valid option (other than a purely selfish desire not to be on-call!) so I suppose that answers that query.

That makes it sound as if I have no worries about homebirth, I do, but I also have worries about hospital birth. Statistically I have more chance of finding myself encountering a difficult labour, birth when working on the labour ward than I will at a homebirth. If things start to deviate from a clearly defined norm at home I will transfer the woman in immediately, I have absolutely no intention of increasing the chance of harm befalling the woman and baby or finding myself, deliberately, in an emergency situation. I can’t d this in the hospital. Yes, I can ask the Doctors to attend but, as the midwife providing care in labour I have to stay, provide the care the Doctor advises and sometimes be present at an extremely sad outcome.

I wrote the truth when I said that there will always be women who demand homebirth, and I believe that as the caesarian section rate rises, so will homebirth as women search for a less medicalised approach to childbirth. If we don’t provide the choice of homebirth with NHS midwives more women will feel that the only route they can take is that of unassisted childbirth, freebirthing. Obviously, if they have the money they can choose to employ an Indie (Independent Midwife), they can provide better individualised care but they are unable to acquire insurance at present so this may make them less appealing as an option.

There is no ‘perfect’ solution as if we ban NHS homebirths the freebirths will rise and women and babies will die unnecessarily. That’s why I assist women birthing at home.

P.S  I’m ‘on-call’ now and if the phone rings the adrenaline starts flowing.

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I always warn the Mum’s who have laboured quickly that they could find themselves quite unpopular with their new chums from antenatal classes. It’s a double-edged sword really, if a woman has a short labour other women may consider has she ‘got off lightly’ and, as she can’t hope to rival them in the traumatic, epic nature of her labour, she may be perceived as not having worked so hard to bring her baby into the world.

A quick labour is not always that fantastic though, it may be over quickly, anything under 2 hours* is classed a precipitate labour, but it comes with it’s own problems. For a labour to be completed in such a short length of time the contractions are generally almost continuous and extremely long and intense, immediately. This makes it extremely difficult for the woman to adjust to labour and find a coping strategy. Also, it makes travel to the maternity unit extremely fraught, for both the woman and her companions. In precipitate labours it is not unusual for the birth to occur before the woman has reached the maternity unit, or even a place of safety, hence the tales of babies being born down toilets. Here is the first danger associated with a rapid birth, baby taking a tumble onto a hard surface and the cord snapping in the process. There is also, for baby, the possibility of the speed of the birth leaving it shocked and slow to respond, so requiring extra stimulation to encourage her to breath. Babies born quickly will often have red faces, close inspection shows it to be lots of tiny red ‘spots’, burst blood vessels, petechiae, with the whites of the eyes having burst blood vessels, sometimes leading to the iris’ having a small ring of blood around them.

The poor woman, having been totally overwhelmed by labour, is possibly in shock as soon as her baby enters the world. Due to baby entering the world at breakneck speed severe lacerations and tears to the vagina and perineum are likely, particularly if the birth was unattended and the woman was panicking. Even though her labour has been short she is exhausted, and frequently her uterus is as well so fails to contract efficiently which means that women who experience precipitate labours are at an increased risk of retained placenta and haemorrhage.

There are other, more severe and rare, complications, associated with precipitate labour. They are extremely rare and I’m not going to mention them here, but if you are interested one can be found here and here. A piece if research conducted in the 70’s by Erkkola and Nikkanen seems to show that precipitate labour does not result in adverse outcomes for newborns.

Precipitate labour is difficult to predict in a woman having her first baby. Obviously a premature labour is more likely to be rapid; induction of labour can lead to over-stimulation of contractions so causing labour to be precipitate, really it is something that just happens to some women and babies!

* If I book a woman with a previous labour and birth of under 4 hours I make a note of this as a ‘rapid birth’ as she is at a higher risk of precipitate labour in her current pregnancy. I also discuss with her the advisability of making her way to the maternity unit as soon as she believes that labour is starting and if she believes that the birth is imminent, phone an ambulance, make sure the door is unlocked, sit or kneel and grab a towel. If her previous birth had been trouble free, no retained placenta or excess blood loss, I suggest a homebirth.

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“Following the Channel 5 programme broadcast 9 July 2008 (Extraordinary People – Outlaw Birth) featuring three women in the UK and the USA who opted to give birth unassisted at home, the NMC would like to clarify the following points.
Legal position
In the UK it is legal to give birth at home without any professional or medical help.

However, it is illegal for an unqualified, unregistered person to perform the role of a doctor or midwife during the birth.

Standards and resources
As part of their training, all midwives are taught that they must

  • Work in partnership with women to facilitate a birth environment that supports their needs.
  • Provide care that is delivered in a warm, sensitive and compassionate way.

The Midwives rules and standards states that a midwife

  • Should respect the woman’s right to refuse any advice given

The Code states that

  • You must listen to the people in your care and respond to their concerns and preferences

In addition, a recent report from the Royal College of Obstetricians and Gynaecologists (RCOG) states that

  • Women who choose a home delivery as their birth option should be supported in that choice, appropriate to the level of clinical risk.

Responsibility
In a free birth situation, the mother-to-be takes full responsibility for the birth of her baby.

The mother may choose to have any friend, partner or relative present at the birth.

They may support the mother emotionally but it is not legal for them to assist her in the birth or take any kind of responsibility for the successful outcome of the birth.

Midwives must respect a woman’s decision to have a free or unassisted birth.

The Code and NMC Midwives rules and standards require midwives to be supportive and not be judgemental or critical of this choice.

If midwives have any concerns at all about the woman’s decision, they must address them to their Supervisor of Midwives.”

Further information
Free birth advice sheet [PDF]
The Code
RCOG Standards for Maternity Care
[PDF] (external website)

Well, that’s made it all very plain. I think! Support her choice, be non-judgemental, contact my Supervisor of Midwives if have any concerns about her choice. Ummm, if I’m supporting her and being non-judgemental then going to my Supervisor could be perceived by a woman as obstructive and judgemental. Oh well. All I can say is, as I said here, if you thinking about it then please don’t just read the legal stuff and DIY sites on the web, there are a lot of sites out there with enthusiastic people who mean well but can be somewhat blinkered when it comes to the nitty-gritty. Talk to your midwife, see if a compromise can be reached, most of us don’t want to be ‘in control’, we would just like to try and help you, and your baby, have a positive, safe birth.

 

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I’ve just finished watching the channel 5 programme about unassisted childbirth and I feel many mixed emotions. As a woman I feel rather jealous of the three women shown freebirthing in the programme, especially the first one who really did appear to experience a non-traumatic, pain-free, dream of a birth, as a midwife I fnd that rather worrying. I mean, if I was swept up by the images and beauty of the concept why shouldn’t a significant number of women, who are in a position to have a go at birthing by themselves, decide that they would like to experience an unassisted birth?  Would that be a problem? Not to me, no, but it may cause them an assortment of problems, some life-threatening. I am absolutely delighted that a went well for the three women, and babies, in the progamme but that is troublesome. Although the doctors warned about a couple of complications that could occur, this will just be perceived as the medical establishment ‘shroud waving’ and there are very real and dangerous problems which may occur during childbirth.

Why are more women considering this ‘lone’ birthing as an option? There will be a few who will enter into it due to a personal belief, or as an extension of a life-style but I believe that the majority will choose free-birthing as a result of a previous birthing experience. Perhaps they believe that the attendants were not sympathetic to their needs, or their choices were dismissed or ignored, whatever it is, the maternity services, midwives, doctors have failed them. I do place some, well quite a lot, of the blame here on promises, and hence expectations, engendered by government and built-up by the media. Women and their families are told that they have choice but this is never qualified by the reality of shortage of staff, resources and amenities. Some elements of the media and pressure and user groups paint a negative picture of attended childbirth, I would include channel 5 in this group. There are many images of midwife-attended, home, birth-unit or hospital maternity care they could have used which could have shown a woman in a non-medicalised environment. Instead the images shown were of a woman semi-recumbant, on a  hospital bed, with a doctor busy setting-up an intravenous infusion, complete with an electronic pump, hardly the most tempting alternative to the impression of a pleasurable birthing experience for the three women depicted in the programme.

I would urge anyone contemplating unassisted childbirth to do more than read-up about it and watch DVDs. Please, contact your local maternity unit then, if you are still unhappy with the options or choice offered, contact your local NMC supervising authority as they are there for women who are seeking help or support concerning the provision of their midwifery care.

Women and babies can, and do, die during attended childbirth in hospital and at home but, “while many factors contribute to maternal death, one of the most effective means of preventing maternal health is to improve health systems and primary health care to ensure availability of skilled attendance at all levels and access to 24-hour emergency obstetric care” and, “Because complications of childbirth too frequently cause neonatal death, skilled assistance is recommended for all deliveries along with access to the appropriate level of neonatal care when needed.”

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