Valerie Gommon Midwife’s Blog

Archive for the ‘NICE’ Category

The idea that the umbilical cord should not be cut immediately after the birth but left to pulsate giving the baby extra blood, oxygen and stem cells is not a new idea to myself or many of my colleagues.  I have long believed that the baby should remain “attached” via the umbilical cord to his/her mother and my usual practice is to await “delivery” of the placenta before asking the mother or father to cut the umbilical cord.  I believe that early cord clamping interferes with the normal physiology of birth.

Recently Dr David Hutchon, a retired consultant obstetrician from Darlington, wrote in the British Medical Journal that maternity staff should wait for several minutes before cutting the cord and has also called for further research into leaving the cord intact.  http://topnews.co.uk/216535-expert-calls-hospitals-change-practice-clamping-newborns

The National Institute for Health and Clinical Excellence (NICE) still advocates active management, which includes early clamping and cutting off the cord. These guidelines mean that doctors and midwives are sometimes reluctant to change their practice.  This is despite the fact that both the World Health Organisation and the International Federation of Gynaecology and Obstetrics advise doctors to refrain from early cord clamping.

In summary, it is definitely worth thinking about whether you would prefer your baby’s umbilical cord to be left to pulsate and indeed possibly left intact until you have delivered your placenta.

Midwife Gloria Lemay also comments on this issue on her website.

www.gentlebirth.org/archives/lateClamping.html

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 National Institute for Health and Clinical Excellence (NICE) are suggesting that midwives carbon-monoxide test women to check whether they are smoking – http://bit.ly/bTmg83.  Is this helpful or “policing”?

NICE suggest that every expectant mother should be tested during her pregnancy to enable smokers to receive advice on quitting.  Whilst this might be a positive intervention there is also concern that some women may not engage with midwives if they are seen to be “policing” and judgemental.  It is certainly something that will need careful consideration and sensitive handling as many hard-to-reach clients are also smokers and it would be easy to alienate these women further.

The NHS has made huge attempts to help women stop smoking http://smokefree.nhs.uk/smoking-and-pregnancy/

A baby born to a smoker is:

  • Twice as likely to be born prematurely
  • More likely to suffer from placenta problems around the time of birth
  • Three times more likely to be underweight at birth (even if born on time)
  • More likely to be a victim of cot death.

Whatever stage of pregnancy it is never too late to give up – you and your baby will benefit immediately.  You can call the NHS Pregnancy Smoking helpline 12pm to 9pm, 7 days a week 0800 169 9 169


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


Twitter