Friday, 14 November 2008

Sharon's Story Part 1 - normal birth of a 12lb baby

Virginia originally published this story on the Kent Midwifery Practice website. It attracted my interest - who wouldn't be surprised to hear about the homebirth of a 12lb baby? The pregnancy and birth were straightforward, but the mother lost sufficient blood to be classified as having had a postpartum haemorrhage. The bleeding was stabilised at home and the mother remained in good condition throughout, but given the quantity of blood lost and size of the baby, she transferred to hospital for a check-up. When I read Virginia's original story, there were many more questions that I wanted to ask. Virginia has agreed to re-publish the story here, and to elaborate on some of the details. The original story is quoted below, in arial font. Questions and comments from me are in italics, and Virginia's additions to the original story are below them - Angela Horn.

Sharon's Story - an Unusual Normal Birth

I remember the first words I heard when Sharon rang me at the beginning of her pregnancy “I would like a home birth but my husband wouldn’t like it”. Well, I hear that a lot and feel that is only a minor hurdle to cross. If a woman really wants a home birth then getting husband on board is usually easy. I went to visit Sharon and Paul and gave them a DVD of another client of mine who had recently been featured on the Home Birth diaries series on the Discovery Channel. I chatted to them about the safety of home birth, risk factors and Sharon’s previous 3 hospital births.
Sharon and Paul felt that the births of their first two daughters were OK, although medicalised with induction of labour, continuous monitoring, episiotomies, managed third stage etc. However, the birth of their last daughter and then the poor treatment they received during a late miscarriage made them lose their faith and belief in the local NHS maternity services.

Sharon had birthed 3 big babies; the largest was the second baby at 9lb 13oz. The third baby had been induced at 37 weeks following a diagnosis of polyhydramnios and an estimated weight of nearly 10 lbs. The actual weight at birth was 9lbs. There had never been any diagnosis of diabetes or any other maternal or fetal problems.

This client had a history of polyhydramnios in a previous pregnancy.
Was an explanation ever found for that?

No explanation was ever found for the polyhydramnios in the previous pregnancy. It was classified as mild and therefore standard recommendation is that it is treated with expectant management.

However her last pregnancy was not treated with expectant management the client had been induced at 37 weeks. Effectively that baby could well have been 5 weeks early and suffered from respiratory distress syndrome however the client had been led to believe her baby was at real serious risk and that she had no choice. Induction of labour is not without risk. The client found the experience traumatic and therefore did not want to take that route with this pregnancy unless a clear benefit to her baby and/or herself could be demonstrated. She employed me to respect her choices and be honest with her.

This pregnancy never received a confirmed diagnosis of polyhydramnios. She had an upper-end of normal amniotic fluid index.
Back to the story:

We deduced that Sharon therefore grew big babies as normal for her. We decided that we would expect a big baby and not be concerned. Easier said than done during the first trimester!!

Editorial note: Your conclusion was that big babies were 'normal' for Sharon - as a lay person I assume that means that no medical problems were ever found, Sharon and her babies were healthy, so it wasn't the case that her babies were big because of gestational diabetes or anything else 'wrong' - it was just their growth potential.
Back to the story:

All went well. Ultrasound scans and routine bloods all showed a normal pregnancy. Sharon had some episodes of dizziness that were unrelated to anything.

Virginia, do you mean the dizziness was unrelated to anything in the pregnancy?
I mean that she did not have low haemoglobin or blood pressure, no ear infections, other infections etc so we put it down to a “pregnancy ailment” as all the usual explanations have been eliminated. We know women sometimes feel symptoms that will eventually go and have no underlying reason. Woman can have vaso-vagal episodes; I have looked after many who have (I also had them). Dizziness is a common pregnancy complaint and it would not normally be referred to a doctor unless it was severe or chronic.
Sharon's observations and haemoglobin all remained normal and the dizziness stopped with rest. I continued to advise her about diet and encouraged her to reduce her carb intake and increase her protein, calcium vitamins etc.We had hours and hours of discussion. Sharon had so many questions. We discussed every aspect of normal and abnormal birth. We discussed the whys and wherefores, the if and might be of every test and possible happening imaginable. We discussed the medical model of care, the history of childbirth even evolution and natural selection. Sharon was taking an anatomy and physiology course and so the physiology of birth was of great interest to her. Sharon was like a sponge and soaked up everything we discussed. I never at any time felt that Sharon was not making a truly informed choice about any aspect of her care.At 34 weeks I concluded that once again Sharon was growing a large baby and had gallons of liquor on board. The baby was also breech.
We discussed a scan and other investigations and Sharon declined as she wanted to stay away from the hospital as much as possible in order not to “open a can of worms” (her words) as had happened before.

I asked my partner Kay to visit Sharon at 36 weeks to assess presentation and overall health. I had always visited Sharon in the calmness of morning when the children were at school however Kay’s visit was in the evening on a particular stressful day. It was not surprising therefore that Kay found Sharon with an elevated blood pressure. She was also unsure of the presentation and therefore a referral was made to the local hospital.

While at the hospital Sharon had blood taken to assess for pre-eclampsia, as we expected.

If you expected this, why wasn't blood taken beforehand?

That would be just plain silly as she was going to the hospital. Why would one take blood prior to transferring to hospital? In this situation it is standard for blood to be taken at the hospital. We have blood forms and bottles for some trusts but we cover about 7 different hospitals and each has its own different protocols, so there was nothing to be gained by taking the blood before arrival.

Did you do a urine test at the same time as the raised BP was found?

Yes, of course, we always test urine at antenatal appointments, and in this situation, as with all her other tests, no abnormalities were detected.

However [the hospital midwives] also had her previous history and did a blood glucose test [for gestational diabetes] which was normal.

Did Sharon have any earlier glucose tests this pregnancy?

She was tested for glycosuria (glucose in the urine) at every antenatal visit. [urine analysis in the first two trimesters is a valuable screening tool for women at risk of developing gestational diabetes - (Gribble RK, et al. The value of urine screening for glucose at each prenatal visit. Obstet Gynecol 1995;86: 405-10.) ] She had never shown any glucose. In previous pregnancies she had routine glucose blood testing and all had been negative. She was reducing carbs and so I felt no reason to suggest a glucose tolerence test, especially given the research concerng the test's unreliability (Enkin 2000). Moreover, Sharon declined the test.

Sharon had taken our notes with her and so the midwife who cared for her could read them and was well aware of the amount of discussion we had over the previous weeks. Despite this midwife felt the need to shroud wave and talk about the risks of big babies and advise against a home birth. She said that babies who have large volumes of liquor needed to be in hospital in order to be suctioned. In fact she went on so much that in the end Paul had to tell her to be quiet as she was upsetting his wife!

I happened to call the hospital to find out how Sharon was and the midwife caring for her spoke to me. She said that Sharon’s bloods were normal but they had advised her to stay as she was “tightening”. I think I laughed and said I hardly think that was a reason to keep a woman in hospital, especially in view of the fact that she was having a home birth and it was probably Braxton Hicks contractions anyway.

The midwife then went on to tell me she had looked up Sharon’s history and between baby 1 and baby 2 an incidental swab had detected group B strep and therefore they recommend a hospital birth with IV antibiotics. I quoted the RCOG Green Top guidelines to her that this was not a risk factor and said Sharon had not had IV antibiotics during her last labour.

Later Sharon told me that the same midwife had tried to undermine her confidence in me by asking Sharon if “her midwife” knew what to do if her baby’s shoulders got stuck. She also scared them about cord prolapse.
She “informed" Sharon and Paul that I practice without insurance.

The insurance issue is something I discuss at the consultation visit long before I book clients and so they were fully aware of all the issues [- of course they didn't need to be 'informed' about this - they already knew].

I was very offended by the midwife's comments and angry at her scaremongering. I wrote to her asking for an explanation, quoted our Code of Conduct about respecting our colleagues and asked for an apology. I did not get an answer.

Why were you so offended by this midwife's comments?

Because she had the client's notes and could see, if she read them, that Sharon had discussed all of these issues in detail with me. I felt that this 'shroud-waving' approach was coercive and hostile, and was not taking into account the woman's full medical history, or her individual circumstances.

The Midwives' Rules state that:

A midwife..
  • Must make sure the needs of the woman or baby are the primary focus
    of her practice
  • Should work in partnership with the woman and her family
  • Should enable the woman to make decisions about her care based on
    her individual needs, by discussing matters fully with her
  • Should respect the woman’s right to refuse any advice given

Generally I am fortunate to have an excellent working relationship with local NHS midwives, but in this case I had a personal history with this particular midwife and I felt that this influenced the way she approached my client. On reflection, this probably also affected the way I reacted to her comments.

Sharon stayed in overnight and had a scan the next day. The baby was cephalic and an estimated weight showed between 8-9 lbs. Her blood pressure settled and she came home. She was asked to return for a consultant assessment and GTT test, which she declined.

She accepted a repeat scan one week later which estimated the fetal weight as between 9-10lbs. They also diagnosed polyhydramnios. No surprise there then! The baby was cephalic with the head deep in the pelvis. The Sonographer concluded no abnormality seen to account for the increased fluid. A second opinion agreed and concluded that it was probably due to the size of the baby alone.

You say Sharon had 'gallons of liquor' in this pregnancy. Did that worry you?
-When I said she had gallons of water I was not saying it in a negative manner, rather an observation and ever mindful of the audience of women I was writing for. I would suggest that any midwife who knew a woman had previously birthed large babies would expect this one also to be large and therefore also have plenty of water around the baby. The two go hand-in-hand. Just as you would expect a larger placenta for a larger baby.

I did not prepare for the birth any differently based on my clinical findings of “gallons of water”. It was at 34 weeks when I said there was “gallons of water” It was later at 37 that an NHS scan suggested polyhydramnios. The client, on my advice, went for a private scan for a second opinion. I suggested the repeat scan as despite the word “polyhydramnios” being written on the scan report, it was contradictory - the measurement was below the usual threshold for polyhydramnios. MILD Polyhydramnios, calling for expectant management, is defined as a deepest pool of 8cm. This pregnancy showed a deepest pool of 7.5cm, hence my advice to seek a second opinion. The second opinion could find no problems.

Despite the reassurance that all was normal and despite me knowing that 40% of babies with shoulder dystocia are less than 4 kg, I could not stop all the shroud waving of that hospital visit having an effect on me and against my usual practice I suggested membrane sweeps prior to 40 weeks to encourage labour and planned to ask Kay to attend the birth.

What's the significance of 40% of shoulder dystocias being in babies under 4kg?

It means that we can’t presume that all big babies are a risk or that smaller babies are not; a midwife always needs to be alert to the possibility of shoulder dystocia. It also means that most large babies DO NOT have shoulder dystocia. There are other risk factors for shoulder dystocia such as recumbent position, oxytocin augmentation and assisted delivery, so it is even more important that a woman with a risk factor avoid those things.

The RCOG Green-Top Guideline on Shoulder Dystocia (Guideline No. 42December 2005) says:

"The large majority of infants with a birth weight of >=4500 g do not develop shoulder dystocia and, equally importantly, 48% of incidences of shoulder dystocia occur in infants with a birth weight less than 4000 g."

What training have you had in management of shoulder dystocia? Have you ever had to put it to use?

I have regular training in the management of shoulder dystocia. Independent midwives are not exempt from updating their practice or from Supervision. At Kent Midwifery Practice we are luckily very supported by our local trust, and are invited to all emergency skill drill training days.

Shoulder dystocia, although very rare, is a life-threatening emergency for baby. Emergencies in labour is something I discuss with women in the antenatal period and I have even been seen to lie on the floor and demonstrate the position I would quickly ask the woman to adopt should a problem occur, much to the amusement of some. However, a shoulder dystocia is dealt with in the same manner no matter where the woman gives birth - hospital or home. I have dealt with shoulder dystocia at home on one occasion. It was rectified using the procedures I am trained in and the baby was fine. It was an unexpected situation. It has not occurred during the births of the biggest babies I have attended, when I most anticipated it.

This baby was predicted to be about 9-10lbs by scan, so the predicted size was larger than average, but not enormous given Sharon's past history. Why did you recommended membrane sweeps prior to 40 weeks?

I do not recommend membrane sweeps as a matter of course, rather than on an individual basis. During discussions I raise it as an option as per NICE guidelines on induction of labour. It is important we use the ”think ahead philosophy” and put an action plan in place if there are any doubts or niggles. Of course there were issues and things to discuss in this pregnancy and the story tells of hours and hours of that discussion, but when I wrote up the original story for my website, it was just a summary. The medical model definition of 'normal' is much narrower than the evidence-based definition. We know that many women who are categorised as high-risk come to no harm at all; that's the nature of 'risk', after all.

In the NHS they have to apply guidelines for large populations of women; the practitioners may not have time to spend hours investigating each client's history and preferences, and working out her individual risk profile. It is much quicker to tick a box saying 'large baby' than it is to investigate whether the risks which are increased for large babies, are actually increased in this case. However, I have the time to care for women as individuals, apply the evidence to her, including, and prioritising, her informed choices.

It is very hard for women, and midwives, not to be influenced by the “what if " syndrome. Doctors usually work to this rationale. They see a compromised baby following a long labour and they worry that every long labour will produce a compromised baby, yet there is no evidence it is the case.

I resist that way of thinking most of the time. There is a quote from Denis Walsh [in Evidence-Based Care for Normal Labour and Birth- A guide for Midwives (2007)], that I try to adhere to, “The ability to not necessarily adjust one’s care because of a sub-optimal outcome takes experience and a supportive environment”

I have confidence that, in the vast majority of times, nature does a better job than mankind, not the other way round. My logical, confident brain was saying “we have found no abnormality, therefore we can presume normal, this woman has had big babies before, so can have another big baby”

If the average size baby is 8lbs then it is obvious the range is from 6-10 lbs yet the medical model of care would have women believe that a 10lb baby is a huge baby and IS therefore a high risk regardless of other factors. I did not want any of these considerations to impact on the woman’s chosen plan of care. The longer she was pregnant, the longer the considerations had potential to impact on how we all approached the labour. Even in a very straightforward pregnancy with the most confident of women they start getting outside pressure from care givers, magazines, friends, family etc to be induced once they are past 40 weeks and that pressure increases with every day. I did not want that to be added to the equation.

The evidence suggests membrane sweeps at or around term reduces the incidence of formal induction. In this instance I thought that a membrane sweep was a consideration to prevent a post-term pregnancy adding to the equation.

So were you worried about the fluid or the size?

I was not worried either about the fluid or the size. I thought the scan was about right; on my clinical findings I guessed around 10lbs and she had birthed big babies before. As for the fluid, well, the head was deep in the pelvis so there was no concern regarding the mechanics of it. Although a percentage of babies with increased fluid have abnormalities, most do not and this was one of them as far as we knew. The scan demonstrated that the liquor level was below the thresholds for polyhydramnios, both for the single deepest pool and the highest recommended AFI [amniotic fluid index].

Why aren't you in favour of routine vaginal examinations?

Vaginal examinations are an intervention in normal labour. There is no evidence that they should be done routinely. I do perform vaginal examinations if I think the findings will help to plan the care of the woman, change the plan, improve the care, or that the information I will receive cannot be obtained in another way.

Vaginal examinations are not without risk. They can introduce infection, cause disappointment for the woman if she is not too far dilated, accidentally rupture membranes, which in turn increases risk to the baby of infection and heart rate anomalies, or allow the midwife to see meconium which maybe merely due to a term, healthy baby but could cause worry and a change of plan.

On this occasion I had done a membrane sweep, feeling a head deep in the pelvis, the client had recent scans and I was confident in my palpations. I had no reason to think there was anything other than a vertex presentation. In my professional opinion there were no health benefits to doing a vaginal examination. The only reason for doing one in this situation would be to determine her progress in labour, but it would be unreliable. The information I would have received could be obtained by waiting. Progress in a multip can not be determined by a vaginal examination as a woman could be 4cm dilated one minute and her baby born 10 minutes later.

On this occasion I examined the client at her request. She wanted to be reassured labour was underway and this was her experience in past labours. Without all the “issues” I may have been more encouraging in telling her to wait and discouraging the vaginal examination; I rarely perform them on multips and definitely not just to assess progress as it just doesn’t work.

Many a story has been heard of a women having been examined and told she had a while to go then immediately gave birth to her baby. There is always a chance that a midwife could get caught out and the presentation be different to that she had felt it was, or was on a previous occasion, but again I go back to that wonderful quote by Denis Walsh.
NB Readers may also be interested in this article questioning the value of routine VEs, by Chris Warren - Invaders of Privacy - originally published in Midwifery Matters, Issue No. 81, Summer 1999

In this case, you did not do a VE for 5 hours after the waters had broken. Clearly you must have been sure that there was no cord prolapse, but for the non-midwives reading, can you explain how you'd know this without doing a VE?

The membranes ruptured before I had arrived. The fetal heart rate was normal when I arrived, the baby active since the membranes ruptured, and so cord prolapse could be eliminated. Using eliminating cord prolapse as a rationale to perfom a vaginal examination is very old-fashioned and outdated. It is an intervention that has the potential to cause more harm than good. Moreover, this case was low-risk for cord prolapse because the head was deeply engaged. If a head is deeply in the pelvis then it is unlikely there is room for a cord to slide out. Even more so with a big baby.

[Editorial note: the RCOG Guidelines on Umbilical Cord Prolapse state that:
"With spontaneous rupture of membranes in the presence of a normal fetal heart rate patterns and the absence of risk factors for cord prolapse, routine vaginal examination is not indicated if the liquor is clear."

There were no risk factors for cord prolapse in this case, as polyhydramnios had been excluded, the head was deeply engaged and the baby large. The most important risk factors for cord prolapse are a poor fit between the presenting part and the pelvis, allowing the cord to slip down past the presenting part.]

Sharon laboured normally and well. She asked me to examine her after 5 hours and again against my usual practice, I agreed. Normally I would reassure women that this was an intervention unproven in its benefits, but that shroud kept rearing its ugly head and influencing my practice.

Sharon was 8 cms and the head was low. A couple of hours later and Sharon was pushing. The head was large and Sharon was having difficulty pushing it out underwater and so I suggested she stood up for gravity to help. This was all it took and the head was born. The body was born with the next contraction with absolute ease. However, because she was now standing in the pool I had to lean over the pool to catch the baby. As the baby rotated I called Kay closer to help I said “don’t worry - the shoulders are free; I just need help in case I drop it”! Both of us caught this huge beautiful baby girl and passed her to her brave confident mum.
The story does not end there.

Apart from the third stage, which we'll discuss later, was there anything difficult about this birth?

There were no problems whatsoever with this labour or the birth of the baby. The client pushed her baby out with no problems whatsoever.

Thanks Virginia. We'll continue the story about the third stage and beyond in a separate post, followed by a discussion of Supervision of Independent Midwives.