Reflection on a normal birth

I wrote an article a few years ago that was published in The Practising Midwife and I had cause to re visit it recently when I attended a birth complicated by meconium stained liquor. I thought it would be good to include the article in this blog as it covers so many issues that worry both women and midwives alike, things such as long, stop start labours, meconium, long 2nd stages, infection and prolonged rupture of membranes.....in fact if I had not written it myself I would think it a marvelous reflection of normality.....its a bit long but well worth a read if I say so myself

Reflection on a normal birth
Lindsey had a lovely home birth. Not really unusual and certainly not unusual in the life of an independent midwife. However Lindsey’s homebirth was achieved against so many odds and against so many objections that she would have encountered had she been being cared for under a medical model of care, her birth and the woman herself is well worth calling amazing.
Five days after her estimated due date Lindsey called me around 05.30 to say her membranes had ruptured at 0100 but that the baby was very still and not moving much hence her call so early in the morning. I reassured her that she is not usually awake this early so it may be that the baby is asleep at this hour usually but that I would come and see her immediately.
I arrived to find baby well, with a very reactive heart rate and by now movement was evident. The head was very low in the pelvis, hardly palpable at all with the back laying left lateral. Wonderful I thought!! However when Lindsey showed me her liquor loss there was meconium diluted into it. Meconium can be a sign that baby is becoming hypoxic although not necessarily an absolute indicator. It can be that baby is mature enough to open its bowels. It is important to determine between the two possibilities so that the birth is not only a safe one but also that the labour is not interfered with leading to further complications.  I do not automatically advise transfer for a hospital birth where well diluted or old meconium is evident but I do keep a very close eye on the fetal heart and would advise urgent transfer at any deviation from normal. In this case labour had not yet started and we did not know when it might begin and so I advised that a trip to the local hospital for a well being CTG was appropriate.
We arrived at the local hospital where I know many of the midwives and doctors and have good relationships with most. Lindsey had a CTG which was normal, it was reassuring that baby was well and healthy. A Consultant obstetrician on the ward advised immediate induction of labour due to the meconium and ruptured membranes which was no less than the advice we had expected. However Lindsey was aware of the evidence and the risks of induction and so declined and decided to go home to await labour.   The midwifery staff were very supportive of Lindsey’s decision to go home and reassured us both we could return if we encountered any problems.
Having had a similar situation in another area a couple of years previously when a woman and I had to fight our way out of the hospital, having encountered terrible coercion and bullying from the midwives to conform to what the medical team where advising, this now was a lovely supportive beginning to what was to be a very unusual labour. To know welcome help was on hand should she need it at a local hospital is reassuring for both woman and midwife.
Relationships are not always easy between Independent Midwives and NHS staff due, I believe, to a lot of myth and misunderstanding of an IM’s role in the care of women. I have however worked hard on building good working relationships with this particular trust and to a large extent have achieved it.
Lindsey went home, and so did I, with a plan for me to visit her at 1700. When I arrived it was to find Lindsey, her husband Ian and her mum all having tea. Lindsey was chirpy but at last was having mild contractions every five minutes. Lindsey and I had shared many antenatal discussions about pregnancy, labour, birth and everything associated and so when I bought up the subject of vaginal examinations she was well aware of the risks both physical and physiological and the limited benefits to be gained. We came to the mutual conclusion there was no clinical indication for any intervention including and especially an invasive examination. We went on to discuss how she may cope with the coming night. We recapped all the issues surrounding meconium stained liquor, in fact both Lindsey and Ian asked relevant question repeatedly which left me in no doubt that at all times they were making very informed choices. All was well physically with both Lindsey and baby and so I left once again to go home to get some sleep.
At 2300 I received a call from Ian to say the contractions were now coming quite strong and regular. When I arrived it was to find Lindsey lying on her side very sleepy on her large bed with her mum chanting relaxing hypo birthing words in her ear. Lindsey’s contractions were very regular 3 /4: 10. The contractions looked expulsive and Lindsey told me that she felt surges downwards with each pain. It certainly looked liked active labour now and in fact I wondered if Lindsey was fully dilated given the way she was acting. We discussed a vaginal examination again and this time we both felt it appropriate. It was 23 40.
I initially thought Lindsey was almost fully dilated and was shocked at how low the baby’s head was. Literally my fingers were only inserted to my second knuckle to find the head. On closer examination I could feel cervix around the back of the baby head and eventually concluded that Lindsey was around 6 cm dilated. Lindsey was really pleased especially when I told her how low the head was and that could only mean she would not be long before she saw her baby! If I only I knew!!
Lindsay had a nice warm pool of water waiting for her downstairs so I suggested she get into it. At 0030, now around 24 hours since her membranes had ruptured Lindsey started to involuntary push. The pushing went on for about 20 minutes with contractions still 3 /4:10. All observations for both Lindsey and baby were normal and so I sat back and waited for a baby to appear. However after half an hour the contraction began to slow down and space out. I suggested she may be coming to her “rest and be thankful” stage. This spacing out of contractions can occur at full dilatation, when the level of oxytocin in the blood falls due to the lack of the feedback mechanism from a fetal head putting pressure on the cervix. I did not know it at the time but I was quite wrong!
Contractions did not return and so I encouraged her out of the pool to have a little walk around. At 0230 the contractions picked up again in intensity but Lindsey no longer had any expulsive urges. This may have been therefore a positional issue with the low head of the baby stimulating Fergusons Reflex to cause the pushing urge. Who knows for sure but the art of midwifery was telling me this may be so.
For the next 4 hours the contractions continued regular and strong. All was well with baby. I heard lots of variations in the baseline rate, some acceleration and no decelerations. I was very reassured all was well. Lindsey alternated between resting and activity as any labouring women does, she kept well hydrated, passed lots of urine and all her observations were normal. She often had the urge to open her bowels but by now I suspected it was only due to the very low head and not to full dilatation.
At 06.30 once again contractions slowed down. We re visited the subject of vaginal examinations. Lindsey as always looked at everything from all angles and we devised a plan, depending on the findings, prior to any examination. She decided that if she was more dilated than the last time she would continue to be active but if no change then (at my advise) she try and get some rest as the contractions had slowed down. Obviously the other remaining option which I always reminded her of was that we could transfer to hospital at any time for some intervention.
A vaginal examination disappointedly showed no progress, that Lindsey was still 6cm dilated and the position of the baby was unchanged. By now the contractions had all but stopped. Lindsey went up to bed and slept soundly for an hour. From downstairs I heard just 2 small contractions in all that time. I wondered long and hard what was going on here. I knew most woman by now would have been augmented long ago but despite looking hard I could find no real abnormality in either Lindsey’s or the baby’s condition. Lindsey had no wish to transfer to hospital and had the full support of her husband Ian and her mother.
At 0800 Lindsey awoke, got up and started to pace around refreshed and eager to restart the labour. By 0900 the contractions started up again and by 1000 they were back to 3 /4:10. This pattern continued until 1400 when unbelievably they once again started to die off.
By now I was getting to the point where I just could not believe what was happening. I discussed Lindsey’s labour, progress, care and choices with both a midwifery colleague and my very supportive supervisor of midwives. I was careful to do this out of Lindsey’s hearing as I did not want her to think that I was either worried or unsupportive as I was neither. However as most midwives know our practice is sometimes judged by our peers and so I questioned in my own mind what was happening.
At 14.15 Lindsay and Ian were walking around the garden in the sunshine. She looked nothing like a woman in labour and so I took photographs of her. She was smiling and happy. I decided it was time for a very frank and full discussion and to devise a plan of action. The first thing we discussed was another vaginal examination. Lindsey did not want one!!
I told them that in my opinion the choices they had were
1) Do nothing, as long as mother and baby remained well (or otherwise) for I could not make them do anything they did not want to. I would however let them know if I felt I needed to strongly advise them that their choices may compromise immediate safety of either Lindsey or their baby.
2) Have a vaginal examination and depending on the findings devise a time frame for action
3) If the choice is no vaginal examination have a time frame in the short term to perform one i.e. at 1700 and make a further plan then
4) Immediate transfer to hospital
Lindsey was upset at this time and started to cry. Ian suggested that it was not a good time to make any decisions with her being distressed and said it was not urgent due to baby and Lindsey being well. They decided that Lindsey would have a vaginal examination around 1600 and in the meantime would rest. Once again Lindsey slept. No contractions at all for around an hour then a really big one awoke her.
I have never known such a supportive and sensible husband.
At 1640 Lindsey decided to have a vaginal examination. The findings were unchanged. However now I could feel a very large bag of fore waters. Lindsey became very distressed during the examination and asked me to stop. The liquor Lindsey had been draining throughout her long labour had continued to be meconium stained but it was minimal. To now feel this large bag of for waters was surprising.
I suggested that the options now were to
1) Transfer to hospital for augmentation and other interventions
2) To re examine break the bag of for waters which may bring back contractions and then have some pethadine which may relax a now very upset and stressed woman.
3) Do nothing.
Lindsey decided to take option 2.
I rarely perform artificial rupture of membranes as the risks far outweigh any benefits as far as the evidence is concerned. However I felt it was warranted in this case especially as liquor had already been draining, baby was so low and there had never been any cause for concern with the heart rate. I ruptured the membrane and a huge amount of very clear liquor drained. I then gave Lindsey 100 mg of pethadine and the entonox. She rested then for 3 hours cuddled up to Ian on the bed.
At around 1700 contractions returned and although they were only 2:10 they were very strong. At around 1845 some were once again sounding expulsive. I had however been fooled before and so did not get excited. Lindsey continued to lie on her bed but around 2000 the expulsive contractions were very strong and Lindsey felt inside with her own fingers. She could feel her baby’s head. I was not surprised by this as I had always felt it very low. This very low head was the most reassuring thing of all and gave me confidence to support Lindsey in her choices to continue in this very extraordinary labour. 
At 2000 the contractions were all uncontrollable pushes. Another vaginal examination found the cervix to be 8cm dilated and we both felt huge relief and exhilaration.
Squatting beside her bed and pushing uncontrollably at 2100 I caught sight of a baby’s head. It was what we had waited many many hours to see. Once again Lindsey got back into a nice warm pool.
For the next three and a half hours Lindsey pushed her baby steadily towards life. She got out of the pool after a while and used a birth stool. Her baby was born in absolutely perfect condition at 0030……She sustained a very small tear that healed in a few days. She pushed her placenta out herself with minimal blood loss.
Lindsey had ruptured membranes for 48 hours. She had meconium stained liquor. Lindsey had remained at 6cm dilated for over 20 hours. Her labour had stopped and started many times in 24 hours. Lindsey had made all her own decisions based on her knowledge of all the choice available to her. The choices she made were the correct ones. Had she chosen intervention she may have had her baby a day or so earlier but at what cost?? There was no infection, no distress, no bleeding, no incontinence, no disempowerment or disappointment. Her baby had apgars of 10 and 10. Despite having peaks and troughs of feelings she coped amazingly. Following the birth she was neither exhausted over and above what would expected for any mother having just given birth and neither was she traumatized or upset by her experience. She says she had a wonderful labour and birth!!

Labour Ward Rituals

Why oh why does nothing ever change in the medical dominated world of midwifery? Maybe it is changing but it is kept hidden from me and I see little change in the 13 years I have been away from the labour room rituals. Is there ever going to be a time when I accompany women to hospital when they need to go for assistance but they are then treated with dignity and the experience is one of joy ( and good women centred practice) in all respects?....

Recently I took a client in to hospital with suspected early labour at 34 weeks. I went home as nothing much was going on but 24 hours later was called back by my client as all of a sudden baby was on its way fast.

 When I arrived on the labour ward I walked into the brightest lit room you have ever seen, every main light was on but also a spotlight was beaming down onto a visible head. Two male paediatricians were in the room arms crossed leaning against the window a bored look on their faces.....doing nothing of course just waiting there watching the woman in her most private time. There was also a doctor present and 2  midwives, another person kept popping in and out but I, and I am sure also my clients, have no idea who it was. As the birth was so advanced and in front of so many people there was no way I could make any changes or even comment on anything I saw, it would have been inappropriate and far too confrontational, but it really was awful.

The woman was in typical labour ward position, propped up on her back  (this was a woman who was planning a home birth and wanted everything natural) . She was being encouraged to use the valsalver manoeuvre of sustained breath holding and pulling back on her thighs. This manoeuvre has been demonstrated to be dangerous practice by the World Health Organisation and has been labelled “practice be abandoned” as it can cause fetal distress.  

One midwife was standing next to me and I was able to whisper to her " please consider not cutting the cord if this baby is well as the evidence is clear that it is beneficial especially for premature babies" of course I was ignored and when a healthy pink crying baby was born a few minutes later the blood rich cord was instantly clamped, cut, the baby wrapped in a towel and handed up to his mother. The mother was overjoyed, of course she was, baby was healthy a good size and in perfect health.  The irony of it was that as the midwife was cutting the cord all the blood spurted all over her face and arms! She thought it quite funny, I thought it quite sad! Shame the blood didn’t spurt into the baby!  If they were passing baby to mum anyway why couldn't they have left the cord? It was what mum wanted and should be common practice...its even in NICE now!

I helped mum to unwrap baby and the baby commenced to nuzzle at the breast, I covered them both and that was where I hoped they would at least remain, however after about 5 minutes the baby was taken from his mother for a paediatrician to look at him. You could see he was healthy just by looking at him in mums arms! All the Doc did was listen to his heart (yes it was beating he had been pink and crying and breathing for a good while now)and then the midwife commenced to put a nappy on him (did mum want this?  of course the answer is that she didnt know for she didn’t ask.... did she even stop to think that the parenst may have looked forward to being the first ones to dress their baby?) She then wrapped him AGAIN  in 2 towels and finally gave him back to mum with no mention of skin to skin or feeding. As I see it this is nothing more than labour ward ritual,  this taking of baby for a paediatrician to look at, it happens at Caesarean sections too yet a midwife is completely able to assess at birth instantly if a baby needs a doctor or its mother. Of course as I was there I encouraged the mum to unwrap (again) put him skin to skin (again) and breast feed which he did beautifully and instantly. Why does this happen ?If I had not been there maybe the mum would not have unwrapped the baby and would have continued to hold her heavily wrapped baby without attempting to feed or certainly not as early and quickly as she did. At that point with him being born early, I considered skin to skin and feeding was the most important thing for that mother and child yet the midwives began immediately to pester the mother to stop feeding and hand him over to weigh and get prophylactic antibiotics started. The only thing wrong with this baby was he was 6 weeks early. He was a good weight, over well over 5lb and it was a spontaneous quick labour in a healthy mother. It seems so bizarre that there was such a rush to get drugs into him that he may not need but that they were more than happy to deny him the blood and feeding that he did need.

Why couldn't this baby have been born without an audience? Surely just outside the door is as good as in the room? Why did she have to be born under a spotlight and why wasn't the women in a better position to achieve a more positive birth, help with pain, prevent tearing etc. she could easily have been on all fours, the room dark and everyone waiting outside in case they were needed. Most importantly why was the cord not left to pulsate? They passed him to mum anyway so why not keep the cord on ? Just in case readers are not aware of the overwhelming benefits to leaving cords to pulsate the blood into the baby (rather than over the midwife) you can look at this link:

http://www.bbc.co.uk/news/health-15736550 

Ok on with the struggle to make changes….

To push or not to push...that is the question

Attended a lovely birth on New Years Day. In hospital, so I was unable to 'catch' the baby but was able to support my client and her partner throughout. Labour was induced for medical reasons and strong regular contractions quickly ensued. After a short while my client said she wanted to push and it became apparent that she was in second stage of labour. She was told by the hospital midwife not to push but to breathe through the contractions. She started pushing anyway and a lovely healthy baby born shortly afterwards.


This had made me think about lot of issues surrounding the issue of pushing.

Firstly, why women are so often not believed when they say they want to push? I have heard that story too often, even with a woman who have had babies before and the head is visible! Whether the urge signals the second stage of labour or not, being told to suppress those feelings and fight them is counterproductive. Just acknowledging that a woman has those feelings can help her by demonstrating that we believe her and trust in the normal physiology of birth.

Secondly, If a woman's cervix is fully dilated and her baby is moving down the birth canal then she is in second stage of labour and her baby will soon be born. Fantastic! So why tell her not to push for heaven's sake!

And thirdly, if her cervix is not fully dilated there isnt any compelling evidence from research that this will cause a woman or her baby harm.In fact early urges to push are common and in some labours may encourage baby into more a favourable position for birth.

Lastly, women's urges often ebb and flow. So encouraging them to be instinctive and push as they feel inclined will almost always result in strong overwhelming expulsive urges only when baby is well down in the birth canal and about to be born.

So I for one will always believe a woman when she says she wants to push and continue to tell her to do just what she feels she needs to do.

Strong women not good girls

Just wanted to have a moan about a little thing (or maybe it's the tip of a very big one!) ...but its bugged me for years. In fact since I was a student midwife a very long time ago and I noticed one particular midwife saying it. And I would say that midwives say it most, less so doctors, and that it tends to pop up in the second stage of labour.

Telling women that they are '...good girls'. I cringe inwardly and then want to scream and shout at same time. I think it's rude, patronising and infantilizes women.

So why is it said to women when they are doing one of the most strong, grown-up things in their lives?

Power and control may have a lot to do with it. Also the culture of birth, the labour ward etc. Or maybe it's just that as professionals we forget what messages our language conveys and we need to pay attention to it more.

Are gloves always necessary during birth?

As I have nothing to hide about my practice and am confident in what I do and the care I give, I agreed to take part in HOME BIRTH DIARIES which, in my opinion, is the best woman centred and positive programme about pregnancy and birth on the telly....

In comparison to it I hang my head in shame at some birth programs, especially ones that take pride in admitting they are demonstrating conveyor belt like care and that one born every program is more like one extracted every minute. However we wont go there in too much detail but I may just remind you of those type of birth shows after I have had my say....

Back to Home Birth Diaries and in particular the episode showing Sadie, a women from Rochester having her 2nd baby. The birth in that episode is clear, close up and beautiful. A baby being born just how it should be. I also happen to know that it ranks as one of Discovery Health's and viewers favorites yet I have come in for criticism from some viewers, those of which are midwives themselves. I am used to criticism, being an independent midwife, and usually do not rise to it for the reasons I began this blog with, but this particular criticism has been mentioned to me twice in a few days so I thought I would address it.

Why do health professionals wear gloves?

We do so to protect ourselves and our clients against infections and blood born diseases.

I do not, however wear gloves to catch babies......shock horror ? please let me explain.

I do not "deliver" babies or have hands on other than if help is needed or if I have to be invasive in any way. Should that type of assistance be needed I always wear gloves, if I need to perform vaginal examinations I wear gloves, during the third stage of labour I wear gloves, to clear up any mess of any description I wear gloves BUT if a baby is just falling into my hands, as in Sadies birth, I take OFF my gloves just prior to catching the baby. A healthy, clean (maybe a bit wet) baby falls into my hands....what is the difference than when I hold the baby an hour later?

There is no risk AT ALL to a mother, baby or myself if my hands are clean, not cut or have any abrasions and I am aware of both the mother and my own HIV and Hepatitis B status. There is more chance of the latex gloves causing an allergic reaction to the baby. Furthermore how nice that baby is welcomed into the warm, clean hands of, if it cant be its own mother or father, a midwife who so well known to the family that she feels part OF the family.

Please my fellow colleagues and critics do not compare what I do to with what goes on in hospitals where strangers care for strangers, unless you are comparing my outcomes to those outcomes....in 13 years of practicing the way I do I have caused or caught no infections. My clients only have the ones they left hospitals with....My way of working is called individualised care...try it you may like it.

funny breastfeeding video

Well 7 months of hard work is over and now its just the waiting and seeing. Just before christmas last year a group of us including my good friend Bernie from www.mybirthtv.com thought about making a breastfeeding video. Not an educational one, (not to say they are not amazing because they all are), but a funny, cheeky one that will provoke attention and get the subject talked about. We were looking for a funny modern topical idea and it all gradually came together.....I have written the whole story about the making of it and why etc already so wont go into long detail again but if you want you can read it here. Anyway the video is on You Tube and the response is pretty amazing...both ways....I would say 99% positive but with a few people just not "getting it". Glamorous women saying "we are proud of who we are, proud of what we do, come and do it too its fun", not taking themselves too seriously, poking fun at themselves even and all for a very good reason....feeding our babies in the best possible way. We had lots of mums turn up on the day of filming all looking beautiful in their own ways, all willing to feed on camera...I say to everyone who took part ....very well done...didnt we have fun?
watch it here

breast is always