Protecting Your Back During Pregnancy

During pregnancy changes in your body can affect your back and your posture.  As the weeks pass your weight is no longer centred in the middle of your pelvis but moves forward with the weight of the growing baby.  For most women their posture adapts to compensate for this shift and you may find yourself either slumping forward and flattening out the curve in your low back, or counter balancing the weight by leaning back, at your upper body, which leads to a greater curve and a shift of your weight on to your heels.  The muscles of your back, lower abdomen and your pelvic floor are designed to move and stabilise the joints in your back and pelvis but as your baby grows they are put under more potential strain.  This, along with the adaptations you may make to your changing shape, combined with hormonal (hormones are chemicals that carry messages around your body) changes that loosen the ligaments around the pelvis, can result in low back pain, upper back pain, pubic bone discomfort and general postural strain.

What can you do to reduce those risks?

Stand Tall – imagine that someone is making you feel taller by pulling a string attached at the back and top of your head at the same time as you tightening your tummy muscles and pelvic floor as much as you are able.

Sit Correctly - make sure your back is well supported. You may prefer a dining chair to a soft chair or sofa.  Placing a small rolled up towel in the hollow of your back may help if you are finding your back is adopting a flattened posture.

Avoid Heavy Lifting - Your loosened ligaments make them vulnerable so ask for help whenever possible.  If you do have to lift, make sure you hold the object close to your body, and bend your knees rather than your back.  If you are shopping divide your goods into equal loads for each hand.

Wear Comfortable Shoes – Generally, if you are finding the curve in your low back increasing, flat shoes may be more comfortable as heels will accentuate the curve.

Adapt The Way You Carry Out Your Chores- eg when vacuuming stand in a walking position, with the Hoover in front of you, then move your feet to the next area and Hoover in front of you again.  Don’t be tempted to push it so far away from your body that you end up bending and twisting your back.

Exercise Regularly - but unfamiliar routines may damage the joints that loosen during pregnancy so it is wise to seek advice if you are unsure of the suitability of your exercise regime. The most appropriate forms of exercise include swimming, walking, aqua natal classes, Pilates and yoga.  It is important that the instructor is qualified or experienced in teaching pregnant women.  If you are experiencing pelvic girdle pain, or symphysis pubic dysfunction, then always seek advice from a Chartered Physiotherapist prior to beginning any exercise.

You can reduce the risks to your pelvic area and pubic joint by:

1. Standing evenly on both feet.
2. Sitting on both buttocks and not crossing your legs.
3. If you have other small children don’t carry them on one hip.
4. Avoid movements where you are swinging your leg sideways, for example when you get in and out of bed, or a car, turn your hips, pelvis and back in the same direction, while keeping your back straight, so you are moving as a whole and not twisting.

Once your baby is born there is a period of time, while your hormones re-adjust and you resume your usual tasks, when your spine remains susceptible to damage.  This may even be increased by a busy, unfamiliar schedule involving lifting and carrying car seats and prams, combined with feeding postures, picking baby up from their crib and carrying them. It is important to protect your back in the same way you did when you were pregnant.

If you find you cannot resolve your discomfort with this simple advice seek the help of a Chartered Physiotherapist who will be able to identify your specific problems and aggravating activities.  They can then provide you with a tailored programme that will fit in with your schedule.  They can also advise and provide you with supports to relieve/reduce low back pain and pelvic girdle discomfort. 

This information is provided by St Judes Clinic and is intended as general advice during and after pregnancy.  For more detailed advice please book an assessment with us or seek further medical advice from your GP.

Moira D’Arcy  Grad Dip Phys MCSP AACP APPI

Practice Principal

St Judes Clinic

26 Lake Street

Leighton Buzzard

LU7 1RX

Tel: 01525 377751

E-mail: enquiries@stjudesclinic.com

http://www.stjudesclinic.com/health/pregnancy/

The placenta is the fetal life support system, but can also become more than this, and is a powerful symbol that many believe deserves some respect when it has fulfilled its main aim. 

A new TV programme on Channel 4 called ‘How to be a Good Mum’ made me decide to do a topic on placentas. I tend to hate programs like this because they always portray what can be reasonably sensible well thought out ideas, throw them all together and turn them into a program designed to shock and mock anything mildly different from the perceived ‘norm’.

The first episode showed a lady making a print from her placenta in quite gory horror style detail. Each to their own maybe, but here are some ideas I found on the internet!

1. Plant It! 

The most obvious and common thing to do with a placenta (after throwing it out that is) is to plant it in the garden or a pot.  Sometimes this is done as part of a ceremony, naming day, with friends, family or just a personal thing done without announcement, just to show respect to the thing that nourished and fed your unborn baby for all those months.  Maybe to throw it out seems in some way disrespectful after all its hard work?

2. Print From It!

This is easier than it sounds.  It can be frozen for some time, defrosted, washed, dried and the side closest to the baby including the cord can be inked and printed to look like a tree, with all the veins looking like branches.  They can be quite beautiful.  They can also be printed from soon after birth using the blood left within it to make the print.

3.  Encapsulate It!

There are many practitioners that will encapsulate your placenta for you.  This basically involves mulching it up, drying it out and turning it into a powder form that’s put into tablet capsules for you to take.  The benefits are said to be that it can balance your hormones in the weeks and months after birth, increase your milk supply and quality, and increase energy.  Its been reported to decrease the risks of developing post natal depression also. In fact it’s not a new idea, its been a traditional Chinese medicine practise for centuries.  This needs to be done within 48 hours after birth.

4.  Ingest It!

Ok, I mean Eat IT! The benefits are the same as above but you could do this yourself at home and not need anyone to help you. I think most people are generally aghast at this idea, but it’s not so uncommon in other parts of the world. In fact there are many rituals and ceremonies that involve this, and are a way of welcoming the new baby into the community and celebrating its safe arrival. If you google this subject you can find many recipes and ideas from simple smoothies to bolognaise!

In fact MOST mammals eat their own placenta and the benefits are said to be that it encourages milk production, and encourages the uterus to shrink down after birth. 

5.  Burn it!

Some cultures burn the placenta in a clay pot and then bury the ashes.

6. Make a Teddy!

Artist Alex Green set off a media storm after his Placenta Bear went on display at the ‘Doing it for the Kids’ exhibition.  He explained:

“The goal of the exhibition is to inspire designers, educators and parents to be more critical of the toys that shape a child’s values and the impact toy making has on the environment.”

7. Other Cultures Do This!

In Yemen the placenta is placed on the family’s roof for the birds to eat, in the hope that it will guarantee the love between the parents.

In Malaysia the placenta is seen as the child’s older sibling and thought that the two are reunited at death. The midwife carefully washes the placenta, cord and membranes and wraps them in a white cloth to be buried.

In Nepal, the placenta is given the name ‘bucha-co-satthi’ – meaning ‘baby’s friend’

The Tanala people of Madagascar observe strict silence throughout the labour and birth and as the placenta is being delivered. When the placenta comes, everyone present claps and shouts “Vita! Vita!” – meaning ‘finished’.

Philipino women often bury their placentas with books with the hope that this will ensure an intellectual child!

To Conclude:

Whether you choose to eat it, paint with it, throw it out or whatever, there’s no denying that the placenta is a beautiful thing. It is the connection between mother and child and can be a very spiritual symbol. Whatever we decide we should not judge other people’s choices even if they appear alien to us. Being different is what makes the world an interesting place.

According to the UK Department of Transport, 60 to 80% of all car seats are used incorrectly, with harness tension being the single biggest failing. Getting the correct harness tension is even more difficult in winter as it is hard to tell whether you have a good harness fit if a child is wearing a thick coat.

To get the correct harness tension over a puffy snowsuit or thick coat, a parent really has to tighten it substantially, which can make the child uncomfortable as their freedom of movement is restricted. Being tightly strapped in a thick coat can also lead to the child overheating once the car warms up.

To test whether you have correct harness tension when using a coat or snowsuit, you can do the two finger test: 

1. Put the coat on the child.
2. Strap the child into the car seat and tighten to ensure a snug fit.
3. Remove the child from the car seat – without loosening the straps.
4. Take the coat off the child.
5. Strap the child back into the seat – but don’t adjust the straps.

 Do the Two finger test.  If you can fit more than two fingers underneath the harness at the child’s shoulder bone, the harness tension needs to be tightened or you should avoid using the coat in the car seat.

The safest bet is to strap the child into their seat correctly wearing their normal indoor clothing so you can be assured of the correct harness tension.  To keep them warm before the car has had a chance to heat up, parents can place a coat or blanket over the top of their child, or use a product which is designed expressly for this purpose. The key thing is to ensure that whatever is used, still gives you easy access to the harness release button on the car seat so that they can be released easily in an emergency.  You should also make sure that when you buy the car seat it is the correct one for your car and it is fitted correctly.

Morrck baby hoodies are designed to fit in your car seat or buggy or anything with a 5 point harness, avoiding the need to use other outdoor clothing, you can just wrap and go.   The harness feeds through the openings in the travel wrap and fastens over baby’s indoor clothing. This provides extra protection across your baby’s forehead and ears in cold, windy weather and lies completely flat behind your baby’s head when it’s not being worn.

Morrck’s Baby Hoodie has been tested by an independent testing facility and it was certified as having passed the relevant elements of the ECE Reg R44.04 car seat safety test. Baby Hoodies are available from www.morrck.co.uk

Clive Morgan from The Will Partnership has kindly written some thoughts for this Guest Blog.  Clive can be contacted at clive.morgan@willpartnership.co.uk

Guardians for Minor Children

One of the most important reasons for making a Will is to appoint guardians for minor children. If a child is orphaned (or the death of the parent with parental responsibility occurs) the courts – as advised by Court Welfare Officers and Social Services – will determine who will raise that child. The parent’s only method of avoiding this is to appoint guardians of their choice within a Will. If clients have minor children, they should be advised to choose guardians within their Will(s) - someone to raise them in the highly unlikely event they can’t. It’s not an easy thing to consider but clients can make some simple arrangements now that will allay some of their fears, knowing that in the extremely unlikely event they can’t raise their children, they will be well cared for.

Who Makes a Suitable Guardian?

- Is the prospective guardian/s old enough? (He or she must be an adult – 18 years old)

- Do they have a genuine concern for the children’s welfare?

- Is the client’s choice physically able to handle the role?

- Does he or she have the time?

- Do they have children of an age close to that of the client’s children and do they enjoy a good relationship?

- Can the client financially provide to raise their children via their Will?  If not can the prospective guardian afford to raise them?

- Is their home large enough to accommodate an increase in family size (if not clients may retain their own home for a period of time to house guardians plus children or provide funds for the guardians to increase the size of their home or move, particularly where the clients are certain their choice of guardian is right even through the accommodation is not)?

- Does the guardian share the client’s moral beliefs?

- Are the potential guardian(s) known, liked and trusted by both parents and the children?

- Are they living local to clients so that children could stay at the same school, with the same friends and have as little upheaval as possible during what will probably be the most disturbing time of their lives?

- Have a similar age and circumstances to the client?

- Guardians are usually a relative.

- Would all the children be able to stay together?

As any minor’s daily welfare will be the responsibility of the guardians, it could be worth considering the inclusion of one of the guardians as an executor.

A good question to ask the client could be: ‘If you had an urgent problem tomorrow, who would be the first person you would call to collect your children from school or to be here at home with them until your return and why?’

Clients should name at least one primary guardian (or if the main choice is married/co-habiting then both persons should be chosen) who would act in the event of the death(s) of all persons/parents who had parental responsibility. In addition it is advisable for clients to choose substitute guardians who would act in the event that the primary guardians could not or will not act.

Legally, clients can name co-guardians, who live at different addresses but it’s not a good idea because of the possibility that the co-guardians will disagree how the children will be raised. Where this possibility arises it might be best to appoint one as primary and the other as the secondary guardian which then clarifies the position.

If parents can’t agree

Both parents should name the same person as guardian in both of their Wills. If clients don’t agree on whom to name, a court fight could ensue if both parents die while the child is a minor. Faced with conflicting wishes, a judge would have to make a choice based on the evidence of what’s in the best interests of the child.

A personal view of the writer is that almost any guardian named in a Will is a far better situation than leaving it to the courts – as advised by social services – to decide. If parents can never agree anything else between them guardians is one area where it is vital they should.

Sometimes initially each parent wants each of their own parents as guardians for often different reasons. But once you have a conversation with them about who they think the children would want to live with and who they stay with most often, the ideal solution is often one set of grandparents become the primary guardians and the other the secondary substitute guardians. We inform the guardians of their role in order for them to accept, but we do not inform them of which level of guardian they are. The client may also opt not to inform them so there can be no family arguments over a situation which hopefully will never occur.

At the first meeting when the subject of guardians comes up and agreement does not appear straight forward suggest the clients talk with the people they’d each like to name. Candid discussions with their potential guardians may bring new information to light and help them reach an agreement in time to take their instructions at meeting 2.

Choosing different guardians for different children

Most clients want their children to stay together; if they do, name the same guardian for all the children. You can, however name different guardians for different children. Parents may do this, for example, if their children are not close in age and have strong attachments to different adults outside of the immediate family. For instance, one child may spend a lot of time with a grandparent while another child may be close to an aunt and uncle. In a second or third marriage, a child from an earlier marriage may be close to a different adult than a child from the current marriage. In every situation, you want to help the clients choose the right guardian they believe would be best able to care for each child.

Choosing a different person to watch the money

Some parents name one person to be the children’s guardian and a different person to look after financial matters. Often this is because the person would be the best surrogate parent would not be the best person to handle the money. For example, a client might feel that their bother-in-law would provide the most stable, loving home for the children, but not have much faith in his abilities as a financial manager. Perhaps clients have a close friend who cares about their children and would be better at dealing with the economic aspects of bringing them up. Clients can name one as guardian, the other as executor and trustee to manage their children’s inheritance and advance money to the guardian to maintain the children or it is possible and often prudent to appoint one of the primary guardians as an executor/trustee in addition, provided there are other executors and trustees appointed who are not guardians thus maintaining some balance with no one person (or couple) controlling all the money together with the raising of the children.

Making your wishes known

Most people have strong feelings about how they want their children to be raised. Clients concerns may cover anything from religious teachings to what college they’d like a particular child to attend. One option is to write a letter to the guardian, outlining thoughts and feelings about how the children should be raised where it is ‘wished’.  Whereas if it is to be a firm direction and condition/requirement of the guardian, then it needs to be mentioned within the Will. It is always best to be brief – without too much detail – as it could cause the guardian guilt and frustration, if unexpected circumstances thwart their attempts to carry out the wishes or directions of the client to the letter. The best guarantee of an upbringing a client would approve of is to simply choose someone who knows them and their children well, and whom they trust to navigate life’s complexities on their children’s behalf in the same manner as the clients would if they were alive to do so.

If clients don’t want the other parent to raise their child

If one of a child’s parents dies, the other parent usually takes responsibility for raising the child provided the surviving parent has parental responsibility. This, of course, is what most people want. If clients are separated or divorced, however, they may feel strongly that the child’s other parent shouldn’t have custody if something should happen to them. But a judge will grant custody to someone else only if the surviving parent:

• Has legally abandoned the child by not providing for or visiting the child for an extended period, or
• Is clearly unfit as a parent.

In most cases, it is difficult to prove that a parent is unfit, absent or has serious problems such as chronic drug or alcohol abuse, mental illness, or a history of child abuse. If clients honestly believe the other parent is incapable of caring for their children properly, or simply won’t assume the responsibility, you should advise the clients to have an Exclusion Form drafted. In the event of a court case this would give the judge something to take into account particularly because this is the only realistic way the parent who has died can make the court formally aware of the problems and their wishes. Judges are always required to act in the child’s best interest. In choosing a guardian, a judge commonly considers a number of factors in accordance with the welfare checklist, some of the the main ones are:

- The child’s preference, to the extent it can be ascertained

- Who will provide the greatest stability and continuity of care?

- Who will best meet the child’s needs?

- The relationship between the child and the adults being considered for guardian

- The moral fitness and conduct of the proposed guardians.

Some Important Points Regarding the Children’s Act, Parents, Children and Parental Responsibility

In English law Parental responsibility is a legal phrase used to define who has the rights and obligations in making decisions which affect the child’s life. Parental responsibility includes the following legal rights and responsibilities:

• Providing a home for the child
• Having contact with and living with the child
• Protecting and maintaining the child
• Disciplining the child
• Choosing and providing for the child’s education
• Choosing the child’s religion
• Agreeing on the child’s health and medical care
• Consenting to medical treatment for the child
• The right to choose guardians for your children in the event of your death
• Accessing the child’s medical and educational records
• Naming the child
• Responsibility for the child’s property
• Allowing confidential information about the child to be disclosed

Who has parental responsibility?

- Mothers automatically have parental responsibility.

- If the parents are married at the time of the child’s birth then the father has automatic parental responsibility. If the parents subsquently marry, the father automatically aquires parental responsibility upon marriage if they have not done so by any other method.

For unmarried fathers the rules are more complicated. Being the biological father of a child does not mean that they have an automatic right in law to parental responsibility. Likewise, even though they may be registered as the father on their child’s birth certificate, this does not always mean that they have automatic parental responsibility. If the father is unmarried and separate from the child’s mother and does not have parental responsibility, then they do not have a legal say in the child’s upbringing.

Fathers do have parental responsibility if:

• They are the father of a child born after 1st December 2003 and their name is on the birth certificate.

They do not have parental responsibility if:

• They are the father of a child born before 1st December 2003 and are not married to the child’s mother.
• They are the unmarried father of a child born after 1st December 2003 and they are not named on the child’s birth certificate.

Applying for parental responsibility

There are a number of ways of getting parental responsibility and these are:

• Entering into a voluntary parental responsibility agreement with the mother
• Marrying the mother
• Applying to the court to obtain a parental responsibility order
• Obtaining a residence order
• Being appointed as the child’s guardian

To apply to the court for a parental responsibility order, a father needs to show a number of things:

• The application is being made in the interests of the child’s welfare
• A degree of commitment to the child exists
• A degree of attachment between the child and father exists
• The father’s reason for applying for the order is genuine and well-meaning

If parental responsibility is granted then it has to be exercised jointly with the mother of the child and therefore any decision regarding the appointment of guardians must be a joint one. 

- The right to appoint guardians rests solely with the parent or parents who have parental responsibility and therefore unless the father has parental responsibility he has to be appointed guardian in the mother’s Will in order to raise his own children or apply to the court upon the death of the mother.

-Step parents acquire some rights for stepchildren upon marriage but the right to determine guardians is not one of them. If a step parent wishes to raise stepchildren in the event of the death of their partner they would have to be appointed as a guardian within the Will of the deceased person who has parental responsibility.

- Guardians raising a minor child acquire the right to appoint guardians in the event of their deaths.

- Guardians commence acting upon the death of the second parent or first parent if the mother has sole parental responsibility.

 Homebirth & PPH

Women often worry about what would happen if a woman bled heavily after a home birth. Throughout history, severe blood loss has been one of the main causes of women dying in childbirth, and it remains the most common cause of maternal death in the world [WHO, 1994].

Efficient management of postpartum haemorrhage is one of the wonders of modern obstetrics. The key is the availability of oxytocic drugs, which make the uterus contract down and normally stop bleeding.

You can choose to have either a ‘managed’ or a ‘physiological’ third stage, at home or in hospital. A ‘managed’ third stage means you have an injection of syntometrine as a precautionary measure. A ‘physiological’ third stage means you take a ‘wait and see’ approach to the delivery of the placenta, and only have drugs if you are worried about bleeding or if the placenta is taking longer than you want to wait for it to turn up

Sometimes one hears of doctors trying to dissuade women from home birth because of the risk of postpartum haemorrhage yet in fact severe bleeding after a home birth in the UK is rare, and postpartum haemorrhage is usually managed at home or by transfer to hospital. Despite the fears of some doctors, you would be very unlikely to bleed to death after a planned home birth in a developed country.

A famous review of quality studies of home birth (Olsen, 1997) looked at outcomes for over 24,000 women and found no maternal deaths. The National Birthday Trust Fund study looked at around 6,000 planned home births in the UK, and found no maternal deaths.

Where treatment for postpartum haemorrhage is needed, there are two elements. Emergency treatment focuses on stopping the bleeding, and in severe cases, keeping blood volume up while the bleeding is stopped. The other element of treatment is helping you to recover from blood loss, by administering a blood transfusion or iron supplements, this usually occurs several days after the bleed after blood tests have been performed.

What can a midwife do about heavy bleeding at a home birth?

Your midwife would follow exactly the same steps that she would take in hospital. Oxytocic drugs to manage blood loss are part of the basic kit that midwives take to every home birth.

If these did not bring the situation under control quickly then an ambulance would be called, and the midwife would take other steps if necessary, such as manually compressing your womb to stop bleeding.

In the UK most midwives can put an intravenous drip in at home while they are waiting for an ambulance to arrive.

What if the midwife isn’t there?

In the rare circumstances that a baby is born so quickly the midwife has not arrived yet, or the bleed has occurred after the midwife has left (also extremely rare), then you can do the following:-

• ·       Call 999 if you can’t get hold of your midwife immediately
• ·       Massage the uterus firmly – this often stops the bleeding immediately
• ·       Pass urine
• ·       Bi-manual compression – only if bleeding is extreme – involves someone continually massaging uterus externally and internally until help arrives

When the midwife arrives…

• ·       She considers what we call the 4 T’s: Tone, Trauma, Tissue and Thrombin (clotting) factors.
• ·       She can make sure the woman has passed urine and does not have a full bladder.
• ·       She can use massage of the uterus, syntometrine or ergometrine medication to try stem bleeding. These medications induce a sustained uterine contraction. The massage of the uterus will sometimes expel any tissue obstructing good uterine clamp-down.
• ·       The midwife can check for a tear, sometimes we can tear internally and it be less obvious
• ·       Bi-manual compression will be used and transfer to hospital will happen as soon as an ambulance arrives if bleeding is not slowing.
• ·       If bleeding has been easily stopped and woman feels fine then she may end up declining transfer to hospital. However in hospital they can offer a number of extra helpful interventions for anyone who has experienced or is experiencing a life-threatening PPH.

Placental Problems

• ·       Occasionally the placenta doesn’t separate properly and obstructs, the midwife can manually remove it allowing the uterus to contract down and stem the bleeding

Can more be done in hospital than at home?

• ·       The answer is yes, but only because there are more staff on hand, however the chances of having a life threatening PPH are far far greater in a hospital than at home in the first place.
• ·       The most common reason for PPH is to do with atonic uterus, where the womb fails to contract down properly. At home, this is dealt with in the same way and with mostly the same drugs that would be used in hospital.
• ·       It’s important to mention that PPH at home is reasonably rare, by the very nature of the fact that the major risk factors for PPH are things which only happen in hospital (instrumental deliveries, long hours on syntocinon drips, caesarean section etc).
• ·       The last confidential enquiry into maternal deaths listed approx 5 deaths from PPH, all of which were in hospital, four of them were following instrumental deliveries and one following caesarean.

 How likely is post-partum haemorrhage after a home birth?

• ·       PPH is significantly less likely to happen after a home birth than after a hospital birth.. This is probably because home birth reduces the risk of interventions which can contribute to PPH
• ·       For more info, see the National Birthday Trust Fund study in the first instance, but numerous other studies have also found a reduced PPH rate in planned home births.
• ·       Part of the reason for higher rates of blood loss after hospital birth is that PPH is statistically more likely to occur after intervention such as caesarean section, assisted delivery (forceps or ventouse), or medical induction or augmentation of labour (having a drip to speed labour up). None of these things will be happening at home. If you were to have any of these interventions, you would already be in hospital.
• ·       There are some ways in which planning a home birth actually reduces your chances of having a PPH. Simply planning a home birth significantly reduces your chances of ending up with a caesarean or an assisted delivery – labour just seems to progress more smoothly at home, leading to less call for intervention. As these interventions increase the risk of PPH, by reducing the risk of the intervention, you are reducing the risk of PPH.

Can you have a home birth after having had a PPH with a previous baby?

• ·       To try to work out the chances of a PPH recurring, and whether this is ‘safe’ for a home birth, you’d need to know why the PPH occurred, and if the same circumstances were likely to recur.
• ·       Much depends on how you felt after the PPH.  Some women feel great even after losing a considerable amount of blood whereas others may feel terrible only losing 300ml.
• ·       Its often hard to accurately measure the amount of blood loss. In the UK we call a loss of 500ml a PPH, but Europe don’t record a PPH unless over 1000ml.
• ·       What were the circumstances the PPH occurred in? Were there known risk factors for PPH which would not apply this time? For instance, PPH is more common after assisted deliveries, first babies, large babies, induction or augmentation of labour.

o      If she needed an assisted delivery this time she would transfer to hospital, so that shouldn’t affect her status as regards home birth.

o      Likewise, her labour is not going to be induced with prostaglandins or augmented with syntocinon.

• ·       Was the PPH a ‘true’ PPH in terms of being blood loss from her uterus, or was it associated with perineal tearing or episiotomy? Blood from both sources ends up in the same measuring jug, but the difference is significant.
• ·       Did she have a retained placenta, or did the bleeding occur after the placenta was delivered – some ‘uterine atony’ involved?

Conclusion

All in all the risks of a PPH are lower in a planned homebirth than in a planned hospital birth.

However if one should occur, there are many ways it can be treated successfully at home, or by transfer to hospital.

It’s also important to realise that a negative outcome from a PPH can also occur in a hospital situation as well as at home.

Having experienced a PPH following a birth is not an automatic barrier to home birth in the future, it would depend on the reasons why it occurred. In fact planning a home birth may significantly reduce the chances of having a PPH in the future.

I see many clients who are suffering with parental stress and are struggling to find ways to deal with it. Our children know just the right button to press to get our stress levels soaring!

Some common symptoms of stress can be:

• Feeling Irritable
• Tiredness
• Anxiety
• Depression
• Headaches

Some things that have helped some of my clients are:-

• Try to step back from the situation, take a deep breath and go and make yourself a cup of tea to give yourself some space for a couple of minutes.

• Have a distraction box, this can be great for any ages, fill it with toys, crayons, colouring books, craft stuff or whatever is relevant for their age. It does not have to cost a lot as you can pick up cheap items from many supermarkets. Ask your children to pick something from the box to act as a distraction to keep them busy for five minutes while you have some time to yourself.

• Your thoughts and how you perceive events around you can change your mood and stress levels. You can’t always change the world around you but you can change your reaction to it.

• Try to plan things to look forward to you are important too and need some ‘me’ time to help you to de-stress

• Know your limits, if your expectations of yourself are always sky high you will inevitably spend a great deal of time being disappointed and frustrated. Instead, be realistic in what you can achieve.

• Get Support seeking support from other people can be the key to getting through stressful situations. Ironically, your reaction when under stress can often be to withdraw from those who might offer the most support. Even worse, stressful times can put a strain on the relationships you most depend on.

• Talk to family and friends about how you are feeling. Talking openly about how you feel can be like opening a door, it helps you get back in control and can highlight the choices you have.

• Not taking on too much, accepting offers of help from others are great ways to help reduce your stress levels.

As parents we also need to remind ourselves that we are doing a good job and to recognise that good is good enough and that no one is perfect.

Learn to relax physically

To help reduce your stress levels relaxation is important but being able to relax your body is a skill. A lot of my clients find it hard to relax as they have spent all day racing round after their children, going to work, doing housework and then when it is finally time to sit down their body is still so full of adrenaline they find it near impossible to switch off.

Some good ways to help you relax are:

• Physical exercise such as go for a walk or join a dance class.
• Read a book this is a good form of relaxation as it makes you sit down and also acts as a distraction from the stressful days events by making you concentrate on the contents of the book instead.
• Breathing exercises Try breathing in for five breaths then out for six slowly.
• Treat yourself to a relaxation tape or listen to some of your favourite music.
• Or do nothing, sometimes just to sit still with a cup of tea can do wonders J

By Donna Jones

Counselling by Donna

www.dj-counselling.co.uk

RESPONSE TO CONTROVERSY OVER
PRIVATE MIDWIFERY PROVIDER:

SOCIAL ENTERPRISE PROVIDES THE ANSWER
IM UK reads with interest the mixed reactions to news of a contract between private midwifery provider One to One (Northwest) Ltd and NHS Wirral.  The service offered is one the NHS can rarely deliver: continuity of care from a midwife the woman knows, through pregnancy, birth and postnatally. However, concerns have been expressed about the impact of profit-driven private providers on the NHS.

“IM UK believes that the answer lies in social enterprise midwifery: continuity of care delivered by an organisation run by midwives and service users for the benefit of the local community,” states Annie Francis of IM UK.

“That is why we are establishing a social enterprise, named Neighbourhood Midwives, to offer local, community based midwifery services.  Care will be free at the point of access for women but provided by a social enterprise, whose values and culture are firmly rooted in a social mission and purpose. We are well down the path and are ready to provide services from April 2012.

“We are keen to be fully integrated into the whole maternity care pathway, ideally through the planned networks currently being discussed. We will be able to offer care to women planning a homebirth but often unable to access this choice because of current shortages of midwives within the NHS.”

Historically, insurance issues have been a barrier for not-for-profit providers.  During recent debates on the Health and Social Care Bill, Baroness Julia Cumberledge emphasised the need for social enterprise organisations such as Neighbourhood Midwives to be able to access insurance via the NHS Litigation Authority (NHSLA). 
For further information contact:
Annie Francis
07977695948
annie.francis@independentmidwives.org.uk

Jill Crawford
07870924857
jill.crawford@independentmidwives.org.uk

On 3 April 2011 the standard rate of statutory maternity, paternity and adoption pay increases from £124.88 to £128.73.  Furthermore there will be changes to maternity and paternity leave with a right to additional paternity leave for fathers with babies due on or after 3 April 2011.

Fathers already have the right to take up to two weeks’ paternity leave which is paid at the statutory rate. The new right involves fathers (or partners of the mothers) taking up to 26 weeks leave if the mother returns to work without taking all of her maternity leave, the child is 20 weeks old and before they have their first birthday. The new legislation will also apply to fathers/partners who are matched for adoption on after 3 April 2011.  The right extends to the spouse, civil partner and partner of the child’s mother where they have the main responsibility (with the exception of the mother) for caring for the child.  The new right might be particularly welcomed by couples where the mother is the higher earner and who wishes to return to work and allow the child to be looked after by her partner.  The father (or partner) will have to give no less than eight weeks’ notice of their intention to take the leave and will have similar protections whilst on additional paternity leave to those that women benefit from during maternity leave (i.e. the right to return to the same job, keeping in touch days, etc).  An employer has the right to request evidence of the birth/adoption.

Actions employers need to take:

•Review maternity and paternity policies and procedures to ensure they takeinto account the changes from April 2011 onwards

•Put systems in place to ensure the correct information about additional paternity leave and pay is captured – by using template notices and employee/mother declaration forms

•Organise internal processes to ensure that entitlement to additional paternity leave/pay is included

For more information contact Sandra Beale on 07762 771290.

www.sjbealehrconsult.co.uk

Midwives always say that term is between 37 and 42 weeks of pregnancy and we know that women do vary tremendously in their length of gestation.  Some women always have their babies at 37 weeks, some at 43 weeks, so why do “we” panic and suggest that women be induced at 7 or 10 days over the “magic” 40 weeks?  Indeed who came up with this figure of 40 weeks?  It is often cited that the French regard a normal pregnancy length to be 41 weeks!  Remember 40 weeks is just an arbitrary figure, and indeed many (if not the majority) of women will go over this time.

Although many women are very “fed up” by the end of pregnancy it is worth thinking about the risks and benefits of accepting a hospital induction.  It is also worth noting that different doctors and different hospitals set wide ranging dates for induction so there is clearly room for discussion with your midwife or doctor about if and when you should be induced.  Remember no one can force you to be induced!

The most important thing to remember is that you should monitor your baby’s movements – although the movements will change towards the end of the pregnancy as the baby runs out of room s/he should still move in his/her usual pattern.  Another important thing to monitor is that your bump continues to grow and is not getting smaller.  If you are at all concerned speak to your midwife or local maternity unit.

I should say is that Induction of labour is not an easy option and should, in my opinion, be avoided if at all possible, however there are many debates about when a labour should be induced; the NICE (National Institute of Health and Clinical Excellence) suggest that women should be OFFERED induction at between 41 and 42 weeks of pregnancy.  Of course there may be medical reasons for an induction, and these should carefully be discussed with your midwife and doctor, however there are also risks associated with induction, for example you are more likely to have a longer, more painful labour after an induction and you are more likely to need some help for example a ventouse or forceps delivery or a caesarean section.

If it is agreed that an induction is preferable, I would urge you to try “alternative” methods or induction before resorting to a surgical induction http://midwifevalerie.wordpress.com/2008/12/09/alternatives-to-hospital-induction/

Although methods of induction vary slightly from area to area, the principles of a “surgical” induction will involve you going into the hospital where you will first be checked over (blood pressure, urinalysis, abdominal palpation), your baby’s heartbeat will then be monitored for a period of time to ensure that the baby is well and that it is safe to proceed with an induction.

You will then be assessed internally to ascertain the best and safest method to induce you.  If it is your first baby and you are not yet in labour it is likely that the doctor will prescribe a drug called “Prostin” which is inserted into your vagina to soften your cervix with the aim of starting labour.  (Prostin is an artificial preparation of the hormone prostaglandin which is naturally present and involved in the labour process.)

Your baby may well be monitored for a period after the insertion of prostin – we want to ensure that s/he suffers no adverse reaction to the drug, – the monitoring is performed by placing two elastic belts around your abdomen to hold a “transducer” (a plastic probe) onto your tummy to obtain a print-out of the baby’s heart pattern (this is just a glorified version of the sonicaid that the midwife uses antenatally to listen to your baby).

Once the midwife is reassured she will be happy for you to get up and perhaps go for a walk or go to the hospital restaurant – it is a good idea to eat as you will need lots of energy when you are in labour!  Some hospitals will also allow you to go home and wait for labour.

Prostin does not always work first time, indeed often women need two, three or sometimes more doses and these are usually repeated at 6 hourly intervals.

An alternative to prostin is to break your waters – this can only be done if your cervix has already started to open – this is more likely if this is not your first baby, or if you have had prostin which has started the process but not put you into labour.

Breaking the waters is not particularly painful, although it can be very uncomfortable.   The midwife or doctor will need to do an internal examination and will attempt to “pop” the bag of waters that your baby is inside.  We use a plastic hook and literally try to burst the balloon of water!

Very often after the waters have broken labour will naturally start within a couple of hours, so again we wait … you can go off for another walk (are you getting a sense of the timescale here … an induction can go on for several days, so don’t expect things to happen in a hurry!).

If at this point the woman still is not in labour we usually suggest giving her a drip with a drug called synotocinon which usually starts uterine contractions.  These contractions are frequently more painful than a natural labour and because we are giving a drug we will also need to continuously monitor the baby’s heartbeat meaning that you are somewhat constrained in your movements (you can still stand by the bed or sit in a chair though).

In a few cases despite all our best efforts none of this will work and we proceed to a caesarean section.

Despite my doom and gloom, many women who are induced successfully labour and go on to have a normal birth, but to give yourself the best chance of a normal birth think carefully about whether an induction is right for you.  The decision as to whether you are induced or not should be made by YOU, in consultation with your doctor and midwife, remember it is your body and your baby; you have the right not to be induced.  A normal pregnancy is defined as between 37 and 42 weeks – so you are not even overdue until you get past 42 weeks!

More information can be found in “Induction – do I really need it?” available from www.aims.org.uk or, as always, I am very happy to speak to you info@3shiresmidwife.co.uk 

For related reading please see the following blog posts:

http://midwifevalerie.wordpress.com/2010/01/24/induction-of-labour/

http://midwifevalerie.wordpress.com/2010/10/02/postmaturity-going-overdue/

http://midwifevalerie.wordpress.com/2008/12/09/alternatives-to-hospital-induction /

http://midwifevalerie.wordpress.com/2009/07/16/natural-childbirth-the-medicalisation-of-birth/

Of course I have antenatal appointments; from the first tentative telephone enquiry I then arrange to meet up with a potential client (usually for an hour or so) so that we can discuss their past experiences, their hopes for this pregnancy, their concerns and most importantly so that they can get a “feel” as to whether they actually like and trust me.  Once a couple have decided to book me as their midwife I then usually give all their antenatal care in their own home (although I have done antenatal visits in The Bank of England medical room!).  The format of visits is that I carry out all the usual blood tests, urine and blood pressure checks, but also leave a lot of time for discussion so that over the course of the pregnancy we cover issues such as waterbirth, Vitamin K, when to call me and so on.

My clients come from a wide area – I am happy to take clients who live within approximately an hour’s radius of my home in Leighton Buzzard – so I do spend a fair bit of time driving, as well as liaising with G.P.’s and hospitals where necessary.

Four times a year I jointly organise an Antenatal Exhibition, this is an opportunity for pregnant couples to gather information about breastfeeding, pregnancy yoga, cloth nappies and the like.  We also organise Birth Preparation Workshops and am often to be found at the Community Desk in Central Milton Keynes on hand to speak to expectant parents and also regularly attend Study Day’s and midwifery meetings to ensure that I keep myself up-to-date with current research.

Obviously I spend much of my time being “on-call” for births.  My own family are now pretty much grown-up and the commitment isn’t as big as one might imagine as I rarely have more than two births during a month – it is important that I don’t over-commit myself as the whole point of what I do is that I guarantee to be there for the birth.  Babies don’t always read the text books though!  I have had three births in one week, as of course some babies do come early and some come late!  As you will appreciate, the birth is the big event, and it can on occasion go on for some time.

Baby being here doesn’t mean that my job ends!  In fact, postnatal visiting is often one of the busiest times as the family may need quite a lot of support in the early days.  The majority of my clients choose to give birth at home; however some either need to, or choose to give birth in hospital.

I visit my clients for up to four weeks postnatally and it is a joy to see the baby thriving and although discharging clients is always tinged with sadness it is also great to know that I have played a part in helping the family on to the next stage of their life.  (I do usually keep in touch, perhaps not as often as I would like, but I often get e-mails and photographs and usually pop in when I’m passing!).

So, in summary I guess the main differences between me and an NHS midwife are that you are buying my time; antenatal visits usually take around an hour and a half (instead of perhaps 10 – 15 minutes at your local surgery), are arranged more frequently and take place at a time and place to suit you. Most importantly you will receive full continuity of care – I will see you at each visit to build our relationship and plan your care and you will know that (barring exceptional circumstances) I will be with you in labour and available 24/7 for urgent help.

I am always happy to discuss anything that you are concerned about; please do feel free to call.

Written by Valerie Gommon, BA (Hons), RM, Independent Midwife

www.3shiresmidwife.co.uk 01525 385153