Valerie Gommon Midwife’s Blog

Archive for the ‘caesarean’ Category

I know I’ve been quiet of late, not many blog postings.  This is mostly because I’ve been busy clinically, and I thought that today I’d share a recent experience of a breech birth with you.

I had previously cared for my client with her second baby – she had a quick and straightforward birth with that baby and so I was prepared that this labour could be quick again.

The pregnancy progressed without any concerns and at term she called me to ask me to attend … she didn’t feel she was actually in labour, but in view of the fact that she lived some distance from me, she felt she may need me to be there to go into labour.

On arrival with my client I performed the usual checks, blood pressure, urinalysis and abdominal palpation.  Hmmmm … felt strange … I asked if I could perform a vaginal examination (something that I rarely need to do) and sure enough there was no head presenting.  Indeed to start with I wasn’t sure what was presenting – perhaps a leg, perhaps an arm … but her cervix was very dilated, so she had been quietly labouring overnight!

We discussed her options, and I consulted with other colleagues for suggestions and asked another midwife to attend.  Obviously this was not going to be a usual scenario and we discussed transfer to hospital.  My client felt that neither she nor baby were in immediate danger so she preferred to stay at home and try a “knee-chest” position to attempt to move the baby.  This was actually quite successful, and a further vaginal examination showed that the leg/arm had moved.  I still wasn’t sure what I was feeling, and mother and baby were well so we continued.

On a further examination I determined that it was definitely a little leg and foot presenting, so at least we now knew what we were dealing with!  My client felt very trusting that all would be well, or at least accepting of whatever happened.  Her labour was slow and not at all usual, but, it was similar to her two previous labours and we were reassured by this.

Slowly, slowly things progressed and eventually we saw a little foot presenting!  I have some experience of breech birth (as did my second midwife) and I felt quite confident in both my ability and the mother’s.  The foot became a leg, one leg became two legs, little boys “bits” showed, the torso emerged, then one arm and another, before finally a head was born with the membranes stuck tight!  The baby was in good condition and needed no help (something we were all expecting, as breech babies are much more likely to need some resuscitation).

Wow, what a great day – mother was so very pleased with herself, and Dad too – he was great!  Midwives hugged and baby was cuddled!

So, breech babies can be born normally.  Of course it is always going to be slightly more risky and some breech babies will need to be born by caesarean, but this woman would almost certainly have had a caesarean if she had gone to hospital and here she was tucked up in bed with her family at home.

Oh, and by the way, he weighed 9lb!

The first thing I should say is that Induction of labour is not an easy option and should, in my opinion, be avoided if at all possible.

There are many debates about when women 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 www.nice.org.uk/nicemedia/pdf/CG70quickrefguide.pdf

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 https://midwifevalerie.wordpress.com/2008/12/09/alternatives-t…ital-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 passed 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

In recent years most breech babies have been born by caesarean section in the UK.  Doctors usually suggest that a caesarean is the preferred option, however some midwives and doctors do not necessarily agree and certainly some mothers prefer to attempt a vaginal birth.

There is an excellent resource written by Jane Evans called “Breech Birth – What are my options?” available from www.aims.org.uk which talks about all the options.

If you should find your baby in the breech position there are several things you can try in an attempt to turn the baby cephalic (or head down).

First of all you could ask your doctor about External Cephalic Version (ECV) when a doctor attempts to manually turn the baby (from the outside).  This is done under very carefully controlled conditions; usually on labour ward just in case the baby becomes distressed and a caesarean is needed.  ECV can be quite uncomfortable and even painful but does have a reasonable success rate.

I always think it is worth considering alternatives, be that acupuncture, homoeopathy or chiropractic.  After all you have nothing to lose and they may well be successful.

Another suggestion is to lie at an angle, either on pillows or ironing board, with your head down and feet up and help the baby to turn over this way.  The theory is that this angle helps the baby tuck their head, thus making it easier for them to flip over, like doing a somersault.  It is recommended doing this fifteen to twenty minutes two to three times a day as early as 32 weeks and until the baby turns head down.   At the same time try to relax and visualise the baby moving into a head down position – even try to communicate with the baby and “tell” him/her to go head down if they can.

Another version of this would be to try few somersaults in the swimming pool (if you can manage it!).

Massage, either used alone or in combination with other ideas mentioned here, such as the “breech tilt” may be helpful.  Simply rub both hands wide and flat around the belly in the direction you want the baby to turn.  Both hands should stay opposite each other and move circularly, around the baby.

A slightly more drastic option is to place an ice pack (do not place directly on your skin) or even a frozen bag of peas against the top of your uterus may cause your baby to attempt to turn it’s head away from the cold temperature, or some people talk about shining a torch on their abdomen to direct the baby to the bottom of the uterus – weird and wacky, but worth a try … you’ve not got anything to lose!

If you want to speak to a midwife about any of these ideas you can always contact me info@3shiresmidwife.co.uk

 
Milton Keynes General Hospital is in the news this week with a story about a client who allegedly objected to non-white staff being in the delivery room. Apparently hospital staff have complained to the Equality and Human Rights Commission about the way the situation was handled earlier this month when an unnamed white woman had a Caesarean section at the hospital. The hospital said it had begun a full investigation and said it is thought to be the first time such a request has been made to them.

http://news.bbc.co.uk/1/hi/england/beds/bucks/herts/8330102.stm

http://www.dailymail.co.uk/news/article-1223598/Pregnant-woman-race-demand-Buckinghamshire-hospital-facing-prosecution.html

ENTONOX

Also known as “gas and air” (50% oxygen and 50% nitrous oxide).

Self administered through a mask or mouth piece

Used to breathe in and out during contraction

Helps you cope with the pain and also acts as a distraction by giving you something to focus on

ADVANTAGES

Helps take the edge off the pain

Does not affect baby

Can not overdose

Can stop using it at any time

DISADVANTAGES

Can make you nauseous or vomit

Can make you feel “drunk” or out of control

MEPTID

A pain killing drug similar to pethidine.  It is given by injection either into your bottom or thigh.  It usually relaxes you a bit and takes the edge off the pain.  This drug has to be prescribed.  We give an amount proportionate to your weight.

ADVANTAGES

This drug helps some women

The effects on the baby are probably slightly less than pethidine

The nausea/”drunk” feeling may be less than pethidine

Can be given again after 2 hours

DISADVANTAGES

It can make some women feel nauseous and vomit

Some women do not to feel “out of control”

It may affect the baby’s breathing/ability to breastfeed if given shortly before the baby is born

Can not have meptid if having a waterbirth

PETHIDINE

A pain killing drug, given by injection into your bottom or thigh.  It takes about 20 minutes to take effect and lasts for up to four hours.  It usually takes the edge off the pain and relaxes you.

ADVANTAGES

Effective pain relief for some women and relaxing if nervous

Can help you to sleep

DISADVANTAGES

Some women do not like the “out of control” feeling

Can cause nausea and vomiting

For some women it has no effect at all

Pethidine crosses the placenta and can affect baby’s breathing/ability to feed (antidote is available)

Can not have if having a waterbirth

DIAMORPHINE

Similar to Pethidine – A pain killing drug, given by injection into your bottom or thigh.  It takes about 20 minutes to take effect and lasts for up to four hours.  It usually takes the edge off the pain and relaxes you.

ADVANTAGES

Effective pain relief for some women and relaxing if nervous

Can help you to sleep – long lasting

DISADVANTAGES

Some women do not like the “out of control” feeling

Can cause nausea and vomiting

For some women it has no effect at all

Diamorphine crosses the placenta and can affect baby’s breathing/ability to feed

Can not have if having a waterbirth

EPIDURAL

An epidural is where painkilling drugs are passed into the small of your back via a fine tube. It is called a regional anaesthetic, which means the drug is injected around the nerves that carry signals from the part of your body that feels pain when you’re in labour. The result will be that your belly feels numb, giving you very effective pain relief

ADVANTAGES

Good pain relief – especially if labour is long, or instrumental delivery is required

It can be used during a caesarean section and therefore avoids the use of a general anaesthetic

DISADVANTAGES

You need to remain very still whilst epidural is being sited

It causes a drop in maternal blood pressure:

You will need an intravenous drip to counter this drop in blood pressure

Drugs used pass through the placental barrier

Your baby will need to be continually monitored – in extreme circumstances the baby can become distressed necessitating an urgent caesarean section

You will usually need a urinary catheter to empty your bladder

It can slow the labour necessitating a syntocinon drip to get contractions going again

It restricts your movement – usually you will be confined to bed and it can be harder for the baby to get into the best possible position for birth, this can make the labour longer, and make it more likely that you need help (ventouse, forceps or caesarean section)

It may not be 100% effective and you can have “break-through” pain

There is a lack of sensation to ‘push’ in the second stage and this leads to an increased need for ventouse or forceps deliveries

The effects can take some time to wear off


What is the definition of Natural Childbirth?  A hospital might say that a woman whose labour was induced and who had an epidural was a normal birth; others might say that induction, augmentation, analgesia, episiotomies etc do not constitute a normal birth!

A more radical definition of a natural birth might be a labour that starts spontaneously between 37 and 42 weeks gestation, and progresses to a vaginal birth without any intervention or pharmacological drugs.

Natural childbirth has been given a bad press – women choosing natural childbirth have been described as “hippy types” and indeed there has been an item in the press this week about a midwife who suggested that women would do better to avoid epidurals that has caused considerable outrage!

Pregnancy and childbirth are normal life events, not medical condition; a woman’s body is perfectly designed to give birth.

Of course some pregnancies and labours will need medical help – but the vast majority of women will go through their pregnancy and birth without problems and this process works best when interference is kept to a minimum.

For example anything we do to interfere with this natural processes has consequences – if mother and baby are well I am suggesting that we (the medical profession) should not interfere!

One example of this is the huge number of women whose labours are induced – why?  In some areas women are induced at 41 weeks (interestingly in France a normal pregnancy is defined as 41 weeks!).

Induction is not an easy option.  It is usually quite a lengthy process which makes the mother tired.  It is also usually more painful and the mother is therefore more likely to need pain relief, possibly an epidural … the mother is then less mobile … making it harder for the baby to find a way through the pelvis and consequently she is more likely to need the help of a ventouse or forceps, or even a caesarean section.

We all know that although caesareans are very safe in this country, it is still far safer for both mother and baby if the baby is born vaginally.  A caesarean section is major abdominal surgery which will take weeks and months to fully recover from – and the mother will have a demanding baby to care for too!  Babies born by caesarean also have many more problems, and are far more likely to need to receive Special Care.  There are also implications for future pregnancies – so, although fantastic if needed, caesarean sections are far from ideal.  The World Health Organisation recommends a 5 – 10% caesarean section rate, but our rate is approaching 30%, and I believe 90% at The Portland private maternity hospital!

This interference in birth has been called a “cascade of intervention”, because we do a) we have to do b) and because we do c) d) is also necessary this is also described as “iatrogenic” or hospital induced.  Whatever we do has consequences, for example a woman with an epidural will need more careful monitoring, she will need an IV drip and also a catheter – so you can see this spiral effect, because we do this, we have to do that and so on …

I believe there are several factors that lead to this escalation of intervention in childbirth:

Our cultural conditioning, fear, poor health habits and medical intervention in normal birth (perhaps because of fear of litigation) that make birth difficult often requiring more intervention, including surgery.

With good preparation, much intervention can be avoided – women who have a midwife they know and trust are less likely to need analgesia.  With good preparation they should be in optimal health for the birth – complementary therapies they may have experienced acupuncture, homoepathy, osteopathy or any number of helpful treatments during their pregnancy which will help align their body and prepare them for birth.  They may also have practised relaxation or hypnosis techniques all of which can be hugely beneficial.  There is also much a woman can do to help herself: mobilization, relaxation, support, the use of water …

The satisfaction that a woman feels when she has successfully given birth is amazing – it is empowering and is a fantastic start to the parenting journey, and of course breastfeeding is so much easier when you haven’t got a caesarean section wound on your abdomen.

If things didn’t work out this way for you, remember that you did the very best you could at the time.  Some labours do need help and some mothers and babies wouldn’t survive without the help of our medical colleagues.  If this has raised questions or distress for you I am more than happy to speak to you please do feel free to email me info@3shiresmidwife.co.uk

A difficult or traumatic birth experience has long-lasting implications for both the mother and sometimes her child.  We don’t have many babies in our lifetime and it is important to get things as right as we possibly can!

Joanna Moorhead writes in The Guardian about how hospitals are trying to reduce the trend of repeat caesareans www.guardian.co.uk/lifeandstyle/2009/jun/16/caesarean-elective-section-giving-birth

The caesarean section rate is shockingly high.  The Association for Improvements in Maternity Services (AIMS) wrote in 2004 that the caesarean rates had continued to rise to 23 per cent, but many hospitals had rates approaching 30 per cent, indeed The Portland private maternity hospital had almost a 90% section rate.  The national caesarean section rate has continued to rise and in 2007 – 2008 was quoted as 24.6% .

Moorhead’s article highlights the dilemma – one woman was encouraged to attempt a vaginal birth after having had a caesarean first time around – sadly this woman ended up with a repeat caesarean however another woman was supported by a sympathetic obstetrician and given information about the benefits of trying for a normal birth – this woman went on to have a normal birth and was very happy with the outcome.

In fact the chances of having a vaginal birth after a caesarean are actually very good (this is obviously something you will need to discuss with your midwife and obstetrician) and I am happy to report that I have supported many women to achieve this.  There are some women however who will need a caesarean and we need to be careful not to make them feel that they have failed when a caesarean is necessary.  It is important to remember that without recourse to good medical help some women and babies would not survive!

If this is something you wish to discuss further I would be happy to speak to you, feel free to contact me by email info@3shiresmidwife.co.uk

I have also been given a copy of “Real Healing after Caesarean” by Martha Jesty which I confess I still have to read!


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