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Archive for the ‘Unassisted childbirth’ Category

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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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“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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“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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