Valerie Gommon Midwife’s Blog

Archive for the ‘Obstetrician’ Category

http://www.timesonline.co.uk/tol/life_and_style/health/article6932530.ece

Men who panic when their partners go into labour may be rushing them into hospital too early. Professor Mary Nolan, of the University of Worcester, said that their interference could be overriding the advice from midwives and leading to greater numbers of complicated births.

Labour can last 12 to 18 hours for a woman giving birth for the first time, and the longer women are in hospital the more likely they are to receive medical interventions such as painkillers or drugs to hasten labour when they don’t need them.

Midwives try to encourage women to stay at home as long as possible because evidence suggests that the longer a woman stays out of hospital, the more straightforward her labour. Hospitals also want to avoid women blocking beds for hours before they give birth.

But a survey of 2,400 women visiting the parenting website Babycentre.co.uk and follow-up phone interviews with new mothers found that despite the advice of midwives to stay at home during the early stages of labour, many fathers had been anxious to get to hospital quickly.

Professor Mary Nolan, from the University of Worcester, said: “Women rely on their partners to support them during labour but many first-time fathers feel that they should get their partner into hospital as quickly as possible.

“Although women are prepared to heed the advice to stay calm and remain at home until they really feel like their labour is progressing fast, the fretting of their partners drove them to go in earlier than they would otherwise have done”.

The findings come as the role of fathers before and during childbirth will be debated at the Royal College of Midwives’ Annual Conference in Manchester today.

Michel Odent, a leading French obstetrician and author, will argue that men should not be present in the delivery room when women give birth, as their anxiety can be catching and make labour longer, more painful or likely to result in a Caesarean section. Men now attend more than 90 per cent of births in the UK, a proportion that has grown significantly since the 1950s.

Dr Odent believes that the birth process had become too “masculinised” in recent years, and delivery of babies would be easier if women were left with only an experienced midwife to help them, as used to be the case.

“It is absolutely normal that men are not relaxed when their partners are giving birth, but their release of adrenaline can be contagious,” he said yesterday. “When a woman releases adrenaline she cannot release oxytocin, the main hormone involved in childbirth, which can make labour longer and more difficult.”

“We have to reconsider the political correctness of the couple giving birth together; it’s not necessarily the best way.”

Duncan Fisher, chief executive of the website Dad.Info, will oppose the motion that “Birth is no place for a father”.

“Of course, not all men are nervous and a lot of women would be even more nervous without their partner there,” he said. “Mothers want them there because it is not home.”

Professor Nolan added that the presence of a caring partner in the labour ward could be valuable to women, especially if shortages of staff meant that no midwives could provide continuous care and support during and after birth.

A poll of 3,500 new mothers for the RCM this week found that one in three were left alone and worried during labour or shortly after giving birth on the NHS.

Andy Burnham, the Health Secretary, said this week that he intends to reform the system of hospital funding to take account of patients’ satisfaction rates, starting with maternity care.

Andrew Lansley, the Shadow Health Secretary is due to announce Conservative policies today which will include “drawing in the whole family around the time of birth” and improving antenatal care. “We often do not involve the father and grandparents as much as they and the mothers would like,” a Tory spokesman said.

Cathy Warwick, the RCM’s General Secretary, commented: “We support a mother’s right to choose her birth partner during labour. There is no evidence base or research, of which we are aware, to suggest that a father’s presence impedes and interferes with the mother’s birth. We will welcome a healthy discussion of these issues during the debate at the conference.”

(Written November 2009)

I was really pleased to hear a very balanced “Case Notes” radio programme about Maternity Services presented by Dr Mark Porter.

The programme discussed the varying styles of maternity care, including homebirth and Consultant Obstetrician, Mike Marsh from Kings in London was supportive and open to women’s choices.

This won’t be up for long, but well worth listening to ….

http://bit.ly/ahpbMa

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

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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