Home births are down

How can we empower and educate YOUNG mums to recognise home birth as a reasonable choice?

http://www.rcm.org.uk/midwives/news/fewer-women-are-giving-birth-at-home/?utm_source=Adestra&utm_medium=email&utm_term=

ONE TO ONE MIDWIVES IN THE WIRRAL

A private firm of midwives is now providing one to one care for mums in the Wirral and Birkenhead - under contract to the NHS! And - this is the top bit - they have INSURANCE for intrapartum care. Yes, independent midwives INSURED to do births under contract to the NHS.

Perhaps the awful Albany Midwives story was not in vain.

Increasing the chances of normal birth at Chelsea and Westminster

I'm on two Maternity Services Liaison Committees in my area; I'm part of the "e-group" of interested parties who send in opinions about new developments at Chelsea and Westminster and I've just joined the Queen Charlotte's and Chelsea Hospital committee which, as so many of my NCT clients are QCCH customers, I hope to get closely involved in.
At present I have to say C & W are making the running in the race to normalise birth. Firstly the hospital saw a healthy increase in home birth rates recently, not by accident but thanks to a pro-active midwife, Anne-Marie Mathews. Secondly there are plans to put up a lovely poster headed "Birth matters: keep it natural" in the labour ward which gives easy quick advice for increasing your chances of a normal birth.
A lead midwife, Annabel Bryant, has designed the poster and it just beautifully sums up what I do with a client in nine simple bullet points! I am so thrilled by this idea that I hope she won't mind me repeating the list here:

·        Encourage me to stay upright and mobile

·        Help me to adopt comfortable positions

·        Coach me with my breathing and relaxation techniques

·        Support me with massage

·        Offer me immersion in water

·        Play the music of my choice

·        Keep the lights low

·        Respect my privacy and dignity

SHIFT CHANGE SYNDROME

I've kept myself rather out of the doula world this year. Too many worries at home mean I've cut right back on this, my favourite work, because the emotional burden is just too much; I know how to put boundaries between work and home life, sure, but as a doula one is shouldering the emotional life of another family besides one's own and right now, without going into details, my own is quite enough to be getting on with.
But when an antenatal teacher colleague rang me yesterday morning asking to have a quick chat with her brother, whose wife was in labour, I could not resist the opportunity for a bit of long-distance doula-ing.
After several dud attempts to call the father to be, who was having trouble finding a phone signal, I got through to him and from his slightly disjointed, utterly worn-out account this was the picture:
First time mum R. had been in labour about 36 hours on and off. She had gone to the nice local midwife-led birthing centre in the evening and was found to be 4 cm dilated; got in and out of the pool overnight; by 7am was up to 9cm dilated. So far so good. But by 10am the midwife was now suggesting she "go to hospital for help" (synto? epidural? ventouse? she didn't specify) because mum was exhausted and had been "stuck" at 9cm for about  3 hours and her contractions were slowing down.

His voice breaking with tiredness, the dad asked me - "Shouldn't we go to hospital? R is completely exhausted, and they keep checking the hearbeat which makes it hard for her to rest, and who are we to ignore the advice of a midwife of 30 years experience?"

Any doulas out there recognise this narrative? It's what I am tempted to name "shift change syndrome". My first question was: "How's the baby's heartbeat?"

"Oh, fine," he said. So no problem there. No medical reason, as far as the baby's concerned, to get doctors in as yet.
R was kneeling up on the bed leaning over the raised end of the bed, sucking on Entonox.

I considered the facts: simply it looks as though a first time mum has laboured well through the hours of darkness, and contractions are getting a bit further apart when three things happen at once:

1. Daylight comes, which often brings with it a slowing down of labour, whatever stage things are at.
2. Mum's cervix gets to a point of dilation where the head is no longer pressing so vigorously as before on it to stimulate oxytocin production.
3. There is a change of personnel just as she was reaching 9/10 centimetres dilation. The by now trusted night shift midwife says a reluctant good-bye at a critical moment, and a new face appears, someone who hasn't been present through the whole labour story but enters the room and puts her own interpretation on the scene. It doesn't help that it happens to be the sort of midwife who boasts that she has 30 years' experience (which means she was trained at a time when, let's face it, mothers were still expected to labour on their backs and do what the doctor told them). Even if, though, R's care had been taken over by a more subtle personality, the change in carer would have had a powerful effect on her labour, inducing the fear of the new -  which causes an adrenalin bounce and, again, depresses oxytocin production. But to be taken charge of by someone whose words suggest powerfully to R that she is not coping, that she "can't do it on her own"...catastrophic.

So I said: "OK, suppose you do go to the hospital (a 30 minute drive). It's now 10.15am. Believe me, if she wants an epidural it's going to be nearly lunchtime before she actually gets it. The drive will slow down labour. The epidural will probably slow it down too though it would let her rest. The journey might slow her labour down even more. And if it doesn't, suppose she is starting to want to push while she's in transit? That's going to be really unpleasant for her and she might as well have stayed in the birth centre."

"But she's exhausted!"
"Exhaustion goes with the territory at the end of labour," I said, and wondered if I'd been too cruel, but pressed on.

 "The truth is that it's all nearly over; and the truth is that she can do it - her body will give her an adrenalin shot when she needs the extra effort to push. What she needs now is someone there who believes she can do it -  and she needs an oxytocin boost. Why not go back in, close the curtains, give her lots of physical contact, yes, give her a big cuddle, try nipple stimulation, and tell her she can do it and that you believe in her. Oh, and see if you can get her to cut back on the Entonox - just a few puffs at a time, any more isn't helping."

He staggered off. I didn't hear anything for a while; I assumed as I usually do that I had been too cruel, that she had gone to hospital, the baby had been malpositioned and wasn't going to come down in a month of Sundays, she had required epidural, synto, ventouse, forceps, the whole dog's breakfast...

Then a text from my friend: R had decided to take my suggestion and stay put in the midwife-led birth centre - and gave birth beautifully and naturally to her baby daughter just two hours after I'd spoken to her husband. 

Hooray! If only doula-ing was always this easy! But, remember: this was a mum who WANTED a natural birth. If she had been in a consultant-led unit from the word go, I wonder if she would have been able to resist the "30 years experience" midwife's negative suggestions?

This episode has got me thinking a lot not just about how much I miss being a birth doula...but also about what happens when the midwives change shift at a hospital or birth centre birth (home birth midwives generally stick around for the duration) and I feel I should warn my clients and classes of how this will affect them.

Firstly, labour may slow down and you will need to get to know this new person FAST so that mum can feel comfortable with her. Once mum has relaxed, and "forgotten" about the new person, things will hot up again.
Increased tension may cause mum to feel pain more. Again, once she's got accustomed to the new person and relaxed again, her endorphins will kick back in.
The second shift midwife hasn't seen the mum labouring before. She doesn't know her. She needs to be filled in on what's happened. She has her colleague's notes to look at - but I believe she also needs to listen to the partner and the mum (if mum feels like talking).
So here are my tips for avoiding SHIFT CHANGE SYNDROME:

• You have hopefully built up a good relationship with the previous midwife; make the most of this by telling her exactly what you want conveyed to her successor. A job for the partner.
• Have another copy of the birth preferences handy; if you've written this document out in the way I advise my clients and classes to, then it will give an instant snapshot of what kind of woman you are and what your aspirations are.
• Try and have the partner field all the questions, not the mum, so that mum's focus is not broken.
• Ask the midwife a few questions back - you need to get to know her very fast indeed so be nosy!
• The change in personnel, with questions and conversation, may break the mood and bring mum out of her "zone" and that's not good for the labour. HypnoBirthing couples may find it a good time to do the Birth Companion's Deepener script - or to do any other deepening script that they think will help mum to zone in. (It might impresse the new midwife, too. )
• See the shift change positively, as a chance for a change in scene or mood that YOU are comfortable with. For example, if you are free of moorings, lines and tubes, take a walk down the corridor, visit the loo, change the music.

Don't assume from what I have written here that shift change is always a danger point. I've seen a brilliant, inspirational "second shift" midwife work absolute wonders with a tired mum who was beginning to lose heart and being intimidated by a knife-wielding consultant. She was just one of those people who had the experience and confidence to know that this was not a time for "poor old you" but a time for "OK, Kathy, you gotta get this baby out now - the doctors are talking about caesareans. I want you up and pushing. Put the gas down and get to work, kiddo." (An approach which can go disastrously wrong, by the way.)

And there have been "first shift" midwives that I was heartily glad to see the back of, as well as some who simply stay over past the end of their shift because they want to see the job through.

The NHS midwife is one of the most incredible health professionals in the universe; but she is not a mind-reader. Make her understand what YOU want and she will then be best placed to help you.

www.birthhypnosis.net

Nestle - what would we do without them?

What would we do without those brilliant people at Nestle?

As though being the kind and generous global food and drinks giant which has done SO MUCH to introduce unenlightened women of the developing world to the elegant, civilised art of feeding their babies 

 - in a way which, while it may have a few easily waved-away side effects (poor baby growth due to mothers trying to skimp on the stuff, limited protection against infection, dodgy hygiene, use of hard-earned pennies that could go elsewhere) DOES have the great benefit of making MORE MONEY for Nestle -

WERE NOT ENOUGH,

those clever people in the lovely, clean Nestle labs have come up with a true miracle of science: 

THE WORLD'S FIRST COMPREHENSIVE INFANT AND TODDLER NUTRITION SYSTEM!!!!!

here's the link to this great advance for humankind:

http://www.nestle.com/Media/NewsAndFeatures/Pages/Nestle-launches-BabyNes-first-comprehensive-nutrition-system-for-babies-Switzerland.aspx

And here's a picture of it in action:

D'oh! Silly me.

I just pasted in a picture of a woman breastfeeding her baby by mistake.

I'm such a klutz with this blogging business.

I mean, who on earth but a daft old non-techy would absent-mindedly think THIS was what is meant by "the world’s first comprehensive nutrition system for infants and toddlers"

I've just looked again at the Nestle website and I must have missed the bit where it says that the world's first comprehensive nutrituion system for infants and toddlers is "based on Nestlé’s latest scientific achievements in baby nutrition and systems technology"?

Aren't I just an old fluff-head.

 What could POSSIBLY have made me think that human lactation is any match for the global food and drinks giant's "unmatched expertise in baby nutrition gained over 145 years since the invention of Farine Lactée by Henri Nestlé" ?

No, HERE'S a picture of the world's FIRST COMPREHENSIVE INFANT FEEDING SYSTEM:

As if you could confuse the two!

I mean look at all the advantages of the "BabyNes" (for so it is named).

It hasn't been trialled for over 70 million years.

It doesn't change the nutritional content of the milk with the needs of the baby throughout the day.

It requires sterilising, measuring, checking.

It is not free.

It is not disposable or ecofriendly and it needs a power source.

It is not so easily packaged that you don't even have to remember to take it with you when you go out.

In fact, it's hard to see how we have managed without it all these years.

It says on the BabyNes page that Nestle "supports breastfeeding for the first six months of a baby's life".

I wonder how they do that.

I'm sure they have a way. I just haven't noticed it yet. 

On the other hand...wouldn't it be wonderful, if Nestle had just stuck to making great chocolate bars?

New guidelines on NHS Caesareans published by NICE

The National Institute for Health and Clinical Excellence has started the process of updating its guidance on caesarean births with more emphasis on explaining to women what the risks and alternatives are.
The guidelines are up for consultation at present. They propose that women who have multiple C-sections should be informed that their risk of bladder damage etc is as high as if they have a vaginal delivery.
So...they aren't told now?
The guidelines also suggest that a woman who says she wants a CS because she is terrified of labour should be referred to an appropriate healthcare professional to talk over her fears.
So...there are doctors who simply say, "yes, absolutely" and book a woman in for major abdominal surgery without a thought for what mental torment might have brought her to this point?
Rather revealing.

Water birth and infection risk

A study which concludes that water birth does NOT increase infection risk in mothers or babies. They also found that water birth reduced the need for analgesic drugs and shortened first and second stage labour. Result! So please could more hospitals invest in wireless monitoring kits so as to reduce the number of women who get told "you can't use the pool because..blah blah blah-di-blah...."

Women who join my home birth group here in beautiful rural (not) Shepherds Bush get a 10% discount off a well-known brand of birthing pool. Just mentioning it.

Pre-eclampsia: has this study found a simple, low cost dietary answer to protecting women?

This is a really interesting study. Did you realise that pre-eclampsia might be linked to dietary factors?

The BMJ has published a study done in Mexico involving women at high risk of pre-eclampsia. The women given food bars with high supplements of L-arginine (an amino-acid) and anti-oxidant vitamins showed a quite dramatic decrease in pre-eclampsia.

Only thing is...Mexico's not a very rich country so with all due respect it may be that the women involved were not getting a good diet.  In countries where women normally have a good balanced diet with the requisite amounts of dairy products, poultry and plant protein sources then maybe these levels of L-arginine and anti-oxidants are reached in the general population.

All the same, it's all the more reason to lay off the fizzy drinks and pile on the yoghurt, milk, chicken breasts, wholemeal bread, nuts, lentils...all the usual suspects!

Actually when I think of it, this might be just another study which concludes, "good food is good for you".

From the BMJ website (links below)

(1) New study suggests dietary supplement can protect against pre-eclampsia
(Research: Effect of supplementation during pregnancy with L-arginine and antioxidant vitamins in medical food on pre-eclampsia in high risk population: randomised controlled trial)
http://www.bmj.com/cgi/doi/10.1136/bmj.d2901
(Editorial: Can a dietary supplement prevent pre-eclampsia?)
http://www.bmj.com/cgi/doi/10.1136/bmj.d2777
A dietary supplement containing an amino acid and antioxidant vitamins, given to pregnant women at high risk of pre-eclampsia, can reduce the occurrence of the disease, finds a study published on bmj.com today.
Pre-eclampsia is a serious condition where abnormally high blood pressure and other disturbances develop during pregnancy. It affects about 5% of all first-time pregnancies and is dangerous for both mother and child.
Pre-eclampsia is thought to be linked to a deficiency in L-arginine, an amino acid that helps to maintain a healthy blood flow during pregnancy. Some experts also think that antioxidant vitamins can help protect against the condition.
So a team of researchers in Mexico and the United States set out to test the theory that a combination of L-arginine and antioxidants would prevent the development of pre-eclampsia in high risk women.
The study took place at a hospital in Mexico City. Pregnant women at high risk of pre-eclampsia were randomly divided into three groups: 228 received daily food bars containing both L-arginine and antioxidant vitamins, 222 received bars containing only vitamins, and 222 received placebo bars (containing no L-arginine or vitamins).
The supplements began when women were around 20 weeks pregnant and continued until delivery. Blood pressure and L-arginine levels were measured every three to four weeks at the hospital clinic.
The proportion of women developing pre-eclampsia was 30.2% in the placebo group, 22.5% in the vitamin only group, and 12.7% in the L-arginine plus vitamin group.
This means that women in the L-arginine plus vitamin group were significantly less likely to develop pre-eclampsia compared with the placebo group. However, vitamins alone did not significantly reduce the occurrence of pre-eclampsia.
The team also found that L-arginine plus vitamins significantly reduced the risk of premature birth compared with placebo.
"This relatively simple and low cost intervention may have value in reducing the risk of pre-eclampsia and associated preterm birth," conclude the authors. However, they say that further study is needed to determine whether these results can be repeated and to identify whether they are due to L-arginine alone or the combination of L-arginine and antioxidant vitamins.
This trial reports an important finding but crucial questions remain, say two UK experts in an accompanying editorial. For instance, how do L-arginine and vitamins work together, what are the potential harmful effects, and what are the effects in other settings and populations?
They suggest that, before more trials are started, a rigorous systematic review is needed "of the numerous inconsistent strands of evidence relating to L-arginine and its possible effects on pre-eclampsia."
Contacts:
Research: Professor Felipe Vadillo-Ortega, Department of Experimental Medicine, School of Medicine, Universidad Nacional, Autonoma de Mexico, Ciudad Universitaria, Mexico
Email: felipe.vadillo@gmail.com
Editorial: Liam Smeeth, Professor of clinical epidemiology, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
Email: liam.smeeth@lshtm.ac.uk

The NHS trial of HypnoBirthing: BBC reports (sort of)

Some of my HypnoBirthing colleagues are a bit disappointed with this report from the BBC...the same old "you are getting very sleepy" cliches are trotted out, the linking is clumsy...but hey, chaps, we have come a long way. You can watch the report here:

 http://www.bbc.co.uk/news/health-13451452

Now setting the bias of reporting aside, the main thing is there IS a trial which suggests that someone somewhere has twigged the idea that if more women were properly prepared for childbirth it would increase normal birth and decrease reliance on costly interventions.

So maybe the day may come when people like me do not have to patiently explain over and over again that no, natural childbirth does not mean self-flagellation; no, hypnosis is not a stage trick; no, a doula is not a sort of shaman...

Home birth group

I've just put the dates for all future CHISWICK AND HAMMERSMITH HOME BIRTH GROUP dates in my diary right up to the end of 2012.

I've also put them on the HOME BIRTH GROUP page on my website  not to mention Facebook and I've tweeted the link with my @dailybabystuff Twitter username.

I run the Home Birth group as a casual drop-in meeting.

Typically we discuss subjects such as:

• How to arrange a home birth
• Your rights in choosing your place of birth
• Reasons why you might be advised against a home birth by medical caregivers
• How to get your home ready (not as much trouble as you might think!)
• Safety of home birth and common objections from family and friends
• Sharing experiences about home birth (The Good, the Bad and the Funny!)
• When you have to transfer to hospital

We welcome home birth mums and dads and of course midwives, doulas, grandparents - anyone who wants to find out if a home birth is the right decision for the particular birth they are involved in.

Is it reflux? Is it colic?

I've been finding out some fascinating stuff about reflux and colic and I'd like to share it with you.

Every other baby I meet these days seems to have something called reflux but an awful lot of these babies seem to have what in my day we just called colic. It's really confusing - are they the same thing?

So here's what I've found so far.

Gastric Oesophageal Reflux (GOR) is the normal phenomenon of stomach contents washing back past the oesophageal sphincter into the oesophagus. 70% of all healthy, happy, thriving babies do it several times a day. The peak period is 3-7 months and normally babies have stopped by 12-15 months old.

Gastric Oesophageal Reflux DISEASE (GORD) is when the reflux causes the baby pain and/or not to thrive because it is affecting digestion, feeding and causing damage to the oesophagus

My take on this: GOR is when the spitting up is mainly a problem for your laundry basket. GORD is when it is distressing the baby persistently and causing poor health.

“Silent reflux” – no outward signs (i.e. no regurgitation) but baby is unhappy because stomach contents are washing up a short way into the oesophagus àoesophagitis.

NB: JUST BECAUSE IT LOOKS LIKE REFLUX DOESN’T MEAN REFLUX IS CAUSING THE PROBLEM – THERE MAY BE UNDERLYING REASONS! Such as excessive gassiness, constipation, a food intolerance (especially to cow’s milk/soy milk), INFECTION, sensitivity to tobacco smoke, “colic” (baby is too little “switch off” crying) – MUM SHOULD ALWAYS CONSULT DOCTOR IF IN DOUBT (see “red flag” list)

An easy way of remembering the various solutions for GOR and GORD is:

·         Gravity – anything that helps the food go down and the air go up

·         O (= a boob!) – improve the breastfeeding technique or pattern

·         Reassurance/relaxing – anything to soothe baby (and mum)

·         Diet,  Doctors and other health professionals – medical and alternative therapy solutions

Gravity:

Baby as upright as possible during feed – eg in a wrap sling

Keep upright after feed 30 to 40 mins – a sling/carrier can help a lot

Baby upright as when over your shoulder rather than slumped in a chair (American Journal of Paediatrics, Orenstein and Whitington, October 1983)

Frequent burping BEFORE, during and after feed

Avoid car seat immediately after feed

Avoid nappies or clothing tight round tummy

Baby at 30 degrees – not flat –  in cot or on babygym

When changing nappy, put a cushion under baby’s head

Sleepcurve and special wedges

O   = a boob (Better breastfeeding)

Check the latch – getting air in?

One breast at a time, allow baby to continue until stops.  Sucking à continuous muscle movement through digestive tract àkeeps it all going down; baby emptying breast ensures baby ends with calorie-rich hind milk which stays in stomach longer; at end of feed flow is slow àless coming in at top while muscle movement still keeping things moving down.

In some cases with overactive letdown even two feeds in a row on one breast. Consider whether using a breast pump in between feeds is really helping.

Feed baby when not over-hungry so not gulping in air.

Feed baby more often to encourage smaller, more manageable feeds and more downward action.

Reassuring, relaxing and soothing

A pacifier helps baby carry on the helpful sucking action

Atmosphere calm and cosy –You are not a failure if you can’t “stop the baby crying”, you are a hero for giving baby the kind of environment that helps baby to calm self eventually

Mum relaxed with a glass of wine? (recommended by  Dr Jack Newman!)

Lying down;

Massaging Baby tummy and back, upright

Movement that is rhythmical and swaying - rocking, buggy, swing-seat, your lap, your arms

Support from others: Take turns, Find another mum with a colicky/reflux baby

Diet, Doctors (and other health professionals)

Write down everything mum eats for 3 days and log fussy episodes – is there a pattern?

Try cutting out one suspect eg dairy products for 3 days

All these foods and substances have been implicated in GOR and GORD:

cow’s milk protein, chocolate, spices, citrus, cauliflower, onions, broccoli, mustard, aspirin, decongestants, peanuts, wheat, tomatoes, cucumber, soy, apples, bananas...

 A probe or endoscopy can check for acidity and/or damage to the oesophagus.

·         Antacids  - infant Gaviscon

·         Acid blockers eg Pepcid

·         Motility improvers (muscle tone) eg Domperidone

Also many parents find relief after treatment by a cranial osteopath, herbalist.

"The Folly of 'Fully'"

Practising Midwife May 2009

Sara Wickham's article breaks into the accepted idea of 10 centimetres exactly as the universal "fully dilated" measurement.

I have always thought 10 centimetres was a suspiciously round number. I mean, did someone at the Academie Francaise des Sciences, where the metric system now called the ISU system first saw the light of day, think hard and say, "I know, let's measure a woman's fully dilated cervix, and adopt a standard measurement exactly ten times that, and call it a metre!" I don't think so.

Indeed history tells us that the metre was originally defined as one ten-millionth of the distance from the North Pole to the Equator along the meridian which runs near Dunkirk and Barcelona. Even though you could presumably fit exactly one million fully dilated cervixes along that line, I doubt this was a test uppermost in the Academie's minds.

Wickham proposes that a normal range for "fully" or as one of my doula friends says, "fully delighted" would be more natural and more in line with the acceptance of RANGES of normality for all other measurements in childbirth.

Great birth story

Another fantastic birth story from a HypnoBirthing client today.
Her waters broke early one evening, she went briefly to hospital for a check, and within 24 hours she was having 20 second surges every five minutes (she rang me around 7pm to tell me). This intensified through the night, she managed the night with a TENS and HypnoBirthing breathing. When she got to the birth centre at 5am she was 7 centimetres dilated.
The first water leakage must have been hindwaters as as she stepped into her birthing room her forewaters went with a gush. She got straight into a birth pool and after quite a long second stage birthed her little girl. The long second stage was mainly due to the baby's having her hand up by her face.
She had no pain relief besides the TENs at first then the pool - otherwise she depended entirely on the self-relaxation and breathing techniques I had taught her in her HypnoBirthing sessions. Partner stuck her special birth pictures up around the room when they got to hospital. She listened to her HypnoBirthing affirmations throughout the second stage pushing.
In her own words she felt calm and relaxed throughout her labour!

Home Birth Safety - major study

Major study in the Netherlands shows home birth as safe as hospital for low risk mothers, reported 15 April 2009:
http://news.bbc.co.uk/2/hi/health/7998417.stm

Very stupid and annoying columnist called Melanie Reid in The Times the next day:


http://www.timesonline.co.uk/tol/comment/columnists/melanie_reid/article6101189.ece

Well, Melanie Reid, how would you like to be told you, or women like you, are "spoilt and complacent" because you insist on tying up scarce NHS resources with your expensive, consultant-delivered epidural anaesthesia and the cascade of interventions, requiring more and more medical staff to be involved in the delivery of your baby, which it often brings in its wake?
You wouldn't like it one bit. And of course no birth professional would be so purblind, mean-spirited and stupid as to describe a woman as "selfish" because she insists on the kind of high-maintenance birth environment Melanie Reid clearly thinks is essential for all women. Yet she thinks it is fine to throw this abuse at other women who want to make different choices.
How sick I am of women journalists who think that because they had a baby once, they know all there is to know about EVERYONE ELSE's labour and birth!

Euphemisms and birthing language

The language around birth is very important. With HypnoBirthing it is all-important since hypnotherapy is an entirely language-based therapy.
in this month's "Practising Midwife", the distinguished midwife Sara Wickham discusses euphemisms such as "pop" - "often preceded by the word just"..."an attempt to soften any number of clinical procedures which are routine but which individual women might not consent to if it was made explicitly clear that she had a choice"
and points out, perhaps subversively, that language which softens ie makes less frightening a procedure might not be bad. "I avoid using medical terms that I perceive as fear-filled (haemorrhage, risk factor) and choose words which I feel to be less hormonally and emotionally upsetting to women (bleeding, challenge).
She prefers calling sanitary towels bunnies - "removes the connotation of dirtiness"
She mentions Ina May Gaskin's rushes for contractions, but sadly not the HypnoBirthing surge...
She might have added that linguistically many of these "less threatening" words are of Anglo-Saxon origin instead of Latin/Greek origin.
Wickham S Euphemisms: good, bad or ugly? (2) The Practising Midwife Vol 12 Number 4 April 2009 page 35
Also refers to Nicky Leap (1992). The power of words, Nursing Times 88:60-61

Pre-labour cervix weeping

Back in October 2006 - have I really been a doula all this time? I noted with interest in this blog a midwife discussing the phenomenon of the cervix "weeping" a few days (5-7) before going into labour.
Well whaddyaknow, my current birth client seems to have had that exact experience last night, at 38 weeks exactly. It was so noticeable, with a distinct "gush" of clear fluid, that she thought it might be her waters breaking and we were on the QV all night.

Home Birth as safe as hospital birth

http://news.bbc.co.uk/2/hi/health/7998417.stm

Strange that it is thought that breech birth and prolonged labour can only be dealt with in hospital.

Excellent birth story from a US HB mum

http://bebeprocawood.blogspot.com/2008/04/here-it-is-neils-birth-story.html

Home Birth: The Sunday Telegraph

Excellent and factual article about home birth in Sunday Telegraph and no scare-mongering.
http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2008/03/09/nhomebirth109.xml

new breastfeeding helpline

A breastfeeding helpline to support new mothers has been officially launched by the Government. Public health minister Dawn Primarolo announced a £150,000 year package for the advice line to give women practical support and information. Studies have shown that babies who are breastfed are less likely to be obese in later life and gain protection against conditions like asthma, eczema and chest infections. Mothers benefit too, with studies showing a protective effect against ovarian and breast cancer. The Department of Health recommends exclusive breastfeeding up to six months, with continued breastfeeding alongside solid foods afterwards. A new report published by the Scientific Advisory Committee on Nutrition (SACN), suggests a need for more support for new mothers. It looks at the Infant Feeding Survey of 2005, which showed breast feeding rates went up from 69% in 2000 to 76% in 2005 across the UK. However, only half of women in England were still breastfeeding after six weeks. The Government cash will help support the new helpline, which will be run by two existing networks. The Breastfeeding Network and the Association of Breastfeeding Mothers, which receive around 28,000 combined calls each year on breastfeeding, will merge and run the advice line. The Government hopes the newly-created National Breastfeeding Helpline will be able to handle a far higher number of calls than either organisation on their won. The new helpline number is 0844 20 909 20. Copyright © 2008 The Press Association.

Great waterbirth

My client X asked me to be her doula for the second time, a year after I attended the waterbirth of her second child.
We had some doubts about whether this would be a straightforward labour...but as it turned out, it was totally straightforward.
X had some cervical issues that might well have given some doctors reason to refuse to support her choice of natural labour. But the hospital we were at respected her as an intelligent informed mum and agreed to support her wishes. In the event, the cervical issues made absolutely NO difference to a steady dilation speed and a strong labour which ended with a gorgeous waterbirth of a beautiful baby girl.

Nancy's HypnoBirthing home water birth

In 2006 I had the privilege of being the HypnoBirthing educator who led Nancy and her husband Tecwin through the HypnoBirthing programme. Their progress and Nancy's remarkable labour and the birth of Sid, their second son, was tracked by the series Home Grown Babies (first shown on Living TV).
Someone (don't know who yet) has put extracts from the episode on YouTube. It is an amazing story.

http://www.youtube.com/watch?v=Ks1-23fcERg&feature=PlayList&p=31717DCA62BBD447&index=0

http://www.youtube.com/watch?v=6HiljszP1FE&feature=PlayList&p=31717DCA62BBD447&index=1

(begins with a bit of an interview with me in it)

http://www.youtube.com/watch?v=M75c73A22vE&feature=PlayList&p=31717DCA62BBD447&index=2

This bit shows the birth.

Guardian letters page

Jennifer Hall says it all:

http://www.guardian.co.uk/letters/story/0,,2186472,00.html

That moment when you feel you can't go on...

With all my own labours there was a moment when I thought, What WAS I thinking? Why am I doing this? I want to stop! Now! I want to give up and start again tomorrow! Likewise virtually all my birth clients have had a "dark night of the soul" moment when they felt they could not possibly, possibly carry on. This is usually the moment a woman asks for an epidural. It nearly always means that birth is very near the end.
A typical example was my recent client J. who really did not want an epidural but suddenly announced during labour that she must have one, she could not possibly endure another contraction as powerful as the past 3-5. We were in a low tech labour room where epidurals were not administered so we had to walk down the corridor to the high tec unit. The intensity of the contractions indicated that she was in "transition" (as I hate calling the phase covering the end of the cervix's dilation and the beginning of the baby's descent) and the walk really seemed to help things along! As a result she was feeling the urge to bear down within minutes of reaching the second room, the midwife quietly cancelled the anaesthetist and the baby was born not long after.
It is always difficult to explain to a woman that this moment, the moment you feel you cannot go on, is the sign to her supporters that the end, the moment she holds her baby, is almost certainly very close.
After her baby was born, J. said to me, "I am SO glad I didn't have an epidural!"

The C-Section issue: "too posh to push"

This is a very good succinct article which summarises the issues around the rise in C-sections. Author Sarah Buckley points out that most women would rather have vaginal birth; she is of the opinion that the medical establishment pushes the C-section rate up; points out how much more risky C-sections are than most mums realise; and rightly adds, "if you didn't know, the pushing can be the best part!"
This was how it was for a doula client of mine recently who said as she felt the urge to push, "I'm really enjoying this!"

http://www.theaustralian.news.com.au/story/0,20867,21770725-7583,00.html?from=public_rss

Nancy's triumphant birth on Home Grown Babies!

My lovely HypnoBirthing client from last November, Nancy Evans, featured in the Living2 series Home Grown Babies a few days ago.
Her first labour had been a traumatic hospital experience filled with fear and confusion and at one point Nancy is seen bursting into tears at the memory.
Her birth was amazingly tranquil. She speaks during the labour of how comfortable and peaceful and safe she feels!
For the record, she went into labour about 8am, went into the pool about noon and baby Sid was born just after 2pm. The midwives were amazed by how peaceful and serene Nancy was throughout the labour. Apparently she didn't cry out or complain of pain once.
HYPNOBIRTHING WORKS!!!!
If you are looking out for the series, which will hopefully be repeated, check out episode 9 for Nancy's story.

Home Births

Evening Standard 5 April 2007

Delivering the truth on "risky" home births

Any woman with a low risk pregnancy in London would be mad not to consider a home birth, especially if she has had a baby before.
In the capital, a transfer to hospital only takes a few minutes by ambulance. If things look dangerous, a midwife will advise a transfer long before those few minutes become critical.
Last weekend I found myself wondering yet again why humans are the only mammals who respond to birth pangs by running away from home to a huge, unfamiliar building. I am a doula, a professional birth companion. My client and I were trapped for hours in a Victorian pile with bloodstained communal toilets and broken plumbing – a Ghormenghast of a place. Not the cosy nest other mammals prepare, but the labour ward of St Mary’s Hospital, Paddington.
The hospital website boasts of “a caring and pleasant environment, excellent labour facilities with individual birthing rooms and a birthing pool”. We are wedged into a tiny room that is nearly all bed and machinery. One of the rooms opens directly onto Reception, and none have curtains screening the doors. Staff barge in frequently and interrogate my client in mid-contraction. Builder’s rubble fills the one shower stall: the ceiling has fallen in.
A labouring woman needs to be mobile to help her baby to move down – no hope of this in the few inches of space between the bed and door. Someone, somewhere, is playing pop music ceaselessly through the night. The whole building is shouting at us: “Give up! Have a C-section!”
Birth is the work of the instinctive part of our brain, which needs a familiar, private environment to function well. It is not good at accepting strange situations – and it can be very stubborn. So while the thinking part of the brain “knows” that hospital is “safe”, the primal brain is saying, “I don’t know this place or these people, I’m going into emergency mode and slowing down labour right NOW!” Fear increases tension, which increases pain.
A third of Dutch women give birth at home. Dutch women are not known for being masochists: they are known for being sensible. Doctors who gleefully recount the risks of home birth (based on statistics from rural districts in other countries) less often mention the problems of hospital interventions even in wards far more pleasant than Paddington’s Ghormenghast.
Few people realise that a midwife’s homebirth pack includes entonox and other pain relieving drugs, and resuscitation equipment. Few know that home birth in the UK died out only because Sir John Peel , the Queen’s Surgeon-gynaecologist, believed that birth would be safer in hospital than in 1960s working class homes with outside toilets.
Things are different now. We no longer live in slums, we have MRSA in hospitals. It is time to put aside Peel’s patrician scruples, and bring birth home.
Sarah Johnson

Ten things to know when you are having a baby

I love this list! I can't disagree with any of it, try as I might. Fiona Dill writes for the local paper in Bermuda. Suddenly I wish I'd had my babies in Bermuda.

Ten things everyone should know before giving birth
By Fiona Dill
1. Be well informed: Gather as much information about pregnancy and birth as you can, and try and attend childbirth education classes...Going to classes should help give you the up-to-date information to make informed choices about your birth, pain relief and other options that are available to you. The chances are that as a result, you are more likely to feel better able to cope with the prospect of labour and birth. It's also a great way to meet people who are in the same situation and make new friends.

2. Make a birth plan: Using the information you have learned from the classes and other sources you will be able to put together a plan for your birth. Flexibility is essential but it will help you to focus on what you want and help your obstetrician and the midwives caring for you to know what you are hoping for... through your childbirth education classes and discussion with your obstetrician, you should be able to discover what is important to you and what is relevant to the [local] situation, and this can be put in your own words on your plan.

3. Get good support: A supportive birth companion (aside from your midwife) is one of the most effective forms of care a woman can receive in childbirth. Research shows that it has far more influence on the way you feel about the birth afterwards than even the pain relief you opt for. Although most fathers want to be at the birth, it's not right for every man and is something that must be discussed before labour begins! If you feel close and very comfortable around your partner, able to do your own thing without feeling inhibited, then going through birth together may work well and be a very special experience for you both. Other options might be a mother, sister or close friend. You might also choose to have a doula who can relieve the pressure from the father and facilitate his participation at his own comfort level.

4. Help your baby into the best position: There is no doubt that your labour will be easier if your baby is in the optimum position for birth – head down with the back of her head towards your front. There are various things you can do that may encourage the baby into the best position … try kneeling on all fours or leaning over a exercise ball while you are watching TV, or leaning forwards slightly when you are standing (supporting your upper body on a shelf or your partner (!) and gently swaying your hips in a circular motion). Ask your obstetrician, midwife or childbirth education teacher for more details.

5. Recognise the latent phase of labour: This is a very important part of labour and is often the longest. Women often report 'niggling' contractions for days, or the contractions can stop and start which is exhausting and frustrating. If you can stay relaxed and try and get as much rest as you can during this phase and recognise you are not yet in established labour, it'll mean you are more ready when labour really 'kicks in'!

6. Relax!: Relaxation is the key to an easier birth. It is unrealistic to think you'll be able to do this in labour with no preparation so your childbirth education classes should cover it.

7. Communicate: Talk to your obstetrician and midwives. They are there to offer you support and advice during your pregnancy, labour and birth. Discuss with them your hopes and fears, find out what your options are if you go overdue, your waters break before you go into labour, different positions for the birth, what you can do if your labour slows down, choices for third stage (delivery of the placenta) and so on.

8. Don't rush to the hospital: It might be tempting as you're so excited that your labour has finally started, but many women get to the hospital before they are in established labour (ie, their cervix is 3-4cm dilated), which can mean either returning home or spending the majority of your labour in the hospital. Contractions should be strong (lasting around 60 seconds), regular and about five minutes apart. There are obvious exceptions to this: if you are GBS positive or your waters go before your labour starts. It is a good idea to discuss with your obstetrician what their preference is for when you should go in and if in doubt, ring the hospital and speak to a midwife who will be able to advise you as to the best thing to do!

9. Keep on the move: Changing position during labour is of great benefit, both in helping you deal with the contractions and in encouraging the baby through the pelvis in the best position. Women who walk around in labour or who remain upright are less likely to need pain relief and more likely to have a straightforward birth. When you first arrive at the hospital you will usually need to be monitored on the bed for ten to 20 minutes to check that all is well with the baby, but once the midwife is happy with the results then you are free to get off the bed and mobilise as you want to ... walking, leaning over onto the bed, using a birthing ball, sitting on the toilet etc. If your labour is long and you are tired you can lie on your left side on the bed or be propped up leaning over the head of the bed. Ask your midwife for some more ideas if you need some inspiration and encouragement!

10. Be positive: Arming yourself with information, getting to know your body and staying active can all help towards you achieving the birth you want. Although some women definitely need interventions for the safety of their baby or for themselves, many more women can give birth safely without them.

Fiona Dill is the mother of five children, a nurse (BSc (Hons) in Nursing Studies), a childbirth educator (Diploma in Antenatal Education), a doula and a parenting course facilitator. Her column usually appears every other week in Saturday's Weekender section. Contact: fionadilllogic.bm

More women choosing home birth

From the Daily Mail 14/12/06


More women are choosing to give birth at home.
Figures from the Office for National Statistics showed that 17,279 UK births in 2005 took place at home, compared with 15,198 in 2004.
Analysis by the NCT showed that the biggest increase - 18.9 per cent - was in Wales, where ministers have pledged to increase the number of home births.
That figure is up on the 16.2 per cent recorded in the previous year.
Wales now has a home birth rate of 3.61 per cent - the fastest growing home birth rate in the UK, the charity said.
England meanwhile had a below UK-average rise of 13.4 per cent for the same period, with a home birth rate of 2.53 per cent.
Scotland had the second highest rise in the number of home births with an increase of 14.6 per cent over the period, the NCT said.
In Northern Ireland, the number of home births fell by 12.9 per cent, resulting in a home birth rate of 0.33 per cent.
Mary Newburn, head of policy at the NCT, said: "Wales is now leading the way in provision of home birth services and choice for women.
"It would be fantastic if England could emulate this success, but the evidence suggests this will only happen if there is a commitment to a specific health service target to increase the home birth rate.
"Currently women in many areas of the UK still find it difficult to choose a home birth.
"There is not enough balanced information available to enable them to make an informed choice about where to have their baby, and the shortage of midwives means that too often the option of a home birth is either not being offered or services end up being withdrawn at short notice."
The Government has pledged to increase women's choices when it comes to where to give birth. Ms Newburn said: "The Government's aims now need to be realised so that women are able to benefit from a real choice of where to give birth, including at home.
"We know of many low-risk women all over the UK, including Brighton, London, Liverpool and Leeds who have had straightforward pregnancies yet have been denied a home birth in the last 12 months for reasons beyond their control."
TV presenter Davina McCall, the NCT's ambassador for home birth, said: "I gave birth to all three of my children at home and it was truly amazing.
"It's great to hear that more and more mums are having the same fantastic experiences, but isn't it a shame that a lot of other women still won't have their wish to give birth at home come true this Christmas?"
but there are wide regional variations, the National Childbirth Trust (NCT) said today.

Epidural anaesthesia and breastfeeding

A study published in the International Journal of Breastfeeding has found a link between epidural anaesthesia and unsuccessful or hard-to-start breastfeeding.
This link is not new: a study in 1997 found much the same link.
This one blames the effects of fentanyl, the opoid often used in epidurals, on the baby.
To put it bluntly, the fentanyl dopes the baby up.
This is bad news as women have, in my experience, been consistently told by the medical profession that the epidural does NOT cross the placenta.

http://www.timesonline.co.uk/article/0,,2-2497626,00.html
Meanwhile in a sidebar to this report, Dr Thomas Stuttaford makes some comments which badly need scientific back up, though he does not provide such. According to him, the epidural is marvellous because it "increases bonding" between mother and baby!!!
I wonder what evidence he has for this? In my experience a mum who has had a theatre forceps delivery or emergency c-section because of the difficulties caused by her epidural finds bonding a bit more difficult than an empowered, oxytocin-sodden mum who has felt in touch with her body throughout her labour.
I've checked on PubMed and I cannot find any study which backs him up, except those which show that C-section mums find it easier to bf and bond after a local epidural anaesthetic as opposed to a general anaesthetic. Well, Duh!
I find Dr Stuttaford's lack of concern for the possibility of a baby being UNABLE TO LATCH ON PROPERLY after birth seriously worrying!!!!
In the past I have also seen him brush aside the danger of an instrumental delivery, increased by having an epidural, as an unimportant concern. (70% of primips who have an epidural end up with an instrumental delivery)
Since there is now concern for the short term effects of forceps and ventouse on a baby's comfort, I am puzzled by his very cavalier attitude to epidurals and instrumental delivery.
I seriously wonder if Dr Stuttaford has ever seen a natural birth where a woman was in a quiet, safe environment, allowed to labour in positions of her own choice, with caring, unobtrusive support?

Actor chooses home birth shock horror

Tamzin's home birth choiceTuesday, December 5, 2006
Bodies actress Tamzin Malleson has revealed that she chose to have a home birth after witnessing the horrors caused by inept gynaecologists and obstetricians in the BBC drama.
The TV star, who is mum to seven-month-old daughter Teddie with co-star Keith Allen, says she didn't want to go anywhere near a hospital when it came to her own labour.
"When I was pregnant a lot of people said they couldn't believe I was even thinking of having a baby after working on the series.
"I had a home birth, and Bodies was partly responsible for that. I didn't want to go anywhere near a hospital and I considered it safer to have a birth at home where I felt confident, relaxed and in control. I was happy at home - in agony, but perfectly happy!"
"Keith was brilliant, he was very supportive. We had an absolute disaster with the birthing pool - we live in a cottage and our water comes from a spring, and the pump chose to break.
"Keith was going up and down the hill with a wheelbarrow filling up from people's gardens in the middle of the night," she recalls, chuckling.

Nancy has her baby!

WELL DONE NANCY!!!!


My HypnoBirthing client Nancy gave birth beautifully and peacefully in her home birthing pool last week...on film!
She was being filmed by Bernadette Bos, writer and director of the Home Birth Diaries series on Discovery Health and Home. Berny is making a new series, which will air in the spring and probably be called Home Birth Stories.
Berny said she had not filmed a HypnoBirthing birth before and although I wasn't there, it seems that the relaxation and visualisation techniques I had taught Nancy really made a difference.
Nancy, who had a long and troublesome labour when her first child Rudy was born (and also haemorrhaged badly) was ecstatic afterwards. I finally got the news of baby Sid's birth during a school concert in which my son Leo, 12, was forming a humble but enthusiastic part of the school choir... a double joy!
She had a six hour labour, with surges beginning around 8am. She spent most of the first part on her birth ball and slid into her pool around 11.30pm. She breathed baby down; then towards the end of the second stage the baby's heartbeat began slowing alarmingly. So Nancy started pushing harder and baby was born 2.05pm. He needed a bit of extra care but was OK in five minutes.
Seems the heartbeat issues were caused by a KNOT in his umbilical cord which was tightening as he descended - yikes!
I know I am biased - but I feel sure that without HypnoBirthing, Nancy would not have had the energy reserves for the pushing, or the emotional composure to deal with this moment of alarm.

Is this the stupidest mum in Britain?

Mum's anger at lessons on breastfeeding07 Nov 2006

A MUM has sparked controversy after she was reported as saying she will take her seven-year-old son out of classes in a protest at him being given lessons on childbirth and breastfeeding.Val Bickley, of Barnard Castle, says her boy is too young to be taught about pregnancy and would rather the emphasis was on reading and writing, rather than childbirth.

And she is reported to have questioned why Startforth Morritt Memorial School, has lessons in breastfeeding, saying "it's disgusting".

But the school has defended its stance, stating the workshops have been successful in the past.Headteacher Linda Sams said: "The children have been studying the topic of babies and play and when the health visitor comes in she will be holding a workshop that looks at a number of things connected with this topic. She will be talking about how babies like to be close to their parents when they feed and she will discuss breast feeding."

It is a workshop that is being successfully delivered to schools across Teesdale and has been delivered to schools in previous years without any problems."We have offered an alternative activity for this child to take part in while the workshop is going on. Other parents are supportive and quite happy for their child to be included."Sandra Turner, from the Association of Breast-feeding Mothers said: "

The ABM believes that if, from a young age the child is taught the right way to breastfeed, then eventually, we will have a much healthier nation."

Breastfeeding over 6 months boosts mental health

Obvious if you think about it. Breastfeeding = cuddles with mum at home.

This is from Medical News:

Breastfeeding Boosts Mental Health31 Oct 2006 A new study has found that babies that are breastfed for longer than six months have significantly better mental health in childhood. The findings are based on data from the ground-breaking Raine Study at the Telethon Institute for Child Health Research, that has tracked the growth and development of more than 2500 West Australian children over the past 16 years. Researcher Dr Wendy Oddy said there was growing evidence that bioactive factors in breast milk played an important role in the rapid early brain development that occurs in the first year of life. "Even when we adjust the results to take into account other factors such as the parents' socio-economic situation, their education, their happiness and family functioning, we see that children that were breastfed for at least six months are at lower risk of mental health problems," Dr Oddy said. The study found that children who were breastfed for less than six months compared to six months or longer had a 52% increased risk of a mental health problem at 2 years of age, a 55% increased risk at age 6, at age 8 the increased risk was 61% while at age 10 the increased risk was 37%. The analysis is based on a scientifically recognised checklist of child behaviour that assessed the study children's behaviour at 2, 6, 8 and 10 years of age. Dr Oddy said that children that were breastfed had particularly lower rates of delinquent, aggressive and anti-social behaviour, and overall were less depressed, anxious or withdrawn. "These results are powerful evidence for more support to be given to mothers to help them breastfeed for longer," she said.

Waters or wee?

Sometimes it can be hard to tell if your waters have broken as women may experience a sort of "dripping" effect. I was very interested to read this from a midwife on an online forum:

For years I was aware that women often had a watery loss about aweek before
they went into labour and I just called it a cervical 'weep'. Iwas laughed at by
several colleagues and GPs that I worked with at the timebut I continued to
reassure women that this was quite normal and a positive sign for the start of
labour. Some twenty years on through my midwiferycareer I attended a wonderful
study day lead by Tricia Anderson and Stephanie Meakin. Part of this day was
dedicated to the cervix and the changes it went through during pregnancy. To my
great joy, amusement andchagrin (because I had never got round to researching
the subject!) therewas all the evidence describing the change in the cervical
collagen which allows the cervix to dilate. The 'old' collagen is broken down
and, in many women, appears as a watery loss from their vagina. The collagen
change also requires a high level of glucose so this explains the woman's need
for sugary food for about a week before she goes into labour. The loss can come in
dribs and drabs or may present in a gush, as if the membranes have broken.

Homebirth in London "a pipe dream"

THE rapid turnover in London's maternity units could be putting mothers and babies at risk of infection.
That's according to a report by the Evening Standard which highlights the "conveyor belt" service being offered in London's hospitals.
Figures obtained under the Freedom of Information Act show that in one sixth of hospitals more than one woman gives birth in the same bed each day.
The worst culprits are Barts and the London, Homerton, King George, Kingston, Queen Elizabeth and St Mary's.

Critics say the swift exchange of mothers and babies could be increasing the risk of infection as well as denying women the support they need after birth.
Ten women have died after giving birth at a maternity unit in Northwick Park hospital in north London where health chiefs admit the conditions were "poor" before special measures were imposed.
More midwives needed
The report highlights a shortage of midwives across the UK, particularly acute in London where on average midwives are having to deliver 44 babies a year.
Louise Silverton, deputy general secretary of the Royal College of midwives told the Evening Standard: "We have estimated 10,000 more midwives are needed to promote the quality of care women should expect.
"The Government assures us it is committed to real choice for women about where and how they give birth.
"Sadly these figures indicate choice is not present in London and home birth is still a pipe dream for many."
An NHS London spokesman stressed, however, that maternity departments in the capital were all part of a network in which women can easily be found beds in neighbouring hospitals where necessary.
He said services in London were under review and plans to change the location and size of units were expected to be drawn up by next summer.

Is Waterbirth Safe? Important article from mid 1990s.

From MIDIRS 1994
(hastily pasted in - may look a bit odd)
Is water birth safe?The facts behind the controversy.The dust is beginning to settle after the press publicity which linked somebaby deaths with the use of water in labour. Now is the time to examine thefacts and determine whether there is serious cause for concern. Jily Rosser,editor of MIDIRS Midwjftry Digest, investigates~The Bristol babiesWhat actually happened at the water births at the centre of all thecontroversy? Most of the media attention focused on St Michael's Hospital inBristol, where there were two bad outcomes (a perinatal death and braindamage) to babies born to women who laboured in water. A letter to theLancet' (written by obstetricians, paediatricians, but no midwives) raisedthe possibility that the temperature of the water may have led to'significant fetal cerebral vasodilation.... Theoretically this couldcritically compromise a susceptible fetus.'In the case of the baby who died shortly after delivery the mother, a 29year old primigravida, was in the water for two and a half hours. Thetemperature of the water was kept 'at a comfortable level.' Being booked fora domino delivery, she received care from her community midwife. Toward theend of the first stage of labour she left the water on the advice of themidwife, who had picked up a late deceleration in the baby's heart rate. Shemoved to a conventional labour room on the delivery suite and a CTG wasattached to her. A short CTG was obtained, by which time delivery wasimminent. Subsequently an apparently normal baby was delivered in poorcondition and it died 15 hours after birth. The post mortem showed no causefor the asphyxia, and at the time no connection was niade with the mother'simmersion in warm water during labour. The bereaved mother does not believethat water had anything to do with her baby's death.In fact, the notion was only raised when a second baby was born in poorcondition following the use of the pool. In the Lancet letter it states thatthe temperature of the water was just under 39.7°C when the woman enteredthe pool, but does not mention that the midwife soon noticed and cooled itimmediately to just under 37°C. Thus the woman was not exposed to water anyhotter, or for any longer, than she and all other pregnant wonien wouldexperience in the course of having a bath in the normal way at home. Thewoman was using the water for pain relief and did not intend to deliver inthe pool. Clear liquor was draining. Towards the end of the first stage thebaseline was raised to 160 bpm and the midwife picked up a deceleration withthe hand-held Doppler.The woman was advised to leave the pool, because 'women are asked to conicout of the water if we are at all worried about them'2 moved to the labourward, and a VE fifteen minutes later found her cervix to be fully dilated.During the second stage further decelerations were noted and a baby boy wasborn in poor condition. As with the first case, resuscitation was prompt anduncornplicated; nevertheless, the baby developed grade three hypoxicischaernic encephalopathy and is brain damaged. He is still too young for aprognosis to be made.This then, is the factual basis of the concern over the use of water inlabour. The impact at St Michael's has been some tightening of the protocolsaround water birth, and a slight reduction in the number of women choosingto deliver under water. But it is to the great credit of the St Michael'smidwives that the protocols around use of water in labour were alreadytight3 and as the senior midwife on labour ward points out, they work:the only two babies with whom they had difficulty did not deliver underwater, but were asked to leave the pool in good time.ProtocolsPrior to offering the pool room to clients the midwives had gathered as muchinformation as they could. In the absence of evidence from clinical inalsthey devised very cautious guidelines based on the experience of others.They were acutely aware that, as a woman and midwife led innovation, waterbirths were particularly vulnerable to criticism from the medicalestablishment. There was also a strong sense of responsibility that allpatterns of care should be rigorously evaluated.4 To this end, detailedstatistics are kept on all the women using water in labour, and this carefulapproach has enabled the St Michael's midwives and the birth pool, toweather the stonm The only changes made in the protocols were:4 MIDIRS Midwifery Digest (Mar 1994)4:1I. that the water be kept cooler than before until delivery is imminent(34-35°C in first stage, 37-38°C in second stage)2. the woman is asked to leave the pool if her temperature is raised oreither her or the baby develop tachycardia3. she is asked to leave the pooi every three hours for a short CTG traceThe irony of this last recommendation (that is as little based on researchas water birth) is not lost on the midwives.The St Michael's midwives clearly believe that there is no evidence that,because the women laboured in warm water there were poor outcomes for thebaby. So why was the reaction of the medical profession so strong? It istempting to interpret their reaction in terms of control. The use of waterin labour is outside their province; at St Michael's no obstetrician hasever been called in to the birth pool room2. It is possible that thediscomfiture that many doctors feel is placated by their insisting onpseudo-scientific protocols which can at least be quantified and recorded.Many must feel considerable relief at having negotiated an electronic fetalheart monitor into the birth pooi room, even though it is illogical of seekto make one unevaluated intervention safer by insisting it is monitored by asecond unevaluated intervention.Birth underwaterSo much for labouring in water, what of giving birth underwater? Again, thefacts must first be described. Historically, one well known case is that ofthe baby who died in the Dordognes region of France in the late 1 980s. Infact, this baby was not born underwater but, at an unattended home birth wasborn in the membranes~. The parents were unable to deal with the situationand the baby drowned in its own amniotic fluid. More recently, in mid 1992in Vienna, Austria, a baby was severely brain damaged following a waterbirth at home. This birth was also unattended: when the midwife arrived some25~30 minutes after the birth she found the baby still underwater, with theparents standing out of the pool and watching it sucking its thumb.6 Inneither of these cases was water the issue; lack of a trained attendant was.But while scrutiny of the facts is reassuring in all the above cases, in themost recent case it is not. For in October a baby died following awaterbirth in Stockholm, and there is a real cause for concern. A woman wasgiving birth at home, attended by two experienced midwives. They listened tothe fetal heart after every contraction with a hand-held Doppler and it wasnormal throughout. Shortly before the birth the woman defecated, and thebaby boy was born intocontaminated water. The midwives observed the baby making respiratorymovements as he was being brought to the surface, and he emerged severelyasphyxiated. The midwives were not able to resuscitate the baby with mouthto mouth or bag and mask. Thirty minutes later, in the hospital, thepaediatrieians found the baby initially impossible to ventilate and it wassixty minutes before he started to breathe. The ventilator was switched offafter ten hours. The forensic post mortem 'showed clearly' that the baby hadinhaled water into the lungs7. Professor RagnarTunell, the paediatrician whooversaw the case, has painstakingly pieced together all the elements of thetragedy and his personal belief is that the following occurred. This was oneof the 20% of babies born severely asphyxiated in whonî there are nodetectable problems with the heart rate in labour. The severe asphyxiaoverrode the inhibition to gasping which normally occurs in babies bornunder water, and the baby inhaled into his lungs quantities of highlycontaminated water. Resuscitation was made difficult by the resistance inthe fluid-filled lungs. It would appear that this baby might not have diedhad he been born into air. A second inescapable conclusion is that he mightnot have died had he been born in hospital. Planned underwater births havebeen discontinued in Stockholm.The responseWhat now are we to do with this information? There have been kneejerkreactions both ends of the spectrum. Denial is certainly unhelpful. Thefounder of a pool hiring company sent out a press release saying that in thecase of the Swedish baby 'there is no evidence whatsoever that the babydrowned or died as result of the mother using a water birth pooPY Such illinformed comments do a disservice to her customers. On the other hand wehave the president of the Royal College of Obstetricians and Gynaecologi stsexpressing concern over mammals being born into the unnatural medium ofwater~°. It is difficult to know whether to be pleased that the RCOGrecognises that humans are mammals and that the birth environment shouldsuit our mammalian nature, or to be cynical that the labelMIDIRSMidwifery Digest (Mar 1994)4:15unnatural' is so readily applied to water birth in a pejorative sense, butnever mentioned in connection with, say, induction or epidural. The RCM gavea more measured response but included the worrying advice that 'the babyshould be brought to the surface within one to two minutes of delivery".'The only safe advice is to bring the baby to the surface immediately.It is the comparison with epidural that is the most tempting to explore.Here too is an intervention designed to relieve pain in labour, introducedwithout adequate evaluation of its safety and known to affect coretemperature in labouring women. There must have been, as a statisticalcertainty, unexpected perinatal deaths in apparently healthy babiesfollowing the mothers' use of an epidural in labour. but no letters in theLancet, written by concerned practitioners, followed these.UnethicalSeveral recent articles have been critical of midwives readiness toundertake water births when their safety remains unevaluated.'2'3 But thereis an important distinction between health professionals introducing anintervention of unproven benefit with which women are expected to comply asthey are told it is of benefit to them or, more likely, their baby (eg CTGin normal labour, routine ultrasound scan in pregnancy) and professionalsresponding to client requests for an intervention such as waterbirth. Whileobjective evaluation is equally important in both cases, the first instanceis unethical. The second is not. In fact, midwives who have responded toclient requests for water births have strenuously sought information; in1993 MIDIRS responded to 187 requests for a search on use of water inlabour; over the past several years the total number of searches requestedmust be approaching a thousand.ConclusionAs Sheila Kitzinger, who has been calling for research into water births forover three years, said 'It was so obvious that sooner or later a baby woulddie.' Apparently normal babies do occasionally die unexpectedly. As water isused more often in labour, so the likelihood of a death occurring followingthe use of \vater has risen. The question is, is the relationship a causalone, or coincidental? The balance of evidence to date suggests that the useof water as pain relief in labour is very safe. Many babies have been bornthis way.Associated problems have been very rare, and with none of these has a causalrelationship been cstablished. Careful watch does need to be kept, datacollected methodically and the outcome of the trial currently beingundertaken by the National Peritiatal Epidcmiology Unit is awaited withinterest.Giving birth under water is a more delicate qucstion. Certainly thousands ofbabies have been born underwater without any difficulty. indeed many withgreat benefit. But one has died. And it is likely that he would not havedied if he had been born in air. The reexamination of the events leading upto his death can reveal no other preventable factor. And the contributingfactors (severe birth asphyxia following an apparently normal heart ratethroughout labour, heavy faccal contamination of the water, birth at home)are not rare events. This scenario could be repeated.Midwives are beholden to explore with every client planning to givc birthunder water not only the benefits but the risks, however slight, so that thewoman is able to exercise informed choice. It must then be the woman'sdecision.1. SK Rosevear, R Fox, N Marlow. and others. tweet. Birthing poolsand the fetus (correspondence), vol 342. no 8872.23 Oct 1993. ppI t)48- 1049Ann Tissard, Clinical Midwifery Manager. Delivery Suite, SiM ichael 's Hospital Bristol. Personal communication.3. Footner K. Bristol's new birth pool. MIDIRS Midwifery Digest. vol2,no3,Sep 1992. pp27l-274.4. Ann Remmers. midwifery manager, St Michael's Hospital. Bristol. Personalcommunication. 1994.5. Michel Odent, London. Personal communication. 1993.6. Michael Adam, Obstetrician. Vienna. Personal communication. 1993.7. Ragnar June11, Professor of Paediatries. Stockholm. Persotialcommunication. 1993.8. Ingrey J. [press release]. London: Splashdown Water Birth Services.18th Oct 1993.9. Chamberlain G. Statement on birth underwater. [press release]. London:Royal College of Obstetricians & Gynaccologists. 15th Oct 1993.10. Chamberlain C.Waterbirths [letter to ChiefMedieal Officer] .London:RCOG, 11th Oct 1993.II. Watcrbirth advice. Midwives Chronicle. vol 106, no 1271, l)ee 1993.p474.12. McCandlish R, Renfrew Ni. Immersion in water during labour and birth:the need for evaluation. Birth vol 20 no 2. Jun 1993. pp 79-85.13. Wise J. Waterbirth: trial or error? British.Journal of Midwifery vol I.no 6, Nov/Dec 1993, pp 249-250.Rosser J. MIDIRS Midwifery Digest, vol 4, no 1, Mar 1994, pp 4-6.Original article written for MIDIRS by Jilly Rosser midwifeMIDIRS /994.neterences6 MIDIRS Midwifery Digest (Mar 1994) 4:1Hope this helps. Blames misprints on scanning but better than nothingloveMaragret