Who wants a cherry on the top?

Is choosing or knowing your midwife really as important as the evidence says it is? We are informed by studies that knowing the midwife improves outcomes with all variables….you know, less caesarean sections, less babies in special care, more women achieving normal birth, less hospital stays, more breastfeeding, more satisfaction with the process……I am sure the list can go on but already it is clear to see a cost saving, and far less complaints maybe, if all these things were reduced? How much money could be saved by the implementation of continuity of care? The Government know it, the NHS knows it, the trusts know it, the mangers know it and the midwives know it. But do the women know it? Does it matter to women that they get to know the midwife who will be caring for them at the birth or is all they want is a knowledgeable, caring, kind midwife?

Currently Neighbourhood Midwives is trying to make changes to the way maternity services are delivered by setting up an employee-owned social enterprise organization. They state that their primary purpose is to provide an NHS commissioned caseload midwifery homebirth service, based in the local community, “wherever it is required”……

Wherever it is required? Surely the question should be; is it required?

In order to gain the relevant information to answer this exact question, a colleague who is working on the implementation of Neighbourhood Midwives asked this question on the Facebook page “One Born EveryMinute-The Truth”;

 “Does it matter to you that you don't know the midwife who will look after you in labour? If not, why? If you could have a choice and choose a midwife whom you knew and who could care for you throughout your pregnancy, would you choose this option”?

As would be expected on a page that is primarily about evidence based midwifery practice, there were quite a few women raving about having the option of knowing ones midwife and continuity of care.  To be fair there were also a lot of comments from women who had amazing experiences but who did not know their midwife and then some women were saying that it really doesn’t matter as long as the midwife is kind and caring.

I have been thinking about the final comment as I remember having the exact conversation with a mentor many years ago when I was a student midwife. The mentor told me that “all women want is a king caring midwife.” However this was also the same midwife who said “the important thing is a live healthy mother and baby,” when we were discussing birth plans.  Well of course I do not think we could argue either of those points because both are important and any birth would be unbearable without either. But why does anything have to be sacrificed? Why can’t women have it all? Why can’t lots of things be equally important? Why can’t importance have parallels?

 I love really using analogies so I will compare it to going to a restaurant and choosing a dessert…..

OK I really want a dessert the type of which I know is sold in another restaurant and which I absolutely adore.  They do something similar here and I have tried it at this restaurant too but here it’s not quite the same.  It is not a fancy dessert in fact it’s been around for years, including at this place but in the other restaurant it is so utterly special because it is with a fresh cherry on the top. The cherry makes it exquisite to taste. Lots of people want it with a cherry too but as it has never been available they settle for the dessert as it is served here. Despite asking for a cherry I am told by the waiter that sorry I cannot have a cherry. What he knows and everyone else knows is that the fresh cherry has loads of health benefits and is exquisite to taste but according to the restaurant  owner they would have to install an expensive machine to de stone the cherries. Even though they know that people will come to the restaurant from far and wide and rave about it and that in the long run their takings will improve they think “oh well it’s been ok for most people for all this time so we will keep the dessert as it is”.  There are some people that eat at the restaurant who love the dessert as it is, they say it is perfectly good enough and cannot for a second believe that a cherry would make any difference. Some diners say all that matters is that the dessert tastes nice and so let’s just leave it as it is………

But I know the truth, and all those other diners who have tried it at the other place, knows the truth, is that they have never experienced it with a cherry on top, that if only others would try it a different way they would widen their eyes and say “oh my oh my the other way was good I admit but oh how delightful how exquisite and how memorable is this desert with the cherry on the top……and healthy too…. wow we are having it all…..

Who wouldn’t want midwifery care with a cherry on the top?

Meconium stained liquor

In a note regarding last week’s OBEM I asked why it was that a multiparous woman being induced for postdates was being subjected to continuous monitoring,(EFM). It was clear that she had been induced by prostaglandin suppository alone and was not on a syntocinon drip. I had a discussion with an NHS labour ward colleague and was able to rule out that EFM, in this case, was linked to induction process so I was confused. However what I obviously missed and what was subsequently pointed out on Facebook page, One Born Every Minute-The Truth, was that there was meconium stained liquor seen during the birth. (note to self wear your glasses next time)

So I thought I would pose this question; is meconium stained liquor always a reason to constantly monitor a baby in labour? I think I am correct in saying that finding meconium in the amniotic fluid is a reason that is often cited to transfer from a home birth, midwifery led unit or birth centre to a consultant led unit and also to commence EFM (information taken from local trust guidelines). The labour therefore has shifted from a normal one to an abnormal one, from low risk to high risk and maybe the course of the woman’s birth and or birth plan completely changed because of the meconium alone.

There is plenty of information on what meconium is and what harm it can do (Google it) so I want to focus on the changes it brings to the course of labour and whether those changes are indeed always necessary.

According to the National Institute for Clinical Excellence, (NICE) continuous EFM should be ADVISED for women with significant meconium-stained liquor, which is defined as either dark green or black amniotic fluid that is thick or tenacious, or any meconium-stained amniotic fluid containing lumps of meconium. Whereas continuous EFM should be CONSIDERED for women with light meconium-stained liquor depending on a risk assessment which should include as a minimum their stage of labour, volume of liquor, parity and the fetal heart rate. Nice also states that “significant meconium stained liquor” is an indication for transfer to an obstetric unit. It seems that NICE are definitely about defining and describing different categories of meconium which may change the advice given and or choice of care.

We can presume, from reading individual Trusts guidelines, listening to women’s stories and of course watching good old OBEM that labouring women are told that there IS meconium and therefore they need to be constantly monitored due to it being a risk factor for baby, but are they told ALL the details and given a choice?

Are women informed that the meconium in the water is light and that as they are having a 2nd or subsequent baby the labour may be quick and that if baby has no problems with his /her heart rate it is recommended that continuous EFM be only CONSIDERED? Are women told that the need for EFM is not absolute, and furthermore that in her particular case, it has been considered and there is no reason to constantly monitor the baby as long as all else stays well? Her birth plan does not have to change she can remain moving around and being intermittently monitored at home, in a birth centre or indeed in the hospital of her choice?

I have reviewed a very recent research paper (2012) which was published in the International Journal of Paediatrics and reviewed 133,000 births between 37 and 43 weeks complicated by meconium stained liquor. With a bit of mathematics I have changed the percentages into numbers and this is what the study found.

Meconium in the water is a relatively uncommon problem and in this study affected only 8 in every 100 births, and of those babies less than 7 in 10,000 became ill. In terms of mortality rates, the chances of meconium related death in childbirth was 2 in 100,000.

Other studies have quoted different statistics but in all recent evidence the incidence of meconium aspiration syndrome is similarly very low. That is not to say that it is to be dismissed lightly as it can cause extremely serious illness and fatalities in the extreme cases.

The issues once again are informed choice. Some parents would want to act on the chance they could be one of the 2 in 100,000 who child dies or even one of the 7 in 10,000 whose child is ill but equally importantly some would want to make choices based on the likelihood of them being one of the 998,000 or of the 9,993 who could continue with their plan of a normal non-medical birth.

Either way they should be given the facts in order to make a choice

Medical Help for the few?

I watched OBEM last night mostly with a smile on my face and the occasional “oh no why?” so lets start with what was really good….I thought the story of Cody was a real positive story about pre-eclampsia. As Billie admitted herself whilst most women have heard about it and know it to be a problem, many are not informed about how bad it can be. It’s a shame given what we know about kangaroo care that Cody and Billie did experience it for the first hold as it would have been an amazing example of excellence but again maybe it was done at another time and we just did not see it due to editing.



The same for the story about the baby with the cleft lip. Brilliant information giving. TV has as the ability to normalise situations (which can be a double edged sword) so by seeing the sweet baby, seeing his lip and how well it was repaired, may go a long way to helping women who are also told their baby may be similarly affected. It appears that Carolyn was induced post dates but we know no more so we cannot make presumptions whether or not it was an informed choice. (note to self add stuff about the evidence and risks of induction of labour) However Carolyn was constantly monitored during the birth. Why? Following birth the cord was cut for no apparent valid reason and baby was immediately removed from his mother. Why?



The midwife who was with Tania I felt did an excellent job of support sitting with her (off the bed) talking and encouraging her. She was however being constantly monitored. Why?

However... cushion hit TV when another midwife gave incorrect information by saying women ”should progress at 1cm per hour” There is NO EVIDENCE of this. This is outdated, discredited information that can cause harm. Some woman will progress faster and some slower and as long as all is well, the clock has no part to play in a normal labour. Once again I would like to mention the Royal College of Midwives campaign for normal birth. If the midwives do not want to read complicated and or deep research papers then the RCM make the evidence simple. I got really excited to see Tania have good midwifery support, sitting on a ball, resting for a while on the bed, then all fours for 2nd stage……then it all fell apart when a midwife (not the primary one) said “lets turn you over” and once again constant monitoring, Valsalva and a shouting match. No need for any of it……she would have done just as brilliantly leaving her alone to push under her own steam. The fact the baby was OP (back to back) just adds weight to the argument that she was an amazing woman who was quite able to give birth to her baby without interference.



Amazing stories, lovely babies and a missed opportunity once again to normalise birth for the majority and show medical help for the few.....

Also published on One Born Every Minute The Truth facebook page

All midwives do is sit around and eat

Since my last blog the, One Born Every Minute- the Truth, Facebook page has grown and grown.... not all of the lively discussion on there has been praise for the page mind you, maybe that is because it has touched a nerve for some.  Understandably I suppose because if I was a midwife who uses, for example, the Valsalva manoeuvre or who has never helped a woman birth other than on the bed (yes they are out there) or who always attaches a fetal monitor, or always cuts a cord, of course I would take all the criticism personally too, (although I may just then look to change my practice).  Tongue in cheeks comments aside though, that is not the intention of the page. The purpose is not to condemn the midwives rather than some of the practices which, if keep on being seen over and over on TV without being challenged, will continue to be regarded as ok and as normal by both women and health care professionals.  It is important to challenge bad or discredited practice, indeed it is part of the midwives rules to do so, or it will never stop and women will always be exposed, depending on who cares for them, to sub-standard care.  

I actually thought last night was pretty ok, with some exceptions which I will come on to later. I thought  it was ok however only because as a midwife who has worked in similar situations and in a labour ward I can see through the editing, where conversation have taken place and things missed out. But can the women who are regularly watching and to whom a labour ward is a very unfamiliar place see it the same way?

I want to first consider how it showed the midwives. It was all very relaxed and calm.....But if I was a midwife working in a consultant unit it would make me reflect on all the days and nights I felt like I was trying to be two people and it may just make me pretty cross.   It showed the midwives sitting, eating chocolates, chatting; talking and getting on lovely.......a true reflection? I do not think so….All midwives know how it is in a consultant unit most of the time. The truth is (I bet) the majority of the time they are rushing around with a million things to do, the office is empty, they are rushed off their feet and hardly get time for a cup of tea let alone a rest and a chat.....so when it IS busy thus and women for whatever reason are alone in the room, because we know that does happens and at times, is unavoidable, what exactly will those women be thinking? They just might be thinking that the midwife is leaving them alone, vulnerable, scared and wondering how long the labour is going to go on for, in order to eat chocolate and bemoan the size of their thighs! How is this painting midwifery in the NHS in a true light?  What is this doing to the political appeal for more midwives? Some of the midwives who have been challenged enough on, One Born Every Minute- TheTruth, to speak out have argued that it is entertainment only, that most things can be blamed on editing and that what we see is not really happening (non evidence based practices, Valsalva manouvre, constant monitoring, encouraging epidurals, unkind or untrue things being said). Well I tend to agree with you on this one gals......the bit about midwives sitting around chatting and eating choc? That bit I give you really is pure entertainment.....is it not?

I am so mad at some of the things I see and hear on One Born Every Minute I have set up a facebook page to talk about it...so pleased that in just a couple of days it has over 800 likes!! so here it is and also here is my first bit of ranting on the subject One Born Every Minute..The Truth

Factual or fiction?

The Channel 4 television show One Born Every Minute won a BAFTA in 2010 under the category of Best Factual Series.  A definition of the word factual is:

"The available body of facts or information indicating whether a belief or proposition is true or valid".

Whilst it may be assumed that  the audience knows that editing has taken place, especially those who are aware of the time involved in the labour/birth of a baby, there is no doubt that what is being seen, said, and done is fact for it is happening as we are witnessing it. What is questionable is whether or not these “facts” or the actions and words of the professionals involved are true or valid? Turn that into professional speak and it could be asked if the words and actions are evidence based.   Are they in line with the rules and codes of the governing bodies of the professionals involved? If the answer is no then surely there are further issues to be considered and questions to be asked.

During the Wednesday 29th March episode, Midwife Zoe Leonard was encouraging long sustained breath-holding whilst caring for Vicki who was pushing in the second stage of labour.   This practice is known as the Valsalva Manoeuvre which involves prolonged breath-holding.

With prolonged breath-holding there is an increase of the maternal intrathoracic pressure by forcible exhalation against the closed glottis, which causes a trapping of blood in veins preventing it from entering the heart. When the breath is released, the intrathoracic pressure drops, the trapped blood is quickly propelled through the heart producing an increase in the heart rate and blood pressure and followed by a slowing of the heart rate. All of this disrupts the blood flow to the uterus and ultimately to the baby which then shows up or is interpreted on the fetal heart monitor as fetal distress.

There is no evidence that the Valsalva Manoeuvre shortens the second stage, decreases fatigue or minimizes pain. The evidence suggests that it alters the contractile pattern of uterine smooth muscle, leading to inefficient contractions and failure to progress. Studies suggest that encouraging women to believe in their ability to push the baby out may be as important as the type of breathing. 

Studies published between 1992 and 2009 show that the physiological effects of Valsalva Manoeuvre can include: impeded venous return; decreased cardiac filling and output; increased intrathoracic pressure; affected flow velocity in middle cerebral artery; raised intraocular pressure; changed heart action potential/repolarization; increased arterial pressure; increased peripheral venous pressure; altered body fluid pH, which contributes to inefficient uterine contractions; decreased fetal cerebral oxygenation.  The World Health Organisation, (WHO) concluded that it is a dangerous practice and should cease.

Later in the same programme when interviewed, Midwife Zoe said that babies can, if left too long in labour, "get tired" (labour ward talk for become hypoxic) if the 2nd stage goes on too long.  There is no evidence to support better outcomes when time limits are imposed on any stage of labour. More importantly, Zoe is obviously not aware of the evidence around her practice with efforts to encourage Vicky to birth her baby quickly.  Is Zoe disregarding them the evidence in favour of dangerous practice? Either way she is in breach of her Nursing and Midwifery Council Code, (NMC) as according to Rule 6- Responsibility and sphere of practice, the guidance indicates that practice should be based on the best available evidence and that a midwife must make sure that the needs of the woman and baby are her primary focus.  The NMC code of professional conduct: Standards for conduct, performance and ethics (2010) states that a midwife must keep her knowledge and skills up to date.

This programme needs more editing in order to stop showing bad or dangerous practice. Whilst the programme makers must be delighted in their ability to pull in large audiences, the success of other birth programmes has demonstrated it does not always need sensationalism and car crash births in order to do so.  It must not be forgotten that the viewers may include new and impressionable midwives who may get the message that it is fine to copy what they see and for women to accept as normal what they too may be exposed to or ask to do when they face childbirth.  Questions needs to be asked and they include; why are awards being given for dangerous practice and are the NMC watching?

REFERENCEs

 Martin C 2009, Effects of Valsalva manoeuvre on maternal and fetal wellbeing, British Journal of Midwifery, vol. 17, no. 5, pp. 279-85

Nursing Times  95:15, April 15, 1999.

WHO (1996) Care in Normal Birth: a Practice Guide.

Taking the baby

Need to have another little rant! Was watching 'One born every minute' on Ipad in kitchen. Anyway, was really cross with events after a baby girl was born with difficulty (a condition called shoulder dystocia) when head is born but the shoulders get struck. When she eventually came out she was floppy and shocked and need resusitation. She responded well and started breathing and crying. She was wrapped up and left under a heat lamp whilst a paediatrician told her parents baby needed to go to special care unit. I cannot comment about that decision; what makes me mad is why that mother did have her breathing, crying baby put into her arms first! Instead, her baby was wheeled away on the resusitaire and her poor shocked distressed mother was left lying on an operating table. It was some time later that she was 'allowed' to hold her.

There is a phrase that midwives use when they accompany a woman to theatre for a caesarean section or instrumental birth; 'taking the baby'. What that means is the midwife is the person that the doctor gives the baby to immediatly after its birth. The midwife then carries the baby to a resusitaire where a paediatrian is waiting to check the baby over. If the baby is poorly then that is the best thing for that baby; it may need lots of care and this will be the safest place for it. Usually babies come out well however. Sometimes fathers hover around wanting to see what's going on. They are often told to sit back down at in the chair they were placed in, so they don't get in the way. When the paediatrician is happy he/she will wrap the baby up and leave. The midwife may then decide to weigh the baby, give it vitamin K and put labels on. Several minutes have now elapsed; the mother is generally craning her head round to see what's going on and is everything all right? When the midwife has finished, she will re-wrap baby up well in towels and blankets and then when SHE is ready, give the baby to it's mother to hold. Sometimes also whilst the woman is being sutured or whatever, the father and the baby are taken out of the operating theatre and have to wait a short while to be reunited with the woman in a recovery/post natal ward.

When will this brutal and controlling ritual stop? As it's so easy to do so! I do it everytime I go into an operating theatre with a woman. We insist on skin to skin. It just requires some cooperation with theatre staff, making room on a woman's upper chest between electrodes and lying a baby with warm towels and hat on. If the woman doesn't want to, then the father can. Weighing and vitamin K can wait. Baby can have labels put on easily in any position. The family can stay together at all times.

These first few minutes after birth are so important to a mother - they can NEVER be re lived.

So as professionals, it is our duty to stop 'taking the baby' and ensure it's the baby's mother who enjoys those first few minutes. It's really not rocket science! Just kind, thoughtful and humane care to a family who especially need it during a heightened stress situation.

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!!