Valerie Gommon Midwife’s Blog

Archive for the ‘forceps’ Category

Pregnancy

“The condition of having a developing embryo or fetus in the body.”
“The process by which a human female carries a live offspring from conception until childbirth.”

Pregnancy is referred to as a gestation period – the time between conception and birth. Approximately 40 weeks (280 days). Measured from the first day of the last menstrual period. For women who use a procedure that allows them to know the exact date of conception (such as in-vitro fertilisation IVF, or artificial insemination) the gestation period is 38 weeks (266 days) from conception.

Pregnancy is divided into three stages – called trimesters, each lasting about 3 months.

An embryo is a multicellular diploid (has two sets of chromosomes) eukaryote (an organism whose cells contain complex structures enclosed within membranes) in its earliest stage of development; from the time of first cell division until birth. In humans, it is called an embryo until about eight weeks after fertilization (i.e. ten weeks after the last menstrual period or LMP), and from then it is instead called a fetus.
Embryo is the term used to describe the developing baby in the first 8 weeks and the term Fetus is the term used after 8 weeks until birth (when all the structure of the baby and systems of the body such as the digestive and nervous systems have developed).

Facts at 24 weeks
24 weeks is the legal cut off gestational age for a legal abortion (although abortions or terminations can be carried out later in the pregnancy on medical grounds).

COMPLICATIONS OF PREMATURE BIRTH
Babies born after 34 weeks have a low risk of problems although they are sometime slower to feed.
A baby born before 33 weeks will have more serious problems such as immature lungs.
Very premature babies (born under 28 weeks) need to be delivered in a hospital with a neonatal intensive care unit.
Doctors have been able to improve dramatically the survival hopes for babies born as early as 22 or 23 weeks.
However, very premature babies face a huge battle at the start of life. They are at risk of serious conditions including:
* Hypothermia, due to lower levels of fat
* Low blood glucose, which can lead to brain damage
* Respiratory distress syndrome – which can cause blindness
* Brain haemorrhage
Long-term they may have cerebral palsy and have sight and hearing problems.
They are also more likely to have motor impairments and co-ordination and concentration problems.

Birth
Occurs at around 38 weeks after fertilization, so 40 weeks pregnant. Term is considered to be 37 – 42 weeks gestation. The fetus has developed enough to survive easily outside its mother’s body. Babies are usually born head first but occasionally are born breech.

http://www.babycentre.co.uk/v1027487/inside-pregnancy-weeks-28-37

There are a variety of birthing methods; the majority of babies are born by a natural vaginal birth but some labours might need help such as
Ventouse, Forceps, Caesarean section.

The process of natural birth involves what is known as “labour” the baby passing from the mother’s abdomen through the vaginal passage and into the world. There are three stages of labour:

Stage 1: The cervix has to open and stretch around the baby’s head until it is 10cm open.

Stage 2: The baby has to come out, either by the expulsive efforts of the uterus and the mother breathing the baby out, or by her actively pushing the baby out.

Stage 3: The placenta or afterbirth has to be expelled.

Linked blog posts:

https://midwifevalerie.wordpress.com/2008/12/07/so-you-are-pregnant-preparing-for-the-birth/
https://midwifevalerie.wordpress.com/2008/12/19/the-big-day-the-birth/

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Homebirth

Posted on: July 17, 2010

There are many benefits to be gained by giving birth at home.  The woman is in familiar surroundings and is therefore more relaxed allowing the birthing hormones to work properly.  Labour is usually shorter, less painful and the mother is more likely to have a normal birth (so less need for ventouse, forceps or caesareans), she is more likely to breastfeed and less likely to suffer postnatal depression and she is more likely to report that she is satisfied with her experience.  These claims are backed up by research and evidence can be found at www.nct.org.uk/about-us/what-we-do/research/roepregnancy-birth

The British Government policy is to encourage homebirth www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073312) and in the Netherlands 30% of babies are born at home – would they really be supportive of homebirth if it were so dangerous?  A large retrospective cohort study from the Netherlands in 2009 http://www.welbornbaby.com/images/Home%20Birth%20Netherlands.pdf confirmed that the planned place of birth was not the main factor in contributing to perinatal morbidity and Low-risk women should be encouraged to “plan their birth at the place of their preference, provided the maternity care system is well equipped to underpin women’s choice”.  Furthermore, also published in 2009 was another study, from Canada http://www.sciencedaily.com/releases/2009/08/090831130043.htm which showed that planned home birth in low risk women were comparable to hospital births.  Both these studies concur with the latest US study http://www.sciencedaily.com/releases/2010/07/100701072730.htm demonstrating that women who plan home births experienced significantly fewer medical interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative vaginal and caesarean deliveries. Likewise, women intending home deliveries had fewer infections, perineal and vaginal lacerations, haemorrhages, and retained placentas. Data also showed that planned home births are characterized by less frequent premature and low birth weight infants.

This same American study is often quoted by obstetric practitioners because a conclusion read that infant mortality was trebled by planning a home birth, but suggested “it was because of an increased need for resuscitation among home births and therefore, the personnel, training, and equipment available for neonatal resuscitation represent other possible contributors to the excessive neonatal mortality rate among planned home births.”  The methodology of this study has also been severely criticised www.nct.org.uk/about-us/what-we-do/policy/choiceofplaceofbirth.

In conclusion, planned home births are very safe.  It is the presence of trained midwives with correct and necessary equipment that is most important factor, rather than location, in regards to safety of mother and baby.

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

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!


There has been quite a bit of debate this week about whether women should have access to an epidural in labour.

Of course in the majority of cases women do have access to an epidural in labour if this is what they choose, however many maternity units cannot GUARANTEE that a woman will get an epidural when she requests one.  This may be for several reasons.  A woman who has an epidural needs to have one to one midwifery care to ensure the safety of both the mother and her baby.  If a unit is particularly busy or poorly staffed a midwife may not be available to give this level of care (it is well documented that midwives are often caring for two or more women who are in active labour), secondly, an anaesthetist may not be immediately available.

The debate occurred because there have been several articles in the media recently regarding the National Childbirth Trust’s (NCT’s) views on women’s access to epidurals following the publication of a guidance document, “Making Normal Birth a Reality”, drawn up by the NCT with the backing of the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists. www.appg-maternity.org.uk/resource/Normal+Birth+Consensus+Statement+NEW+LOGO.pdf and www.nct.org.uk/press-office/press-releases/view/128

There was a very interesting debate on Woman’s Hour this week when Belinda Phipps, the Chief Executive of the National Childbirth Trust was interviewed opposite Smriti Singh.  www.bbc.co.uk/radio4/womanshour/02/2009_10_thu.shtml and

The programme highlighted that epidurals are extremely safe (and I say thank goodness for the fantastic medical care we have if it is needed), but I personally do feel that there are very good reasons for avoiding an epidural if possible.

Epidurals are not recommended until a woman is in “established” labour, that is that she is having regular, strong contractions and that her cervix is dilated (usually to 3cm).  The reason for this recommendation is that if the epidural is given earlier the labour could stop as labour may not be fully established.

By having an epidural, a woman is usually confined to bed.  She will need to have her baby continuously monitored by a cardiotocograph machine (CTG) as the epidural can affect the baby, she will also need an intravenous drip because the epidural can significantly lower her blood pressure and she may well also need a urinary catheter to keep her bladder empty.  Being confined to bed will not allow the normal active behaviour of the mother which will help the baby into the optimum position for birth, nor will she have the affect of gravity.  Epidurals occasionally allow the labour to progress more quickly, but more likely the labour will slow and an oxytocic drug (syntocinon) will be needed to increase contractions, and so the “cascade of intervention” continues.  It is also true that women are slightly more likely to need assistance from either a ventouse or forceps to deliver their baby as it is more difficult to “push” out the baby when you have an epidural.

Whilst being an advocate for my clients, and if (given this knowledge) a woman chooses an epidural I honestly believe it is my job to support her in this choice; this said, I believe that far fewer women would actually choose an epidural is they received appropriate one to one support, preferably from a known midwife during their labour.


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