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Risky modelling for child abuse: could these methods actually increase abuse, maltreatment and violence?

“What kind of love is it that has violence as a silent partner?” Keri Hulme- The Bone People

This week the Guardian reported “Vast quantities of data on hundreds of thousands of people is being used to construct computer models in an effort to predict child abuse and intervene before it can happen” https://www.theguardian.com/society/2018/sep/16/councils-use-377000-peoples-data-in-efforts-to-predict-child-abuse

The software can be used to generate revenue for the council through the Troubled Families payments-by-results scheme. Under the Troubled Families scheme, councils are paid £1,000 for each family they sign up to the programme, with a further payment of £800 when the family meets certain criteria.
This move is described as a way to reduce costs in a context of increasing austerity, cuts to services and deprivation within a neo-liberal agenda. There are calls for complex thinking and modelling increasing use of technology


Should the UK be increasingly going down the road of predictive modelling? Is there any evidence that this approach can pre-emptively predict abuse risk and prevent outcomes- complexity thinking often finds unintended negative consequences when changing complex system
This topic has been extensively explored as a predictive modelling system for child abuse was created and modelled in New Zealand
There are many possible serious consequences to trying to model risks to children of future child abuse:

1 Ethical and legal: Is it ethical or legal to share or use peoples data in such a way?

it may also not be legal under GDPR (which asks that ‘You can only use the personal data for a new purpose if either this is compatible with your original purpose, you get consent, or you have a clear basis in law’.
Who will be able to access this data, and what will it mean for people and families who are scored in a high risk category?

Issues relating to the ethical principles:
Existing risk instruments lead to an unacceptably high level of false positives (families inaccurately deemed to be high risk) and a high level of false negatives (dangerous families wrongly judged safe)

2 Stigmatisation of already vulnerable and marginalised groups:
“As the variables used rely more heavily on data about mothers (as is more available in the data), and use socio-economic status (SES) as a variable, female caregivers will overwhelmingly be identified as ‘risky’” (Keddell 2015)
This is likely to result in increased public stereotyping and rejection “assigning the label ‘risky’ permanently to people who have not harmed and may never harm their children based solely on statistical association.” (Keddell 2015)
Whilst we might know factors that are associated with abuse, these are NOT causal. Labelling people as ‘at risk’ to their children is likely to reinforce existing structural inequalities

3 Individualisation and increasing risks:
“Where risks are individualised, for example, this clearly reflects a neo-liberal concern with personal responsibility and a limited role of the nation state.”
So we ignore the fact that people that are living in areas with very real risks and concerns, noise, pollution, debt, violence, food insecurity, disability, lack of access to healthcare, education, culture, art, community, safety and instead blame them for their individual ‘choice’ to engage in any kind of perceived ‘risky’ behaviour. This takes responsibility away from the state for having to work to reduce inequality and improve living conditions.

4 Complexity and ‘machine’ learning:
Big data is seen as an answer to the huge issues we as a society are facing but data is useless if we are not asking the right questions or if we are unable to understand, interpret or use the results. The complexity of the methodological processes make it difficult to predict the ethical consequences of big data systems
“The whole point about big data analytics is that the number and form of calculations that need to be carried out exceed the scale and complexity which people can comprehend directly” (McQuillan 2018)
McQuillian goes on to equate this to the use of drone technology. If we risk score populations then we are removed from the individuals and the real consequences to them, both of knowing they are believed to be ‘a risk’ but also of their story and personal circumstances, which could result in dehumanisation.
Unconstrained machine learning can become a drone perspective, a targeting gaze that blurs legality and divides the social along decision boundaries of “us and them.”

5 Unintended consequences:
Another recent example of risk modelling looked at teen dating behaviour and whether a theoretically informed, empirically based algorithm that could adequately estimate the likelihood of physical and sexual TDV perpetration during vulnerable developmental periods. The study found that adolescents with positive test results on the algorithms were over twice as likely to perpetrate dating violence over the course of 6 years. (Cohen, Shorey et al. 2018)
The authors themselves, and commentators on the study recognise that labelling teenagers as potential future perpetrators of dating violence could be highly stigmatizing and lead to a self-fulfilling prophesy where individuals believe they are destined to enact violence. (Thurston and Howell 2018)
This sort of modelling is also used in the criminal justice system and has historically led to increasing fragmentation and alienation of those deemed ‘risky’ (for example ethnic minorities, those with serious mental health conditions, children leaving care etc.) and increases in the very behaviours which are being flagged in this misguided effort at prevention
“The policy implications of these findings are stark. Developmentally speaking, experiences of reduced fairness correlate with social isolation, deprivation of dignity, reduced faith in public institutions, and an increased propensity towards activities and behaviours deemed risky or socially non-normative” (Nichols 2017)
Once a person or placed is categorised as ‘at risk’ is it possible for that label to be removed? And under what conditions. This is also important in communities
“It is increasingly common to use measures to determine relative degrees of vulnerability across a particular institutional geographic context (e.g. the designation of Neighbourhood Improvement Areas and Vulnerable Schools by the municipality and the school board, respectively). Officially, the scales are used to ensure equitable distribution of limited resources, but they also result in particular spaces being coded institutionally (through crime or school achievement data, for example) as vulnerable or unsafe. These designations justify the use of place-based public sector interventions that are not always experienced as resources or supports by people who become their focus.” (Nichols 2017)
I presented at the Public health England conference last week about an asset based community development project on the Wirral that I am evaluating. Interviewing individuals across the area it is clear to see people are very aware of the reputation of the area that they live in.
Also at the conference I attended a session on using data to model future trends, this is increasingly used by councils to plan services and predict trends:

It’s also possible that the current interest in screening for adverse childhood experiences (ACE) could be used to feed into these models rather than thinking ‘what happened to you’ but what who might this mean you could harm in the future?
The data used to feed into these algorithms are what we know about associated risk factors for child abuse and maltreatment, upstream efforts should be looking at what we already know, not focusing on identifying families where abuse is occurring but looking at the wider environment around the family and prevent the conditions that lead to abuse occurring. (Keddell 2018)
“Since rates of maltreatment decline as material supports increase (Pelton, 2015), efforts to reduce poverty must be pursued” (Gillingham 2017)

Risk modelling to prevent child abuse, but also the wider uses of big data and machine learning need to be robustly evaluated to evaluate whether it is ethical and results in better predictive values or improved outcomes or unintended increases in risk.
Safeguards should be in place to prevent data being manipulated in this way without consent and for public discourse about the wider societal ramifications of using big data and machine learning (Amrit, Paauw et al. 2017)

Amrit, C., et al. (2017). “Identifying child abuse through text mining and machine learning.” Expert systems with applications 88: 402-418.

Cohen, J. R., et al. (2018). “Predicting teen dating violence perpetration.” Pediatrics: e20172790.

Gillingham, P. (2017). “Predictive risk modelling to prevent child maltreatment: insights and implications from Aotearoa/New Zealand.” Journal of public child welfare 11(2): 150-165.

Keddell, E. (2015). “The ethics of predictive risk modelling in the Aotearoa/New Zealand child welfare context: Child abuse prevention or neo-liberal tool?” Critical Social Policy 35(1): 69-88.

Keddell, E. (2018). “The vulnerable child in neoliberal contexts: the construction of children in the Aotearoa New Zealand child protection reforms.” Childhood 25(1): 93-108.

McQuillan, D. (2018). “People’s councils for ethical machine learning.” Social Media+ Society 4(2): 2056305118768303.

Nichols, N. (2017). “Technologies of evidence: An institutional ethnography from the standpoints of ‘youth-at-risk’.” Critical Social Policy 37(4): 604-624.

Thurston, I. B. and K. H. Howell (2018). “To screen or not to screen: overreliance on risk without protective factors in violence research.” Pediatrics 141(4): e20180075.

Further discussion of UK councils using data to model child abuse risk

Doulaing, kittens and wet-nursing

breastfeeding 1

I’m not able to do as much doula work as I’d like nowadays, as a full time working single mum, parenting a teenager and school child with #ADHD I’m pretty busy. I still do one to one sessions and teach workshops when I can. But doula work is in your bones, the doula mindset I now use in my everyday life all the time, approaching difficult people as if they were in labour can work wonders. If someone has unpredictable behaviours, extreme emotions, confusing needs- you can do well by loving presence, deep listening, going barefoot, breathing slowly, mirroring calm. Finding a transcendent part of you that sees the sacred in our everyday transactions. looking at the environment you are in- can it be changed to reduce peoples anxieties? Lights turned down, think about the acoustics, the smell. This week my son has been very anxious and worried, he has ADHD and probably ASD and the change from school to holidays combined with his birthday had led to him needing to be within touching distance of me at all times at home, this can be very tiring and stressful and he was worried about bedtime and sleeping too. A friend of mine called round whilst he was spiralling into panic and took him into the garden, they talked about the plants and he suggested my son chew and smell a few herbs, that it helped him if he was anxious. I took my son back to bed and he lay smelling his leaf while we read a story and until he calmed down and fell asleep.

Last year after our dog died of old age and I decided to get two sibling girl cats. They have been lovely to watch, very close. I thought about getting them neutered but decided to let them have one litter of kittens. As a child we had lots of pets and I witnessed two litters of puppies be born and grow up, this shaped my own interest in physiological birth and was one of the reasons I became a doula. I thought it was important for my children to see the normality of the life cycle.

My son watched in interest as local male cats started to frequent our garden after the cats went into heat, one male in particular seemed to have a close bond with my two sisters. We even witnessed them mating one morning so could introduce the birds and bees conversation with my son naturally. We then observed our cats behaviour start to change, to eat more, to become more solitary, not as close with her sister she would hiss if she came too close, she started eating more and I told our son we needed to be gentle with her, not pick her up too much or scare her. The male cat still showed regularly in the garden.

Eventually as I went away for a weekend, I thought the kittens would be due in about a week. I wondered how she would manage with her first litter. One dog I had as a young adult had a litter of puppies (she was a rescue dog and already pregnant otherwise I would have had her neutered) and coped well with the birth, until disturbed by my then partner returning with our other dog and friends, after which she left a puppy in its sac and did not care for it as she had the previous puppies and I had to intervene.

After the weekend I returned to find cats, neither of which looked pregnant. I quickly searched the garden and house for kittens, finally finding them in a cupboard in my bedroom, six kittens, all well and healthy, no mess, she’d done it fine all on her own.

She’s been a great mother, breastfeeding the babies on demand, purring loudly, but not let her sister too close. One early morning I found the daddy cat in the room too, chirruping at the cat and watching his kittens. A week later I found both sister cats in with the kittens. I was glad to see them friendly again, and when I looked at the kittens, I noticed one smaller all black kitten, her sister had had a kitten herself, just one. They are now co-feeding all the kittens, mostly found all together in a big heap of furry cats and loud purring. I was worried about the mother with six kittens who was struggling to keep weight on, so this should help her manage the load.

cats and kittens

My young experience of watching puppies feeding, I’m sure influenced my own determination to breastfeed, and helped give me determination when my first baby was sleepy after a long labour and diamorphine. Kept me going through the pain of a tongue tie for over a year when she self weaned. I always felt is was important to breastfeed anywhere and everywhere, not covering up, to normalise breastfeeding in society, as I’m sure hiding breastfeeding away means that people feel it is something to be ashamed of and also stops girls learning what it looks like to latch a baby on. You end up with attitudes like this (and this is a man whose wife did breastfeed!)


My son I fed till he also self weaned at nearly three and a half. Breastfeeding past a year is less common now in European countries, but historically was the norm and is usual in countries around the world today. In some countries breastmilk is also given to invalids and women commonly share breastfeeding with their sisters and friends like my cats


I personally have nursed a few other peoples babies, mainly when they have been having early breastfeeding difficulties and the baby was hungry and struggling to latch


Mothering can be very hard in today’s society, without the ‘village’ community, women trying to learn all the skills on their own without prior experience and without support, levels of postnatal depression are high, but it is often  the bonds we make with other new mothers that are sustained friendships throughout our adult lives and get us through those sometimes dark early days, sleepless nights and the continued joys and sorrows of parenthood


breastfeeding 4

Just like other animals, we humans are primed through evolution to birth our babies, breastfeed and live in community, supporting each other

Attending an unexpected birth: power of rebozo

Last week I got to attend a lovely home waterbirth. This hadn’t been a planned event, I was asked to come do one of my overdue sessions as the labouring woman’s waters had broken for 24 hours and labour was not established. After doing some rebozo and bellydancing active labour began fast and furious and I stayed to help fill the pool and wait for midwives to arrive.

This is Anoushka’s birth story (shared with her permission)

Baby was eventually born on the 14/6 at 1045 weighing 8.8lbs. I had a long latent labour of ten days where contractions were happening irregularly then waters went on wed. Contractions didn’t speed up and that, so after 24 hours of waters having gone it was looking likely that I’d have to go in to hospital to be induced. On the thurs morning, I asked a doula friend Selina to come over to talk about induction and she’s also a Maternal movement for Fetal positioning practitioner, so she said she would see if some movements might help things along. Jade my birthing partner had stayed with me that night to see if a chilled out night without Ramy night help bring things along, it hadn’t! So, Selina came over at 8am ish Thursday, we had a good chat about the hospital birth plan, contractions still ten ish mins apart. Selina then did some rebozo, inversions and belly dancing moves and within the space of that half hour, contractions changed to being very intense and 3 min intervals. Selina suggested to jade the get the pool filling as the contractions continued to pick up intensity and speed. I asked for the midwife to be called as I was starting to panic at the speed that the contractions were coming. I really needed to get into the pool as could feel pressure but it wasn’t full, so jade and Selina were throwing buckets of water in to try and get it filled faster. I think I got in the pool at about 10am, Emma my midwife arrived at 1020 and baby was out at 1045. It was so quick and surreal, jade said I seemed really in control but I felt the opposite. There was nothing that I could consciously do except feel baby move down and out, it was like I was inside my body just watching. Jodhi was born in his membranes (sac) but the waters inside had gone and I was able to pull him out of the water myself, which was amazing. He needed a couple of breaths as went a bit limp and we had to get out of the pool as I bled a bit more than usual but we were happy on the sofa. The second midwife Nikki arrived afterwards and they both stayed until late afternoon, making sure we were both fine. We ordered Domino’s and had some lovely calm time My parents arrived soon after Jodhi was born and my Dad got to cut the cord. They went to get Ramy and we surprised him with his new baby brother when he got home. Ramy is besotted and is a brilliant big brother as I knew he would be. As I expected Jodhi had a tongue tie which was snipped on day 3, lucky us he had 2 ties! So feeding has been quite worrying but thankfully he’s lost a normal amount of weight so is getting enough milk, we are just waiting for poops to come! I can’t thank my parents enough and jade and Selina helping for J into the world, he would have been born on the floor if Selina wasn’t there filling that pool up! Can’t recommend Selina’s services enough https://www.facebook.com/UnlockingBirth

Anyone who would like to try the techniques I used to encourage active labour to start, I describe them in my blog post here:


What are little girls made of? Gender ideology and why it harms us all

boy girl 2

Do you know the difference between gender and sex? Probably not, neither did I until recent years, but its becoming increasingly important (especially for parents) to know the difference.

(caveat: I am not an academic scholar of gender or social science, although I do research in public health, this post is mainly made up of my own understanding of sex and gender and experiences as a woman, mother and doula)

Sex = male and female

Gender = masculine and feminine


Sex refers to biological differences; chromosomes, hormones, internal and external sex organs.

Gender is socially/culturally constructed and describes the characteristics that a society or culture thinks are masculine or feminine.

People and organisations often use these words interchangeably, especially when talking about things like equality (how can you have equality in a socially constructed characteristic?) so are frequently using gender when they mean sex.

Part of this is to do with British prudishness and the fact we use the same word for male/female (sex) and reproduction (sex) so many forms ask instead for your ‘gender’ and then list male or female (sex) which for the majority of people is thought to be the same thing, but if gender is actually ‘the characteristics that a society or culture thinks are masculine or feminine.’ then maybe you’re gender isn’t quite so simple as male/female? If you don’t fit with the characteristics your society thinks are feminine and you are a woman, what is your gender?

I very rarely wear make up, I don’t often wear dresses or skirts. I don’t like the colour pink much. I like to light fires and camp and fish and chop wood.

Does this mean I am more masculine? Is my gender male? On the other hand I’m definitely biologically female. I’ve given birth twice! #confused

If only organisations/people understood that in most instances when we say gender, we mean sex.

Gender roles vary by historical time, country, religion and group etc. Originally gender roles came from sex differences or biology (women are pregnant, give birth, produce milk to feed babies etc.) so women stayed close to home and raised babies and young children while men hunted and protected (this again would vary by culture, time, place etc.) but from these roles came all our stereotypes of what it means to be a woman or a man (you can probably easily list what society sees as men’s things and womens things) and like the nursery rhyme above the idea that the sexes are different is reinforced from a very young age, even more so in recent years, with ‘gender (sex?) reveal parties and an obsession with boy/girl differences in clothing and toys.

blue and pink



Most people see gender roles as’ Stereotyping and limiting, trying to make little girls and boys fit into a prescribed box which limits their possibilities, and think it might be these gender roles that cause many of the problems in society, for example the high suicide rate in young men, may be in part caused by the idea that men ‘should’ be strong and silent, that its weak to ask for help or share feelings and so have to face their problems alone.


Gender roles have also limited women and girls (don’t get your dress dirty, don’t play rough, be nice, be pretty etc.) but its mainly biological sex not gender that globally leads to so much ineqality for women (e.g. femicide, selective abortion, unwanted pregnancy , rape, FGM, child brides, prostitution)

Only 100 years ago most women could not vote…


Around the world girls are still much less likely to go to school than boys and in many countries women and men do not have the same rights


(this should read sex equality not gender)

This is known as ‘patriarchy’ where men hold the power, and has been a common feature of most societies throughout history


In the last few decades many people have attempted to subvert and move away from gender roles and stereotyping.

boy george

And nowadays many people try to do what is termed ‘gender neutral parenting’ where boys and girls are treated the same, and not socialised into roles base on their sex. This can mean not always dressing them in blue/pink. Buying toys that aren’t branded for boys/girls etc.

Some people decide to ‘cross dress’ their children from a young age (deliberately, regularly dressing boys as girls)- this is different to children having access to a range of dress up clothes and toys and choosing their own as they wish, but more a parental choice. There is evidence that raising children without a sense of their own sex (and suggesting sex can be changed) is leading to more children with gender identity disorder.

Children’s sense of themselves is built by how adults and the world around them treats them, they follow our lead, so its important to consider carefully what we are telling them.

Parents may now worry that if their child is attracted to opposite sex toys/clothes that that is a sign they are transgender, rather than it being a child’s normal curiosity. Many children love to dress up and have different interests, this can be effected by their siblings, culture, parents, personality. It is common for children to go through a period of ‘trying on’ different personas, and living as characters in their imaginary world or from media they watch, this does not mean they are transgender.

This reinforcing a binary rather than freeing children from the constriction of gender roles



There have also always been people that didn’t fit with societies views of sex and gender. Sometimes people deliberately tried to be different to cause controversy (like artists) . And men and women have cross dressed for entertainment or access to lives they couldn’t live as themselves (especially women who were unable to publish books as themselves, go into medicine, be pirates…)

cross dressing





So what is gender ideology and why is it harmful?

In the last few years there has increasingly been a change in the way gender and sex are talked about, with the idea that gender is not a binary and that people can be on a spectrum. That has led to people calling themselves a variety of names from non-binary, to queer and trans-gender. They have started describing people that are not trans as ‘cis’. What this means is that people born male and female are happy to describe their gender as masculine or feminine (but as I described earlier, gender is socially constructed ideas of what masculinity or femininity look like, they change all the time, and stereotype people, limiting them to a set of behaviours as ‘normal). I would argue that all people are ‘gender fluid’ to a degree. Our behaviour and self view changes.

This idea is regressive because it reinforces a gender binary. Instead of freeing people from having to behave in prescribed ways, it says that if you behave in male ways you could be a man (born in the wrong body) and visa versa.


In clinical psychology and psychiatry, individuals who experienced distress because they did not identify with their biological sex  used to be known as ‘transsexuals’ A diagnosis of ‘transsexualism’ appeared first in DSM-III in 1980. Recently the name of the diagnosis changed to ‘gender dysphoria’ .



The term ‘assigned‘ sex or ‘assigned’ gender is now frequently used, which refers to when a baby is born and it is declared a boy or girl based on the appearance of external genitals. Between 0.018 and 1.7% of the population (dependent on definition https://www.ncbi.nlm.nih.gov/pubmed/12476264) have a ‘intersex‘ condition  which can mean they have genitals that appear male/female when they are the opposite sex.


Gender and Sex are separate from sexuality, which is usually described as heterosexual (being attracted to the opposite sex)  homosexual (being attracted to the same sex so lesbian or gay) or bisexual (attracted to both sexes) with additions in recent years of pansexual and asexual


Also known as LGB minority sexualities are discriminated against globally and face violence and are only now beginning to get equal rights in some areas (like same sex marriage).

Trans people were added to LGB in the late 1980’s, although strictly speaking trans is concerned with biological sex or gender not sexuality. The initialism has widened to include intersex and queer in recent years (LGBTQI) and gender identities appear to be ever increasing


Some people that feel that their gender identity does not match their biological sex (I would argue most of us feel this at times) want their body to resemble the gender/sex they feel more affinity to. There are a number of aesthetic and medical changes they can make


and legally people in the UK can apply for a ‘Gender recognition certificate’ to legally change their sex on their birth certificate to that which matches their preferred gender. In contrast to some systems elsewhere in the world, the Gender Recognition process does not require applicants to be post-operative (so a man can legally be a woman with a functioning penis and testicles, and a woman a man with uterus and breasts-that’s why you’ve seen newspaper articles about men having babies). They need only demonstrate to a Gender Recognition Panel that they have suffered gender dysphoria, have lived as “your new gender” for two years, and intend to continue doing so until death.


“Transgender activists say that the process of legal gender recognition is unnecessarily invasive, humiliating and lengthy. The UK government has proposed to reform the Gender Recognition Act to de-medicalise and speed up the process. The aim is to introduce a process based on self-declaration with no medical gate-keeping.”


So all you would need to do is say you feel like a woman or man to legally change sex. This potentially cause issues in same-sex institutions like prisons


The number of people applying for a GRC has been low (in line with what you would expect for people with dysphoria) but lately things have changed, many more people are identifying as gender non-conforming, non-binary-queer or transgender and correspondingly numbers of people requesting medical treatment to match the gender (sex) they feel more comfortable with. There are several groups that are transitioning more frequently

  • Children
  • Teenagers
  • Middle aged men

There could be several reasons for this steep rise in referrals



I feel it is concerning that so many more children are being referred for gender reassignment. This usually involves first socially transitioning children (as young as 3) by giving them an opposite sex name and dressing them as the opposite sex, then giving a child puberty blockers (untested as to long term consequences of blocking puberty for many years) and then giving cross sex hormones so the child develops opposite sex characteristics (e.g. a deeper voice in girls, facial hair and a higher voice in boys). Girls are advised to first bind their breasts and then have them removed (double mastectomy). Boys can be given artificial breasts and both boys and girls can have artificial sex organs (obviously all of this comes with medical risk)



These are often referred to as ‘top surgery’ and ‘bottom surgery’.

However much women or men change themselves, and even with legal recognition from a GRC  it is not currently possible for humans to change biological sex and many transgender people choose not to go through medical or aesthetic procedures and are happy to remain anatomically the opposite sex to that which they identify.

There is increasing pressure for transwomen and transmen to be regarded as the sex they identify with (with the mantra ‘transwomen are women’) and language changed accordingly (so if transwomen (men) who self-identify as women (based on their gender identity) they should be accepted as women, despite still having male genitalia (leading to the conclusion that ‘not all women have vaginas’ and for transmen (women) not only women get pregnant or breastfeed. This has led to many organisations changing the terminology they use so as not to offend (using ‘pregnant people’ not women and ‘chest feeding’ not breastfeeding’)




So… to recap…

Sex refers to biological differences; chromosomes, hormones, internal and external sex organs. (except now it doesn’t)
Gender is socially/culturally constructed and describes the characteristics that a society or culture thinks are masculine or feminine. (except now it doesn’t)

If this is confusing, imagine how much more confusing it is for children, who are now having lessons in school about gender identity and being told they can be born in the wrong body…


Many children have neuro developmental conditions (like autism and ADHD) which leads to difficulties with executive functioning. This means their understanding of concepts around identity can be delayed, and they are also more likely to be gender non comforming. (50% of referrals of children to the Tavistock clinic are on the autistc spectrum)


My son has ADHD. Even at six and a half he still lives in a wonderful world where anything is possible. Fantasy and reality overlap, combine. A couple of weeks ago he told me he was the daddy of our two young cats (and yes, in case you were wondering trans species is a thing, like trans race and trans gender)


I talk to him a lot about his ‘science’ brain. About working out whats real and whats not, because whilst its cute to go along with fantasies about toys coming alive and super powers, its probably more likely to harm him than help him (though I’m sure a vivid imagination will benefit him as he grows)

And what about teenagers? I have one of them too, and she already has trans gender friends, and those describing themselves as pansexual and queer (she’s 14). I just hope she’s heard me talking about sex and gender to realise that its perfectly okay to step outside of the constraints of gender roles but that doesn’t mean you were born in the wrong body…

Teenagers are all about risk taking, and finding somewhere to belong. There are all sorts of groups encouraging gender questioning teens to see themslves as transgender, sending girls free chest binders (which can lead to irreperable damage to growing breast tissue or even gangrene) and telling them where to go (or even order online) testosterone.

Parents are advised to go along with affirming their childs new opposite sex identity, even if they had never expressed a similar desire before, with the threat of suicide risk


Self harm and suicida ideation are common in teenagers and both, puberty blockers & cross-sex hormones both carry risk of depressive side-effects and there is very little accurate data (especially now many surveys ask for gender, if this is all about identity then we can’t reliably know how many girls or boys are feeling this way)

“If we fail to record the biological sex of young people we are unable to try to understand why suddenly such a disproportionate number of young women want to ‘identify’ out of womanhood. Is ‘identifying as a boy’ just the latest coping mechanism for girls brought up in a culture where images of women being sexually abused in porn are casually passed around in playgrounds, and the internet ensures no escape from the pressure on girls to be ‘perfect’? And is the world so dangerous for lesbians that being seen as a man is a safer alternative?”



Data is important, its not just about high income countries, this type of ideology could effect global data collection which is vital to prevent violence to women and girls (VAWG)

VAWG data is essential to help quantify and qualify problems, inform policies and design programs based on evidence. The need for better collection of data related to violence against women has been recognised by the EU, the Council of Europe and, at international level, by the United Nations in their commitment to eradicate violence against women



Our kids grew up with Harry Potter, they love the idea that there is magic, transmutation, and that the inner you can ‘sort’ you into groups based on your true identity…


Belief in magical thinking (pseudoscience) and conspiracy theories are increasingly popular with adults too: anti-vaccines, gut instinct (logical falacies/cognitive biases) homeopathy, climate change denial, chem trails, flat earth…



There’s also many teenagers involved in cosplay and anime whch is all about dressing up and changing sex/species etc, is there any wonder kids are struggling with identity issues, especially if we are telling them in primary school that its possible to change to the opposite sex.

Many studies have found that a large percentage of children that question their gender (sex) identity will eventally desist and accept their sex (with many of these coming out as lesbian or gay) but if they have already been socially transitoned as young children, had puberty delayed and or cross sex hormones they may be infertile, have an inability to have a satisfying sex life and/or have had sexual organs removed.

I would argue its unethical to make descisions like these for children that will affect their long term futures, these descisons are better made as adults



Its become very difficult to talk about these issues openly as globally, gender ideology has been accepted as truth without discussion and the majority of people don’t understand the concepts well enough to see the future implications of descisions like self decleration of sex and tranitoning children. People that speak up are labelled as intollerant, bigots, right wing. It was only after I was thrown out of a parenting group (which was for evidence based parenting) for questioning if there was research evidence about transitioning children that I began to understand who serious this situation had become. (people who speak up about trans gender ideology are known as gender critical or terf’s: terf stands for trans exclusionary radical feminist and is used as a threat by trans activists)


A woman was recently suspended from the Labour party for saying women don’t have penises..


Please if it concerns you too, speak up, talk to you’re children and teenagers about sex and gender. Talk to your friends and colleagues.

What is a woman? Barbie doll’s? Is it make up and hair styles and shoes (sugar and spice and all things nice…)

Are men GI Joe’s tough, muscley, silent, no emotions? (puppy dogs tails…)

Not all trans people support this ideology, many are horrified by whats happening, and speak out




Lets go back to all working together to reduce the limiting constraints of gender roles, embracing the feminine within men and boys and the masculine within girls and women, fighting to stop violence against all people and equal rights whatever our sex or sexuality

Thanks to all those actively subverting against gender norms (like the artist Grayson Perry in the picture below and the recent Welsh Government campaign #thisisme which challenges gender sterotypes to tackle violence against women, domestic abuse and sexual violence) and speaking out about gender ideology. We need a completely different construction of gender to make room for trans people without harming human rights.











On my daughters fourteenth birthday

My girl. On your 14th birthday. Thank you. Being your Mother has taught me everything that is important to know.
Waiting for you taught me about longing, about wanting something so much you don’t know if you can live without it. It taught me surrender and acceptance and then you taught me joy.
Being pregnant with you my life changed, I made so many friends that I love today, I learnt about a woman’s power, about choice about consent.
Your birth was hard and I learnt stamina and pain and the amazement of recognition of another soul grown in your body.
It changed the course of my life, led me to a love of research and my work now in Public health, and of supporting other people’s journeys to parenthood through being a doula.
Learning how to be a mother, to be in relationship with another person, unconditional love that is bottomless and ever expanding. Being a home to someone, physically and emotionally, being a safe place of succour and life, giving more.
How to grit your teeth and keep breastfeeding, swearing through pain, because damn it I was going to do this, and the ease of feeding once we got through the early days, learning what you liked as a person (being rocked in the baby chair so hard it was like a roller coaster and being upright all the time). The contentment of knowing this was the only important thing I needed to do at this time, to nurture this person. Being in a physical relationship of the comfort of anothers body and learning how to let others rest in you.
Bravery to embody my choices with joy, to mother by living my life with you in it, learning yes I could take babies to festivals, parties, travelling.
Supporting other mothers and fathers walk the path, realising the absolute importance of friendship and comradeship through life.
And as you grew you taught me so much about letting go, giving space to another to evolve and become themselves
“Your children are not your children.
They are the sons and daughters of Life’s longing for itself.
They come through you but not from you,
And though they are with you yet they belong not to you.

You may give them your love but not your thoughts,
For they have their own thoughts.
You may house their bodies but not their souls,
For their souls dwell in the house of tomorrow,
which you cannot visit, not even in your dreams.
You may strive to be like them,
but seek not to make them like you.
For life goes not backward nor tarries with yesterday.

You are the bows from which your children
as living arrows are sent forth.
The archer sees the mark upon the path of the infinite,
and He bends you with His might
that His arrows may go swift and far.
Let your bending in the archer’s hand be for gladness;
For even as He loves the arrow that flies,
so He loves also the bow that is stable.”

Khahil Gibran on Children

I am so proud of the person you are becoming, the woman you are growing up to be. Sharing life with me, always resilient and courageous, no nonsense, a wonderful big sister, picking up the slack when I need help. Working together as a family through our life.
Excerpt from a poem I wrote about my girl a few years ago:

I can’t write a poem about my girl,
She’s too big for the page,
She’d argue with everything I wrote down
Stick out her pointy little chin
And karate chop me.
Or cover me in glittery lip gloss kisses.
Her tight brown silky ringlets bouncing,
Eyes like melted chocolate covered daggers,
Skin a creamy frappuccino.
It only seems like yesterday she was born, stargazing,
Stubborn from the start.

When you were two you led a troop of toddlers across the field of Africa Oye
To the ice cream van,
You held out your warm, grubby, empty little hand
And like a miracle,
He handed out each of you an ice cream:
You knew he would,
Your will could move mountains.
Shaking your booty to 4Music
Singing your heart out to R n B tunes,
Wanting to know where your brown mother is.
Sorry huni, there’s just me…

Physiological Birth

closing the bones post

I have previously discussed some of the issues which complicate the discourse around ‘normal’ birth’ and ‘safe’ birth and the concept of risk.


The term ‘normal’ is problematic as it has social meaning (i.e what is usual) and also that what is not ‘normal’ is ‘abnormal’ .

I prefer to use the term ‘physiological’ which means the usual fuctioning of a living organism.

There is current discussion on the push for ‘normasl’ birth and to reduce the CS rate and/or unneccessary interventions.

This is a complex issue, there is still much to learn about how and why risk status changes during the birth process and when it is necessary to intervene to prevent risk.

For my Masters in Public health dissertation I was interested in the differences in post birth condition of mothers and babies after vaginal births with and without common interventions.

For this I used the current definition of ‘Normal birth’ (from http://www.birthchoiceuk.com/Professionals/BirthChoiceUKFrame.htm?http://www.birthchoiceuk.com/Professionals/statistics.htm )

women have a “normal birth” if they do not have any of the following procedures:

  • induction of labour (with prostaglandins, oxytocics or ARM)
  • epidural or spinal
  • general anaesthetic
  • forceps or ventouse
  • caesarean section
  • episiotomy

I looked at ‘The Incidence of Women giving birth in Liverpool in 2005-07 having a ‘Physiological Birth’ as compared to ‘Normal Births’ and ‘Cephalic Vertex Births’: Are there differences in health outcomes for mothers and babies by type of birth?’. This was a quantitative hospital-based cross-sectional study using delivery records’ data available at Liverpool Women’s Hospital (LWH). All birth records with a gestation of 37-42 weeks from 01.01.2005 to 31.12.2007 were obtained for mothers who gave birth to live singleton infants and whose delivery records had been entered on the hospital database (13, 963 Vaginal births)

I presented my results at the ‘Normal Birth confernce in 2009.

The incidence of physiological birth in Liverpool in 2005-07 was 24.5%

19.1% of women having their first baby had a physiological birth.

Physiological birth was associated with-

  • Greater odds of breastfeeding after delivery and on discharge
  • Lower odds of having a post partum hemorrhage
  • Lower odds of having a perineal tear
  • Lower odds of babies being born in a compromised condition

The powerpoint I prsented at the conference with the full results is attached below. This data is currebntly unpublished although I have been working on a journal article for some time.

Normal birth conference Selina Wallis

Painful birth?


Can birth be painless?

A recent article by Milli Hill in the Telegraph suggested that birth not be as bad as people fear.


But this has created a backlash from people who feel that this view contributes to the trauma of women who go into labour convinced they can birth without needing pain relief, or at home, or without ‘losing it’.


As a doula I have accompanied many women through birth and given birth myself twice. So I have seen labours that were unbearable from the early stages to women having ecstatic birth[1], women singing through their second stage.

In my previous blog I talked about how childbirth is a profound event for women, where pain creates an altered state of consciousness which may help women cope with the pain of childbirth and prime women to experience the psychological shift to becoming a mother.


I agree with Milli that it’s well known that fear and anxiety can lead to greater pain during birth. The associations between expectation, cultural conditions, personal outlook (including locus of control) memory and preparation in relation to pain during childbirth are complex. It has also been suggested that attachment style can effect labour pain. [2] and can also effect whether the presence of a partner during labour reduces pain[3]

People can be surprised by their own response to the sensations of birth, some people cope better than they imagined. One aspect which has not been discussed is the role of malposition- the position of the baby effects:

Pain– women with a baby in a malposition (OP/back to back, asynclitic, deflexed etc.) are more likely to experience extreme pain from early in labour, this combined with a greater length of labour and exhaustion make it more likely they will need pharmacological pain relief (and malposition is also associated with breakthrough pain during an epidural[4] and needing more top ups of pain medication[5, 6]) Increased pain during labour[7], is itself is a marker for CS risk[8]

There are a number of ways women’s pain is assessed and documented in labour. One recent tool is the Roberts ‘Coping with labour’ algorithm[9] which provides a mechanism for pain documentation, and care suggestions for the laboring woman. This has been assessed in a large tertiary care hospital as more useful and helpful than a numeric rating scale. [10]

There is some evidence that antenatal birth preparation can reduce anxiety about birth and decrease labour pain experienced.[11, 12, 13] and there are numerous papers describing environmental factors (circadian, lighting, music, furniture, place of birth[14,15]) non pharmalogical pain relief methods (water, massage, aromatherapy) support (continuity of care, doulas, midwives) and maternal factors (fitness, exercise, personality, preparedness, movement etc.)[16,17]

Severe pain in labour has been associated with both postpartum depression [18] and PTSD[19]

The coping with labour algorithm looks like a useful tool to combine a better understanding of the factors that can effect coping in labour and ways to help women cope.

The new algorithm was designed in part to reduce dissatisfaction with the numerical pain rating scale, women found the questions intrusive and distracting. The coping with labour tool can be used by midwives from observation and queries about coping to women are only made on arrival, when noticing changes or a shift change[9]. There is also an understanding that not coping in labour can signal the ‘transition’ between first and second stage and be a sign of rapid progress, when reassurance of the physiology of normal labour could reassure women and reduce anxiety in relation to overwhelming sensations.

One woman I spoke to found being asked about pain, contributed to her focus on the pain, and made her doubt her coping ability:

The ONLY reason I had pethidine with my first was because the midwife (after a shift change the first never mentioned it) kept saying ‘did I want pethidine’ ‘are you sure you don’t want pethidine?’ ‘it’s only going to get worse, would you like the pethidine now?’ – I gave in to stop her asking

Both distraction and catastrophizing have substantial effects on perceived pain[20], so questioning women about pain in labour could effect women’s perception of coping.

Looking at longer term outcomes, in a  five-year follow-up study of a randomised controlled trial; “The Ready for Child” trial. To compare the long term perspective of the birth experience in nulliparous women attending a structured antenatal programme to that of women allocated to standard care.  Birth characteristics of women reporting a less positive birth experience in the long term, irrespective of group allocation, were significantly more likely to experience an epidural, cardiotocography monitoring, and less likely to used water as pain relief and have a spontaneous vaginal birth.[21]

Another study to investigate women׳s use of pharmacological and non-pharmacological labour pain management techniques in relation to birth outcomes, found that:

•Water use for pain decreases the likelihood of special care nursery admission.

•Epidural use for pain increases the likelihood of special care nursery admission.

•Epidural use for pain increases the likelihood for instrumental childbirth.

•Epidural and pethidine use decrease the likelihood of continuing breast feeding.

•Breathing techniques and massage increase likelihood of continuing breast feeding[22]

So can labour be painless?

Yes sometimes, and there are ways to help cope better in labour, but a large part is down to luck/ chance and not within our concious control, needing pain relief when pain is severe and unremitting is not a failing

“my inner sex
stabbed again and again with terrible pain like a knife.
I have lain down.

I have lain down and sweated and shaken
and passed blood and feces and water and
slowly alone in the centre of a circle I have
passed the new person out”

(from ‘The language of the brag’ by Sharon Olds)


  • A huge number of factors combine to effect how women experience pain and cope with labour
  • Malposition is an important factor that can increase pain and negative outcomes
  • Women who experience severe pain may have a malpositioned baby, if this does not resolve, pharmacological pain relief may be needed
  • Birth preparation can provide women and their birth partners with tools that can help women cope with labour
  • Focusing on pain in labour can increase pain, use of language related to ‘coping’ with labour might be more appropriate
  • Offering pain relief in labour may
  • Women that experience severe pain and require pharmacological pain relief, despite intensive birth preparation are not personally responsible for the level of pain they experience, it is likely that a combination of childhood experience, cultural environment and malposition combine to create intolerable pain
  • There should be no shame in needing more pain relief than was planned





  1. Mayberry, L., & Daniel, J. (2016). ‘Birthgasm’ A Literary Review of Orgasm as an Alternative Mode of Pain Relief in Childbirth. Journal of Holistic Nursing, 34(4), 331-342.
  2. Costa-Martins, J.M., et al., The role of maternal attachment in the experience of labor pain: a prospective study. Psychosomatic medicine, 2014. 76(3): p. 221-228.
  3. Krahé, C., et al., Attachment style moderates partner presence effects on pain: a laser-evoked potentials study. Social cognitive and affective neuroscience, 2015. 10(8): p. 1030-1037.
  4. Sng, B.L., et al., Incidence and characteristics of breakthrough pain in parturients using computer-integrated patient-controlled epidural analgesia. Journal of clinical anesthesia, 2015. 27(4): p. 277-284.
  5. Wong, C.A. The Influence of Analgesia on Labor—Is it Related to Primary Cesarean Rates? in Seminars in perinatology. 2012. Elsevier.
  6. Hess, P.E., et al., An association between severe labor pain and cesarean delivery. Anesthesia & Analgesia, 2000. 90(4): p. 881-886.
  7. Alexander, J.M., et al., Intensity of labor pain and cesarean delivery. Anesthesia & Analgesia, 2001. 92(6): p. 1524-1528.
  8. Ismail, S., S. Chugtai, and A. Hussain, Incidence of cesarean section and analysis of risk factors for failed conversion of labor epidural to surgical anesthesia: A prospective, observational study in a tertiary care center. Journal of anaesthesiology, clinical pharmacology, 2015. 31(4): p. 535.
  9. Roberts, L., et al., The coping with labor algorithm: An alternate pain assessment tool for the laboring woman. Journal of Midwifery & Women’s Health, 2010. 55(2): p. 107-116.
  10. Fairchild, E., et al., Implementation of Robert’s Coping with Labor Algorithm© in a Large Tertiary Care Facility. Midwifery, 2017.
  11. Firouzbakht, M., et al., The effect of perinatal education on Iranian mothers’ stress and labor pain. Global journal of health science, 2014. 6(1): p. 61.
  12. Toohill, J., et al., A Randomized Controlled Trial of a Psycho‐Education Intervention by Midwives in Reducing Childbirth Fear in Pregnant Women. Birth, 2014. 41(4): p. 384-394.
  13. Brixval, C. S., Axelsen, S. F., Thygesen, L. C., Due, P., & Koushede, V. (2016). Antenatal education in small classes may increase childbirth self-efficacy: results from a Danish randomised trial. Sexual & Reproductive Healthcare, 10, 32-34.
  14. Bernitz, S., Øian, P., Sandvik, L., & Blix, E. (2016). Evaluation of satisfaction with care in a midwifery unit and an obstetric unit: a randomized controlled trial of low-risk women. BMC Pregnancy and Childbirth, 16(1), 143.
  15. van Haaren-ten Haken, T. M., Hendrix, M. J., Nieuwenhuijze, M. J., de Vries, R. G., & Nijhuis, J. G. (2017). Birth place preferences and women’s expectations and experiences regarding duration and pain of labor. Journal of Psychosomatic Obstetrics & Gynecology, 1-10.
  16. Jones, L. V. (2015). Non-pharmacological approaches for pain relief during labour can improve maternal satisfaction with childbirth and reduce obstetric interventions. Evidence-based nursing, ebnurs-2014.
  17. Levett, K. M., Smith, C. A., Bensoussan, A., & Dahlen, H. G. (2016). Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour. BMJ open, 6(7), e010691.
  18. Kwok, S., et al., Childbirth pain and postpartum depression. Trends in Anaesthesia and Critical Care, 2015. 5(4): p. 95-100.
  19. Soet, J.E., G.A. Brack, and C. DiIorio, Prevalence and predictors of women’s experience of psychological trauma during childbirth. Birth, 2003. 30(1): p. 36-46.
  20. Campbell, C. M., Witmer, K., Simango, M., Carteret, A., Loggia, M. L., Campbell, J. N., … & Edwards, R. R. (2010). Catastrophizing delays the analgesic effect of distraction PAIN®, 149(2), 202-207.
  21. Maimburg, R. D., Væth, M., & Dahlen, H. (2016). Women’s experience of childbirth–A five year follow-up of the randomised controlled trial “Ready for Child Trial”. Women and Birth, 29(5), 450-454.
  22. Adams, J., Frawley, J., Steel, A., Broom, A., & Sibbritt, D. (2015). Use of pharmacological and non-pharmacological labour pain management techniques and their relationship to maternal and infant birth outcomes: Examination of a nationally representative sample of 1835 pregnant women. Midwifery, 31(4), 458-463.

Childbirth: Pain, disassociation and altered states of Consciousness: Birth as a hero’s journey?


** EDITED 09.08.18 to add information on this study:

Das, R. K., Tamman, A., Nikolova, V., Freeman, T. P., Bisby, J. A., Lazzarino, A. I., & Kamboj, S. K. (2016). Nitrous oxide speeds the reduction of distressing intrusive memories in an experimental model of psychological trauma. Psychological medicine, 46(8), 1749-1759.

This study found that Nitrous oxide speeds the reduction of distressing intrusive memories in an experimental model of psychological trauma- but in  dissociated individuals N2O aggravated PTSD-like symptomatology.

Considering that nitrous oxide (gas and air) is commonly used during labour it may be that this effects women birthing that have PTSD or the development of PTSD after a traumatic birth.

*This post evolved out of my birth experiences, attending over 40 births as a doula, and conversations with women and their partners at the home-birth group in Liverpool that I ran over a number of years. Quotes come from conversations on the #MatExp Facebook group. This is a long post, there is a summary of points made and implications for practice at the end

Transition to Motherhood

The transition to motherhood is a profound psychological event, which has been described as a ’normative crisis’ in the female life cycle[1] requiring the giving up of one identity and the assimilation of another. This can be accompanied by changes in behaviour, mood and self that can feel overwhelming. There is little professional or public literature which agrees on the psychological symptoms women experience.

In antenatal classes women are prepared for childbirth and motherhood, mainly through factual accounts of the physical processes occurring, how the baby develops and grows, the changes in the body, how the cervix dilates, uterus contracts to push the baby out. Breasts produce milk for the baby. But there is little preparation for the mental changes that occur in pregnancy, birth and postnatally, except for warnings about low mood. Psychological changes are seen in the lens of deficit and crisis.

Adolescence too, whilst historically and culturally celebrated, in the western world is also increasingly seen as a ‘risky’ time and surveillance encouraged for potentially pathological symptoms. [2]

These transitory times of life which include psychological ‘crises’ include puberty, marriage, birth, and death, have been marked by initiation rituals since prehistoric times.[3] Native and premodern societies used rituals during these transitional periods in life, (which are viewed as normal and expected personal development and growth) to celebrate and assign social identity.

The social meaning given up to Motherhood in Western modern society is that woman should be happy, content, enjoy mothering and that mothering comes naturally.  [4] This comes in a social setting where there is increasing pressure on women to be financially independent, leading to later age to start a family, and fewer women experienced in childrearing of younger siblings. There has also been a movement away from organised religion.[5]Thus the removal of childbearing experiences from the religious realm has created a culture with “no sacraments for the blessing of childbirth, no ritual to support a woman in childbirth”; this, in turn, “robs this part of feminine life of all its psychological depth and importance”[6]

Three phases have been said to occur during all initiatory processes: separation, liminality, and integration. (For motherhood, this could be marked by pregnancy, birth and postnatal phases)[7]and childbirth can be seen as similar to initiation ritual through several psychological elements, such as the experience of pain or powerful bodily sensations, an altered state of consciousness(’laborland’) a symbolic experience of death and rebirth, self-­‐ transcendence, or an ecstatic feeling of unity.[1]

Mental state during childbirth



Although little literature exists to describe to expectant women how being in labour feels, there are cultural expectations of women’s experience and behavior during birth, which usually revolve around pain and drama[8]. Midwives describe using women’s behavior to assess whether active labour has begun[9] and how labour is progressing.[10-12] this behavior is described as ‘labour-land ‘or being ‘In the zone’[13] and is thought to be due to the hormones released during labour and the pain of contractions.

Hormones also have an effect on the way pain is experienced in labour. The hormone called beta-endorphin is an opiate or pain-killer that occurs naturally in the body. It is similar in a number of ways to the synthetically produced drugs pethidine and morphine. The subtle balance of hormones changes again when the cervix reaches full dilation. This phase is called the ‘transition”


“Labor land is like a deep meditative state. It is like an out of body experience except that it occurs so internally, totally within your body and in the meditative part of your mind.  Being in this state allows the mom to get into the rhythm of her contractions and to develop a routine of what works for her to stay on top of the intensity of her labor.

It is important that no one tries to talk to her or pull her into her conscious mind when she is in labor land.  This can take her out of her zone and make it more difficult for her to deal with the sensations she is experiencing.

Some people don’t appreciate the power and importance of labor land and interpret this altered state of consciousness from the outside as a state of weakness where the woman is incapable of dealing with what is around her.  This is not a state of weakness but a state of great strength.  This is where a woman accesses the full power she has within.  Being able to go so internal does leave her vulnerable to outside stimulation.  As a support person you are the protector of her space.  Your job is to take care of all the external factors so she can stay internal through the birth.”

(from http://yourbirthcoach.com/2011/11/25/getting-to-labor-land/)

These changes of behavior in active labour include:

  • Sense of separation of mind and body
  • Altered time perception
  • Zoning or spacing out
  • Feeling like things are unreal
  • Being unaware of things happening

Women and midwives have also described:

  • Not wanting to eat or drink (altered taste perception)
  • Altered sense of smell
  • Sensitivity to noise and light
  • Not wanting to speak, be touched, and communicate

These types of behaviour are known in psychology as ‘dissociation’ and describe a ‘detachment from reality’. This detachment can be temporary (linked to a particular experience) or on-going/repeating.

Dissociation is thought to be a normal human function and is a spectrum that encompasses daydreaming, meditation, hypnotherapy.[14] Dissociation is used by athletes to cope with performing at the limit of their capabilities for long periods. [15]. Lack of an ability to dissociate may be linked to anxiety disorders.

Dissociation is also the means by which the mind protects itself from trauma (and is associated with post-traumatic stress disorder-PTSD). When an experience is traumatic the mind dissociates, however sometimes (especially if the experience is repetitive in nature) or happens during childhood, the dissociation can reoccur in situations that are not currently traumatic or even lead to multiple identities developing.[16]

Altered states of consciousness and dissociation during childbirth

There have been few studies that have looked at how common experiences of dissociation are during childbirth. Two recent studies found a prevalence of approximately 10% (11.3% of the sample experienced significant dissociation.) [17]

One of these studies found that important predictors of dissociation in labor included both predisposing (e.g. childhood maltreatment trauma, pre-existing psychopathology) and precipitating (e.g. perception of care, negative appraisal of labor) factors. [18]

Other studies have found much higher rates using qualitative methods (it may be the reports depend on factors such as when women were asked, what instrument is used to measure experience and cultural factors). In Anderson’s study on women’s experience of the second stage of labour sense of separation of mind and body was one of the strongest findings in her study the author concluded that disassociation was not a frightening experience but it enabled the women to keep in control. [19]

It may be that a woman’s interpretation of her experience as unexpected and/or different/abnormal may affect whether the experience of disassociation during childbirth is adaptive (useful/helpful) or maladaptive (frightening/trauma inducing).

Whilst in a dissociative state “Some sensory cues are likely to provoke alarm in us all, such as sudden unexpected loud noise or rough aggressive touch” (from http://www.iriss.org.uk/resources/trauma-sensitive-practice-children-care)

“At the heart of trauma is terror”

Another consideration is what occurs during disassociation (if the woman experiences interventions, upsetting care, coercion or difficulties during the birth).

A combination of negative emotions prior to and during birth (particularly shame) with dissociation and an instrumental delivery appear highly correlated with developing PTSD after birth.[20] Both dissociation and shame can adversely affect interpersonal relationships (which may make it difficult for midwives and other care-givers to create and maintain a positive relationship with a woman during childbirth, and suggests that continuityof care may mitigate this by building up trust and respect prior to labour.)

This may also be why changes of shift can be difficult for women who have built up a positive relationship with a midwife as they can interpret their leaving as abandonment or feel unable to build a relationship with a new caregiver.

Transfer from one environment to another (MLU to CLU or home to hospital) can also be trauma inducing. [21]

The hospital environment itself can be triggering, as an unfamiliar environment may present as a threat (which is why making birth environments as home-like as possible is not just window dressing but may actively prevent trauma).

 Place of birth appears to effect both optimism and resilience, with home and natural hospital births being associated with a better childbirth experience. [22]

The recent UK NHS maternity review suggested low-risk women should be encouraged to birth at home or in a midwife led unit. [23]

I asked women on the #MatExp Facebook group (over 1000 women, partners and healthcare providers interested in improving maternity care) about their experiences of disassociation during labour.

My first labour I freaked… I hated everything about it, and if I could have exited my body there and then I would have. I felt “spaced” and drunk and I didn’t know what time it was. I can’t really describe it well – sorry. Second time round I listened to hypnosis during labour and it really grounded me, as a result I felt much more in control and towards the end I even announced I was bored!”

“I remember getting so annoyed at the midwives talking with my second. I had my headphones in and I could still hear them even though they were being respectful (and it turned out there was some pretty scary stuff happening with my baby) but I could hear them whispering and I wanted to tell them to shut up because I was concentrating, but I couldn’t find my voice. And when they touched my arm to get my attention I was SO angry with them for breaking my little bubble. Feelings I’d never have usually.”

“It was definitely like a trip. First time, 2nd was too quick and I was too in my rational head until the last 5mins. But first time I had that amazing experience of connection: to all the mothers who were labouring with me in that moment around the world, to all the mothers who ever had been and all the mothers who ever would be. It was enormous and wonderful and comforting. The daffodils out of the window meant something deep and meaningful too, but can’t for the life of me remember what! Anyway, definitely like one of those trips where you’re convinced you’ve got the answer to life, the universe and everything!”

Like being in a parallel universe. Human interactions are difficult and confusing. Strangers are scary. I was unable to speak, unable to even access the vocabulary! All sensations on high alert and almost unbearable: slightest noise, smell, taste, light. Everything is very black and white like when you’re a child.”

My first labour I had birth trauma. I felt like a bystander with everything happening to me but no involvement from me, a nightmare that ended up with a fully dressed baby that could have been anyone’s handed to me. I watched myself being cut open via the lights in theatre &it was like watching it happen to someone else on a YouTube video. My vbac’s were very different, I did still have an “out of body” experience when in active labour, I was very aware of touch & vocal about whether I liked it or not. I also hypnobirthed & felt more aware of what was happening in my own body, I knew my 3rd baby was on his way well before my midwife did & didn’t need a VE to tell me otherwise.”

“Being in an altered state is the only place to be in labour in my view. Enabled me to transcend some less than idea birth environments and supporters. Did not protect from ptsd in first (difficult) birth – I think because the sensations are kind of imprinted deep in the psyche when you are in that state. Even now I long to dance in the stars as I once did – and thank the Goddess for those amazing experiences.”

“Yes definitely an altered state, that wasn’t scary for me as it’s how I’ve always got through severe pain or fear and it feels like something I can control (lack of control – now that does scare me!) The down side was that I seem very quiet and calm and I don’t think anyone around me realised how bad the pain and exhaustion had got. I also found it impossible to maintain that and have a conversation and make decisions. Unfortunately as we hadn’t planned at all for things going wrong and I didn’t know the midwives there wasn’t really anyone I could hand over to.”

“This is how gas and air made me feel! Everything was spinning, I was detached, couldn’t form a sentence, it was awful..”

“Second time was definitely a trip! I had no drugs at all. At times I completely went inside my body and experienced the contractions as balls of intense creation energy, sorry if that sounds so hippie but there is no other way to describe it! I felt like a goddess! In between I felt stoned or slept. Amazing! Afterward I felt healed from my first (highly medical) birth.”

“I felt horribly out of it during my second labour. I remember telling my husband I needed the loo and he got a little cross, telling me I had to speak up and tell be midwives but I couldn’t. I was literally frozen with fear. At one point I had a senior midwife holding open my cervix with her hands, two anaesthetists, three other midwives and two doctors in the room with me, all wearing masks, all talking over me. I’ve always felt so guilty about not being able to speak up and blamed myself for a long time for what happened. I didn’t know it was a common thing for women to feel that way”

“I remember them discussing me getting an epidural as my blood pressure was so high and I was just on the bed screaming through the contractions. Everything was so fuzzy. I knew they were talking about doing something I didn’t want but couldn’t do anything about it. An anaesthetist kept coming in and out. In the end I was fully dilated before they could do it so I never had it. Terrifying.”

“I loved my first two stages of labour, didn’t feel it hurt at all, laboured unexpectedly quickly (from midwife who didn’t know me point of view -she later asked if I had a high pain threshold – I don’t remember it being painful at all until she pulled out the placenta) at home so when paramedics arrived I smiled and was happy to have them in my birthing space as only my husband was there who was an unwilling birth partner. They said they didn’t realise how far I was along as I was so calm. I remember them trying to hold my hand and I thinking I didn’t want them in my personal space. Also they tried to give me gas and air which I hadn’t asked for and being irritated I had to push it away, it was interfering in my space. Then after she came out I turned to pick her up and they shouted ‘no’ at me – it knocked me out of my zone and into fear and compliance – I feel traumatised about that. And I saw them get my baby’s first gaze, I was devastated!! She was cleaned before she was given to me and I transferred into hospital for placenta delivery after being told no midwifes available to come out to me. In retrospect I wish I’d free birthed or had a doula as everything was so lovely before anyone interfered.”

“Regards ‘altered state’ yes. I had a long induction (started in the Monday morning, baby delivered at 10am on the Thursday by forceps) where I was left alone a lot and really expected to know what was happening without anyone telling me. I felt very very isolated and detached. Wandering the corridors of the ward at night unable to sleep or eat. Labour was around 20 hours and not allowed to eat and couldn’t rest. Was put on a drip for fluids only during labour. I think lack of sleep and nourishment really contributed to my trauma. I was so spaced out. I’ve no doubt some of the midwives tried to communicate with me but I didn’t take anything in. In theatre I had a traumatic delivery. Baby was out very fast and then taken to NICU – I then had a 4.5l PPH during a further 2.5 hours of surgery to try to stop the bleeding under spinal block. I lost consciousness at one point – I really thought I had died. I really thought I could just let go. I felt like I was watching myself on the table at times. Covered in blood. The whole time I felt like I was going to fall off the table (strange angle to preserve blood flow to my head) so felt in constant danger the whole time.”

“I had gas and air at a few points too and that was mind altering in a different way, quite nice when I thought things were going well and I could chat away on it though I was a little concerned I was embarrassing myself like a drunk person! Once it was clear things weren’t going well I was given it again but it did nothing for the pain and I just got rather paranoid and scared, so I think state of mind before hand is quite important, with my third I experienced going inside my body and I actually saw my son going through the birth canal from Inside it was so weird but amazing and I had no drugs”


It seems there is a complex relationship between previous experiences, personality type, the natural process to dissociate during childbirth and experiences during childbirth (which encompass both intervention and care) which affect the sense of agency and body ownership and may or may not lead to PTSD after birth.

Pain, memory and PTSD


The relationship between pain, dissociation, childbirth and PTSD is not simple and the literature is contradictory. Studies have predominantly showed that women underestimate the pain they would experience during birth. [24]

Epidural anaesthesia has been associated with a lower prevalence of postpartum depression but not PTSD. [25]Women have described feeling ambivalent about epidural pain relief. Describing relief but a change from euphoric to a ‘normal ‘state which indicated to the author that the internal experience is in focus before the use of epidural analgesia, while the more external experience is predominant after initiation of epidural analgesia.[26] Optimal desired pain control during the birth process may decrease the prevalence of postpartum depression. [27] How we interpret pain has everything to do with how we will respond to it and our expectations and emotions also play a part in how we experience pain. Memory of pain and affect is influenced by the meaning and affective value of the pain experience. In a study where expectations and memory of pain were studied in women, who gave birth by vaginal delivery or Caesarean section, or underwent gynaecological surgery, surgery led to an overestimation of all but one of the recalled variables of pain. Participants who gave birth by Caesarean section were the most accurate at recalling pain and affect. Memories of pain and affect were most variable in participants who gave birth by vaginal delivery. [28]

Fear of childbirth results in experience of more intense labour pain and report a negative experience of birth. [29]

When studying women’s memory of labour pain post childbirth it was found that memory of labour pain declined during the observation period but not in women with a negative overall experience of childbirth. Women who had epidural analgesia reported higher pain scores at all time points, suggesting that these women remember ‘peak pain’.[30]

Protective factors relating to PTSD and childbirth

A critical review of qualitative literature relating to the factors affecting women’s experiences of pain in labour found two main themes (i) the importance of individualised, continuous support and (ii) an acceptance of pain during childbirth [31]

In a second critical review of qualitative research this time looking at women’s experiences of coping with pain during childbirth feeling safe through the concept of continuous support was a key element of care to enhance the coping ability and avoid feelings of loneliness and fear. A positive outlook and acceptance of pain helped women cope. These findings were consistent across socio-economic, cultural and contextual differences suggesting that experiences of coping with pain during childbirth are universal. [32]

The ability to move during labour, and change position can be helpful both to facilitate birth without injury [33] and also a greater sense of control [34]. In one study where women randomised to kneeling or sitting positions in the second stage of labour.A sitting position during the second stage of labour was associated with a higher level of delivery pain (P < 0.01), a more frequent perception of the second stage as being long (P= 0.002), less comfort for giving birth (P= 0.03) and more frequent feelings of vulnerability (P= 0.05) and exposure (P= 0.02). [35]

A study in Taiwan found women that were randomised to an upright pushing position had a lower pain index (5.67 versus 7.15, p=0.01), lower feelings of fatigue post birth (53.91 versus 69.39, p<0.001), a shorter duration of the second stage of labour (91.0 versus 145.97, p=0.02) and more positive labour experience [36].

An upright birthing position has also been shown to enhance fathers’ experience of having been positively and actively engaged in the birth process [37] which is important as men can also develop PTSD from childbirth [38-39], Women who report experiencing less stress in their couple relationship are less likely to report PPD symptoms even when they have a personal history of depression and or PPD [40] and a woman’s perceived social support has been found to buffer against the potentially traumatic effect of an emergency C-section.

Both mothers and fathers mental health after birth can effect parent-baby interaction and attachment. [41]

Having a high ‘sense of coherence’ was protective against PTSD following childbirth [42]. The three constructs that underpin the SOC are ‘comprehensibility’ (one must believe that one understands the life challenge), ‘manageability’ (one has sufficient resources at one’s disposal) and ‘meaningfulness’ (one must want to cope with the life challenge). [43] A review of the literature found that women with strong SOC were more likely to experience uncomplicated birth and birth at home, identify normal birth as their preferred birth option in pregnancy and identify a desire to avoid epidural anaesthesia in labor compared to women with low SOC. [44]

Increasing pregnant women’s sense of coherence could be a modifiable factor to increase the normal birth rate, reduce PTSD and reduce improve postpartum emotional state. [45].

Post-traumatic growth

As previously discussed, pregnancy and motherhood can be seen as a ‘normative crisis’ and requires profound psychological role transition. Childbirth marks the separation of mother and child as a unit:

The extreme nature of this experience is what makes the act of delivering a baby a psychological transition, an event of trial and ritual that marks a profound change in a mother’s life.”[46]

There are similarities between mystical and traumatic experiences [47] and self-induced stress is used cross-culturally as a form of healing. [14]

In rituals and with medicinal plants, people push past normal limits in order to experience power, energy, and transformation” [48]

Substances that that create dissociative states (like LSD, peyote, MDMA) have been used historically and culturally for ritual and healing and are also used recreationally in contemporary western contexts. Users describe the capacity of hallucinogenic drugs for healing and personal growth; even adverse experiences (“bad trips”) were regarded as valuable for these purposes [49] and some small studies have also looked at using hallucinogens to therapeutically treat long term PTSD and treatment resistant depression. [50-51]

Posttraumatic Growth (PTG) – deriving benefits following potentially traumatic events – has become a topic of increasing interest.

Some studies have looked at PTG after childbirth. Many women report positive changes as a result of their birth experience[51] experience of peritraumatic dissociation and symptoms are most associated with the greatest levels of growth. [53] Posttraumatic growth in postpartum suggest a potential protective role of posttraumatic growth on the development of disordered eating symptoms. [54]

Social support has been seen to predict PTG. [55]


The transition to ‘motherland’ (constructing a new identity as a mother) can be hindered by traumatic birth experiences that reduce sense of coherence and the ability of the body to successfully birth or feed their baby. [56]

Mastering pain has been viewed as an integral part of a self-actualizing experience.  Women have described a sense of achievement and feeling of pride in their ability to cope with intense pain, which increased their sense of self-efficacy. When empowered by their own attitudes and with the assistance of others, these women felt they met and mastered their birth experience, and some described giving birth as a transcendent experience. [57]

A study exploring first-time mothers’ experiences of birth found that women ‘processed the birth’ by ‘remembering’, ‘talking (storytelling)’ and ‘feeling’. This activity appeared to help most women resolve their feelings about the birth and understand what it actually means to be a new mother. [58]

I asked an antenatal teacher what they taught women and their partners about state of mind during birth:

I talk about undisturbed birth producing sensations of an altered state of consciousness facilitated by the increase of the hormones Beta-endorphin and Oxytocin. I describe this as a natural, helpful aspect of undisturbed birth, producing feelings like being “in the zone,” “miles away” or “going off to another planet” combined with the body’s natural pain relief.

As a hypnotherapist I talk about these experiences as being a form of “birth hypnosis” / “birth trance” which can also include (positive) time distortion, altered physical sensations, and sometimes visual or auditory perceptions; all normal aspects of hypnosis. I introduce this state through a series of exercises and ask their partners to observe. We spend time on how partners can help facilitate and protect this helpful state for their partners. I teach them to practice entering this state with self hypnosis and recordings which I create for them in order to make it a welcome and familiar part of birth for the woman and her birth partner so that it is there to tap into during birth. This was certainly my own experience in my second (pain-free) birth where I used hypnotherapy and self hypnosis.

Unfortunately this state is inhibited when birth is disturbed, when a birthing woman is fearful and in the fight-flight-freeze state. I think first time birthing women often push this helpful aspect of birth away, feeling that they need to stay “on top” or “in control.” When high levels of Catecholamines: adrenalin and noradrenaline are produced, fear and pain (without the soothing effects of beta-endorphin) are part of birth. I suspect that this is where traumatic experiences arise. The combination of (negative) time distortion and possible visual and/ or auditory hallucinations with fear and pain is certainly frightening and I suspect for some women traumatising. This was the case for me in my first posterior birth.”

closing the bones post2


  • The transition to motherhood is a profound psychological event, which has been described as a ’normative crisis’ in the female life cycle.[1]
  • Transitory times of life which include role changes (puberty, marriage, birth, and death) have been marked by initiation rituals since prehistoric times.
  • Childbirth can be seen as similar to initiation ritual through several psychological elements, such as the experience of pain or powerful bodily sensations, an altered state of consciousness (’laborland’) and a symbolic experience of death and rebirth.
  • Many cultures use substances to create dissociative states during rituals and for healing.
  • Dissociative states of ‘altered consciousness’ are commonly experienced by women during childbirth.
  • These states help women cope with the experience of childbirth and may prime women to experience the profound psychological shift to motherhood.
  • If women are unprepared for this dissociative state they may feel frightened or ashamed, especially if women experience traumatic care or interventions, this can result in women developing PTSD.
  • Fear of childbirth results in experience of more intense labour pain and report a negative experience of birth
  • Women who have unmedicated vaginal births are more likely to forget the pain of labour. Having an epidural can make women feel disconnected from the labour process and more likely to remember their labour as painful.
  • Two main factors effect women’s experience of pain in labour:
  • Support and (ii) acceptance
  • A positive outlook and acceptance of pain helps women cope, experiences of coping with pain during childbirth are universal
  • Freedom to move and adopt upright positions in labour give women a greater sense of control and a lesser sense of vulnerability and facilitated a positive birth experience.
  • Having a high ‘sense of coherence’ is protective against PTSD following childbirth
  • Childbirth is “an event so primitive and profound as to be difficult to fully assimilate or put into words. . .”[46]
  • Even if birth is experience as traumatic, it is possible to women to experience posttraumatic Growth (deriving benefits following potentially traumatic events)
  • Experience of peritraumatic dissociation and symptoms have been found to be most associated with the greatest levels of growth.
  • Social support is a modifiable factor that effects coping with childbirth, PTSD, PPD and postpartum transition to motherhood

Implications for woman and midwives

  • Antenatal education should prepares women for the possible psychological changes and experiences during pregnancy, birth and postpartum (including dissociation)
  • Continuity of care is key to a feeling of safety and trust
  • Preparation for childbirth should aim to reduce anxiety and enhance women’s sense of coherence and efficacy (including methods of non-pharmacological pain relief and mindfulness) [59-60]
  • Maternal freedom of movement throughout labour is a simple measure to improve birth experiences for women and their partners
  • Interventions to improve social support for women and enhance couple relationships in the antenatal period is key to improving postpartum mental health and improving parent/infant attachment
  • Childbirth can be seen as a spiritually transforming experience, an increase in personal meaning, religiosity, and spirituality can increase well-being so access to the opportunity to incorporate personal spiritual practices or social experiences (such as mother blessings https://magicalbirth.wordpress.com/2012/05/03/hello-world/ ) could be helpful [61]
  • Doula support can provide women and their families with continuity, one-to-one focus on their physical, emotional and spiritual needs during childbirth and postnatally to improve women’s self-efficacy and transition to motherhood and so could significantly affect women’s mental health in the peri-natal period and increase family sense of coherence
  • Providing opportunities within a group for women to tell their birth stories following birth; may help women to process the birth and connect to other women.[58]






Guest post: when birth is trauma

The Madness of Childbirth




Pregnant State of Mind


I’m Not Really Running: Flow, Dissociation, and Expertise












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Vaginal exams in labour (*Trigger warning)


I decided to write this blog post after a discussion in #MatExp about the use of vaginal exams (VE’s) in labour.

Screenshot 2016-03-11 15.54.52

There were concerns that women felt pressurised into consenting to vaginal exams in order to be admitted into birthing units in labour or to access pain relief/the use of a birthing pool etc.

It was discussed that vaginal exams can feel intrusive and be upsetting and that the evidence base for using them in labour is not strong.

Others felt that they are an essential part of labour management, needed to monitor progress and prevent harm from non-progressing labours.

People wondered if there are no other ways to assess progress?

Should vaginal exams be seen as part and parcel of normal labour care?

What are the risks/benefits to having VE’s and should women have more information antenatally about them?

My own experiences of vaginal exam in labour were not distressing to me, but as a doula I have witnessed distressing events occurring in relation to vaginal exams that include:

  • A woman having 20 VE by 8 different people- her cervix swelled and she had a CS due to failure to progress at 9cm
  • A woman who was asked to get out of a birth pool to check for 10cm dilation when pushing, she was told the midwife couldn’t check her in the pool, she was then not encouraged to get back in the pool
  • Coercion of a woman with an abuse (sexual) history at a homebirth to consent to vaginal exams (when she had discussed not wanting them in appointments leading up to the birth) which was distressing for her
  • Breaking waters during an exam without permission (I’m just breaking your waters as she did so)
  • A midwife gave a vaginal exam, stated the woman’s contractions were less frequent and stated she would “Just have a little fiddle about”she then proceeded to give the most intrusive, painful and upsetting exam I have seem, which was traumatic to watch
  • I have also seen good practice of very respectful care to women with abuse histories and a consultant midwife that was able to give exams when women were in pools/upright

Before we look at what vaginal exams are used for, I think it’s important to remember that for a woman having her first baby in the UK, a vaginal exam in labour might be the first time anyone has put their fingers in her vagina except during sex (which may or may not have been consensual or enjoyable)

A vaginal exam involves a health professional placing (usually two) fingers in a woman’s vagina in order to feel her cervix (the entrance to the womb) to assess her progress in labour (this can also be done as part as a membrane sweep in late pregnancy to encourage labour to start.) Vaginal exams in labour are seen as a ubiquitous part of assessing progress, and therefore diagnosing deviation from expected progress and reduce the risks associated with non-progressive labour. A vaginal exam is often one of the first routine procedures when a woman believes labour has started. A woman may have previously been offered one or more membrane sweeps in pregnancy (which is similar to a vaginal exam) to encourage labour to start.

An exam can assess if a women is in ‘active’ (also termed progressive) labour. Whether a woman is ready to go into labour is to feel her cervix, its position, thickness, texture and dilation. This can be given a bishops score (http://perinatology.com/calculators/Bishop%20Score%20Calculator.htm) which can be predictive of induction success[1] although this seems to be more reliable in women having their first baby (nulliparous) [2] and is disputed as a predictor of labour outcome in women having a second of subsequent baby (multipara)[3]Before labour a woman who has not previously had a baby will usually have a cervix which is:

  • Long (thick)
  • Posterior
  • Hard

Before active labour begins the cervix will more forward, soften, become thin and start to open. Sometimes this is accompanied by contractions and other signs (sometimes early or prodromal labour).

The first exam in labour is often to assess if labour has started. Early labour can potentially go on for days or stop and start again days later with no risk associated with this usually unless the bag of waters surrounding the baby breaks (which could introduce infection) although there is evidence that a long early labour can be due to a babies position and lead to a non-progressive labour and more intervention. The longer a woman spends in hospital during this early labour period the more intervention she is likely to have, also maternity units in the UK are not set up to cater for women in early labour so women are often sent home, sometimes repeatedly.


Active labour is considered to have started after 3-4cm dilation (opening) and will then usually continue with regular strong uterine contractions (which become stronger, last longer and get closer together until the baby is born). It had been thought for many years that labour is a linear process, but recent reviews of the evidence have suggested that dilation and labour length is less predictable, with the early first stage of labour (4-6cm dilation) taking longer (in the US, ACOG in part of a attempt to reduce the cesarean section rate have changed national guidelines to have active labour starting at 6cm instead of 4cm[4 5]).

How is labour progress assessed?

In order to assess labour progress, observations are made by the health professionals involved in a woman’s care. In the UK this is usually a midwife.

In NICE guidance (Intrapartum care for healthy women and babies [CG190] Published date: December 2014)

The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care.It has since acquired a high reputation internationally as a role model for the development of clinical guidelines.


Screenshot 2016-03-11 15.40.41 (2)


Screenshot 2016-03-11 15.40.50 (2)

Screenshot 2016-03-11 15.41.58 (2)

Screenshot 2016-03-11 15.40.59 (2)

A Partogram provides a graphic overview of the progress of labour and records information about maternal and foetal condition during labour. The World Health Organization has designated management of labour with the Partograph as one of the essential elements of obstetric care at the first referral level.

In 1991 in Asia, the WHO examined over 35,000 births in the largest trial of the Partograph ever done . The study found evidence that prolonged labour, postpartum sepsis, and stillbirth were significantly reduced when the Partograph was used. Augmentation rates and caesarean rates were also reduced.[6] Another study looked at the effect of partogram on the frequency of prolonged labour, augmented labour, operative deliveries and whether appropriate interventions based on the partogram reduced maternal and perinatal complications introduction of partogram showed significant impact on duration of labour (p<0.001) as well as on mode of delivery (p<0.01) Results also showed significant reduction in number of augmented labour (p<0.001) and vaginal examinations (p<0.001). The authors concluded by using partogram, frequency of prolonged and augmented labour, postpartum haemorrhage, ruptured uterus, puerperal sepsis and perinatal morbidity and mortality was reduced.[7]


But findings can be contradictory, another recent study looking at the role of partogram in the management of labouring mothers with high risk pregnancies at a tertiary care centre found that partogram use had no significant impact on duration of labour, rate of operative interventions and perinatal outcome.[8] A Cochrane review on the effect of partogram use on outcomes for women in spontaneous labour at term found no evidence of any difference between partogram and no partogram in caesarean section (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.24 to 1.70); instrumental vaginal delivery (RR 1.00, 95% CI 0.85 to 1.17) or Apgar score less than seven at five minutes (RR 0.77, 95% CI 0.29 to 2.06). The authors stated ‘On the basis of the findings of this review, we cannot recommend routine use of the partogram as part of standard labour management and care’[9]

There have been several versions of the partograph. The WHO version from 2000 starts active labour at 4cm dilation. There have also been recent studies looking at a ‘physiological partograph’ with a slower rate of expected progress in earlier active labour.[10]

Partographs have an ‘action line’ (most also have an ‘alert’ line) which signify identification of slow progress and the point at which intervention is advised to prevent harm to the mother and baby. Many studies were done to assess the predictive value of these lines, one study found that the mean duration of active phase of labour increased as the partographic curve fell to the right of alert and action line. Increased rates of instrumental deliveries, LSCS, babies with lower APGAR score at 5 min, and NICU admissions were observed in group III (to the right of the action line) compared with groups I and II.(within normal curve or to the right of the alert line)[11]another study found crossing the alert line in mothers who had normal vaginal delivery, with normal fetal heart rate, and with no oxytocin administration or amniotomy was predictive with high sensitivity for the need for neonatal resuscitation after birth.[12]


How long should labour take and what are the risks of labour taking too long?

“The sun should not rise twice on a labouring woman.”(an old saying in tropical obstetrics)

Friedman’s curve[13] has been used to assess the expected length of labour (usually 1cm per hour in active labour. With full dilation at 10cm and the pushing stage lasting approximately an hour) although other studies have suggested (especially the first time a woman gives birth) that labour takes longer, and in some places (for example the All Wales normal birth pathway[14]) this is reflected in guidelines where women are expected to dilate 0.5cm per hour in active labour and take up to 3 hours in the second stage(pushing).


In many areas of the world, women give birth at home, without attendance by a trained health professional and only access care if they feel there is a problem with the labour. There are also cultural reasons that may discourage women from seeking help in labour as often failure to birth easily is thought to be due to actions of women during pregnancy.

In these countries, there is high maternal and neonatal mortality and morbidity relating to obstructed labour, (one of the five most common causes of maternal mortality) with many women (usually first time mothers) developing an obstetric fistula. Where the tissues that normally separate the vagina from the bladder and/or rectum are destroyed by the prolonged impaction of the presenting fetal part (usually the fetal head) against the soft maternal tissues that are trapped between the fetal head and the woman’s bony pelvis. The World Health Organization (WHO) estimates that more than 2 million women live with the condition and up to 100,000 new cases occur each year.

The formation of an obstetric fistula is a problem that originates during prolonged labor when that labor is obstructed. The critical problem in the first phase of delay is recognizing that labor is prolonged. By WHO standards, labor is prolonged if it lasts more than 24 hours.

Length of labour does not always predict fistula formation, it is strong, frequent contractions where the baby is impacted against the pelvis and does not descend. In women having second or subsequent births this more frequently results in uterine rupture.

Relatively short labours less than 12 hours in length may result in a fistula if the conditions for “a perfect storm” are present. In practical terms, this means that all cases of obstructed labor should be regarded as emergencies and treated promptly to avoid the development of serious complications.[15 16]

There are arguments about the slowest ‘normal’ rate of progress that does not result in increased risk [17] Quite a large number (approx. 37% in one study)[18]of low risk women do develop dystocia, but we don’t know how to predict who will reliably. Some studies have also found that slow progress during a VBAC increases the risk of uterine rupture[19]

Although labor dystocia (slow or difficult labor or birth) is the most frequently documented indication for primary cesarean birth, there is no universally accepted definition.” Failure to define dystocia in evidence-based, well-described, clinically meaningful terms that are widely acceptable to and reproducible among clinicians and researchers is concerning at both national and global levels.”[20]

The frequency and reasons for vaginal examinations in labour

Even though NICE guidance states that women should be offered vaginal exams 4 hourly, a recent study found that almost 70% of women had more VEs than expected when the criteria of 4 hourly VEs was applied. The most common reason given by midwives for performing a VE was to assess labour progress and to assess the commencement of labour. [21]

Other reasons to do a VE include:

Obstructed labour

Ultrasound assessment of the fetal head position in labor is feasible in a busy labor ward. Digital examination is less accurate than ultrasound, in particular in cases of obstructed labor when medical intervention is more likely to be needed. Ultrasound assessment may prove useful in the prediction and diagnosis of difficult and prolonged labor[22]

Second stage of labour

Vaginal exams are often given to diagnose the start of the second stage. Sometimes women feel an urge to push before their cervix is fully dilated (usually due to fetal malposition) and it is thought that pushing on an undilated cervix can cause swelling. There can also be a ‘lip’ of cervix remaining which can be due to asyncliticism (tilted head)[23]


To help women push better?

In one study (Titled: “You’ll Feel Me Touching You, Sweetie”: Vaginal Examinations During the Second Stage of Labor) to determine how caregivers performed sterile vaginal examinations researchers examined videotapes of women during the second stage of labor. Results showed that the examinations were performed in a ritualistic manner by all caregivers, and the way the ritual was enacted repeatedly demonstrated the power of the caregivers over the women. The most common reason for performing the procedure, to help the woman push better, seems to be specific to the second stage of labor and is not described in the literature.[24]

Other possible reasons include:

  • Detecting baby position (especially if breech position or cord prolapse is suspected)
  • Concern over babies’ heartrate and possible rapid labour progress
  • Abnormal bleeding
  • Making decisions about pain relief/transfer/intervention
  • Deciding when to get in a birth pool

Evidence for and against vaginal exams in labour

Even though routine vaginal exams are now seen as part and parcel of intrapartum care the lack of evidence for their use is highlighted by some, with a Cochrane review concluding: “Women prefer vaginal exams to rectal exams. No other evidence was found to support or reject the use of vaginal exams. More research needed to find other ways to assess progress of labour [25 26]

 What can the experience of vaginal exams in labour be like?


There have been few studies looking at women’s experiences of vaginal exams in labour, but those that have been done found that women find VEs in labour to be unpleasant, invasive, embarrassing and sometimes painful and that women felt powerless to control when and how the VE was conducted[21 27] The VE has been described as a type of health care ritual with the labouring women playing a generally passive role with no active part and the healthcare provider demonstrating that they are in control of both the woman and the process of labour itself[20] Women have reported that they have to tolerate the pain and discomfort of the VE as it is an integral part of labour.

Studies exploring the qualitative experiences of midwives and women in relation to vaginal examination in labour have also described midwives using abbreviations or euphemisms as a means to distance themselves from the realities of the procedure. ‘Some midwives were observed washing women’s genitals in a highly ritualized manner prior to vaginal examination, apparently as a strategy for establishing power differentials. ’The authors conclude ‘It is also important to carry out vaginal examination in a way that is not demeaning and does not reinforce notions that women’s bodies are dirty.’[28]

Previous trauma and abuse

Many women have experienced rape, abuse or other sexual offenses in their lifetime.


Based on aggregated data from the ‘Crime Survey for England and Wales’ in 2009/10, 2010/11 and 2011/12 around one in twenty females (aged 16 to 59) reported being a victim of a most serious sexual offence (rape) since the age of 16. Extending this to include other sexual offences such as sexual threats, unwanted touching or indecent exposure, this increased to one in five females reporting being a victim since the age of 16.


Many women do not disclose their experiences but the experiences during pregnancy and labour can trigger unwanted memories and fear. Worry about physical exams can stop women from accessing healthcare (for example cervical smears)[29] and if women feel coerced or disembodied during childbirth they can be retraumatised.[30] It is not always intimate procedures themselves that can be triggering for women, but how they are conducted, ‘re-enactment’ of abuse occurs as a result of crossing a woman’s body boundaries (and this can be a subjective internal sense)[31] it is suggested that:

“As staff may not know of a woman’s history, they must be alert to unspoken messages and employ ‘universal precautions’ to mitigate hidden trauma. Demonstrating respect and enabling women to retain control is crucial. Getting to know women is important in the building of trusting relationships that will facilitate the delivery of sensitive care and enable women to feel safe so that the re-enactment of abuse in maternity care is minimised.”

Prior trauma is the most predictive factor of Post-traumatic stress disorder (PTSD) after birth. [32]

Consent to vaginal exams is necessary but women may not always understand the procedure or may feel coerced into having examinations done, as this is part of routine care, which can be traumatic, both for the woman, her birth partner/s or students, as described in this reflective piece-


It wasn’t supposed to be like this (c) S. Wallis


You thought, you would open up beautifully-like a flower does

warm spring

air spreading your petals, slowly.


You thought, you would open up gently like an anemone,

red fronds unfurling with smooth salty ripples.


Not submit to this, four hourly ritual,

Spreading your legs wide, for relentless gloved fingers to press, into, you.

Assessing your readiness; your worthiness-

Like that boy at your fourteenth birthday party, after spinning the bottle.

You could taste your Mothers stolen vodka in your throat when he fingered you-

Biting your lip, trying not to cry out so the others would hear.


You thought the Universe would be moving through you,

Youe Man kneeling in worship at your feet-

With you birthing the world anew


Not strapped down,

With them crowding round and shouting that you are useless, that you aren’t trying

-that your baby is going to die if you don’t push harder.

And the student midwife is cutting you, and the senior midwife is cutting you again

And the surgeons are hovering, and your Man’s eyes are looking on with horror,

And your baby is limp and grey and quiet…


Even after she starts to cry, her eyes are screwed tightly shut,

And she is over with the medics, not on your belly like you thought

And they are stitching you up, and you are crying, and he is crying,


And you didn’t think it would be like this.


Are there other ways to assess progress in labour?

Several alternative ways to assess labour progress have been suggested, including:

Contraction shapes (fall to rise ratio is higher when labour is nonprogressive)[33]

Rotation/descent[34 35]

Changes in behaviour have been described by experienced midwives that signify active labour and progress in labour[36]. These include:

  • Breathing patterns
  • Smell
  • Movement
  • Skin changes and body temperature
  • Touching
  • Pain perception
  • Contractions
  • Transition

Click to access Second%20Stage%20of%20Labour.pdf

Ultrasound[37 38] has been found to be accurate in the first and second stages of labour, especially where a baby is malpositioned

There is good association between non-invasive ultrasound-based determination of fetal head station and clinically assessed cervical dilatation. When women were asked to compare the experience of vaginal exams and translabial ultrasound the majority (70.5%) considered VE worse than translabial ultrasound (TLUS) as compared to only 4% who felt the opposite.[39]and has been found to be considerably less painful [40]and may be useful to help predict which women will have vaginal births with prolonged second stage and which need assistance.[41]

trans labial ultrasound


Purple line[42 43] the formation of a purple line during labour, seen to rise from the anal margin and extend between the buttocks as labour progresses has been reported. This is being looked at as an alternative measure of labour progress but may not have a high predictive value.http://www.sarawickham.com/questions-and-answers/evidence-for-the-purple-line/

 What changes could we make to services to improve things?

It seems unlikely that a change of practice to stop or reduce the use of vaginal exams in labour would happen in the UK soon, so what can be done to improve things now?

In a study that looked to improve the vaginal examinations performed by midwives, suggestions included[44]:

  • Judging the necessity of vaginal examinations
  • Using effective communication skills
  • Informed consent
  • Exploring the patient’s preferences and choices
  • Providing sensitive woman-centred care
  • Minimising variability during vaginal examinations
  • Paying attention to the frequency of vaginal examination
  • Using alternative ways to measure the progress of labour
  • Managing unresolved traumatic experiences

Screening for prior experience of abuse, rape or PTSD symptoms prior to birth is also seen as key to prevent retraumatisation during birth. This screening needs to be appropriate

A thesis by Amina White ‘BEST PRACTICES FOR LIMITING RISK OF POSTTRAUMATIC STRESS RELAPSE DURING CHILDBIRTH’ outlines a three-part strategy for trauma-informed obstetrical care that calls for PTSD screening, avoiding posttraumatic stress triggers, and enhancing stress-coping resilience in order to promote the physical and mental well-being of trauma survivors during the birthing process.

‘Obstetricians have a clear duty to inquire sensitively about past trauma and to screen trauma-exposed women for PTSD’

If a woman discloses her history, a plan can be made to reduce or avoid ‘micro triggers’

Not all women will want or feel it is necessary to disclose their history, so it is important during labour to look for signs of anxiety, discomfort or distress.

Narrative accounts suggest that survivors whose clinicians ignore distressing micro-triggers are more likely to perceive those clinicians as disrespectful and as providing substandard care

In the event that the clinician and medical staff are aware of a patient’s trauma history, it becomes especially critical to avoid phrases that accentuate powerlessness such as, “Just let it happen, you can’t fight it”

I have personally seen successful birth planning of women with abuse histories with Consultant midwives in the UK that resulted in positive birth experiences, including a homebirth and a planned caesarean section.

A doula may be able to support women in labour and can concentrate of communication, comfort and emotional support.[45]




Vaginal exams are done in labour for many reasons. The first exam is usually to assess if a woman is in active labour. Once active labour has started exams are usual every four hours in order to plot labour progress on a pictorial record (partogram). Although vaginal exams should be ‘offered’ they have very much become part of routine care and women often feel unable to opt out.

Evidence of benefit from vaginal exams is scant, and little research has been done on women’s views in relation to their experience of vaginal exams or consent.

In low and middle income countries many women and babies are damaged by obstructed labour, which leads to negative outcomes including obstetric fistula, uterine rupture and stillbirth.

There is still disagreement about how long is too long to wait for labour to progress when labour is slow in both the first and second stage without intervening.

Possible disadvantages from refusing vaginal exams are: not knowing if active labour has started (so potentially having pain relief like an epidural or diamorphine when labour has not started) not knowing if labour has stalled or for how long (with possible risks to mother and babies health)

70% of women had more VEs than expected when the criteria of 4 hourly VEs was applied

Women find VEs in labour to be unpleasant, invasive, embarrassing and sometimes painful and sometimes feel powerless to control when and how the VE was conducted

1 in 5 women have experienced rape or sexual threats, unwanted touching or indecent exposure since age 16.

Experiences during pregnancy and labour can trigger unwanted memories and fear

If women feel coerced or disembodied during childbirth they can be retraumatised

Language used is important, as being asked to tolerate pain and discomfort, or ‘just a little’ longer can be similar to phrases used during sexual abuse and coercion. Respecting women’s wishes and boundaries is key

Be alert to signs that someone is consenting under internal duress as this can be extremely distressing

NICE guidelines state VE’s should be ‘offered’ they should not be required to access pain relief, birth pools or access to a maternity unit if other signs of active labour are present

Several alternative methods can be used to assess labour progress in particular trans-labial ultrasound is a promising method to sequentially assess labour progress










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#MatExphour Twitter chat on malposition and maternal mobility

I made a Storify book summarising the twitter chat I recently hosted


Upcoming twitter chat #MatExpHour: Malposition and maternal position Friday 5th February




It aims to:

  • Encourage and empower users of maternity services to join conversations about their experiences of maternity care, and what really makes a difference to that experience.
  • Get health care professionals (in and beyond the NHS) and local communities to listen and work in partnership with women and families to improve maternity experiences.
  • To enable anyone to take action to improve maternity experience, however big or small, whoever you are: user, partner, community group or NHS staff


Maternal mobility in labour

How often do you end up shouting at the telly when ‘One born every minute’ is on, and a labour is slow to progress or baby is not coping well and a woman is lying down? Try getting her up!

There’s a large body of research evidence that movement in labour improves outcomes so why do so few women feel able to change position in labour, especially in the second stage?

In 2015 in the UK, fewer women gave birth in a bed than in 2007 and more women chose a water birth or birthing pool (but still <10%)

But approx. 50% of women in 2015 having an unassisted vaginal birth gave birth lying down or lying down with legs in stirrups. The most common position for women to be in when they gave birth was lying down with legs in stirrups (35%), which is a 3% increase from 2013. It should be noted that 15% of women had an assisted vaginal delivery, which would normally require stirrups.


What affects choice of birthing position?

Barriers to maternal movement in labour have been suggested to include: (1) lack of space, (2) inadequate support, (3) use of unwarranted debilitating technology, and (4) movement restricting pain relief.

The link below shows how it is possible to achieve mobility with an induced multiple birth:


The advice given by midwives was the most important factor in this study influencing the choice of birthing positions.


In one study where women were randomised to use a birthing stool or usual care, despite being randomised (rather than freely choosing), women who gave birth on the seat were statistically significantly more likely to report that they participated in decision-making and that they took the opportunity to choose their preferred birth position. They also reported statistically significantly more often than non-adherers that they felt powerful, protected and self-confident.

Midwives should be conscious of the potential impact that birth positions have on women’s birth experiences and on maternal outcomes.. An upright birth position may lead to greater childbirth satisfaction. http://www.sciencedirect.com/science/article/pii/S1871519213000723

What about Dad’s and birth partners?

If a woman gives birth upright, the father is more likely to see the birth as positive, says a study from Sweden… http://fb.me/7BlBeD9fR

What about malposition?

doula (1 of 1)

Many women start labour low risk but experience a cascade of intervention, although there are a number of factors that cause this, I believe the (often) unrecognised missing cause in the majority of emergency caesareans, assisted deliveries and interventions causing long term morbidity to low risk women and their babies worldwide is malposition.

Malposition’s are positions where a baby is head down but is presenting in a way that increases the diameter that needs to pass through the pelvis and birth canal. This can be ‘back to back’ (or occiput posterior known as OP) where a baby has its spine against the mothers spine. Babies in this position are usually ‘deflexed’ (chin not tucked to the chest) and this can cause more pain and delays going into labour or in the first and second stage. Although most babies rotate into an easier position to be born, the longer this takes, the more likely it is that women will have interventions like induction, augmentation, systemic pain relief. Women whose babies stay OP (known as persistent OP) are much more likely to need assisted delivery, episiotomy and caesarean section. They also have a higher chance of perineal tearing, post-partum haemorrhage (blood loss) and postpartum infection. Babies are also more likely to show distress in labour, meconium in the amniotic fluid, lower Apgar scores and need time in NICU.

As well as OP other factors that can result in malposition are asyncliticism (a tilt to a baby’s head in late labour) and compound arms (up above the head)

Recent research indicates there is no ‘ideal’ birth position. But OA babies (with their backs to a mother’s front) are more often flexed (head tucked) which presents a symmetrical and smaller circumference onto the cervix. This leads to less prolonged labour and riper cervix.

Whether a malposition is a problem will depend on many factors-

  • Pelvis shape/size
  • Uterine ligaments
  • Baby size
  • Baby position (this can also encompass flexion (chin tucking) and arms above the head
  • Mothers health in pregnancy (diet and exercise)
  • Mothers mobility in labour
  • Mothers pain relief in labour

Can we do anything about malposition in labour?

I addressed this in my latest post here:


I concluded:

There is a body of evidence that maternal mobility in labour improves outcomes and may aid rotation. More research is needed that can adequately measure maternal mobility in labour and interventions that match the multifaceted practices that midwives and doulas use to support women with prolonged labour or suspected malposition.

Women may want to mobilise in labour but feel restricted by social/cultural expectations (for example the use of the bed in the maternity room)or restricted by the technology being used (CFM, drip).

Comments on facebook about the topic have so far included:

“I think we should change the language. Maternal mobility is not important to women. It is essential to the process of birth. Birth is not able to process as well. We don’t say ‘mobility is important to men when having sex’ or ‘mobility is important to people emptying their bowels’. Saying it is important to women means it can be overridden by welfare of the baby. Suggest Margaret Garrett ‘dynamic positions’ book to anyone who thinks it is nice but optional.”

“Restricting mobility is a dangerous, and unproven, intervention. Spontaneous positioning is the NICE standard of care for ‘normal’ births & should be for all births. It is a human right. Great topic! Emerging evidence for upright breech birth | The midwife, the mother and the breech




  1. Should midwives tell women the position they believe their baby to be in antenatally?
  2. Can antenatal maternal posturing effect fetal position and outcomes?
  3. Can maternal posturing in labour effect fetal position and outcomes
  4. How can midwives and birth partners best support women with malpositioned labours for comfort and to improve outcomes?
  5. Do midwives and doctors facilitate or hinder movement in labour?
  6. How can we support high risk women to be mobile in labour? What about telmemetry and pool use/VBAC
  7. Should pool use be promoted to increase mobility?
  8. How does birth room environment design effect mobility?
  9. Does malposition make it harder for women to move in labour due to pain? How can we support them?

I will post a second blog post to summarise the twitter discussion after Friday.






















Does baby’s position matter in labour and can we do anything about it?


Reply to Catie Mehl of Columbus Birth & Parenting and Angela Horn from Tuscon doulas recently published blog posts about malposition.


Prevalence of OP prior to labour

Up to approx. 30% of babies are OP before labour begins.[1]

Some studies have found that fetal position before labour does not affect birth outcome[2] but others have found the opposite, in one study occipital position was found to be a factor in predicting successful induction[3] with cervical length being longer in OP positions prior to induction.

Around 80% of babies that are OP before labour begins, will rotate in labour[1]

But the longer a baby stays OP in labour, the more likely they are to stay that way.[4]

The deflexion associated with OP may be more important than the fetal position.[3]

Malposition effects labour progress

Persistent OP is associated with prolonged first and second stages of labor and augmentation [5-7]

Malpositioned labours significantly more often cross the partogram action line[8]

Malposition effects maternal and fetal outcomes

Women whose babies that are malpositioned during labour and birth are more likely to have obstetric interventions, including assisted delivery and operative birth [6 9 10]

The incidence of persistent occiput posterior position was associated with significantly higher incidences of induction of labor, oxytocin augmentation of labor, epidural use, and prolonged labor[5]

Maternal movement in labour improves birth outcomes

Can maternal position changes in labour effect rotation from OP to OA?

Most intervention studies using maternal position to try to rotate babies from OP to OA have been unsuccessful[9 11]  although studies have tended to be for short durations (-10 minutes), and include participants that have an epidural (approx. 90%)

One study has been successful in effecting rotation from OP to OA using maternal movement. The authors conducted an observational cohort study of women in Padua, Italy having their first baby. They grouped women into Group-A when they spent more than 50% of their labour in recumbent position (supine or lateral) and in Group-B when they preferred an alternative position (upright, squatting, sitting on the ball, or “on all fours” position) the OP rate at the start of labour was comparable in two groups with 40.6% in Group-A and 36.5% in Group-B.

A strong significant difference was found in terms of delivery outcome.

CS was necessary in 27 patients: 46.4% in Group-A compared to the 12.3% in Group-B.

Significant differences in terms of OP persistence at delivery were also found in those delivering vaginally: in Group-A patients, OP persisted till birth in 39.6% of the cases while in Group-B only in 28% of the cases[12]

Other evidence for benefits of maternal movement in the first stage

Upright positions increase contraction strength. Women labouring in upright, non-recumbent positions have fewer POP deliveries, shorter labours and lower rates of assisted deliveries and CS[12]

Sims’ posture on the same side as the fetal spine has been recommended to enhance rotation from posterior to anterior[13]

Prince of Songkla University Cat (leaning over back of bed at 60 degree angle on knees)and upright positions together with music reduced the duration of active phase of labour and labour pain in primiparous women compared to oxytocin[14]

Cochrane review: Maternal positions and mobility during first stage labour-“Walking and upright positions in the first stage of labour reduces the duration of labour, the risk of caesarean birth, the need for epidural, and does not seem to be associated with increased intervention or negative effects on mothers’ and babies’ wellbeing.”[15]

Other evidence for benefits of maternal movement in the Second stage

Any upright or lateral birth positions compared with supine or lithotomy positions have been associated with reduced duration of second stage of labour, reduction in operative delivery, reduction in episiotomies, reduced reporting of severe pain in the second stage, fewer abnormal fetal heart patterns[16]

“Use of the supine position is associated with negative maternal, fetal, and neonatal hemodynamic outcomes. Despite the persistence of the use of recumbent positions for birth, the evidence supports the merit of upright positions. “

Kneeling squat position significantly increases the bony transverse and anteroposterior dimension in the mid pelvic plane and the pelvic outlet[17]

In a study using MR obstetric pelvimetry an upright birthing position significantly expands female pelvic bony dimensions, suggesting facilitation of labor and delivery[18]

Epidural use

Women with epidurals that change position[19] (every half hour from hands and knees, sitting etc in the passive part of second stage (giving time for the head to come down) and push in a lateral position with the upper hip abducted had greatly reduced assisted delivery rates (19.8% vs 42.1%) higher rates of intact perineum ( (40.3% vs 12.2%), lower episiotomy rate (s (21.0% in vs 51.4%) and time actively pushing, without incurring any other adverse maternal or fetal outcomes[20]. Peanut balls have also been found to improve outcomes for women with an epidural. [21]


The use of the squatting position in managing the second stage of labor results in less instrumental delivery, extension of episiotomy and perineal tearing compared with the supine position[22 23]

Women prefer freedom to move in labour

Freedom to change positions in labour has been identified as integral to a feeling of control and the management of pain in labour, due to the physical and psychological benefits[24]

Women have described being in more control over their pushing in the second stage when they were in an upright position compared to a supine position[25]


Is operative birth necessary?


In a review of >225 thousand birth records in the United states (2002-08) half of Caesarean Deliveries for dystocia in induced labor were performed before 6 cm of cervical dilation. Among intrapartum CDs, approximately half were performed for ‘failure to progress’ or ‘cephalopelvic disproportion’.[26]

It has been reported that most cases of reported cephalopelvic disproportion (CPD) result from malposition of the fetal head within the pelvis (asynclitism) or from ineffective uterine contractions. True disproportion is an unlikely diagnosis because two thirds or more of women undergoing cesarean delivery for this reason subsequently deliver even larger newborns vaginally[27]


Could we reduce intervention for dystocia and malposition with more time?

A review of the evidence relating to dystocia found that current understandings rest on outdated definitions of active first stage of labour, its progress and on treatments without a strong evidence base. These include the cervical dilatation threshold for active first stage, uncertainty over whether a reduced rate of dilatation and reduced strength of uterine contractions always represent pathology and the effectiveness of amniotomy/oxytocin for treating dystocia[28]

It has been suggested that one of the ways to safely prevent primary caesarean deliveries is to increase the active phase of labour start to 6cm and the safe duration of the second stage to at least 2 hours for women having a second or subsequent baby and 3 hours for women having their first baby.[29] or longer with an epidural although the safety of this is contested by some. [30]

International findings

Obstructed labour mostly caused by malposition (and often labelled as CPD) is common in lower income countries and has a high rate or maternal and fetal mortality and morbidity. More needs to be done to prevent and resolve malposition in situations where safe obstetric intervention may not be feasible to save mothers and babies lives and futures[31]

Women in Low and middle income countries (LMIC) are described as having three delay to obstetric care. (1) deciding to seek appropriate medical help for an obstetric emergency; (2) reaching an appropriate obstetric facility; and (3) receiving adequate care when a facility is reached[32]


Maternal and fetal morbidity and mortality is often due to this delayed treatment.

Prolonged obstructed labor can result in fistulas. Because obstetric fistulas are caused by tissue compression, the time interval from obstruction to delivery is critical. Women may not deliver in health care facilities if they do not meet their needs. (this includes the need to move around in labour and use upright positions to birth in, which may be discouraged in the hospital setting) There may be transport and cost implications or Beliefs that problems in labor arise from disturbances in the social environment (and may be caused by actions of the mother) rather than as simple problems of obstetrical mechanics [33]

Even after arrival at a health facility mean waiting time for women admitted with complications was as much as 24 h before treatment.[34]


Barriers and facilitators maternal movement in labour

Barriers to maternal movement in labour include: (1) lack of space, (2) inadequate support, (3) use of unwarranted debilitating technology, and (4) movement restricting pain relief[35]

Difficulty in conducting research relating to maternal movement in labour, which is often dynamic and needs to be directed by the woman, means that amassing strong evidence of the efficacy of maternal movement to resolve malposition is complicated. Cultural influences and provider influences also effect choice of maternal position. [36 37]

Use of a pool in labour has been suggested to increase maternal ability to change position[38] and also mobile telemetry for high risk women to allow greater mobilisation and use of the pool.[39]

Fathers with a partner having an upright birth position were more likely to have had a positive birth experience, to have felt comfortable and powerful compared to spontaneous vaginal births where women adopting a horizontal birth position[40]


Malposition’s are the root cause for much of the morbidity and mortality and unexpected intervention in labours worldwide. There is a body of evidence that maternal mobility in labour improves outcomes and may aid rotation. More research is needed that can adequately measure maternal mobility in labour and interventions that match the multifaceted practices that midwives and doulas use to support women with prolonged labour or suspected malposition.

Women may want to mobilise in labour but feel restricted by social/cultural expectations (for example the use of the bed in the maternity room[41]) or restricted by the technology being used (CFM, drip).

Doulas and midwives can help to facilitate women’s choices by:

  • Antenatal education that provide women and their partners practical experience of maternal positions that can facilitate labour and birth
  • Discussing the barriers and enablers of maternal movement
  • Practical support in labour if technology is needed (suggesting mobile telemetry as a possibility if available, holding monitors in place while women use birth balls or change position with CFM)
  • Suggesting movement changes in labour that might aid women’s comfort or rotation
  • Suggesting the use of a peanut ball if women have an epidural or need to rest in a recumbent position
  • Suggesting position changes in the second stage (particularly if there is a delay or little change in descent)
  • Rebozo can be a useful tool when women have difficulty moving (due to exhaustion, pain, pain relief or technology that restricts movement)42]


  1. Verhoeven CJ, Mulders LG, Oei SG, et al. Does ultrasonographic foetal head position prior to induction of labour predict the outcome of delivery? European Journal of Obstetrics & Gynecology and Reproductive Biology 2012;164(2):133-37
  2. Ahmad A, Webb S, Early B, et al. Association between fetal position at onset of labor and mode of delivery: a prospective cohort study. Ultrasound in Obstetrics & Gynecology 2014;43(2):176-82
  3. Ashour ASA, ABDELLA RM, GHAREEB HO, et al. Preinduction ultrasonographic measurements as a predictor of successful induction of labor in prolonged pregnancy in primigravidas. 2013
  4. Vitner D, Paltieli Y, Haberman S, et al. Prospective multicenter study of ultrasound‐based measurements of fetal head station and position throughout labor. Ultrasound in Obstetrics & Gynecology 2015;46(5):611-15
  5. Fitzpatrick M, McQuillan K, O’Herlihy C. Influence of persistent occiput posterior position on delivery outcome. Obstetrics & Gynecology 2001;98(6):1027-31
  6. Ponkey SE, Cohen AP, Heffner LJ, et al. Persistent fetal occiput posterior position: obstetric outcomes. Obstetrics & Gynecology 2003;101(5, Part 1):915-20
  7. Senécal J, Xiong X, Fraser WD, et al. Effect of fetal position on second-stage duration and labor outcome. Obstetrics & gynecology 2005;105(4):763-72
  8. Mathisen M, Olsen RV, Andreasen S, et al. Is it possible to detect malposition of the vertex at an early stage in labour? A case-control study. Sexual & Reproductive Healthcare 2014;5(4):185-87
  9. Desbriere R, Blanc J, Le Dû R, et al. Is maternal posturing during labor efficient in preventing persistent occiput posterior position? A randomized controlled trial. American journal of obstetrics and gynecology 2013;208(1):60. e1-60. e8
  10. Gardberg M, Leonova Y, Laakkonen E. Malpresentations–impact on mode of delivery. Acta obstetricia et gynecologica Scandinavica 2011;90(5):540-42
  11. Guittier M, Othenin‐Girard V, Gasquet B, et al. Maternal positioning to correct occiput posterior fetal position during the first stage of labour: a randomised controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology 2016
  12. Gizzo S, Di Gangi S, Noventa M, et al. Women’s choice of positions during labour: return to the past or a modern way to give birth? A cohort study in Italy. BioMed research international 2014;2014
  13. Ridley RT. Diagnosis and intervention for occiput posterior malposition. Journal of Obstetric, Gynecologic, & Neonatal Nursing 2007;36(2):135-43
  14. Phumdoung S, Youngwanichsetha S, Mahattanan S, et al. Prince of Songkla University Cat and upright positions together with music reduces the duration of active phase of labour and labour pain in primiparous women compared to oxytocin. Focus on Alternative and Complementary Therapies 2014;19(2):70-77
  15. Lawrence A, Lewis L, Hofmeyr GJ, et al. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev 2013;8:Cd003934
  16. Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. The Cochrane Library 2012
  17. Reitter A, Daviss B-A, Bisits A, et al. Does pregnancy and/or shifting positions create more room in a woman’s pelvis? American journal of obstetrics and gynecology 2014;211(6):662. e1-62. e9
  18. Michel SC, Rake A, Treiber K, et al. MR obstetric pelvimetry: effect of birthing position on pelvic bony dimensions. American Journal of Roentgenology 2002;179(4):1063-67
  19. Lape LA. The relationship between the incidence of occiput posterior fetal position at birth to maternal labor positions in patients with epidurals: Northern Kentucky University, 2011.
  20. Walker C, Rodríguez T, Herranz A, et al. Alternative model of birth to reduce the risk of assisted vaginal delivery and perineal trauma. International urogynecology journal 2012;23(9):1249-56
  21. Tussey CM, Botsios E, Gerkin RD, et al. Reducing length of labor and cesarean surgery rate using a peanut ball for women laboring with an epidural. The Journal of Perinatal Education 2015;24(1):16-24
  22. Ahmed MA-GS, Youssef M. Comparison between squatting versus supine (lithotomy) positions during the passive second stage of labor without epidural anesthesia in nulliparous women: a prospective cohort study. Journal of Evidence-Based Women’s Health Journal Society 2015;5(3):140-42
  24. Johansson M, Thies-Lagergren L. Swedish fathers’ experiences of childbirth in relation to maternal birth position: a mixed method study. Women and Birth 2015;28(4):e140-e47
  25. De Jonge A, Lagro-Janssen A. Birthing positions. A qualitative study into the views of women about various birthing positions. Journal of Psychosomatic Obstetrics & Gynecology 2004;25(1):47-55
  26. Epidemiology of cesarean delivery: the scope of the problem. Seminars in perinatology; 2012. Elsevier.
  27. Horsager R, Roberts S, Rogers V, et al. Williams Obstetrics, Study Guide: McGraw Hill Professional, 2014.
  28. Karaçam Z, Walsh D, Bugg GJ. Evolving understanding and treatment of labour dystocia. European Journal of Obstetrics & Gynecology and Reproductive Biology 2014;182:123-27
  29. Caughey AB, Cahill AG, Guise J-M, et al. Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology 2014;210(3):179-93
  30. Leveno KJ, Nelson DB, McIntire DD. Second-stage labor: how long is too long? American journal of obstetrics and gynecology 2015
  31. Higashi H, Barendregt J, Kassebaum N, et al. Surgically avertable burden of obstetric conditions in low‐and middle‐income regions: a modelled analysis. BJOG: An International Journal of Obstetrics & Gynaecology 2015;122(2):228-36
  32. Barnes-Josiah D, Myntti C, Augustin A. The “three delays” as a framework for examining maternal mortality in Haiti. Social science & medicine 1998;46(8):981-93
  33. Wall LL. Overcoming phase 1 delays: the critical component of obstetric fistula prevention programs in resource-poor countries. BMC pregnancy and childbirth 2012;12(1):68
  34. Cavallaro FL, Marchant TJ. Responsiveness of emergency obstetric care systems in low‐and middle‐income countries: a critical review of the “third delay”. Acta obstetricia et gynecologica Scandinavica 2013;92(5):496-507
  35. Hollins Martin CJ, Martin CR. A narrative review of maternal physical activity during labour and its effects upon length of first stage. Complementary therapies in clinical practice 2013;19(1):44-49
  36. Martin CJH, Kenney L, Pratt T, et al. The Development and Validation of An Activity Monitoring System for Use in Measurement of Posture of Childbearing Women During First Stage of Labor. Journal of Midwifery & Women’s Health 2015;60(2):182-86
  37. Nieuwenhuijze MJ, Low LK, Korstjens I, et al. The Role of Maternity Care Providers in Promoting Shared Decision Making Regarding Birthing Positions During the Second Stage of Labor. Journal of Midwifery & Women’s Health 2014;59(3):277-85
  38. Hall E. The use of water immersion in the facilitation of ‘normal labour’. Diffusion-The UCLan Journal of Undergraduate Research 2014;7(1)
  39. Jackson R. The use of water during the first stage of labour: Is this a safe choice for women undergoing VBAC? British Journal of Midwifery 2013;21(6)
  40. Hasman K, Kjaergaard H, Esbensen BA. Fathers’ experience of childbirth when non-progressive labour occurs and augmentation is established. A qualitative study. Sexual & Reproductive Healthcare 2014;5(2):69-73
  41. Townsend B, Fenwick J, Thomson V, et al. The birth bed: A qualitative study on the views of midwives regarding the use of the bed in the birth space. Women and Birth 2015
  42. Cohen SR, Thomas CR. Rebozo technique for fetal malposition in labor. Journal of Midwifery & Women’s Health 2015;60(4):445-51


Does baby’s position matter in pregnancy and can we do anything about it?

early labour (2)

Catie Mehl of Columbus Birth & Parenting and Angela Horn from Tuscon doulas recently published blog posts about malposition.


Does baby’s position matter in labor? (Part 1 and 2)

These two women presented on this topic at the 2015 ProDoula Instilling Strength Conference. Their presentation, “OP Babies: A Real Pain in the Ass,” examined common misunderstandings of OP babies and back labor and examined current body of research on these topics.

I would argue that the post might have benefitted from some literature searching support as there are many more studies looking at malposition and posterior presentation that have been published in the past twenty years (a quick search on google scholar shows these number into the thousands) than the twenty they read.

In Part 1 (Catie Mehl of Columbus Birth & Parenting) states:

You can’t prevent a posterior baby and start and stop labor is not because baby is OP

There have been few studies that directly looked at the association of fetal position and length or prevalence of prodromal labour. We do know that women that present to their chosen place of birth before active labour are more likely to go on to have more interventions[1]and prolonged latent phase (as well as PROM) has found to be a predictor of failed induction.[2]

I have previously discussed this in my blog post here:


An OP position might not stop someone going into labour but it is associated with prolonged pregnancy[3] and we also know that lack of fetal head engagement predicts prolonged pregnancy. [4 5]And that fetal head above the inter-spinal diameter and poor fetal head-to-cervix contact are associated with dystocia in labour. Descent of fetal head is correlated to dilatation of the cervix, and cervix dilatation < 4 cm at admission was associated with an increased risk of dystocia. Women admitted with little cervical dilatation may have unbearably painful contractions. High risk of dystocia in women admitted in early labour has also been found in many studies [6]

As the blog author states, OP babies tend to be deflexed and another study by Ashour et al. found that in women undergoing induction of labour, prediction of outcome can be provided by determining sonographically the preinduction cervical length, occipital position and degree of flexion of the head which were superior to Bishop score in predicting successful induction.[7]

So this means that OP (and other malpositions) effect flexion and fetal head engagement which can lead to prolonged pregnancy and long latent phase/prodromal labour which is all in turn associated with longer labour more intervention in labour, failed induction, instrumental and CS delivery.

The authors then go on to state: “There is a belief that a person can prevent an OP baby by maintaining specific postures and avoiding others during pregnancy.”

I would agree that the evidence supporting the beliefs that OP is always a problem in labour and is also the only malposition that can effect starting labour and progress of labour is false.

My own position is that whether a malposition is a problem for an individual diad will depend on many factors-

  • Pelvis shape/size
  • Uterine ligaments
  • Baby size
  • Baby position (this can also encompass flexion (chin tucking) asyncliticism and arms above the head
  • Mothers health both pre pregnancy and in pregnancy (diet and exercise)
  • Mothers mobility in labour
  • Mothers pain relief in labour

There is no one ideal position. Flexion (which can be effected by fetal position), asyncliticism (Asynclitism is one of the most frequent malpositions of the fetal head, occurring during both first and second stage of labor. Any fetal head position may be associated. OT position is frequently associated with asyncliticism. If the fetal head does not rotate at mid pelvis (spines) to OA or OP this may lead to deep transverse arrest[8]) compound arms, fetal size and position (of both head and trunk) can all effect labor.

There is also little current evidence that it is possible to prevent malposition prior to labour (and as the authors state, the majority of malpositioned babies, rotate and can be born vaginally). Although we do know that the longer a baby stays in a malposition in labour, the more likely it is for them to stay that way.[9] but…

“no evidence of effect” is not “evidence of no effect”[10]

The evidence for maternal posturing in pregnancy to prevent malposition is currently weak. Is this because the right studies haven’t been done yet? Many of the studies finding no effect in pregnancy randomised women to interventions like Hands and knees rocking with pelvic rocking from 37 weeks (for 10 minutes twice daily ) had no effect on POP or outcomes[11] and a Cochrane review concluded that use of hands and knees position for 10 minutes twice daily to correct occipito-posterior position of the fetus in late pregnancy cannot be recommended as an intervention[12]

Those of us that work with women with malposition in pregnancy might see these interventions that have been studied as too little to change outcomes.

There is evidence of the benefit of general fitness in pregnancy on improving outcomes[13], and also birth ball use[14] (it has been postulated that vigorous circles on the birth ball may aid flexion of the fetal head). A physical exercise program during pregnancy is associated with a shorter first stage of labor[15]

I agree that the evidence is not strong that back pain in labour is due to fetal malposition (at least not always) but excessive pain, especially in early labour is associated with dystocia (which is associated with malposition) and more frequent breakthrough pain during epidural analgesia is common in dysfunctional labors [16] a recent study found that mothers who experience high levels of pain during pregnancy (lower back and pelvic pain which the authors postulate may be due to occurrence of malpositioning of the fetus during pregnancy.) are at increased risk of complications during labour[17]and the authors go on to say that further investigation into the role of pain during pregnancy, fetal position and birth outcomes is necessary.


There is a large body of evidence that malposition effects women’s pregnancies, and can lead to pain in pregnancy, prolonged pregnancy, longer pre-labour and birth outcomes. There is currently little research that has found evidence of an effect of interventions on preventing malposition. OP is not the only malposition that can effect pregnancy and labour outcomes this is partly due to paucity of rigorous studies that use the range of methods currently being utilised by midwives and doulas..[18-21]. There is evidence for exercise in pregnancy to improve birth outcomes and reduce length of labour, pain and need for augmentation, assisted delivery and CS

I will address Part 2 of the blog (Does baby’s position matter in labour and can we do anything about it?) in a subsequent post


  1. Spiby H, Green J, Renfrew M, et al. Improving care at the primary/secondary interface: a trial of community-based support in early labour. The ELSA trial. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO) 2008
  2. Khan NB, Ahmed I, Malik A, et al. Factors associated with failed induction of labour in a secondary care hospital. JPMA-Journal of the Pakistan Medical Association 2012;62(1):6
  3. Fitzpatrick M, McQuillan K, O’Herlihy C. Influence of persistent occiput posterior position on delivery outcome. Obstetrics & Gynecology 2001;98(6):1027-31
  4. Shin KS, Brubaker KL, Ackerson LM. Risk of cesarean delivery in nulliparous women at greater than 41 weeks’ gestational age with an unengaged vertex. American journal of obstetrics and gynecology 2004;190(1):129-34
  5. Craig GM, Booth H, Hall J, et al. Establishing a new service role in tuberculosis care: the tuberculosis link worker. Journal of advanced nursing 2008;61(4):413-24
  6. Kjærgaard H, Olsen J, Ottesen B, et al. Obstetric risk indicators for labour dystocia in nulliparous women: a multi-centre cohort study. BMC pregnancy and childbirth 2008;8(1):45
  7. Ashour ASA, ABDELLA RM, GHAREEB HO, et al. Preinduction ultrasonographic measurements as a predictor of successful induction of labor in prolonged pregnancy in primigravidas. 2013
  8. Malvasi A, Barbera A, Di Vagno G, et al. Asynclitism: a literature review of an often forgotten clinical condition. The Journal of Maternal-Fetal & Neonatal Medicine 2014(0):1-5
  9. Malvasi A, Bochicchio M, Vaira L, et al. The fetal head evaluation during labor in the occiput posterior position: the ESA (evaluation by simulation algorithm) approach. The Journal of Maternal-Fetal & Neonatal Medicine 2014;27(11):1151-57
  10. Altman DG, Bland JM. Statistics notes: Absence of evidence is not evidence of absence. Bmj 1995;311(7003):485
  11. Kariminia A, Chamberlain ME, Keogh J, et al. Randomised controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth. bmj 2004;328(7438):490
  12. Hunter S, Hofmeyr GJ, Kulier R. Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). The Cochrane Library 2007
  13. Thangaratinam S, Rogozińska E, Jolly K, et al. Effects of interventions in pregnancy on maternal weight and obstetric outcomes: meta-analysis of randomised evidence. Bmj 2012;344
  14. LI Y-h, WU N, ZHUANG W. Effect of birth ball exercise combined with free maternal position on labour pain, sense of labor self-control and gestational outcomes. Chinese Journal of Nursing 2013;9(011)
  15. Perales M, Calabria I, Lopez C, et al. Regular Exercise Throughout Pregnancy Is Associated With a Shorter First Stage of Labor. American Journal of Health Promotion 2015
  16. Capogna G, Camorcia M. Analgesia for Dystocia and Instrumental Vaginal Delivery. Epidural Labor Analgesia: Springer, 2015:153-66.
  17. Brown A, Johnston R. Maternal experience of musculoskeletal pain during pregnancy and birth outcomes: Significance of lower back and pelvic pain. Midwifery 2013;29(12):1346-51
  18. Young D. The Labor Progress Handbook: Early Interventions to Prevent and Treat Dystocia. Birth 2012;39(1):85-86
  19. Tussey CM, Botsios E, Gerkin RD, et al. Reducing length of labor and cesarean surgery rate using a peanut ball for women laboring with an epidural. The Journal of Perinatal Education 2015;24(1):16-24
  20. Abdolahian S, Ghavi F, Abdollahifard S, et al. Effect of Dance Labor on the Management of Active Phase Labor Pain & Clients’ Satisfaction: A Randomized Controlled Trial Study. Global journal of health science 2014;6(3):p219
  21. Cohen SR, Thomas CR. Rebozo technique for fetal malposition in labor. Journal of Midwifery & Women’s Health 2015;60(4):445-51

Using the rebozo to turn breech, transverse and oblique babies

Selina-7988I received a text message yesterday to say a woman I had worked with the day before had felt her babies foot kicking n the upper left of her belly! She was on the way to a presentation ultrasound scan (at 35 weeks) and we had done a one to one rebozo turning session the day before (Spoiler: baby was now head down!)

I have been offering malpresentation one to one sessions in the North West (and North/Mid Wales) to encourage babies to turn head downwards and stay head down. I use a variety of techniques including rebozo and Spinning babies.

Babies position in the womb is usually head down by 32 weeks (the head becomes heavy enough at 5-7 months for gravity to pull it downwards resulting in a vertical position) prior to this babies are usually transverse (until 24-26 weeks) or breech (24-29 weeks).


Due to the shape of the uterus babies usually stay in this position (unless the uterus is stretched after many pregnancies when babies can often change position-this is known as an unstable lie).

A malpresentation is a position in the uterus that is not head down (breech, transverse, oblique).

If a baby is not presenting head down towards term, women may be offered an ECV (external cephalic version) to try to turn baby round, or women may opt to birth their baby vaginally (if breech) or plan an ELCS .

I will be publishing a follow up post looking at the evidence on ECV, breech vaginal birth and ELCS for malpresentation.

There are also a number of alternative techniques that women may try to encourage baby to turn head down (including yoga, acupuncture, moxibustion)

I have supported a variety of Mums including twins (both head down at term and born in a MLU at 40+4), First time mum with an oblique baby at 36 weeks to turn head down, transverse at 38 weeks to turn head down and breech.

Tips for malpresenting babies:

1 Use rebozo manteada followed by inversion for 30 secs, 3 times in a row to promote balance and relaxation in the uterus.


2. Use rebozo of the bottom/hips, in knee chest for 5-10 minutes to help back baby out of pelvis

3. Use turning rebozo technique


After the visit women can continue doing inversions (up to 3 in a row, 3 times a day) followed by breech tilt for 10 minutes


If baby turns head down, she will feel feet kicking where the head was, so in the top right or left of womb.

Some women who have had many babies may benefit from wearing a support belt once baby is head down, this can be a physio belt or a sling can be used




There is a clinical trial underway looking at rebozo use as an adjunct to ECV for breech babies



Selina came to visit me twice to help turn my baby from transverse to breech to head down and engaged. Using a mixture of rebozo, pelvic tilts, inversions, ball circles and moxibustion. Also a little shoulder massage at the end which helped me to relax after my exercises. Fantastic work, saved me from being poked and prodded getting baby manually turned at the hospital or ending up with a c-section. Cannot thank you enough”

“I’m nearly 37 weeks now with my second baby and was told at 34 weeks… by my midwife that my baby was breech. Selina came to my house to do a one-to-one session to provide advice on techniques I could use to encourage the baby to move to the right position. I found the session very relaxing and really useful in understanding the different techniques and how best to do them. I have been doing them for the last week and today I had a scan which has shown the baby has moved to the right position 🙂 this has made me feel very happy and relieved as I want to have a home birth and the hospital had been advising if the baby was still breech I would have to have a c-section. A lot of the exercises Selina has taught me will also be great for labour and I hope to have a relaxing, peaceful home birth. Thanks Selina for your help and advice. (has since had a sucessful homebirth”


Risk, safety and normal birth: Commentary and three women’s stories

UPDATED (2017) to include a section on the effects of adverse experiences on healthcare professionals, organisations and the wider community

“You know being born is important.

You know that nothing else was ever so important to you.”

(From ‘Being Born’ a poem by Carl Sandberg)

The Kirkup report was published after an independent investigation into the Morecambe Bay NHS Foundation Trust after the deaths of 19 babies and two mothers. The unit was described in the report as ‘seriously dysfunctional’ and that Midwifery actions to support ‘normal birth’ were partly to blame:

“…midwifery care in the unit became strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care… We…heard distressing accounts of middle-grade obstetricians being strongly discouraged from intervening (or even assessing patients) when it was clear that problems had developed in labour that required obstetric care. We heard that some midwives would “keep other people away, ‘well, we don’t need to tell the doctors, we don’t need to tell our colleagues, we don’t need to tell anybody else that this woman is in the unit, because she’s normal”. Over time, we believe that these incorrect and damaging practices spread to other midwives in the unit, probably quite widely.”


The Kirkup report about maternity care in Morecombe bay highlighted the apparent dichotomy between the ‘normal’ and ‘safe’ birth agendas. Proponents from both of these agendas claim to be interested in healthy mothers and babies.

“Midwives and obstetricians should be on the same side of the fence, but they’re still too busy trading insults over it about whose garden is better. Meanwhile, pregnant women are left to one side unsure of who to trust, pulled in opposite directions by competing cultures who both claim to provide the best care for them.”


When we say we all want a healthy mother and baby, what do we mean? It’s not so simple…


The World health organisation (WHO) definition of health (1946) is that: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Public health looks at the determinants of health, from individual health behaviours to social, economic and environmental conditions.

A mother has a fast, intervention free physiological birth, but she is shouted at by staff as things are happening quicker than anticipated. She is frightened and traumatised and struggles to bond with her healthy baby because she believes she endangered him.

A woman has a long, difficult induction, her baby is malpositioned and there are lots of changes of staff. She has over 25 vaginal exams by eight different people. She labours to 9cm but then needs an EMCS which she feels was caused by the induction. She has flashbacks and cannot drive past the maternity unit where she laboured.

A mother has a good birth experience and her baby is healthy. But she is frightened to go home because her partner has started drinking more whilst she has been pregnant. He gets in her face and shouts at her. She’s worried what he’s going to do if the baby cries.

Would you consider the women in these vignettes safe?

We need to recognise that there are lots of layers to concepts like ‘risk’ and safety’ in pregnancy and childbirth.

Normal birth

In 1997 the World Health Organisation published the following definition of a NB “Spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously [without help] in the vertex position [head down] between 37 and 42 completed weeks of pregnancy. After birth mother and baby are in good condtion.”

Does this mean that women that are high risk at the start of labour or women that become high risk in labour can’t go on to have a normal birth?

In 1997 Beverley Beech from the Association for Improvements in Maternity Services (AIMS) defined NB as “a Physiological Birth where the baby is delivered vaginally following a labour that has not been altered by technological interventions”. Specifically excluded from this definition were births that had had artificial rupture of membranes, induction or acceleration, epidural anaesthesia and episiotomy.

Variation in intervention rates

Intervention levels vary between maternity units, even those with similar demographics and levels of pregnancies with increased risk factors. In the US a recent study of over 41,000 low-risk women having their first babies in 20 California hospitals found caesarean rates for this population ranging from 11% – 30%. Statistical analysis found that over half of the variation between hospitals was a result of differing obstetric practices (Main et al, 2006).

Health outcomes related to birth interventions

Intervention in the birth process, whilst intended to reduce mortality and morbidity, may lead to negative health outcomes including increased likelihood of infection, on-going pain, or negative birth experience (Goer et al, 2008) which, may increase the likelihood of women developing post natal depression (PND) or post traumatic stress disorder  (PTSD) (Creedy et al, 2000).

However it is also recognised that babies die and are left disabled after preventable events during pregnancy and labour.’ Each Baby Counts’ is the RCOG’s national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. TheRCOG estimate that In the UK, each year between 500 and 800 babies die or are left with severe brain injury because something goes wrong during labour. The Each Baby Counts project we are committed to reducing this unnecessary suffering and loss of life by 50% by 2020.https://www.rcog.org.uk/eachbabycounts

Benefits of birth without intervention

Women who give birth without intervention tend to have less post-natal pain and recover more quickly than those who have had interventions such as a forceps delivery or an episiotomy (Carroll et al, 2003). The length of time it takes to recover physically has implications for other areas of post-natal life, including self esteem (Llewellyn and Osborne, 1990), bonding, increased breastfeeding (Ransjö-Arvidson et al, 2001) and decreased Post Natal Depression (Sutter-Dallay et al, 2003; Soet et al, 2003).

Long term effects of difficult birth experiences

Some studies have found that women remember their births clearly, for example Takehara (2014) found that women remember their childbirth experience clearly 5 years later. Another study by Simkin (1992) found that two decades after birth, women’s memories were accurate and vivid, especially: onset of labor; rupture of the membranes; arrival at the hospital; actions of doctors, nurses, and partners: particular interventions; the birth; and first contact with the baby.

Disempowering experiences during childbirth have been found to persist throughout the lifetime, one study demonstrated that the effects of harsh and humiliating treatment, experienced by a number of Swedish women in antenatal care and childbirth in the mid-20th Century, endured for the rest of their lives.(Forssen 2012)

What happens when caregivers and women disagree about how to have a healthy birth?

There are instances when midwives and doctors might disagree on the best way to have a healthy birth or the parameters that make up a ‘normal’ labour, or at what point, deviation from normal becomes unsafe.

Several studies have indicated that at times midwives ‘do good by stealth’ by actions such as not doing vaginal exams so that women’s progress cannot be recorded on a partogram which could trigger interventions due to the crossing of the ‘action line’. This would then give more time for a slow labour to progress, and there is no consensus internationally on the speed at which the first or second stages of labour should progress.

One example of this ‘good by stealth’ is described on a study looking at midwives in Belgium

“Midwives considered themselves as advocates of normalcy and used different strategies to avoid interventions. Only some midwives openly negotiated with obstetricians about care. They were willing to ‘walk on the edges of the hospital rules’ to obtain normalcy. One midwife gave the example that when an obstetrician asked ‘rupture the membranes next time you examine the woman’, the midwife simply did not examine the woman. She thus ‘obeyed’ the obstetrician while at the same time she gave the woman what she thought she needed. One midwife also found that there was a strong sense of ‘social control’ between the midwives to strive for normalcy.”(Van Kelst 2013)

The study states: devious ways were required in order to achieve objectives that could not be voiced clearly and directly

This to me is the key issue. Lack of communication between health professional groups and women.

A study in Spain (del Roasarion Ruiz 2014) look at midwives and clinicians agreement on clinical practice guidelines for normal birth and found that:

“Midwives and obstetricians often have significantly divergent levels of agreement on key recommendations. The participating midwives saw pregnancy and childbirth as normal events, which should be treated accordingly. In their views obstetricians emphasised risks and hereby sometimes even ‘created’ pathology

But many clinicians agree that our drive to reduce risk can cause harm at a population level. On one obstetricians blog he states: (http://ripe-tomato.org/2015/04/11/jims-tweet/)

“There is a battle here, and some truth on both sides.  Modern obstetrics, the stuff I do every day, is obsessed by reducing risk. Caesareans for breeches, antibiotics for positive group B strep swabs, and heparin for anyone with a risk factor for thromboembolism are all unnecessary most of the time, but heaven preserve the doctor who skips them if a bad outcome occurs.

Our obsession with safety has a cost. It causes anxiety. Fetal monitoring does lead to unnecessary Caesareans. People popping in and out of rooms to review progress, give antibiotics and check heart beats, stops women relaxing and may actually slow labour.

And supporters of natural childbirth are right. Hospitals are not perfect. Too many women still labour on their backs. Doctors make stupid decisions. And even if we were perfect, it might still sometimes be better to take a bit of risk to allow nature to take its course.”

In situations where care givers disagree it has been shown that pregnant women have intervened where communication suboptimal. “They did this by rectifying information flows between community midwives and obstetric caregivers.”(Schölmerich 2013)

When factors that contribute to preventable harm in obstetric care are investigated we find that failure to communicate is prominent. (Berlung 2012)

“Defects in human factors, communication, and leadership have been the leading contributors to sentinel events in perinatal care for more than a decade. Organizational commitment and executive leadership are essential to creating an environment that proactively supports safety and quality”(Lyndon 2015)

Sometimes interventions have unexpected consequences, one example is the introduction of the clinical pathway for normal labour (Normal Labour Pathway) implemented in Wales, UK which aimed to support normal childbirth and reduce unnecessary childbirth interventions by promoting midwife-led care. A study was conducted to look at how the pathway influenced the inter-professional relationships and boundaries between midwives and doctors .It stated that:

“The ‘normal labour pathway’ was employed by midwives as an object of demarcation, which legitimised a midwifery model of care, clarified professional boundaries and accentuated differences in professional identities and approaches to childbirth. The pathway represented key characteristics of a professional project: achieving occupational autonomy and closure. Stricter delineation of the boundary between midwifery and obstetric work increased the confidence and professional visibility of midwives but left doctors feeling excluded and undervalued, and paradoxically reduced the scope of midwifery practice through redefining what counted as normal.”

Midwives training emphasises the benefits of physiological birth, but medical training does not appear to have the same emphasis. One trainee obstetrician shared her experience of colleague’s reaction to the sharing of her birth story.

“I’m a doctor training in obstetrics. I had a homebirth with my first baby. This week I was on a course in London with other junior doctors in obstetrics. I mentioned in passing that I’d had a home birth and was quite viciously attacked by 3 doctors I didn’t know. I’m used to raising an eyebrow or two, but have never had anyone be so rude to me. Words used included ‘mad’, ‘stupid’, ‘crazy’ and not in a nice, jokey way. One even said that homebirth was basically ‘mimicking 3rd world conditions’. I laughed out loud at her and pointed out various reasons why that was a ridiculous comparison. I quoted the statistics on why primips transfer to hospital (ie ‘failure’ to progress rather than acute emergencies etc)… but deep down I was really hurt by their attitude to me and to the women they look after. I just don’t understand some doctors and how they interact with their women… Surely it’s our job to provide information and give women the ability to make informed decisions, even if we don’t agree with them. The thought of these docs meeting one of you guys in a clinic makes me so sad at how they might behave.”

Midwives can also be dismissive and ridicule women’s birth plans and hopes, as has been featured on the Television series ‘One born every minute’.

Where does this lack of communication and teamwork leave women?

Women that experience traumatic births and go on to have another pregnancy need to reengage with health professionals to plan for a subsequent birth. This experience can profoundly shape the choices they make and whether they feel able to move forward feeling empowered or retraumatised.

Three women agreed to share their stories to enhance our understanding of the implications of good or bad communication:


Her first birth was an induction and her daughter was born 3 days later by EMCS:

I demanded the section after I started to feel the trauma of the internal exams during the 3 day failed induction. When they said I could have a section instead it was like I went to heaven, it meant they wouldn’t touch me again or perform any more examinations.”

Clare really wanted to have a natural second birth. She organised to have a VBAC in a birth center, but at 37 weeks, was told it had now been decided that she could no longer birth there as she had had a previous cesarean.

They wouldn’t support my wishes to birth on the birth suite because I’d had a previous section after telling me throughout my pregnancy that it was arranged. Called me in at 37 weeks saying I wasn’t welcome on the birth suite and if I insisted on birthing there then I wouldn’t be able to have a birth centre midwife and would have to be continuously monitored. Then when I sent an email in telling them how heartbroken I was they sent an email back telling me they’re sorry they couldn’t help me.”

She then transferred care to another trust that supported her wishes to have a homebirth. She got the pool set up and waited for labour to start, only to go overdue.

“One thing after another. Fighting with everyone. Changing my care. Justifying my wishes. Finding supportive people then to be let down. And then I had it sorted finally at 39 weeks preg I got my pool and was finally ok! Only for my body to not trigger labour. The panic is setting in

Clare kept on waiting for labour to start, until:

“The scan showed decreased fluid today. Fluid was 4.5 just 5 days ago and is 2 today! So has decrease by half in 5 days and they said can be a sign that placenta isn’t working as well as it was. I’m 15 days overdue now. I’m not wanting to push past 15 days over (my mum went 3 weeks over with devastating results) so the worst case scenario is very close to home. So I requested a natural section. Where they drop the curtain and let you see your baby be born and the baby then goes straight onto your bare chest for skin to skin and all checks are carried out on your chest. I’ve seen the videos of this in the uk. Hospital flat out refused to consider dropping the curtain”

Can they refuse me? It’s my baby. I want to see him born!! I can’t believe you can have a birth plan for a natural birth but you can’t for a section. It’s still a birth!”

Clare did her best to find a Trust or surgeon that would support her, but was increasingly being pushed into a corner where she either continued going further overdue with reducing fluids or gave up on her birth plan of a natural cesarean.

But at the very last minute, a consultant rang her at home, at night, to say that she had  facilitated similar wishes in ELCS and as she was working nights over the weekend, she would add the CS for Clare on to the end of her shift in the morning.

“We did the gentle cesarean and it was the most amazing thing in the world. I watched him come out, They didn’t push at all. They let my uterus contract him out but by bit, first his head, then one shoulder, then the other, then his tummy, hips and legs! He was so calm during the first bits but once he was out to his tummy area the cool air put have hit him and he cried abit but I reached for him and as soon as he was on me he stopped and was calm, sniffed me and started searching for the nipple whilst he was having delayed cord clamping. It was truly amazing! They treated it completely like a vaginal birth! The obstetrician was amazing. I felt in complete control. . It would be easy to say that I could have gone on waiting to go into labour for longer and perhaps got my homebirth…but I’m so happy with the experience we had that there’s no point in feeling that way. For a second choice…it was perfect! No regrets. ! I really do feel that it was meant to be this way now, I can’t imagine it another way. I honestly don’t even think I’ll cry when I get home tomorrow and pack away the birth pool!


There needs to be a change for women who find themselves in a disappointing situation and they need to still be respected as a birthing mother instead of a patient. I even wrote a birth plan and they all took it very seriously! Second plans aren’t always so bad when supported by the right kind of people


Describing her second birth:

“Despite it having huge potential to be very traumatic the care I’ve received has meant it was positive, and as a result I’m coping much better with life postnatally.

Pregnancy was littered with issues – high BP, low fluid around baby, small for dates, and repeated reduced movements in the third trimester. I was desperate for a “natural” experience, primarily because my first birth was a horrific induction ending in PPH. When Drs said they wanted to induce me at 39 weeks for RFM and small measurements I freaked out and refused. Some guidance and clarity from people on this group (MatExp) , and a clear discussion with a Dr next day helped me feel able to agree to the induction, although I knew my baby wasn’t ready to be born.

The MW who induced me was one I knew from clinic. She knew about my anxieties and was so supportive all day, offering me my own room even though they usually induce you on a ward, and just having a chat when my husband went to get himself lunch etc. Little things but important ones. At change over I met our night mw and her student. By this point I was contracting so they broke my waters. My birth plan stated I wanted to be mobile, but she really wanted to monitor me constantly. We ended up with me sitting at the end of the bed while the student held the monitor for baby on my belly and I gave a sign every time I had a contraction which they wrote down. This meant I didn’t need to go on the sintocin drip and maintained mobility despite it clearly being being a total pain for the midwives. I achieved a pain relief free labour mostly due to this I think.

At 7cm dilated they lost baby’s trace and asked my permission to put one on his head. I agreed and just as well I did as it became immediately clear that he wasn’t happy. His heart rate was at 30 bpm and not increasing, I was put on my side and it stayed low. The mw in charge and Dr came in. Both asked permission to examine me and both introduced themselves. They called a category one c section and even then they explained everything to me. We were running down a corridor with me on the trolley and a midwife found the time to hold my hand and tell me we were going to be fine. In theatre she sat by me and kept hold of my hand. Every single person in that room told me what they were doing and why. When they delivered him he was totally wrapped up in his cord. They’ve since said he wouldn’t have made it if he hadn’t been delivered there and then. I’m told baby was given almost immediate skin to skin with my husband, and as soon as I was awake he was placed skin to skin with me and that was how we stayed for 24 hours.

So many people from that night came in to see us over the next couple of days. They didn’t have to but they did. All just wanted to hold Oliver and check I was ok. The biggest thing about all of this for me has been the genuine care and compassion as well as total honesty about everything. Last time things were brushed aside or down played which made me feel like I was over reacting. Emotional Care is so important for new Mums and Dads and in our case made the difference between a positive and negative experience.”



“My first birth was traumatic… I felt disrespected by my hcps. I was not able to make informed consent. I was not supported to achieve my birth goals and I ended up with an emcs. As a result I developed distrust of the hcps in my local maternity unit.

For my second pregnancy I chose to sit outside the system and hired independant midwives. I chose to birth at home against consultant advice as I didn’t trust them to look after my best interests. I put in a lot or work and effort to prepare myself for a natural birth which payed off as I had a wonderful birth.

But i was very unlucky, my baby was born not breathing 40 minutes away from hospital from which he has sustained serious brain injury and will live with serious life long disabilities.

Now I will spend the rest of my life wondering whether I should have gone against every instinct in my body and done as I was told by people I didn’t trust. If I had done that would my son have arrived safely??

There is no doubt that the interventions they employed after birth saved his life for which I am grateful. And it is likely he would have had a better outcome if he’d been born in the hospital, if I’d been hooked up to cfm. What a shame that my trust had been completely abused and destroyed first time round.”


Nicola said about her birth “Although there were a few reasons why my birth was considered high risk, myself and my midwives went to great lengths to manage and monitor those risks. In the end none of those risks presented themselves.  We were just desperately unlucky. Birth is inherently risky. We rolled the dice thinking it wouldn’t happen to us and we lost.”

Nicola 2

What can we learn from these women’s stories?

It is vital that women are listened to, respected, treated like competent human beings and that health professionals work as multidisciplinary teams with one goal, a healthy baby and a healthy mother, on all levels.


Women that are disrespected, coerced, humiliated, terrified or traumatised lose respect for health care professionals and become hard to reach, if their attempts to communicate in a second pregnancy are met with rigidity, refusal or ridicule then women can feel pushed into making choices that take them outside of conventional care.

Interprofessional fighting increases risk to women and babies.

Where does this lack of communication and teamwork leave professionals and organisations?

Witnessing adverse events can lead to trauma to health professionals and can have long term effects also on the wider community and organisations community of practice. Both midwives and obstetricians have reported sleep disorders and depressive symptoms (Shroder 2016) and failure to acknowledge and deal with guilty feeling (even with no fault) can effect self forgiveness (Shroder 2017) the authors suggest “that the narrow focus on medico-legal and patient safety perspectives is complemented with moral philosophical perspectives to promote non-judgemental recognition and acknowledgement of guilt and of the fallible nature of medicine.”

Obstetrician Mary Higgins in a blog post for the BMj talks about the ‘fourth victim’ after adverse events which are future patients, and suggests witnessing adverse events can both harm and improve future practice. A study by McNamara (2017) corroborates this view  and suggests that while there was some positive gains for HCPs following an intrapartum fetal death, the majority of their experience was negative. There is currently a lack of training and support for staff, teams and organisations to prepare for and deal with witnessing adverse events during childbirth and support systems should be put in place.

Moving forwards?

  • Health professionals need to understand the importance of communication and teamwork, both inter professionally and with women.
  • Medical education should emphasise physiological birth and ways to facilitate this for women, placements on community where students could have the opportunity of attending homebirths could be considered
  • Measures to improve cohesion between multidisciplinary maternity teams should be considered, staff morale will be improved by establishment of a Community of practice and adequate staffing. Continuity of care would improve safety of mothers and babies
  •  Education should be provided to students and staff on self-care and training in adverse outcome (emotional) management .
  • Consideration should also be given towards the development and maintenance of Schwartz Centre rounds in maternity hospitals
  • Physiological birth and safety are not mutually exclusive
  • Safe physiological birth leads to healthier mothers and babies in the short and long term
  • Women want support for birth choices which increase their chances of a physiological birth, they want access to water, mobility, privacy, the option of a natural cesarean
  • Technology exists and is being used in units in the UK to allow continuous fetal monitoring (CFM) that does not restrict mobility and can be used in water
  • Women whose hopes and plans for birth are respected and taken seriously, are more likely to feel that care givers are on their side, care for them and want to ensure the safety of them and their baby, they are then more likely to trust their opinion if circumstances change, and negotiate a birth that is both safe and leaves them feeling happy, empowered and untraumatised.

Further information

Mobility and CFM



VBAC in water


Commissioning for safe healthy births




 Ethics and VBAC



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Schrøder, K., Larsen, P. V., Jørgensen, J. S., vB Hjelmborg, J., Lamont, R. F., & Hvidt, N. C. (2016). Psychosocial health and well-being among obstetricians and midwives involved in traumatic childbirth. Midwifery, 41, 45-53.
Schrøder, K., la Cour, K., Jørgensen, J. S., Lamont, R. F., & Hvidt, N. C. (2017). Guilt without fault: A qualitative study into the ethics of forgiveness after traumatic childbirth. Social Science & Medicine, 176, 14-20.

Schölmerich, V. L. N., Posthumus, A. G., Ghorashi, H., Steegers, E. A. P., Waelput, A. J. M., Groenewegen, P., &Denktaş, S. (2013). Improving interprofessional coordination in Dutch midwifery and obstetrics. European Journal of Public Health, 23(suppl 1), ckt123-161.

Simkin, P. (1992), Just Another Day in a Woman’s Life? Part 11: Nature and Consistency of Women’s Long-Term Memories of Their First Birth Experiences. Birth, 19: 64–81. doi: 10.1111/j.1523-536X.1992.tb00382.x

Soet, J.E., Brack, G.A., Dilorio, C.D., 2003. Prevalence and predictors of women’s experiences of psychological trauma during childbirth. Birth, 30(1), p36-46.

Spitz, B., Sermeus, W., & Thomson, A. M. (2013). A hermeneutic phenomenological study of Belgian midwives’ views on ideal and actual maternity care. Midwifery, 29(1), e9-e17.

Sutter-Dallay, A.L., Murray, L.E., Glatigny-Dallay, et al., 2003. Newborn behavior and risk of postnatal depression in the mother. Infancy, 4:4, 589-602.

Takehara, K., Noguchi, M., Shimane, T., & Misago, C. (2014). A longitudinal study of women’s memories of their childbirth experiences at five years postpartum. BMC pregnancy and childbirth, 14(1), 221.

WHO (1946) Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948




When labour needs to start

*Updated June 2018

There are several situations when it is preferable that labour start sooner rather than later. These include-

  • prolonged pregnancy (although the WHO recognises than normal human gestation at term is 38-42 weeks many women, especially older mothers have pressure put on them to accept induction from 40-40+10 days, due to a potential increased risk of stillbirth)
  • Elevated blood pressure (gestational hypertension at term)
  • Women with type 1 or 2 diabetes at term
  • rupture of membranes at term without labour

Although some women are happy to accept induction, others would prefer labour to start naturally or are planning to birth at home so do not want o go into hospital for induction.

I have been offering a ‘Starting labour’ one to one session (in the North West and Wales, UK)  for the past few years and have had good results (the majority of women going into labour within 24 hours) although some people have required one or two more sessions and two people have had two sessions and not gone into labour (one was induced, the other went into labour a week later at 43 weeks and had a physiological birth).

Disclaimer: You must not rely on the information on this website as an alternative to medical advice from your doctor or other professional healthcare provider. If you have any specific questions about any medical matter you should consult your doctor or other professional healthcare provider. If you are worried about your babies movements please contact your midwife http://www.countthekicks.org.uk/

The session uses a variety of techniques to try to increase the chances of labour starting by looking at-

Starting labour session techniques

I usually start the session by talking to women about their pregnancy, any previous births (this can give clues about issues which may cause recurrent malposition) family history (some women just have longer gestations, if pregnancy is prolonged in each pregnancy and/or there is a family history or longer gestations) and do some belly mapping  https://itaintthathard.wordpress.com/2012/10/02/belly-mapping-its-fun/ to see if we can work out if baby position might be affecting labour starting.

Women with too much waters (polyhydramnios) may want to avoid inversions (and anyone with severe high blood pressure)

This is my basic routine and I suggest you try to follow this both in sequence and frequency, without missing out bits if possible (some of it will need a birth partner to help) and can be done in early labour too



These two techniques combined help the uterine ligaments relax and straighten, resulting in balance which will help baby be able to move into a position which allows engagement and rotation to fit down into the pelvis

*The first study to describe rebozo use for malposition was published in August 2015. There are currently no published studies looking  spinning babies techniques (including inversion) in pregnancy or labour


After each rebozo session (or as one 5-10 min  session afterwards) you can do some bottom/hip rebozo too and shaking the apples. (wrap the cloth around the bottom, holding the ends close to the body, facing the bottom and shake vigorously like you were shaking an apple tree to make the apples fall down https://www.youtube.com/watch?v=64IiA6N7Ldw then do rebozo lying on back https://www.facebook.com/selina.wallis1/videos/10156451033199120/ this is a great technique if baby is back to back or lying on the right if baby is on the right, try to use some extra pulls on the left side of the rebozo to gently encourage baby to make the short rotation from ROP/ROT/ROA to OA.  This should hopefully encourage labour to start by helping the baby to present the smallest part of babies head into the pelvis, putting more even pressure on the cervix for a quicker and easier birth

If you know or suspect baby is OP (back to back) these techniques may be helpful







Bellydancing has been used for centuries to teach young women about movements that help in childbirth. Bellydancing is also fun and promotes laughter and relaxation which can produce oxytocin and encourage labour to start




A 2013 Cochrane review found one study with statistically significant  evidence of a change in cervical maturation for women receiving acupuncture compared with the sham control



  •   20 mins of gentle breast massage with oil working all the way round and in towards the nipple 3 times a day.

A Cochrane review in 2010 found breast stimulation appeared beneficial in relation to the number of women not in labour after 72 hours, and reduced postpartum haemorrhage rates and a pilot study in 2015 found that breast stimulation in low-risk primigravidas helps in cervical ripening and increases chances of vaginal delivery.



  • 10 mins of vigorous circles on the birth ball (up to 3 times a day)

Ball circles are great to help baby flex (tuck) their head to aid rotation and aid enagement in the pelvis.

A small clinical trial in 2015 found  that performing birth ball exercises for 4-6 weeks at the end of pregnancy found that when  descent and rotation of fetal head was assessed at the beginning of the active phase. Women who had participated in the birth ball exercises had significantly more babies with descent of fetal head into the pelvis (70%) than the control group (40%) and Complete rotation of the fetal head (OA) (63%0 versus control group (33%)



“After a very straightforward pregnancy, I developed high blood pressure in the last few weeks, and found myself booked in for an induction, something I hadn’t really considered and wanted to avoid if possible. I felt very alone and ill equipped to make decisions, and really felt the need for extra support. I contacted Selina very late in the day – 38+6 and 6 days before I was due to be induced! – and she got back to me immediately and came out to see us on the same day. I was so grateful for how quickly she came round, and it was so important to me to be able to do something constructive and helpful with Selina – it really helped me feel like I had a bit of control back. Her techniques and support were invaluable and enormously calming, and seeing her was a great relief for both me and my worried partner. She left us with lots of exercises to do to help get things moving and help with the baby’s position – after spending a day belly dancing, hula-hooping on my birth ball and using the rebozo she very kindly lent us, I went into labour the following evening and was able to give birth to our beautiful daughter naturally at 5 am the morning after. I’m positive that Selina’s techniques helped and the many tips she gave us made me feel calmer, more empowered and so much less alone. I am so glad I got in touch – thank you so much for everything!” (Anna and Ben Slater, Liverpool)

“After having a very medicalised and quite traumatic birth with my first child, I decided I wanted to have a homebirth for my second. With the support and advice from Selina and the Liverpool Homebirth Support Group, I became convinced this was the right decision. However, after going five days overdue, I became concerned that if I reached ten days, medically I could be advised against a homebirth. Selina gave invaluable advice and offered my a range of treatments including aromatherapy massage, rebozo and belly dancing. The next evening, the first signs of labour began, the morning after that I gave birth to our beautiful son safely at home. I can’t thank Selina enough for all she did, not only practically but emotionally she got me through to what was ultimately my desired birth.”

“Selina was kind enough to help me when my envisioned homebirth was in danger of turning into a hospital birth with emergency induction. . She did rebozo sifting, which I feel made all the difference! And some acupressure, used some essential oils and we had fun doing some bellydancing moves to jiggle the baby down. I had been niggling for two nights, but nothing regular. Two hours later however, my contractions were every 5 minutes and I had my baby within a few hours”

Enhanced Midwifery teams

emt1I was lucky enough to spend time with the Liverpool Women’s hospital enhanced midwifery service conducting an evaluation of their service.

The report involved: literature review, interviews with the enhanced midwifery team, colleagues and third sector organisations, quantitative data analysis and a survey of women users

The Liverpool Women’s hospital EMT is made up of:

  • Six experienced midwives providing vulnerable women in Liverpool with needs based individualised care
  • Offered to women with significant mental health problems; alcohol or substance misuse, social services involvement or learning disabilities.
  • Women get 1:1 care at home during the antenatal period and up to 6 weeks post birth.

In order to:

  • Increase early access to antenatal care
  • Improve public health outcomes (breastfeeding, smoking and alcohol, obesity)
  •  Reduce harm to ‘at risk’ mothers and babies
  • The EMT act as an additional safety net to very vulnerable women and babies, they can gain access to women when many other services find engagement difficult and their close involvement with families can uncover hidden risks and dangers that could prevent tragic consequences for mothers and babies.

Summary QIPP points for EMT:

  • Q‐ quality of maternity services for vulnerable women demonstrably improved
  • I ‐ innovative use of partnership working and individualised care
  • P ‐ EMT reduce DNA rates and time lost for Community midwives looking into DNA
  • P ‐ prevention through reduced risk of adverse outcomes by engaging vulnerable women in maternity care

*A journal paper based on this work is in progress


A link to the Executive summary booklet is provided below:


Closing the bones

“Ritual bathing, washing of hair, massage, binding of the abdomen, and other types of personal care are prominent in the postpartum rituals of rural Guatemala, Mayan women in the Yucatan, and Latina women both in the United States and Mexico” (Kendall-Tackett)

closing the bones post

I was taught about the ‘Closing the bones’ ceremony by Stacia Smales Hill, Hilary Lewin and Rocio Alarcon, an ethno botanist from Ecuador, at the Doula UK yearly retreat (which I facilitate and the 2015 one starts tomorrow!).  I was the most recent postpartum woman there so I was chosen to experience a closing with rebozo with a large group of women and whilst I began as an interested observer of the experience, I soon found myself moved to unexpected tears.

In the western world, the focus is on pregnancy and birth, not after baby arrives, this can leave women shocked and vulnerable, especially after a difficult or traumatic birth experience and unprepared for the physically and emotionally challenging task of caring for a newborn, usually without the help and support of other women in the community.  In 2009 I co-wrote a chapter in the book ‘Essential Midwifery practice: postnatal care’ where we discussed ways to improve postnatal care:

“In many cultures the isolation and lack of support experienced by some mothers in the UK is simply eliminated through communal approaches to post natal care in which there is a tradition of caring for new mothers for forty days, with ceremonies to welcome the woman and her newborn back into the community.. Pillsbury (1978) found that the physical and emotional stresses following childbirth are well identified and managed by ritual in an indigenous community, so that the experience and likelihood of depression is minimized” (Nylander, S 2009)

closing the bones post2

When Rocio described how women in her community would visit women after they had their baby for forty days and bath and massage the new mother daily, I think many of us present felt envious of this sort of nurturing care which gives recognition to  the profound opening that giving birth leaves us with, physically, emotionally and spiritually.

‘Closing the bones’ is a term used to describe a number of techniques used by many indigenous cultures including Mexican, South and Central American peoples and Asian societies like the Malay peoples in Malaysia who practice ‘Mother roasting’

“The use of heat –related practices marks as culturally and psychologically significant a biological-medical event” (Manderson, L. chapter in Van Hoover 2004)

Many practices involve heat, massage to ‘bring up the womb’ (possibly to help the uterus contract and prevent postnatal haemorrhage), application of heated stones or herbs, smoking and confinement to the home for usually approximately forty days. The stomach is bound with cloth (or a Rebozo). The herbs used often have anti-microbial and analgesic properties (de Boer 2011)

I have been taught a few of these techniques, although traditionally these are used by women’s families or local traditional birth attendants, every day or every few days post birth, Rocio Alarcon taught us that, if the ‘Closing the bones’ is never performed, that women are left open and vulnerable after childbirth, that their energy will continue to be lost, and this is why western women tend to have less energy than South American women!

She approaches women she meets in England and offers to close their bones, even elderly women can benefit from these techniques.

In my own practice I incorporate aspects of ceremony (setting intentions, releasing fears) with closing the bones massage and Rebozo techniques and sacred bathing as a way to support women to honour the journey they have made to motherhood, to think deeply about the paths they have trod.

“Ceremonial work helps us to create a bridge between our mind and soul, between the sacred and the mundane. Once we enter a ceremonial space we are reminded that the line between our everyday world and the world of our soul, or even the divine is fine and easily crossed. Ceremony provides experiences that our brain interprets as meaningful and can therefore be transformative” (Mackinnon, C  2012)

The experience can help women to process difficult and traumatic birth experiences and enable them to re-honour their bodies as healing, to bring back together parts of themselves that may feel fractured or absent, the part of themselves that existed before they became a mother, the part that went through the transformative experience of birth (and it is this that can literally or figuratively ‘shatter’ us, breaking us open to bring through the new soul) and the new part which is mother.

“Ritual and ceremony are highly efficient vehicles for accessing and containing intense emotions evoked by traumatic experience” (Johnson 1995)

“I found the ceremony very healing and calming, as well as emotional. It helped me to release some feelings and thoughts that I had been having since the traumatic birth of my daughter and allowed me some space in which to try and reconcile these feelings in some way. It also helped me to feel a sense of acceptance for what had happened and I felt it facilitated the process of me experiencing a feeling of closure that I had not had since the day she was born. Physically, the ceremony was beautiful, I felt very comfortable and safe with Selina and this helped me to relax and enjoy being ‘mothered’. I would not hesitate to recommend this ceremony to any new mother as beneficial to both their mental and physical wellbeing, especially if their labour was traumatic or did not go as they had hoped.” (Sam)

closing the bones post3

This postpartum practice can be used soon after birth up to many years afterwards and is deeply nurturing and extremely moving to facilitate, much like working as a birth doula were we strive to serve women and provide care as a (archetypal) mother would, so does the work of Closing the bones’ require a profound acceptance of what was, what is and a deep love for the individual who has allowed you to walk this path back towards wholeness with them.

“The day after I was exhausted and slept a lot. The day after that and continuing I’ve been buzzing! I feel sparkling, almost 100% back to being myself! Feeling very energised and can feel a big wave of creativity and enthusiasm building.

THANK YOU so much! Having you open and close the door to motherhood for me was perfect and I’m deeply grateful “ (Deborah)

“Selina facilitated my closing of the bones ritual with tenderness, wisdom and grace. I found the experience to be very therapeutic, with an empowering effect that has grow by the day since” (Rebecca)


  •  Kendall-Tackett K, How Other Cultures Prevent Postpartum Depression- Social Structures that Protect New Mothers’ Mental Health
  • Nylander, S, Shea, C. (2009) Working with partners :Forming the Future, book chapter in ‘Partnership working’ in: Essential Midwifery Practice: Postnatal Care (Editors: Sheena Byrom , Grace Edwards and Debra Bick) Published October 2009
  • Van Hoover, C. and Hunter, L. P. (2004), The Manner Born: Birth Rites in Cross-Cultural Perspective. Journal of Midwifery & Women’s Health, 49: 270–271. doi: 10.1016/S1526-9523(04)00096-0
  • de Boer, H. J., Lamxay, V., & Björk, L. (2011). Steam sauna and mother roasting in Lao PDR: practices and chemical constituents of essential oils of plant species used in postpartum recovery. BMC complementary and alternative medicine, 11(1), 128.
  • Mackinnon, C. (2012). Shamanism and Spirituality in Therapeutic Practice: Soul and Spirit Matter. Singing Dragon.
  • Johnson, D. R., Feldman, S. C., Lubin, H., & Southwick, S. M. (1995). The therapeutic use of ritual and ceremony in the treatment of post-traumatic stress disorder. Journal of Traumatic Stress, 8(2), 283-298.







Fascia and Birth- What do we know?

doula (1 of 1)

It has been suggested that a tissue called ‘fascia’ (a web of fibrous tissue that permeates the body) may play a part in malposition and dystocia. Some of the techniques that therapists and birthworkers use claim to ‘release’ the fascia (http://spinningbabies.com/learn-more/techniques/other-techniques/abdominal-release/)


But what do we actually know about the fascia and it properties from a scientific perspective?

There is an interesting collaboration between researchers and alternative therapists trying to find out more


But so far it appears that there is little convincing evidence that the fascia has the properties that many currently assign to it, or that it can be physically manipulated to release or relax


Are the numbers of women having posterior babies increasing? Historical references to the Occiput Posterior position

It has been suggested that malposition (and occiput posterior presentation) has been increasing in incidence and also that one cause of this may be our sedentary lifestyle.
In Jean Sutton and childbirth educator Pauline Scot’s book, ‘Understanding and Teaching Optimal Foetal Positioning’ they theorise that our tendency to sit back and relax on soft, semi-reclining furniture like sofas and armchairs as we watch television, and spend more time driving ( in “bucket” car seats), rather than walking, may contribute to the incidence of posterior babies. It is also suggested that historically ‘women’s work’ in the home like, scrubbing floors on hands and knees and also a ladylike posture and good deportment promoted proper alignment of the fetus in the pelvis during the last few months of pregnancy.
Gail Tully at ‘Spinning babies’ agrees that the modern lifestyle is to blame; and also that research studies prior to ten years ago saw a lower incidence of posterior position.
“There is a rising incidence of posterior babies at the time of birth. The high numbers of posterior babies at the end of pregnancy and the early phase of labor is a change from what was seen in studies over ten years old. Perhaps this is from our cultural habits of sitting at desks, sitting in bucket seats (cars), and leaning back on the couch (slouching).”

The current estimates of posterior presentation range from 12-40% prior to labour, 15-50% in the first stage of labour, 19-25% at 10cm dilation and approximately 20% of babies that are OP at 10cm are still OP at delivery (with a range of 3.8 to 12.2% (mean = 7.6%) (Blasi et al 2010, Malvasi et al 2013, Verhoeven et al 2012)

Historical prevalence of OP position

I was interested to see what historical references to posterior position, prevalence and management could be found in the literature. The earliest reference e to OP position I could find was by WILLIAM D. PORTER, M.D. who published a paper in 1929 in the American medical association journal titled ‘POPULAR FALLACIES CONCERNING OCCIPITOPOSTERIOR POSITIONS OF VERTEX’ this described the wok of Smellie in a book of Midwifery from 1744. He was called by a midwife to a case of dystocia, which he decided was caused by posterior presentation and applied forceps (the outcome here is not known)

A study in 1929 found the incidence of OP to be 29.8 (assuming this was detected by vaginal exam or palpation this may not be entirely accurate) but suggests that the prevalence at that time was similar to now and not significantly lower. (Dodek 1931, Torpin 1945). I would assume most women in that era would not have had the labour saving devices that we have now, so that suggests that posterior position may not be caused by a sedentary lifestyle (probably reassuring to women whose babies posterior and may feel it is there fault for not doing enough activity) that’s not to say that I feel there is no point in antenatal exercise as we know that physical exercise in pregnancy reduces the CS rate (see recent review by Domenjov et al 2014)

Historical OP outcomes

Dodek also states that “It often has been said that the vertex occipitoposterior position is the obstetric complication taking the greatest toll of fetal and maternal life and predisposing toward the greatest morbidity and permanent damage among surviving mothers” and TS Wells in 1891 reported that ‘statistics show that the mortality among infants in occiput posterior
cases is 1 in 5’ (TS Wells – British medical journal, 1891 – ncbi.nlm.nih.gov)


Historical OP management

Babies were often delivered by forceps and this contributed to the high fetal mortality. Hoever it appears that obstetricians from the 18th and 19th century know almost as much as we do now about posterior position, its consequences and resulting negative outcomes (although thankfully we no longer expect posterior position to result in fetal mortality)

Gilbert Strachan in 1939 described the signs of a posterior labour as ‘Slow progress with good pains and a roomy pelvis or ‘Primary inertia with early rupture of the membranes’. He also stated that:

“The prognosis of these cases depend almost entirely on the judgement and patience with which they are treated and the greatest virtue is patience.
In cases that rotate the prognosis for mother and child should be but little influenced, it is in those that persist posterior that damage will be done to both parties, with foetal mortality in this series of 26.6% “

The Walchers position (to avoid the use of forceps or facilitate an easier forces birth) was taught from 1838 in England and doctors found that If the legs hung down freely from the conjugate, increases diameter by 1cm (Fothergill 1898)

• What can we learn from this exploration of the historical references of occiput posterior position?

• The incidence of women having babies in a posterior position appears to be similar in the 18th and 19th century

• Obstetricians were aware that it was persistent OP caused a large proportion of maternal and neonatal morbidity and mortality

• Babies that were unable to be birthed were often delivered by forceps, which had a high mortality and injury risk

• Historically obstetricians were aware that the most important management technique in an OP labour was patience (it may be that we see more persistent OP babies because of a lack of patience, and that women may also be less fit going into labour and spend more of labour lying down than would have been common historically)

Into the future

Obstetricians have been aware of the importance of posterior position to the outcomes of mothers and babies for over 200 years, yet very little progress has been made in reducing the incidence or changing management to improve outcomes, considering the large numbers of women that are effected by malposition, very little research is being conducted to look at effective pre labour or in labour interventions to improve rotation


Verhoeven, C. J. M., Rückert, M. E. P. F., Opmeer, B. C., Pajkrt, E., &Mol, B. W. J. (2012). Ultrasonographic fetal head position to predict mode of delivery: a systematic review and bivariate meta‐analysis. Ultrasound in Obstetrics &Gynecology, 40(1), 9-13.

Blasi, I., D’Amico, R., Fenu, V., Volpe, A., Fuchs, I., Henrich, W., &Mazza, V. (2010). Sonographic assessment of fetal spine and head position during the first and second stages of labor for the diagnosis of persistent occiput posterior position: a pilot study. Ultrasound in Obstetrics &Gynecology, 35(2), 210-215.

Malvasi, A., Tinelli, A., Barbera, A., Eggebø, T. M., Mynbaev, O. A., Bochicchio, M., …& Di Renzo, G. C. (2013). Occiput posterior position diagnosis: vaginal examination or intrapartum sonography? A clinical review. The Journal of Maternal-Fetal & Neonatal Medicine, 27(5), 520-526.



Iris Domenjoz, Bengt Kayser, Michel Boulvain, Effect of physical activity during pregnancy on mode of delivery, American Journal of Obstetrics and Gynecology, Volume 211, Issue 4, October 2014, Pages 401.e1-401.e11, ISSN 0002-9378, http://dx.doi.org/10.1016/j.ajog.2014.03.030.

Wells, T. Spencer. “Practical Cure or Disastrous Failure?.” British medical journal 1.1570 (1891): 257.

TORPIN R. THE INFLUENCE OF PLACENTAL SITE ON FETAL PRESENTATION. JAMA. 1945;127(8):442-445. doi:10.1001/jama.1945.02860080014004.

Strachan GI. The Occipito-Posterior Case. Postgraduate Medical Journal 1939;15(165):263-268.

Fothergill WE. WALCHER’S POSITION IN OBSTETRICS. British Medical Journal 1898;1(1931):53.

Bonding and attachment

Issues with bonding and attachment are certainly not new. In past times witchcraft or faeries were often blamed for leaving ‘changelings. This poem by John Greenleaf Whittier is an interesting story with a happy ending after intervention (a past times version of the work of psychotherapists like Dr Amanda Jones perhaps http://www.neuropsicoanalisi.it/NPSA/Jones_Amanda.html http://www.independent.ie/life/family/mothers-babies/i-thought-that-my-baby-was-a-monster-26344972.html)

For the fairest maid in Hampton
They needed not to search,
Who saw young Anna Favor
Come walking into church,-

Or bringing from the meadows,
At set of harvest-day,
The sweetness of the hay.

Now the weariest of all mothers,
The saddest two years’ bride,
She scowls in the face of her husband,
And spurns her child aside.

“Rake out the red coals, goodman,-
For there the child shall lie,
Till the black witch comes to fetch her
And both up chimney fly.

“It’s never my own little daughter,
It’s never my own,” she said ;
“The witches have stolen my Anna,
And left me an imp instead.

“Oh, fair and sweet was my baby,
Blue eyes, and hair of gold ;
But this is ugly and wrinkled,
Cross, and cunning, and old.

“I hate the touch of her fingers,
I hate the feel of her skin ;
It’s not the milk from my bosom,
But my blood, that she sucks in.

“My face grows sharp with the torment ;
Look ! my arms are skin and bone !
Rake open the red coals, goodman,
And the witch shall have her own.

“She’ll come when she hears it crying,
In the shape of an owl or bat,
And she’ll bring us our darling Anna
In place of her screeching brat.”

Then the goodman, Ezra Dalton,
Laid his hand upon her head :
“Thy sorrow is great, O woman !
I sorrow with thee,” he said.

“The paths to trouble are many,
And never but one sure way
Leads out to the light beyond it :
My poor wife, let us pray.”

Then he said to the great All-Father,
“Thy daughter is weak and blind ;
Let her sight come back, and clothe her
Once more in her right mind.

“Lead her out of this evil shadow,
Out of these fancies wild ;
Let the holy love of the mother
Turn again to her child.

“Make her lips like the lips of Mary
Kissing her blessed Son ;
Let her hands, like the hands of Jesus,
Rest on her little one.

Comfort the soul of thy handmaid,
Open her prison-door,
And thine shall be all the glory
And praise forevermore.”

Then into the face of its mother
The baby looked up and smiled ;
And the cloud of her soul was lifted,
And she knew her little child.

A beam of the slant west sunshine
Made the wan face almost fair,
Lit the blue eyes’ patient wonder
And the rings of pale gold hair.

She kissed it on lip and forehead,
She kissed it on cheek and chin,
And she bared her snow-white bosom
To the lips so pale and thin.

Oh, fair on her bridal morning
Was the maid who blushed and smiled,
But fairer to Ezra Dalton
Looked the mother of his child.

With more than a lover’s fondness
He stooped to her worn young face,
And the nursing child and the mother
He folded in one embrace.

“Blessed be God !” he murmured.
“Blessed be God !” she said ;
“For I see, who once was blinded,-
I live, who once was dead.

“Now mount and ride, my goodman,
As thou lovest thy own soul !
Woe’s me, if my wicked fancies
Be the death of Goody Cole !”

His horse he saddled and bridled,
And into the night rode he,
Now through the great black woodland,
Now by the white-bleached sea.

He rode through the silent clearings,
He came to the ferry wide,
And thrice he called to the boatman
Asleep on the other side.

He set his horse to the river,
He swam to Newbury town,
And he called up Justice Sewall
In his nightcap and his gown.

And the grave and worshipful justice
(Upon whose soul be peace !)
Set his name to the jailer’s warrant
For Goodwife Cole’s release.

Then through the night the hoof-beats
Went sounding like a flail ;
And Goody Cole at cockcrow
Came forth from Ipswich jail.

Prolonged latent labour

A recent article appeared on my fb feed, ‘My clients body is broken’ (http://tucsondoulas.com/clients-body-broken/)
There is much I agree with what Angela has said, rest, relaxation, reassurance should be the first things any doula suggests when labour is slow to start.
We have all seen eager first time mum’s, so excited that labour has started that they stay up all night pacing with a tens machine when contractions are still very irregular or far apart. If you add in a second night like that, you can end up with an exhausted mother, especially if she hasn’t eaten much with all the butterflies, desperate to go into hospital and get them to do something to get her baby to come out. This is not an ideal recipe for active labour!
This got me thinking about one of the claims that was made in Angela’s article:

“Prodromal labor is not a problem that needs to be fixed. It is normal!”

How many women experience a latent phase of labour and how long does this usually go on for before active labour begins?

Many signs can proceed the start of labour (e.g. discharge, bloody show, nausea, back ache) but the latent phase of labor is seen to commence with the onset of regular contractions and ends when the rate of cervical dilatation begins to accelerate (active phase) . Contractions in the latent phase of labour can be far apart or can get closer together when women are active and slow down when resting.
Greulich (2007) stated that approximately 5% to 6.5% of women are given the diagnosis of prolonged latent phase of labor.(Using Friedman’s original definition of prolonged latent phase as greater than or equal to 20 hours in nulliparas and 14 hours in multiparas.) and a study by Chelmow (1993) that used a definition of >12 hours for women having their first baby and >6h for women having a subsequent baby) found an overall prevalence of 6.5%

Women with a prolonged latent phase that cannot rest due to frequent or painful contractions that disrupt sleep can become exhausted. Women can end up wanting to transfer from planned homebirth for analgesia purely to get some sleep and I have seen women falling asleep in birth pools in between contractions in the second stage, only to be woken in a panic a couple of minutes later, forgetting where she is and what she is doing.

Recent research has found that length of latent phase duration as well as food intake and the amount of rest and sleep during the preceding 24 hours are independent predictors of [active] labor duration (Dencker 2010)
Chelmow also looked at outcomes after prolonged latent phase of labour and found women with prolonged latent phase labor are at higher risk of cesarean delivery and longer hospital stay and their newborns are more likely to require neonatal intensive care unit admission, have meconium at birth, and have depressed Apgar Scores.

What happens when women go to hospital?

Early admission to hospital (in latent phase) has long been recognised as a risk factor for subsequent labor abnormality and intervention (Bailit 2005) including prolonged labour, more need for analgesia, increased rate of caesarean section, increased PPH and postpartum hospital stay (Janna 2013).
Like the chicken and the egg it is difficult to interpret whether those interventions are due to complications leading from prolonged early labour or from extra intervention due to the early admission. For some more discussion on this on the ‘Midwives thinking blog’ https://midwifethinking.com/2013/11/13/early-labour-and-mixed-messages/

In a another recent study women indicating that they had been in labour for 24 hours or longer at the time of hospital admission were at elevated risk for caesarean birth (Janssen 2014)
Many women are turned away from hospital (either to try to reduce the risk of unnecessary intervention or because the unit does not have room or staff able to care for women who are not in active labour. This can be disheartening for women who are in considerable pain and distress. Hopefully those with a doula will have had more support in the latent phase. However I have read of doulas that refuse to see their clients in early labour, partly so as to reduce the number of people ‘watching and waiting’ (and the subsequent pressure on women to perform by going into active labour (when this is out of their control) and partly to conserve their own energy in what might be a long labour.
This is not much help to women who have been in pain for a considerable time, feeling unsupported by a midwifery service who tell them they are not really in labour and to go home and take a painkiller, and a doula that will not support them in early labour.

  • A period of time where women are unsure if labor has started is normal and may include a range of signs
  • A period of latent phase of labour where contractions have started but are far apart or infrequent is common
  • During this latent phase of labour women have better outcomes if they rest, sleep and eat normally and avoid admission to hospital (unless they have other risk factors or worries about their babies welfare like reduced movements)
  • Women that experience prolonged latent phases, especially with painful contractions that prevent sleep and food intake may need additional support and may be at greater risk for longer labours and more intervention during the birth
  • Prolonged latent phase may be associated with malposition
  • Women with prolonged latent phases may need additional support from their birth partners, including a greater range of comfort measures and support to aid fetal rotation so that active labour may begin

Maybe helping mothers move in ways that aid fetal rotation and so reduce the length of time in a prolonged latent phase is a comfort measure?

I think so
Greulich, B. and Tarrant, B. (2007), The Latent Phase of Labor: Diagnosis and Management. Journal of Midwifery & Women’s Health, 52: 190–198. doi: 10.1016/j.jmwh.2006.12.007
Chelmow, D, Kilpatrick, SJ, Laros, RK Jr. Maternal and neonatal outcomes after prolonged latent phase. Obstet Gynecol 1993; 81:486.
Bailit, J. L., Dierker, L., Blanchard, M. H., & Mercer, B. M. (2005). Outcomes of women presenting in active versus latent phase of spontaneous labor. Obstetrics & Gynecology, 105(1), 77-79.
DENCKER, A., BERG, M., BERGQVIST, L. and LILJA, H. (2010), Identification of latent phase factors associated with active labor duration in low-risk nulliparous women with spontaneous contractions. Acta Obstetricia et Gynecologica Scandinavica, 89: 1034–1039. doi: 10.3109/00016349.2010.499446
Friedman EA. Labor: Clinical evaluation and management. New York: Appleton-Century-Crofts, 1967.
Janna, J. R., & Chowdhury, S. B. (2013). Impact of timing of admission in labour on subsequent outcome. Community Based Medical Journal, 2(1), 21-28.
Janssen, P. A., & Weissinger, S. (2014). Women’s perception of pre-hospital labour duration and obstetrical outcomes; a prospective cohort study. BMC Pregnancy and Childbirth, 14(1), 182


Evidence based medicine and doulas: why we need to look at what we know and how we know it

We expect health professionals to act on the latest and best information and not use their professional power, gender or past experience to put pressure on women to choose one intervention over another, we expect them to tell us the risks and benefits of a choice in a dispassionate manner, using the best available evidence, but we do we do the same?

One of the on-going issues in the doula community is that of the giving of information (and not advice of course…) how do we decide what is appropriate to give? Should doulas know more about how to assess the quality of information?

I often see doulas suggesting that women might decline tests or treatment (from Group B Strep and gestational diabetes to declining post dates induction) whilst most are probably just trying to make sure that women know they have options and are able to decline anything they want to, sometimes it may come across as advice, as described by the woman in this blog post, who feels her doulas reassurance contributed to her babies difficulties after birth:


The Doula UK philosophy states:

“Doulas do not give any medical advice but they should have a good understanding of the physiology of birth and the postnatal period so can provide support to help the woman find solutions when she needs guidance. This distinction between advice and support is important”

And DUK guidelines on social media remind us:

“You are free, of course, to express your own personal opinions but we ask that you exercise the same good judgment, discretion, taste and common sense when communicating through social media as you do when carrying out any official doula activity. “

We are rightly reminded to think about confidentiality and professional relationships, but our interaction on the many support and advocacy groups are also relevant, many doulas use the word doula in their personal facebook accounts, so their personal opinions reflect on the doula community, and even if we don’t self identify our personal accounts as ‘doula’ we are usually still known as such, if we make a personal opinion or suggestion, can that be considered advice?

In an online situation we feel removed from the actual situation, but we need to remember these are real women and babies when we suggest they don’t tell care providers when their waters break or to use homeopathy instead of conventional treatments.

In trying to protect clients from harm, are we tempted to downplay the risk based on our experience and belief instead of evidence based on research?

What do we know and how do we know it?

Epistemology is the theory of knowledge, how we know what we know. Medicine is based on ‘evidence based practice’ (EBP)  , any suggested intervention should be based on a body of reliable evidence from research.

I’m interested in the questions like:

What should we know?

Where should we get evidence from?

How can we assess whether information is true?

We learn from experience, but how many experiences make something true? If it was true for you, does that mean it will be true for everyone else and in every situation?

Our modern world, from technology, to public health to democracy is based on scientific thinking, the idea that a fact is verifiable, that we can know the world around us by repeated experimentation and therefore make decisions based on evidence.

‘“Facts,” John Adams argued, “are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passion, they cannot alter the state of facts and evidence.” When facts become opinions, the collective policymaking process of democracy begins to break down. Gone is the common denominator—knowledge—that can bring opposing sides together. Government becomes reactive, expensive and late at solving problems, and the national dialogue becomes mired in warring opinions.’


It is not enough just to find a study that supports a point you want to make, you need to look at the body of evidence, what is the scientific consensus on a topic (because there are always studies that refute the consensus, is that because there really is another truth, or were they badly designed?) the quality of evidence is on a continuum, we cannot just accept the results and conclusions of a study without assessing its quality and design, otherwise we run the risk of promoting misinformation (false or inaccurate information that is spread unintentionally)

What message are we sending when doulas are dismissive of the risks presented by health professionals but openly promote and support practices which have not stood up to scrutiny?

This we can hope at best, causes no harm, but at worst could lead to worse outcomes than if a woman follows the conservative medical approach.

Several commentators on social media provide evidence based commentaries on topics of interest, but these do not always lead to the conclusion we intuitively feel is correct or that we would like to hear, one example is the recent commentary on giving Vitamin K after birth, the author found that:

“Giving a breastfed infant a Vitamin K1 shot virtually eliminates the chance of life-threatening Vitamin K deficiency bleeding. The only known adverse effects of the shot are pain, bleeding, and bruising at the site of the injection”

And that

“Recently, there have been many myths, misconceptions, and misinformation floating around the internet and social media about Vitamin K. It is important that parents look at the facts so that their consent or refusal is informed. Right now, parents who have been declining Vitamin K may not have all the information, or they may have been given inaccurate information.


There was a sense in comments on the article that some people felt disappointed, like the author had let the natural birth world down by agreeing with the position that intervention was better than leaving things alone, but the facts speak for themselves, this was simply a summary of the state of the evidence.

How to assess the quality of research

The type of research to use depends on the research question, but the most reliable type of study is usually considered a randomised controlled trial (which reduces bias) and systematic reviews/meta analysis which summarise and assess the quality of all the available evidence on a particular topic. Qualitative research (based on peoples views and experiences) are seen as increasingly  valuable in understanding issues from a holistic perspective.

There are several sites which can help us decide on the quality of a research study.

One useful site which uses a brief questionnaire is DISCERN


The Cochrane collective are well known for producing up to date, reliable evidence summaries, but they also have free training courses on understanding evidence based medicine, assessing research quality and how to search for research


One way to get used to assessing research quality is to join a journal club. I was a member of the NCT journal club before I became a public health researcher and I really enjoyed discussing research methodology and conclusions.

I am considering setting up a Doula UK journal club, to help us explore new research and practice critical appraisal skills,  please comment/PM me if you are interested

I feel we need to be mindful about the links we share and the views we put across, , we as doulas should know how to assess the sources we use so that we don’t use unreliable websites or badly designed studies to support our beliefs.

If we ignore scientific consensus (this is not to imply that all discussions with health professionals use up to date and reliable evidence themselves, but that is another blog post entirely) then we risk actively spreading disinformation (intentionally false or inaccurate information, spread deliberately)


This would be a disservice to our community and the women and babies we serve


My thoughts on homebirth

Home birth to me is about more than place, its about dignity, autonomy, privacy, normal life. Giving birth to a baby is not just a physical process, it is emotional and sacred, it is a ritual. I planned to have my first baby at home, I had seen cats and dogs birth as a child and experienced how a quiet, comfortable and dark space facilitated a straightforward birth for them. I read the ‘Zoo vet’ series and was impressed by how aware the vets were that the pregnant animals in their care needed an undisturbed space otherwise births would stall, having strangers or other animals around creating fear was a disaster and often ended in the animals needing intervention to get their babies out safely. There was little support for home birth when I had my daughter ten years ago, especially for a first baby and I didn’t end up having her at home. It was a long, malpositioned labour and I had a large and extended episiotomy. I set up a homebirth support group for other women in my area the year after she was born, which I have run every month for the past ten years. Its a very informal group, just women or couples talking about their experiences through pregnancy and labour and birth. I also trained as a doula (birth partner) and have been lucky enough to attend over 40 births, including many home births. Whilst I have been to lovely births in hospitals and midwife led units, there is a special feeling to home births, the emergence of a family within their own environment, watching women and their partners able to move around naturally, to dance through their living room if they want to, to cook food when they are hungry, to walk barefoot in their garden to get solace from nature. This helps women cope better with their labour, to move through the rhythms of the birth process with less fear, less pain. Allowing couples to have space for private time, for some sweet loving. To allow Men to be as present as they are able to be or want to be but also to be able to step away and take some time in their own space to take stock, without having to wander around a sterile hospital and have to ask for permission to enter wards. At home there is space for people to have their other children if they want them, friends, parents, whoever they need to get through and celebrate this wondrous event. At home care givers are respectful that they are within another’s private space, it removes some of the institutional behaviour you can see in a hospital setting. Not all births can be at home and we are lucky to have hospitals to go to if we need them, but generally I believe the evidence is clear that birthing at home is safer for most women. I gave birth to my son at home nearly two years ago. I spent much of my labour wandering around the park in the sunshine on my own, then filling my own birth pool whilst singing along to a music list I had prepared. I had prepared an alter with items from my two blessingways (Mother blessings to prepare for the birth). I braided my hair in an elaborate style in celebration of this long awaited day. I still experienced the despair of transition, when I knew that it was impossible for me to do this act of giving birth, and it is in these momments when women must surrender their mind into the possession of their body that many women cry out for something, anything to help them (and in hospital may end up with diamorphine or an epidural) but this moved on to the primal pushing urge and soon my son was born into my hands in the water and I felt like a she wolf, elated, euphoric, relieved, so happy to see his face for the first time, this son I already knew from the moment of conception. I was able to get into my own bed to feed him from my breast for the first time. Often after home births I have attended, it is the hours after birth I have most enjoyed at home births. The pop of the champagne cork, cooking a meal for the new parents. Seeing children meet their new sibling for the first time. Home birth is not just about a place, it is a woman taking her birth into her own hands as a sacred act, where she is loved and a space is held for her to do the work to bring the new soul through into this world, into her heart space and her hearth space, where birth should be