Posts Tagged ‘Homebirth’

Yep. Sitting here waiting for the phone to ring, I’m on call. On call is really a poor description, ‘in waiting’ would be more appropriate as recently it’s 90% certain I will be answering the phone and driving off somewhere at some point during the night. Last time it was because paramedics were refusing to take a labouring woman in to hospital, even though she was ‘high risk’, because her contractions were too close together! Off I went, in freezing fog, arrived 40 minutes later and discovered that the woman was in early labour. Only problem was that I then had to go in the ambulance with her to the maternity unit, then get back to where my car was, then get home. Nearly 4 hours in the middle of the night, and I’m still not really quite sure why. Then last week it was to the local Birth Centre because they hadn’t got any cover for that night, the week before it was to a homebirth. Once again tonight the Birth Centre has no cover, I wonder what time I’ll be called?

These on calls are starting to stress me out. It seems that as I get older, and perhaps wiser, I dread them and anticipate more problems, mind you, that might have something to do with more women with ‘problems’ booking homebirths. I must be the biggest pessimist as I lie anticipating the phonecall, imagining all the different scenarios I could find myself in, and then, when the electronic ring shrills out my heart leaps into my mouth and virtually flies around the room. That’s the worse bit, the waiting, the trying to get to sleep. Once I’m on the road, in action, and especially once I’ve arrived I’m in the present, no more imagining, or dreading, just a woman to help and support. Yes, things could still not be ‘normal’, but facts are easier to deal with than the imaginings of a sleepless midwife.

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I’ve just finished a run of working days, hell and heaven would be the words to describe them. Heaven were the weekdays, hell was the weekend.

Heaven = Visiting new Mums and babies on their first day home, listening to their birth tales, reassuring them that baby is fine, helping them out with breastfeeding and then going back on day 5 to be greeted with a smiley face and thanks for the advice and help I had given previously. Heaven is also seeing my women at antenatal clinic, listening to their woes and then making them laugh, answering their questions and giving advice. Meeting ‘old’ patients in the waiting room as they queue for babe to have his first jabs and being treated as an old friend, even hugged by some. Heaven is feeling that I must be doing/have done a ‘good’ job, that I have fulfilled my role to those womens satisfaction and/or expectations.

Hell. Hell is the weekend, working with a truly skeleton staff, unable to provide any sort of individualised care, the women are on a conveyor belt and I am an operative. Hell is arriving at the midwives clinic to discover that 2 of the 5 midwives scheduled to be working were out at a homebirth all night so are not working that day, then the phone ringing alerting the 3 remaining midwives that another homebirth is ‘brewing’. Hell is looking at the clinic list and seeing that there are 30 women attending and then reviewing the home visits to discover that 10 women need a visit. Hell is phoning those women who are expecting a home visit to explain that this is an impossibility and ‘inviting’ them in to the clinic to be responded to with ‘this isn’t my problem, it’s yours’. To attempt to reason with the shouting woman at the other end of the phone, tell her that there is a homebirth happening, that unfortunately these take priority, and that there is now only 1 midwife covering all women requiring postnatal care over an area of 400sq miles. To then be replied to, in words containing many expletives, that she is your priority, that your job is to provide her with care where she wants it and that YOU shouldn’t put a homebirth before her (where are the decision makers at times like this?). Heaven is when 1 of the midwives who has been out all night with a homebirth turns up at the clinic and works all day with you, although it must have been hell for her, sleep deprived as she was.

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There has been a lot in the news recently about a scottish midwife, Anne Duffy who resigned from her job and is now claiming constructive dismissal by her employers. I’ve been interested in the outcome as the decision, it seems to me, will come down to interpretation of the NMC rules.

As yet a decision hasn’t been reached concerning Anne Duffy’s case, so why am I writing about it now?  Well, in the news today was a report about a couple whose baby sadly died as a result of no midwife going out to their home for the birth and the fact that a settlement has been agreed with the Trust.

In Scotland Anne Duffy was the midwife in charge of the maternity unit, which meant that she was the most experienced available midwife, when a call came in that a seriously ill, pregnant woman needed air lifting from an island to the hospital. After a discussion with other staff members she went off in the helicopter, when her actions were discovered she was disciplined and as a result she resigned. Report here.

So, on the one hand we have a case where a midwife attended and was disciplined as a result and  on the other hand, we have a case where a hospital failed to provide a midwife, a baby died, and the Trust have, I assume, admitted fault and made a settlement with the parents.

There are differences here, in one a midwife failed to follow hospital procedure, but fulfilled the professional requirement to provide care, and as a result was disciplined and in the other a hospital failed to provide care and have admitted fault. Can anyone else see the double standard here?

The Huddersfield baby death does bring up the homebirth and midwife staffing issue again though. There must be more to this though as there was already another homebirth underway, there was only one on-call midwife and she was already at the other homebirth so why didn’t the parents come into the hospital?

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

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

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

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

A’s story

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

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

B’s story   

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

C’s story

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

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

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

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

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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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One of the women featured in the channel 5 documentary about unassisted birth, Clio, is discussing her choice in The Mail’s “Freebirthing: Is it madness or the ideal way to give birth?”, the article has so far elicited 60 comments, the majority of which are against the idea of a woman giving birth without trained support. Obviously, as a midwife I am going to counsel against an unassisted birth, I would also advise against an unsupported pregnancy, meaning no antenatal care. I know, and have seen too much to take the attitude that Sue (one of the commentators) does ‘ If you listen to your body and you are healthy there should be no reason why you can’t have an unassisted birth, We need to go back to the old days, pregnancy and birth are not illnesses.’ She is right, pregnancy and birth are not illnesses’, but that does not exclude circumstances which are capable of changing an everyday ‘natural’ event into a life threatening emergency. I remember that fact EVERY time I am called to a homebirth and EVERY time I conduct a routine antenatal examination. Sue wants us to go back to the old days. What ‘old days’ would those be? The days when women died from eclampsia; haemorrhage; puerperal fever, ruptured uterus when babies died or were damaged by obstructed labour, cord prolapse, undiagnosed twins, locked twins? 


So, I’ve let my feelings known, now I’m going to present an example of unassisted childbirth that happened recently. The woman is at term, uncomplicated second pregnancy, apart from her requiring much debriefing about her last labour and birth and a meeting with the anaesthetist to attempt to discover why her last epidural hadn’t worked and an assurance that she would be offered an epidural as soon as she goes into hospital this time. On the day of the birth she as a ‘show’ in the morning and is experiencing slight lower, back pain. Early afternoon saw her having painful tightenings, she sent her husband off to buy a few groceries, he was gone half an hour. He returned to find her on all-fours, telling him that the baby was coming. He insisted they get into the car to go to the hospital, she describes being on the pavement, on her hands and knees, unable to move. He somehow got her into the car, and off they went on a 10 mile drive. A mile from the hospital, stopped at traffic lights in the town centre, she told him the baby was coming, her waters broke and baby’s head started to come. He pulled over, leapt out of the car, asked a group of teenagers to call an ambulance, pulled off his wife’s trousers and baby was born into her underwear. After a struggle with baby and it’s cord, which was tangled in her undies, he gave the baby to his wife. She describes how terrified she was, as initially the baby was ‘floppy’ and didn’t cry, but then she hugged it hard and he cried. They cancelled the ambulance and drove the mile to the maternity unit where Mum had a couple of stitches to a small tear, cord blood was taken, as she was rhesus negative, and they then got back into the car and drove home. When I saw them the next day they were both ‘on a high’. Basically they, especially her, view the experience as being, eventually, better than the birth of their first baby but terrifying at the time. I asked if they would deliberately have an unassisted birth. NO! Would they have a midwife attended homebirth? Not too sure as those seconds, where they thought that the baby was not breathing, made them realise how unpredictable events could be. 

Not freebirthing, in fact very much the opposite as Mylene Klass is someone who had private antenatal and birth care. Now though she is outraged at the lack of care she received after the birth of her baby . I have a few thoughts about this, many contradictory. My overall thoughts are that I can’t defend the lack of care she received from the NHS but…..why did she choose to rely on the NHS for her postnatal care having gone privately during her pregnancy and birth? Was it because her private hospital does not provide a domiciliary service, however much you pay and she would have had to go to a clinic for her and baby to be seen?

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Last night was nieces 21st birthday party, at a club, in that well known hub of youthful exuberance and soulful poetry, Milton Keynes. I was really looking forward to the event as it had all the ingredients for an entertaining evening; family, music, dancing, food, with a little soupscon of adrenaline as I had to give a speech and, my sister’s 2 ex-husbands plus her partner would be there.

First, back to Thursday. I had a relaxing day planned. Little pile of ironing to wade through, whilst catching up on some daytime TV, Fern is not the bubbly personality she was since losing all that weight. Not only are her measurements smaller, her warm personality has diminished as well. Shame, she and Phillip were a great ‘cheer-you up’ team. After the ironing a dabble in baking, used up some past it’s best bread and made 2 bread puddings, love the smell of the mixed spices, and then a trip to the hairdressers to have the barnet cropped for the party last night.

Thursday tea-time my job-share phoned to update me on work happenings and issues relating to our caseload. At her clinic one of our woman, booked for a homebirth, had attended for a stretch and sweep , it was unnecessary as C’s cervix was already 5 cms dilated and the membranes were bulging! Good news, as hopefully this means that labour will start quite shortly. Job-share had told C that she would go on call for her and I told my job-share that if there were problems with 2nd midwives, or things were happening very quickly, then she could call me as I only live 5 minutes away from C.

Thursday evening Son came around, he is still having a flare-up of his ulcerative colitis and they have now started him on azathioprine which is, at the moment, not helping. This flare-up has been going on for months now, he has become really anaemic and that, combined with his recent 2 stones weight loss and the constant discomfort is making him really lethargic and quite depressed. I tried to buoy him up, the new drug takes time to work and we will just have to hope that by the time baby arrives he will be full of energy and able to fully enjoy life again. I am worried about him and so a combination of ‘maternal distress’, the old night sweats and restless legs saw me wandering the house when I should have been sleeping. I was just standing on the tiles in the kitchen, good for cooling off and alleviating restless legs, when the phone rang. As I grabbed it quickly so as not to disturb Hubby I glanced at the clock, 2.45 am. It was job-share, C was labouring but……..the doors to the hospital where the on-call equipment is kept were locked, the porter was not responding to her knocking and both the on-call midwives were out at 2 other homebirths. Having experienced difficulty in gaining access before I had the phone number for the porter so relayed that to her and told her to phone me when she needed me. I got back into bed, was just entering that lovely dream-like state which precedes sleep, when she phoned again, would I join her at the homebirth? I left a note for Hubby just in case he woke up and realised I had abandoned him, phoned labour ward and told them what was going on, grabbed my on-call equipment and nipped off down the road. It was all fairly peaceful. C was smiling between contractions, she was really happy to have 2 midwives there who she knew, her previous hospital birth had been quite traumatic as she felt that the midwives were unfriendly and unsupportive, and all progressed quite smoothly to the birth of a little boy at 6am. By the time we had waited for the placenta, it was a physiological third stage so lasted 40 minutes, tidied up all our equipment, weighed baby and checked him over and then helped C with a bath it was 8.345am before we left. I arrived home, my note was still where I left it so I added the request to wake me at 12 noon and, being shattered, I headed for bed, Hubby was just getting up. ‘Bloody hell. Who was phoning at that time?’ was his greeting. I explained who, what and why and it dawned on him that I had been, gone and returned whilst he was sleeping. ‘You’re on annual leave’ was his comment as I snuggled down and hoped I could sleep. I just love that getting into bed after a night-shift or a call-out. The naughtiness of deliberately getting into bed whilst everyone else is just starting their days activities, the knowing that when you awake it will be the same day and you will still have hours to do things in, like go to a 21st party, it’s almost like gaining extra time in your life.

The party. Well, for all my eulogising about how wonderful losing a night’s sleep can be, I feel that age is catching-up with me and I don’t recover as well so I was possibly less energetic than I had hoped. My niece looked lovely and really, really enjoyed herself. The speeches were lovely, I did a tongue-in cheek imitation of an M & S advert, you know, using the ‘ extra-sweet, hand-dusted, steeped, traditional, 21 year-matured’ keywords, I think it was appreciated (the 3 bacardi’s and no food helped)! I did very little dancing, the music was good but really not suited to a 50 year-old trying out her moves in front of a room full of mainly 20 year olds. My Mother, the ********** , use any expletive descriptive of pure evil here, did her usual and behaved similarly to how she had at Son’s wedding, controlling and attention-seeking. Hubby ended up having to drive her home as she wouldn’t take a taxi. At one point, after being introduced to her grand-daughter’s fiancees relatives she said ‘ Well, of course R’ (her husband) ‘has bi-polar’, attempting to lighten the conversation I interjected with ‘Yes, he’s big and white with a black nose’, she rejoined with how she diagnosed his condition, instructs the doctors on the medication he requires, and then she decides regimes and dosages. Apparently, if it wasn’t for her R would be dead, if it wasn’t for her he would be mentally stable, is my observation. At the party my previous, and present brother-in-laws all behaved impeccably toward each other. One of them I hadn’t seen for about 15 years, it was good to catch-up. When there is a divorce it is an odd situation for other family members. There you are, all a family together, sharing so many parts of your lives and suddenly this quite major member of the family disappears off the radar, this huge chunk of family life disappears. (Huge chunk is not meant to imply that either of my ex-BIL’s are overweight!) We left at 12.30, Hubby was sober and in danger of being deafened by the music, I was tired, tired and tipsy. After several failed attempts, frequent muliple revolutions of roundabouts, we left Milton Keynes, headed into Bedfordshire, had a passing aquaintance with the M1, a close encounter with Whipsnade Zoo and eventually got home at 2.30am. Hubby insists that at no time did he take a wrong turning, he was just enjoying listening to Leonard Cohen

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God bless him, my favourite G.P is once again goading midwives, this time those who attend homebirths, in his offering ‘Midwives and home births: the truth’. I can’t seem to discover any ‘truth’ a la Dr Crippen in this, which I find surprising as he says that this Guardian article, concerning the journalist’s recent experience of his wife’s home birth and including an interview with one of the midwives, ‘sums it all up’, and he then concludes by advising ‘make sure that there is a doctor close by when you have your baby’. I’m not sure why, or how the article supports this advice but if I take the title of Dr C’s entry at face value, then I can only conclude that the good doctor has finally decided that there is a place within the maternity services for homebirth!

It will be sad to stop the debate but soon there should be a definitive answer to the question of where is the safest, best place to give birth, so then Drs C and T will either have the last say or, have to eat their words. A study, Birthplace, by The National Perinatal Epidemiology Unit is underway. The study will answer questions about wellbeing, safety and quality, women’s experience of care, the process of transfer from planned place of birth, and the cost-effectiveness of different systems for care. The study will reach it’s conclusions in 2009 so, within 18 months we should have an answer to the perennial question of how safe is home birth?

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Yesterday saw me stepping back into the land of normality. Late afternoon one of daughter’s friends and her husband came round for a one-to-one active birth chat. Her  second baby is due in 3 weeks and she would like to try and avoid all the intervention she experienced first time round. It was really lovely, informal, chatty and made me feel quite enthusiastic about midwifery again. When I felt I had covered everything I then asked if there was anything else they wanted to talk about and C said what did I think about homebirth. I was surprised as her previous birth had been so medicalised and she has always struck me as a person who requires loads of support. Her husband immediately expressed his doubts, the usual one about emergency caesarians. First of all I explained that there are some situations where homebirth is something we would advise against but having looked at C’s notes and history all looked ‘low-risk’ to date so we would be overjoyed to book her for one as long as all remained ‘normal’, I also said that they could always change their minds, right up until labour started. I discussed the issues of availability of midwives and warned them that if the midwives were already at another homebirth, especially at night, then they would be asked to go to the hospital. I then addressed the ’emergency’ situations. As usual I highlighted the fact that there are a couple of real emergencies that can occur at a homebirth, the shoulders getting stuck, the cord prolapsing, haemorrhage, and then went on to say that many of the situations that arise in hospitals, baby’s heartbeat slowing, long labour, meconium liquor, baby’s head staying high are observed, often for hours without invasive procedures purely because the labour is in the hospital and all the equipment, theatres are there. However, at a homebirth we do not observe once the situation strays from ‘normal’, we act, and the action is to transfer the woman into hospital. Husband seemed reassured by this and so the end result of our meeting was that C is now planning for a homebirth.

Still on a positive I went out for the meal with colleagues. It was so wonderful to dress up, put on make-up, socialise and enjoy a tasty Italian meal, with a couple of glasses of wine!

The good news continues. Another of daughters friends just phoned to say that a little bird had told her I was desperate to go to Ikea. I know, I get sadder, she is going to take me on Monday, at last, I am returning to normal!

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