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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.”

https://patientsafetyfirst.wordpress.com/2015/03/20/responses-to-kirkup-20th-march-2015/

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.”

http://greatnorthmum.com/2015/04/02/25-weeks/

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

Health

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:

Clare

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!

 clares-story

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

Lucy

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.”

Lucy

Nicola

“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.”

 Nicola1

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.

or

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

http://www.monicahealthcare.com/why-monica/introduction

http://www.gloshospitals.nhs.uk/en/Wards-and-Departments/Maternity-Wards/Your-Labour-and-Birth/Mums-up-and-mobile/

VBAC in water

http://www.sciencedirect.com/science/article/pii/S0266613813002969

Commissioning for safe healthy births

https://www.rcog.org.uk/globalassets/documents/guidelines/guidelines–supporting-commissioners/advice-to-ccgs.pdf

MatExp

http://matexp.org.uk/

 Ethics and VBAC

http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.12409/full

References

Beech, B.A., 1997. Normal Birth – Does it exist? AIMS Journal. Vol. 9 No 2 (4-8)

Berglund, S. (2012). “Every case of asphyxia can be used as a learning example”. Conclusions from an analysis of substandard obstetrical care. Journal of perinatal medicine, 40(1), 9-18.

BirthChoiceUK web site (www.birthchoiceuk.com)

Creedy, D., Shochet, I.,Horsfall, J.,2000. Childbirth and the development of acute trauma symptoms:Incidence and contributing factors. Birth, 27(2), 104-111

Carroli G, Belizan J, Stamp G. Episiotomy policies in vaginal births. In: Neilson JP, Crowther CA, Hodnett ED, Hofmeyr GJ, editors. Pregnancy and childbirth module of the Cochrane database of systematic reviews. Oxford: Update Software; 1999. Issue 3.

Del Rosario Ruiz, M., & Limonero, J. T. (2014). Professional attitudes towards normal childbirth in a shared care unit. Midwifery, 30(7), 817-824.

Dexter, S. C., Windsor, S., & Watkinson, S. J. (2014). Meeting the challenge of maternal choice in mode of delivery with vaginal birth after caesarean section: a medical, legal and ethical commentary. BJOG: An International Journal of Obstetrics & Gynaecology, 121(2), 133-140.

Forssén, A. S. (2012). Lifelong Significance of Disempowering Experiences in Prenatal and Maternity Care Interviews With Elderly Swedish Women. Qualitative health research, 22(11), 1535-1546.

Goer, H., Leslie, M. S., & Romano, A., 2007. The evidence basis for the 10 steps of mother-friendly care: Step 6: Does not routinely employ practices, procedures unsupported by the scientific evidence. The Journal of Perinatal Education, 16(1 Suppl), 32-64.

Higgins, M. (2017). The echoes of adverse events. [Blog] thebmjopinion. Available at: http://blogs.bmj.com/bmj/2017/03/02/how-the-ghost-of-patients-past-have-a-deeper-impact-than-we-may-think/ [Accessed 6 Mar. 2017].

Llewelyn, S and Osborne, K., 1990.Women’s Lives,  Routledge.

Lyndon, A., Johnson, M. C., Bingham, D., Napolitano, P. G., Joseph, G., Maxfield, D. G. and O’Keeffe, D. F. (2015), Transforming Communication and Safety Culture in Intrapartum Care: A Multi-Organization Blueprint. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44: 341–349. doi: 10.1111/1552-6909.12575

Main, E. K., Moore, D., Farrell, B., Schimmel, L. D., Altman, R. J., Abrahams, C., 2006. Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. American Journal of Obstetrics and Gynecology, 194(6), 1644-51

McNamara, K., Meaney, S., O’Connell, O., McCarthy, M., Greene, R. A., & O’Donoghue, K. (2017). Healthcare professionals’ response to intrapartum death: a cross-sectional study. Archives of Gynecology and Obstetrics, 1-8.

Ransjö-Arvidson, A-B., Matthiesen A-S., Lilja, G., et al., 200. Maternal analgesia during labor disturbs newborn behaviour: effects on breastfeeding, temperature and crying. Birth, 28(1), 5–12.

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

 

 

 

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When labour needs to start

*Updated Dec 2015

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

First

Then

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

http://tinyurl.com/zdgyelz

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 http://www.homebirth.net.au/2008/03/rebozo-technique.html  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

https://www.youtube.com/watch?v=y6HobDGQ-sU

https://www.youtube.com/watch?v=n0Z7Z1L6MiY

https://www.youtube.com/watch?v=HDWV6qxcvt0

https://www.youtube.com/watch?v=vDnSFyOsDOo

bio1

Next

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

http://www.worldbellydance.com/pregnancy-prenatal/

Relaxation

http://file.scirp.org/Html/6-1440245_43420.htm

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

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002962.pub3/abstract

Plus

  •   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.

http://www.cochrane.org/CD003392/PREG_breast-stimulation-for-cervical-ripening-and-induction-of-labour

http://www.hindawi.com/journals/bmri/2014/695037/

  • 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%)

http://jmrh.mums.ac.ir/article_3562_0.html

Testimonials

“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:

EXECUTIVE SUMMARY BOOKLET


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)

References

  •  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.

Links

http://www.sulistherapies.co.uk/

http://doula.org.uk/content/stacia-smales-hill-doula-profile

http://www.herbfestuk.co.uk/?speakers=view&id=9

http://www.ritesoflife.com/2010/rites/forsta-fodseln/

http://www.sciencedaily.com/releases/2014/06/140630094918.htm?+Brain+News+–+ScienceDaily)


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/)

https://www.youtube.com/watch?v=U8mEM9svsVI

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

http://io9.com/how-a-mysterious-body-part-called-fascia-is-challenging-1598939224

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

https://www.painscience.com/articles/does-fascia-matter.php#sec_dr_schleips_statement


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.
http://midwifeinsight.com/articles/the-dreaded-persistent-occiput-posterior/
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).”
http://spinningbabies.com/baby-positions/posterior

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)

http://jama.jamanetwork.com/article.aspx?articleid=256047

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

References

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.

PORTER WD. POPULAR FALLACIES CONCERNING OCCIPITOPOSTERIOR POSITIONS OF VERTEX. JAMA. 1929;92(3):221-226. doi:10.1001/jama.1929.02700290031008.
http://jama.jamanetwork.com/article.aspx?articleid=263273

DODEK SM. THE VERTEX OCCIPITOPOSTERIOR POSITION: THE TREATMENT OF MORE THAN FIVE HUNDRED CONSECUTIVE CASES. JAMA. 1931;96(20):1660-1664. doi:10.1001/jama.1931.02720460006002.

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.
(http://www.sciencedirect.com/science/article/pii/S0002937814002403)

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.
(http://www.hampton.lib.nh.us/hampton/poetry/changeling.htm)


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.

Summary
  • 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
Selina-7844
References
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:

http://greatminuseight.wordpress.com/2014/04/14/21-doulas-and-donts-my-cautionary-tale/

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.’

http://www.nature.com/scientificamerican/journal/v307/n5/full/scientificamerican1112-62.html

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.

http://evidencebasedbirth.com/evidence-for-the-vitamin-k-shot-in-newborns/

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

http://www.discern.org.uk/

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

http://us.cochrane.org/resources-consumers

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)

http://www.assassinationscience.com/disinformation.html

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


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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