The Assessment of Progress

Posted on September 14, 2011 by

This article was written for AIMS Journal (2011, vol. 23, no. 2) and expands on my previous post about my New Years resolution – which by the way I have kept. AIMS have kindly allowed me to reproduce the article here…

The idea that birth should be efficient originated in the 17th century when men used science to re-define birth [1].    The body was conceptualised as a machine and birth became a process with stages, measurements, timelines, and mechanisms. This belief continues to underpin our approach to childbirth today. In current midwifery texts labour is divided into three distinct stages, and further divided into phases within those stages. The first stage of labour involves regular and coordinated uterine contractions accompanied by cervical dilatation. This stage includes three phases: latent, active and transitional. The second stage of labour begins when the cervix is fully dilated and ends when the ‘fetus is fully expelled from the birth canal’ [2].  Again, the second stage is further broken down into three phases: latent, active and perineal. ‘The third stage of labour is the period from the birth of the baby through to delivery of the placenta and membranes and ends with the control of bleeding’ [2]. This categorisation allows practitioners to measure progress through the stages and create limits and boundaries around what is considered ‘normal’.

The tool used to measure labour in hospital settings is the partogram, which is largely based on a study carried out in the 1950s by Friedman [3] where he plotted the cervical dilatation of 100 women having their first baby in an American hospital. He found that the average rate of cervical dilation was 1.2cm per hour, but that this rate was not linear. In other words, most women gave birth within twelve hours of the commencement of labour, but there was variation in their individual dilation patterns. In the 1970s Phillpott and Castle modified Friedman’s graph to provide guidance for practitioners working in a remote area of Rhodesia. Their intention was to reduce the incidence of poor outcomes associated with obstructed labour in this particular setting [4]. They added an alert line, a transfer (to hospital) line and an action (augmentation) line to Friedman’s graph. The resulting partogram is now a practice tool used in hospitals worldwide to monitor the progress of normal labour. A cervical dilatation rate of less than 1cm per hour is considered ‘abnormal’ according to most hospital policies. However, some hospitals are more generous and will consider a rate of 0.5cm per hour normal for women having their first baby.

Since use of the partogram became widespred, researchers have found that Friedman’s graph does not represent normal labour progress. In contrast, research has found that cervical dilation patterns vary widely between individual women, and the average length of labour is much longer than in Friedman’s findings [5,6,7,8,9]. A recent Cochrane review into partogram use in labour concluded that: ‘On the basis of the findings of this review, we cannot recommend routine use of the partogram as part of standard labour management and care’ [10]. This evidence- based recommendation is yet to be reflected in maternity care. Instead, women have their labours managed in order to follow a partogram with limits and boundaries. Fewer than 50% of women having their first baby will manage to meet the narrow criteria of ‘normal progress’ and avoid augmentation of their labour [7].    The World Health Organisation estimates that the rate of obstructed labour is between 3 and 6% worldwide [11] and so a significant number of women are experiencing unnecessary intervention during their labour.

Methods used to augment labour carry risks and alter the physiology of birth. Amniotomy (artificial rupture of membranes) does not reduce the length of labour, and may increase the chance of having a caesarean section [12]. Intravenous syntocinon can increase contractions and shorten labour, but requires careful monitoring of mother and baby because of the potentially dangerous side effects [13]. When augmentation fails to improve the progress of cervical dilatation, a caesarean section will be performed for ‘failure to progress’. Time limits on the second stage of labour result in midwives implementing directed pushing to get the baby out before they must notify an obstetrician. Directed pushing (Valsalva manoeuvre, sometimes called purple pushing because a woman is encouraged to hold her breath and push hard) does not significantly reduce the length of the second stage [14]. However, it does increase the risk of damage to the pelvic floor and perineum, and is associated with fetal hypoxia, in no small part due to oxygen starvation when mum holds her breath. If directed pushing does not improve progress, or the baby shows signs of stress due to hypoxia, the birth will be assisted using forceps or a ventouse. Most hospitals have policies regarding the length of time between the birth of the baby and the birth of the placenta. These vary from hospital to hospital, but failing to meet the deadline will often result in the placenta being manually removed.

The concept of managing women’s labours to follow a partogram relies on the premise that it is even possible to assess the progress of labour. I challenge the notion that it is possible to identify where stages of labour start or end, or to accurately predict the future progress of a labour. Physical changes in the cervix and uterus occur during pregnancy and the onset of labour is a gradual happening [15]. Therefore, identifying an exact time of labour onset is not possible. The definition of ‘established labour’ includes regular rhythmic contractions occurring at least three every 10 minutes, lasting for 45 seconds and accompanied by progressive dilatation of the cervix [16,2]. However, women’s contraction patterns are as unique as their bodies. At home births I have observed women have infrequent, irregular contractions throughout their entire labour and give birth spontaneously. Therefore, contraction pattern is not necessarily a good indication of how a cervix is dilating.

Assessing the progression of the ‘first stage of labour’ also relies on knowing what the cervix is doing. Some hospitals no longer have a policy of routine vaginal examinations in labour, perhaps reflecting concerns about the practice [17]. Even when vaginal examination remains an element of routine management, the timing of assessments is usually four-hourly. A vaginal examination only reveals what the cervix is doing at the time of the examination. It cannot provide information about what the cervix was doing before, or what it will do in the future. For example, a woman’s cervix may be only 3cm dilated but she could birth her baby within an hour of this assessment. Another woman’s cervix may be 9cm dilated but her baby may not be born for another 6 hours. Using a vaginal examination to determine the start of the second stage is also inaccurate. If a midwife examines a woman at 3pm and finds that her cervix is fully dilated, does that mean her second stage started at 3pm? What if her cervix had been fully dilated at 2pm but the midwife didn’t know? There is only one accurate time recording that can be made during labour – the end of the second stage because the baby is born. Although a time can be recorded for the birth of the placenta, the third stage ends with ‘control of bleeding’, which is open to interpretation.

Despite the inability to accurately measure the stages of labour, maternity documentation requires this information to be recorded. Partograms, birth summaries and perinatal data forms require midwives to record the hours and minutes a woman spends in each stage of labour. The result is creative documentation and some interesting conversations between midwives. Such as: ‘What time would you say second stage started?’ ‘Umm not sure – she was making grunty noises around 5.30pm…’ ‘OK, I’ll put 6pm.’ And between midwives and women: ‘What time would you say your labour established?’ ‘I don’t know the contractions were really hurting by 7am then I came into hospital.’ ‘Hmmm well you had your baby at 9am, so you must have been doing something before 7am… I’ll put 6am.’ Midwives also manipulate the paperwork to fit policies, protect women, and avoid getting into trouble. For example, recording the cervix as being 9cm dilated rather than fully dilated to buy more time for the woman. Or ignoring an hour’s worth of spontaneous pushing before recording the start of the second stage. These strategies allow midwives to complete the required paperwork whilst protecting the woman from unnecessary interventions.

However, these strategies also support and maintain the structures that impose time limits. These fabricated times are recorded in standard maternity documentation and then sent to organisations that collect and analyse the data to provide information about labour and birth. By manipulating records midwives are helping maintain the myth that labour has distinct stages which can be measured accurately. Perhaps more importantly, though, they are re-defining women’s birth experiences, often in contrast to the woman’s own experience. For example, recording the length of a labour only from the onset of ‘established labour’ disregards the hours or days that a woman may have experienced contractions before being considered to be in established labour. Abandoning the concept of stages and the notion of accurate assessment may improve outcomes and reflect women’s experience of birth more honestly. However, individual midwives may find it difficult to practice against the cultural norm. Midwives who practice openly and autonomously within a medicalised system often experience ridicule and bullying [18,19]. Therefore it is not surprising that most midwives continue to bend the rules rather than break them.

There appears to be no simple solution to this situation. The concept of stages of labour, and assessment of progress is deeply embedded in our birth culture and practice. Perhaps change could begin with an open dialogue between women, midwives, obstetricians and policy makers regarding a move to a more evidence based approach to childbirth.
Individual midwives can also make a difference, and should support each other to do so. The content of parent education sessions can be changed to focus on what Downe and McCourt refer to as ‘unique normality’ [20] rather than descriptions of the stages of labour. Midwives can share the evidence with each other and midwifery students, and highlight the failures of the current situation rather than sustaining acceptance.
If enough midwives write ‘not applicable’ on paperwork rather than making up a time, there will be evidence that the documentation needs to change. Experience of observing non-augmented labours will assist midwives to develop their understanding of normal birth, and their ability to identify a truly obstructed labour. These changes may be challenging but the result could be a better approach that respects women’s uniqueness and embraces the unpredictable nature of birth.

References

1. Donnison, J 1988, Midwives and medical men: a history of the struggle for the control of childbirth, 2nd ed, Historical Publications, London.

2. Stables, D & Rankin, J (eds) 2010 Physiology in Childbearing: with anatomy and related biosciences, 3rd ed, Bailliére Tindall: Elsevier, London.

3. Friedman EA 1955, Primigravid labor: a graphicostatistical analysis, Obstetrics and Gynecology, vol. 6, no. 6, pp.567-89.

4. Philpott RH & Castle WM 1972, ‘Cervicographs in the management of labour in primigravidae. II. The action line and treatment of abnormal labour’, Journal of Obstetrics and Gynaecology of the British Commonwealth, vol. 79, pp. 592-8

5. Albers, LL 1999, ‘The duration of labor in healthy women’, Journal of Perinatology, vol. 19, no. 2, pp.114-9.

6. Cesario, SK 2004, ‘Reevaluation of Friedman’s labor curve: a pilot study’, JOGNN, vol. 33, pp. 713-22.

7. Lavender T, Alfirevic Z & Walkinshaw S 2006, ‘Effect of different partogram action lines on birth outcomes: a randomized controlled trial’, Obstetrics & Gynecology, vol. 108, no. 2, pp. 295-302.

8. Neal JL, Lowe NK, Ahijevych KL, Patrick TE, Cabbage LA & Corwin EJ 2010 ‘”Active labour” duration and dilation rates amongst low-risk nulliparous women with spontaneous labor onset: a systematic review’, Journal of Midwifery and Womens Health, vol. 55, no. 4, pp. 308-318.

9. Zhang J,Troendle, JF &Yancey, MK 2002,‘Reassessing the labor curve in nulliparous women’, American Journal of Obstetrics and Gynecology, vol. 187, no. 4, pp. 824-8.

10. Lavender T, Hart, A & Smyth, RMD 2008, ‘Effect of partogram use: outcomes for women in spontaneous labour at term (review)’, Cochrane Database of Systematic Reviews, Issue 4, Art No. CD005461. DOI: 10.1002/14651858.CD005461.pub2.

11. Dorlea, C & AbouZahr, C 2003, Global burden of obstructed labour in the year 2000, Evidence and Information for Policy, World Health Organisation, Geneva

12. Smyth RMD, Alldred SK, & Markham C 2007, ‘Amniotomy for shortening spontaneous labour’, Cochrane Database of Systematic Reviews, Issue 4. Ar t. No.: CD006167. DOI: 10.1002/14651858.CD006167.pub2.

13. NICE 2008, Induction of Labour, National Institute of Clinical Excellence, London.

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

15. Coad, J & Dunstall, D 2005, Anatomy and physiology for midwives, Mosby, London.

16. Fraser DM, Cooper, MA 2008, Survival Guide to Midwifery, Churchill Livingstone, London

17. NICE 2007, Intrapartum Care: care of healthy women and their babies during childbirth. National Institute of Clinical Excellence, London.

18. Bluff, R & Holloway, I 2008, ‘The efficacy of midwifery role models’, Midwifery, vol. 24, pp. 301-9.

19. Stewart, M 2001, ‘Whose evidence counts? An exploration of health professionals’ perceptions of evidence-based practice, focusing on the maternity services’, Midwifery, vol. 17, pp. 279-88.

20. Downe, S & McCourt, C 2008, ‘From being to becoming: reconstructing childbirth knowledge’, in S Downe (ed), Normal Childbirth: evidence and debate, 2nd ed, Churchill Livingston, London

Posted in birth, midwifery practice | Tagged , , , , , , , | 37 Comments

ACM Homebirth Position Statement & Guidance: My response

Posted on August 10, 2011 by

The Australian College of Midwives have issued an Interim Homebirth Position Statement and Interim Guidance for Privately Practising Midwives along with a request for comments. Here is the response I have sent…

As a privately practising midwife who attends homebirths I have grave concerns regarding the above interim documents and the direction of the College in general. I am providing my comments despite having little faith that the opinions of homebirthing women and their midwives will be heard or reflected. My main concerns centre on the expectation that the midwife, rather than the woman determines risk status, and then actively blocks access to birth options based on this assessment.

Evidence-based practice?

After a review of the research literature ACM acknowledge the lack of ‘good quality’ research into homebirth yet concludes that “it seems evident from the literature that planned homebirth is a safe option for women who are at low risk of complications…”. To my knowledge there has been no research specifically examining the outcomes of homebirth for ‘high risk’ women. Therefore, we do not have adequate research about outcomes of homebirth for women who are classified as high risk. However, we do have research supporting continuity of care for all women, and often the only way in which a woman can access this care is by hiring a private midwife and having a homebirth. There is also research available regarding birth outcomes for those women you have categorised as being too high risk for homebirth. Women classified as high risk (eg. previous c-section) often choose homebirth in order to increase their chance of a successful vaginal birth after accessing this research.

It can be argued that the way in which ACM have determined ‘high risk’ (simply by the chance of an adverse event occurring) places all women in a ‘high risk’ category. A woman with a ‘scarred uterus’ has a 0.5% chance of a uterine rupture during labour. A woman with an unscarred uterus has a 1% chance of a shoulder dystocia occurring. However, ACM is not advocating that all women should birth in hospital in case they experience a shoulder dystocia.

In addition, the notion that ‘evidence-based’ means purely ‘research-based’ does not align with the vision of early advocates of evidence-based medicine from which the concept of ‘evidence-based practice’ emerged . For example, Sackett et al.’s (1996) interpretation of evidence-based medicine involves blending research evidence with the expertise/experience of the practitioner and the individual requirements and choice of the ‘patient’. This definition of evidence-based practice seems more aligned with a midwifery philosophy than one which universally applies research findings to practice. Particularly in an area in which ‘good quality’ research is difficult to come by for many reasons. Midwives should develop their own body of knowledge on which to base practice using a variety of types of evidence (experience, intuition, research, stories, etc.), rather than trying to emulate the medical profession and their narrow/technocratic definition of evidence (RCTs).

In any case the right to self determination and bodily autonomy has nothing to do with research evidence or externally defined concepts of safety.

Redefining midwifery

ACM appears to be contradicting and re-defining the role of the midwife. The International Confederation of Midwives (ICM) Philosophy of Care includes these statements:

  • Midwifery care empowers women to assume responsibility for their health and for the health of their families
  • Midwifery care takes place in partnership with women and is personalised, continuous and non-authoritarian
  • The woman is the primary decision-maker in her care and she has the right to information that enhances her decision-making abilities.
  • Midwives provide women with appropriate information and advice in a way that promotes participation and facilitates informed decision making
  • Midwifery care promotes, protects and supports women’s reproductive rights and respects ethnic and cultural diversity
The Australian Nursing and Midwifery Council state that:
  • Midwives value the woman’s legal and moral right (in all but exceptional circumstances) to self-determination during pregnancy, labour, birth and early parenting on the basis of informed decision making (Code of Ethics for Midwives)
  • Midwives focus on a woman’s health needs, her expectations and aspirations, supporting the informed decision making of each woman (Code of Conduct)
  • Explains options while recognising the woman’s right to choose (Competency Standards)
These statements suggest that the role of the midwife is to share adequate information with women and respect their right to choose ie. to determine their own risk status and place of birth. Whereas the ACM statement requires the midwife to determine the woman’s risk status and withdraw support if her choices do not align with regulations. Whilst the midwife should offer consultation and referral – to enforce it does not respect the woman’s choice (and breaches confidentiality). I also object to the use of the word ‘refuse’ and think ‘decline’ would be less judgemental in relation to women’s choice. 
According to ACM “…a midwife has the right to decline to continue to provide, or to accept, midwifery care if it is felt that this would require the midwife to practise outside of the midwife’s scope, skills and competencies.” However, the midwife’s scope is debatable because it is based on what is considered ‘normal’ (by obstetricians) and for many women and midwives VBAC, post-term, breech etc. is normal. The College should support a privately practising midwife’s right to withdraw from care if she is unable to meet the woman’s needs. For example, she does not feel adequately prepared or experienced to attend the birth and/or will bring fear to the birth room. However the midwife should also be supported if she decides not to withdraw care and instead support the woman’s decision to homebirth despite any risks involved. The alternative is to leave the woman without a care provider who can identify if the birth becomes abnormal and transfer if necessary. Whilst some women choose freebirth – this should not be a choice based on the inability to access midwifery care.
Both the ICM and the ANMC state that midwives should promote normal birth and women’s ability to birth. Assuming birth will not be normal because the woman has a uterine scar, is over 42 weeks, has twins, etc. does not reflect a trust in the birth process. Midwives should be able to identify when birth deviates from normal, and when complications arise. But to embrace the obstetric stance of ‘birth is only normal in retrospect’ does not align with midwifery philosophy.
My personal observations from within the homebirthing community

The way in which midwifery is being regulated and redefined is resulting in registered midwives being unable to reflect the philosophy of midwifery and meet needs of homebirthing women. Women are subsequently turning to doulas and birthworkers because they are the only practitioners able to provide ‘with woman’ care at home. As a registered homebirth midwife I feel unsupported by the College and marginalised by my own profession. I don’t want to be regulated the College – I want to be supported. Perhaps an alternative homebirth statement would be: ‘Women have the right to choose where and how they wish to give birth. Midwives must provide adequate information to assist women’s decision making and support their birth choices.’

We could learn a few lessons from history re. midwifery regulation: Gloria Lemay’s podcast Licensing and regulating midwifery – at what cost?

Posted in law, midwifery practice, opinion and thoughts | Tagged , , , | 26 Comments

Induction: a step by step guide

Posted on July 17, 2011 by

This post has been inspired by conversations I’ve had with women about their experiences of induction. Induction of labour is increasingly common, yet women often seem to be very mis-informed about what it involves, or what was done to them during induction and why. For example, one woman was told by her obstetrician that induction involved him using a pessary to ‘gently nudge her into labour.’ Women need to be given adequate information in order to make birth choices. Practitioners need to give adequate information in order to meet legal requirements. I have written about the risks of induction in a previous post so will not repeat myself here. Instead, this post aims to provide some basic information about the process of induction – what is done and why. I would really appreciate input from readers about their experiences of induction – what was done, how it felt etc. I am hoping this post will be a resource for women who are considering induction, or are unsure about what happened during their induction.

Induction is…

In my old 1997 version of the ‘Midwives’ Dictionary‘ induction is ‘causing [labour] to occur’ ie. someone causes a labour to occur rather than allowing the baby/body to initiate labour. The dictionary goes on to say ‘this may be carried out when the life or health of the mother or fetus is in danger if the pregnancy continues.’ Of course this statement is open to interpretation and many inductions are not ‘medically indicated’ (link). However, I am not entering this debate here… I’m trying to stick to the process.

There are a few things you need to be clear about before choosing to be induced:

  • That the risks involved continuing the pregnancy are greater than the risks involved in induction (risk is a very personal concept – see a quick word about risk).
  • You are committed to getting this baby out. Once you start you cannot back out, and a c-section is recommended for a ‘failed induction’.
  • You are not having a physiological birth. You have intervened and this intervention creates risks that require further monitoring and intervention. There is no ‘natural’ induced birth – vaginal birth maybe, empowering perhaps, but not physiological.

There are 3 steps to the induction process. You may skip some of the steps along the way, but you should be prepared to buy into the whole package when you embark on induction.

Note: If your waters have broken naturally the term ‘augmentation‘ rather than induction is used to describe getting labour started. This is because it is assumed that your body has started the labour process itself. You can read more about this situation here.

Step 1: Preparing the Cervix

During pregnancy the cervix is closed, firm and tucked into the back of your vagina. This means that you can have contractions without the cervix opening. In order for the cervix to respond to contractions it needs to make a number of complex physiological changes (Coad 2011). Relaxin and oestrogen initiate these structural changes, and prostaglandin, leucocytes, macrophages, hyaluronic acid and glycoaminoglycans are all involved in softening the cervix ready for labour. You don’t need to remember all of this scientific stuff (I never can). All you need to know is that it is a complex process, and prostaglandins are only one piece of the puzzle.

When you are being induced your cervix will be assessed by vaginal examination. If your cervix has already changed and is soft and open enough to get an amnihook in you can skip straight to step 2.  If your cervix is still firm and closed, attempts will be made to change it so that step 2 is possible. This is usually done by putting artificial prostaglandins (prostin E2 or cervidil) on the cervix in the form of a gel, pessary or sticky tape.  Artificial prostaglandins can cause hyperstimulation of the uterus resulting in fetal distress, therefore your baby’s heart rate will be monitored by a CTG after the prostaglandin is administered. You may also experience ‘prostin pains’ which are sharp strong pains sometimes accompanied by contractions. If there are concerns about giving you prostaglandin (eg. previous c-section) your obstetrician may suggest ways of trying to get your own cervix to release natural prostaglandin by ‘irritating it’ (this is the theory behind membrane sweeps). This is done by inserting a catheter into the cervix and filling it with water ie. you basically have a water balloon sitting in your cervix – very irritating.

Successfully completing step 1 may take a few attempts with re-insertion of prostaglandins. This can take hours or days because you must wait hours before re-assessment and re-insertion. You may respond to the prostaglandin by going into labour therefore skipping the following steps. However, you are still having an induced labour and will usually be treated as ‘high risk’.

Step 2: Breaking the Waters

I realise that this step is not always part of US inductions but I  have never experienced this approach, so will stick to what I know… Once your cervix has softened and is open enough to get an amnihook in, your waters will be broken. This is allows induced contractions to be more effective; the baby’s head to press harder on the cervix; and may trigger contractions avoiding step 3. I was also taught that it reduces the risk of an amniotic embolism (amniotic fluid getting into the blood system) but there is no good research supporting this. There are risks associated with artificially breaking the waters. Once your waters have been broken you can wait a few hours to see if labour starts, or go straight to step 3.

Step 3: Making Contractions

You now have a cervix ready to respond to contractions and no amniotic water in the way – next you need contractions. In a natural physiological labour oxytocin is released from the brain and enters the blood stream – it has two main functions:

  1. It works on the uterus to regulate contractions
  2. It works in the brain to contribute to the altered state of consciousness associated with labour and promotes bonding feelings and behaviour

In an induced labour, artificial oxytocin (pitocin/syntocinon) is given via a cannula directly into the blood stream. It is unable to cross the blood brain barrier therefore only works on the uterus to regulate contractions. I have written about the risks associated with artificial oxytocin here along with references. Basically, it can be pretty nasty stuff which is why your baby will be monitored closely using a CTG. Women usually describe artificially stimulated contractions as being different and more painful than natural contractions. Having supported women during inductions I am also convinced there is more pain associated with induced contractions. Obstetricians will argue that the physiology of a contraction remains the same whether it is initiated by natural or artificial oxytocin – which is true (see this post for an explanation of how contractions work). However, during an induced labour contraction pattern and intensity increases quickly compared to most natural labours. Women are not able to slowly build up their natural endorphins and oxytocin to reduce their perception of pain. In addition the circumstances and environment that often surrounds induction (intervention, equipment, etc.) can result in anxiety, increasing the perception of pain.

Once your baby is born you will need to continue using artificial oxytocin to deliver the placenta. A physiological placental birth is not safe because you are not producing your own natural oxytocin at the level required. Basically medicine has taken over and must finish the job.

In Summary

Inducing labour involves making your body/baby do something it is not yet ready to do. Before agreeing to be induced, be prepared for the entire package ie. all the steps. You may be lucky enough to skip one step, but once you start the induction process you are committed to doing whatever it takes to get the baby out… because by agreeing to induce you are saying that you or your baby are in danger if the pregnancy continues. An induced labour is not a physiological labour and you and your baby will be treated as ‘high risk’ – because you are.

More information / Resources

Parent Information Sheet (QCMB)

Posted in birth, intervention | Tagged , , , , , , | 87 Comments

Guest post: when birth is trauma

Posted on May 13, 2011 by

This is a guest post by Elizabeth Ford (website) who is based in the UK so is writing from a UK perspective. Elizabeth explored birth trauma for her PhD and generously agreed to write a post for MidwifeThinking. There are lots of references for students and/or those who like to access original sources of information.

Artwork by Amanda Greavette: http://amandagreavette.com


For most women, birth is not the blissful event of three easy pushes and welcoming their precious baby into the world. Even for those women who have a short straightforward vaginal birth, it can be a tough slog and a real test of the depth of their resources. However, for some women, birth is much more than that. It is a physical and psychological trauma. The aftermath of a traumatic birth can affect a woman for months or years and impact on her bond with her baby, her relationship with her partner, her decision to have another baby and even her willingness to engage with future health care.

Birth as a trauma

Childbirth is a common event in society so is viewed by most people as “normal”.  It may therefore be difficult to understand how it can be traumatic for some women. However, case studies and other research make it clear that women can suffer extreme distress as a consequence of their experiences during childbirth. A small proportion of pregnancies and births involve events that most people would agree are potentially traumatic, such as stillbirth, severe complications, or undergoing invasive medical interventions without effective pain relief.  Other women may have a seemingly normal birth but feel traumatized by aspects such as loss of control, loss of dignity, or the dismissive, hostile or negative attitudes of people around them.

Post-Traumatic Stress Disorder

Recently it has become recognised that women who experienced a traumatic birth can develop post-traumatic stress disorder (PTSD). Some women experience childbirth as threatening and frightening and go on to develop PTSD symptoms.

The American Psychiatric Association defines the symptoms of PTSD as (1):

  1. Persistently reexperiencing the event, by flashbacks, nightmares, intrusive thoughts, and intense distress at reminders of the event.
  2. Persistent avoidance of reminders of the event, and emotional numbing and estrangement from others
  3. Persistent symptoms of increased arousal. This means difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance or an exaggerated startle response

For a diagnosis, patients must report experiencing all three types of symptoms for longer than one month. Many women (around 30%) experience these symptoms in the days or weeks following birth, and this is a normal way of coming to terms with a stressful or overwhelming event. It is only when symptoms do not get better that PTSD is diagnosed (in 1 to 5% of women).

What causes trauma & PTSD?

Research has been carried out into what makes someone more likely to develop PTSD following childbirth. These risk factors fall into three categories: those that exist before the birth; aspects of the birth itself; and the type of support and care women get after birth.

Some women will be more vulnerable to a traumatic birth because of pre-existing problems. For example women with a history of psychiatric problems and previous trauma are more likely to be traumatised by their experience of birth. In particular, a history of sexual trauma or abuse is associated with PTSD after birth. There is some evidence that women with a history of trauma will be more vulnerable to PTSD following birth if they have inadequate support and care during the birth (2-5).

During the birth, certain complications and events may be more stressful to women than others. Broadly speaking, women are more likely to get PTSD if they have an emergency caesarean or assisted delivery (forceps or ventouse). However, women who have a vaginal birth are still at risk (4, 6). Other stressful aspects of birth, such as blood loss, a long labour, a high level of pain, or a large number of interventions are not clearly related to getting PTSD. Importantly, women who feel out of control during birth or who have poor care and support from midwives and doctors are more likely to get PTSD (3, 5, 7). Furthermore, if a woman is overwhelmed by the experience and copes by dissociating (feeling like she is mentally “not there any more”, or having an “out of body experience”), she will be at higher risk of PTSD (8, 9).

Following the birth, support from friends and family, and possibly that from health professionals, may help women resolve their experiences and recover from a traumatic birth (5, 10). Conversely, a lack of support may prevent recovery or possibly cause more stress and thereby increase symptoms.

Feeling angry when birth is mismanaged

In some cases births are mismanaged and a woman can feel unable to get past her experience. She may go over and over the events in her head and feel angry that she was denied the experience she could potentially have had (11). This can form part of the symptoms of PTSD (intrusive thoughts, irritability & anger). However, PTSD is considered to be an anxiety disorder, and so for this anger and preoccupation to be diagnosed as PTSD, the other symptoms listed above must also be experienced. A woman who feels very angry is struggling with a valid emotional response to being discounted or not listened to during the birth, or even being mistreated or assaulted. Even when women don’t fit into the “PTSD box” (fulfilling all the symptom criteria), they may have a spectrum of subclinical trauma reactions which would benefit from support, counselling, or psychotherapy.

Is PTSD the same as postnatal depression?

PTSD has different symptoms to depression. Depression symptoms encompass a depressed mood i.e. feeling sad, empty, tearful or irritable, in addition to diminished interest or pleasure in activities; significant weight loss or weight gain or decrease or increase in appetite; insomnia or hypersomnia; fatigue or loss of energy; feelings of worthlessness or excessive or inappropriate guilt; and a diminished ability to think or concentrate, or indecisiveness.

In contrast, trauma symptoms are focussed on the traumatic event (re-experiencing it, avoiding reminders of it) and a diagnosis of PTSD is not possible without having experienced a traumatic event.  This is not the case with depression. However, in practice symptoms overlap and a majority of women who have PTSD will also have depression (3, 4).  Effective treatments for PTSD and depression differ. Recommended treatment for PTSD is psychotherapy, and only long-lasting or complex cases of PTSD benefit from anti-depressants.

Do women expect too much from childbirth?

A question that is often asked by health professionals is whether women have too high expectations of achieving a natural or drug-free birth, contributing to them being traumatised when birth does not go as expected. The answer to this is rather complicated but research studies point towards it not being the case. Firstly women’s expectations are found, on average, to be similar to their experiences (12, 13). That is, if a woman has broadly positive expectations she is more likely to have a positive experience. Secondly, if unrealistic expectations were linked to PTSD we might expect to find more trauma responses in first time mothers. This has been found, but subsequent analysis suggests it is due to the higher rate of intervention in these women (14). Finally, one study looked at this question directly and found that a difference between expectations and experience in the level of pain, length of labour, medical interventions and level of control was not associated with PTSD symptoms. However, a difference between expected support from health professionals and the level of care experienced was predictive of PTSD symptoms (13). Women don’t seem necessarily to be traumatised by the events of birth not happening as they expected, but may be affected when they do not receive the care they expect.

Implications for maternity care

Research in this field is at an early stage and more needs to be done before making policy recommendations. However, the body of evidence points towards several considerations. Firstly, some women enter pregnancy and birth with existing risk factors for PTSD, and these women may need particular care. Health professionals should be aware that women with a history of trauma, abuse (particularly sexual abuse) and psychiatric problems are at higher risk of PTSD following birth. There is some evidence that a lack of support during the birth may put these women at particular risk (5).

Secondly, interactions with other people have a strong effect on trauma reactions. For example, PTSD is more likely following events which are perceived to have been intentionally perpetrated rather than following accidents (15). This effect of personal relationships and care is particularly relevant to childbirth (16). There is substantial research showing support during labour and birth improves both physical and psychological outcomes (17), and that perceptions of inadequate support and care are predictive of traumatic stress responses. Women who are traumatised often describe negative interactions with staff such as feeling rushed, bullied, judged, ignored or put off when asking for pain relief.

Understanding the importance of support helps explain why, for example, level of pain is not consistently associated with PTSD symptoms. It may not be the level of pain per se which is traumatising for women, but the experience of unbearable pain in combination with the perception of being denied pain-relief by an uncooperative caregiver. Women also report caregivers proceeding with interventions, such as forceps deliveries or episiotomies, without consent, and sometimes even when the woman has clearly expressed her wish not to have the intervention. Negligent care such as leaving women naked in stirrups with the door open can be intensely degrading and stressful. Many of the traumatising aspects of childbirth could be reduced with consistent and considerate care from maternity staff.

What to do if this has happened to you

If you have had a traumatic birth and don’t know how to get help, the first step is to contact the Birth Trauma Association (BTA; www.birthtraumaassociation.org.uk) who give information and support. They produce a leaflet which you can print out and take to your GP explaining the condition (your GP may not have heard of postnatal PTSD), and you can ask for a referral to specialist psychotherapy services. If you’re in the UK, you can also contact the hospital where you gave birth and ask for a debriefing session with a midwife or consultant to go through your birth notes. This is not a counselling session but may help you to understand what happened during the birth and why events proceeded as they did. If you have physical problems following the birth you can also ask for a referral to a gynaecologist or physiotherapist. If you do not feel able to go back to the hospital where you gave birth, because memories are too painful or it causes you too much anxiety, you could ask your GP for a counselling referral or you could consider contacting a private psychotherapist. Make sure they are registered with the relevant professional association (BACP or BABCP in the UK). Recently in the UK you can “self-refer” to psychotherapy on the NHS through your local IAPT service (www.iapt.nhs.uk). Talking to other women who have been through similar experiences may help, the BTA can put you in touch with other mothers.

And Dads…

It can be traumatic watching a partner go through a harrowing experience while feeling helpless and horrified. The information on PTSD above can also apply to partners. The BTA has a section on their website for dads or partners. It is worth reading this and seeking help for yourself if you feel this applies to you.

More resources and support

I’ve added some links below (this is MidwifeThinking). Please let me know if you have any other links or resources that you think should be included.

Blog posts about birth trauma:

References

  1. APA. Diagnostic and Statistic Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington DC; 2000.
  2. Wijma K, Soderquist J, Wijma B. Posttraumatic stress disorder after childbirth: A cross sectional study. Journal of Anxiety Disorders. 1997;11(6):587-97.
  3. Czarnocka J, Slade P. Prevalence and predictors of post-traumatic stress symptoms following childbirth. British Journal of Clinical Psychology. 2000;39:35-51.
  4. Ayers S, Harris R, Sawyer A, Parfitt Y, Ford E. Posttraumatic stress disorder after childbirth: Analysis of symptom presentation and sampling. Journal of Affective Disorders. 2009;119:200-4.
  5. Ford E, Ayers S. Support during birth interacts with prior trauma and birth intervention to predict postnatal post-traumatic stress symptoms. Psychology and Health. in press.
  6. Soet J, Brack G, Dilorio C. Prevalence and predictors of women’s experience of psychological trauma during childbirth. Birth. 2003;30:36-46.
  7. Cigoli V, Gilli G, Saita E. Relational factors in psychopathological responses to childbirth. Journal of Psychosomatic Obstetrics and Gynecology. 2006 Jun;27(2):91-7.
  8. Kennedy HP, MacDonald EL. “Altered consciousness” during childbirth: potential clues to post traumatic stress disorder? Journal of Midwifery & Women’s Health. 2002 2002/0;47(5):380-2.
  9. Olde E, Van der Hart O, Kleber RJ, Van Son M, Wijnen HAA, Pop VJM. Peritraumatic Dissociation and Emotions as Predictors of PTSD Symptoms Following Childbirth. Journal of Trauma & Dissociation. 2005;6(3):125-42.
  10. Soderquist J, Wijma B, Wijma K. The longitudinal course of post-traumatic stress after childbirth. Journal of Psychosomatic Obstetrics and Gynecology. 2006 Jun;27(2):113-9.
  11. Brockington I. Postpartum Psychiatric Disorders. The Lancet. 2004 January 24;363:303-10.
  12. Slade P, MacPherson S, Hume A, Maresh M. Expectations, experiences and satisfaction with labour. British Journal of Clinical Psychology. 1993;32:469-83.
  13. Ayers S. Post-traumatic Stress Disorder Following Childbirth Unpublished Ph.D Thesis, University of London; 1999.
  14. Soderquist J, Wijma K, Wijma B. Traumatic Stress after Childbirth: the role of obstetric variables. Journal of Psychosomatic Obstetrics and Gynecology. 2002;23:31-9.
  15. Charuvastra A, Cloitre M. Social Bonds and Posttraumatic Stress Disorder. Annual Review of Psychology. 2008;59:301-28.
  16. Ford E, Ayers S. Stressful events and support during birth: The effect on anxiety, mood and perceived control. Journal of Anxiety Disorders. 2009;23:260-8.
  17. Hodnett ED, Gates S, Hofmeyr G, Sakala C. Continuous support for women during childbirth. The Cochrane Database of Systematic Reviews. 2003(3):Art No.: CD003766. DOI:10.1002/14651858.CD003766.
Posted in birth, guest post, intervention, law | Tagged , , , , | 42 Comments

Judging Birth

Posted on April 9, 2011 by

This post is a little different to my usual posts (I apologise to those wanting some physiology and links to research). Instead, I have written about something that keeps cropping up in my conversations with mothers and birth workers. I would be interested in other perspectives and opinions – so, please comment and let me know your thoughts. The post is basically my  own thoughts about how we judge ourselves and birth.

Birthing Behaviour

Artwork by Amanda Greavette: http://amandagreavette.com

Women’s behaviour has been judged and controlled throughout history. We are supposed to be ‘good girls’ – do as we are told and not create any problems for others. However, the act of giving birth is primal and ‘wild’. Our birthing behaviour originates in the limbic system, the area of the brain shared by all mammals. To labour well we need to shut down our neo-cortex – the thinking human part of the brain. The result is instinctive ‘animalistic’ birthing behaviour. Because we are individuals, our birthing behaviour is also individual. Some women become quiet, withdrawn and ‘in control’. Others become loud, wild and ‘out of control’. For many it is somewhere in-between, or both, at different times during labour. Just like behaviour during sex (also controlled by the limbic system) there are similarities between humans, but we all behave slightly differently.

The idea that there is a ‘right’ way to behave or worse, a ‘wrong’ way to behave is unhelpful and judgemental. It seems that being quiet and ‘controlled’ is considered to be the best way to birth. How many times have you heard a woman’s labour described in a positive way because she was ‘so in control and quietly breathed her baby out’? In contrast, the loud woman is encouraged to breath (ie. stop screaming/shouting) and focus. This happens often in the hospital setting where midwives attempt to keep a woman quiet so as not to ‘frighten the other women’. These women are often described as ‘not coping’ – when in fact they are coping just fine… but loudly. It is those around them who are not coping. Michel Odent suggests that the intense fear and sense of ‘losing it’ often experienced near the end of labour facilitates the fetal ejection reflex. Not many women experience this because midwives (or others) intervene to calm the woman and help her gain control of herself.

It’s not just midwives, but also mothers who judge themselves for ‘losing control’ and making noise. I find it sad to hear a birthing woman apologise for her instinctive behaviour – but they do. Indeed there are childbirth preparation programs aimed at learning how to be quiet and in control during birth. Unfortunately, some women who have undergone this training feel like failures when their instincts take over and they become vocal. Perhaps we (society/culture) are afraid of the primal power expressed during birth – here is a woman connected to, and expressing the immense power and strength of woman. The response is to shut her up and encourage her to act like a ‘good girl’ so as not to upset anyone (including herself).

Here is a beautiful example of a mother birthing instinctively and loudly:

So, lets honour our birthing behaviour whatever it may be. Whether you are a quiet, breathing birther, or a loud and wild birther – you are equally, but differently amazing. Midwives need to learn to distinguish between a woman who is expressing her wild birthing instincts, from a woman who genuinely needs reassurance and calming. Talking with her before birth about what she will say if she really does need ‘help’ can be useful. In addition make sure she knows that you will not judge anything she says or does during labour. It is also important that women hear and see birth stories that show a range of birthing behaviours – not just the quiet and in control types.

Birthing Choices and Experiences

Artwork by Amy Swagman: http://themandalajourney.com

Women are also judged (and judge themselves) on their birth choices. Here, you really can’t win. If you choose an elective c-section for no medical reason – you will be judged. If you choose to freebirth your baby – you will be judged. And for every birth choice in-between others will have an opinion and judgement about what you do, or don’t do. There is no right way to birth. For healthy women and babies a physiological, undisturbed birth is probably the safest option in terms of outcomes. However, some women don’t want this – or are unable to have this. Any birth choice a woman makes based on an assessment of the benefits/risks and her own situation/needs should be respected. The focus should be on ensuring women have access to adequate information on which to base their choice – not on the choice itself.

How the birth looks on paper may be very different to how it was perceived by the mother. I learned quickly as a community midwife doing postnatal visits that the ‘birth report’ had no connection to the woman’s perceptions of her birth. Women who had experiences such as ‘failed forceps’ and then a c-section could emerge feeling empowered and more than happy with their experience. On the other hand, women who had experienced ‘normal’ vaginal births without intervention could be traumatised. I find it is best to ask a woman how she feels about her birth rather than making assumptions based on the events. Often feelings centre around the care and respect, or lack of that was given during the birth journey rather than what happened.

Every birth experience is valuable – even those that don’t go as expected or planned. Hindsight is a wonderful thing, and we often look back and wish we’d known X because we wouldn’t have made the choice Y and ended up with Z. Many women choose homebirth based on a previous birth experience that with hindsight could have been very different. It is only because of that previous experience that they have explored and learned about birth and themselves. That previously disappointing (and in some cases traumatic) experience has provided the foundation for self-growth.

Sometimes birth does not go as planned because if left to unfold as nature intended the result would be a poor outcome. Appropriate intervention can, and does save women and babies. However, women are often left doubting their body and can then judge themselves and their birth experience as a ‘failure’. I have recently been discussing this issue lots with my lovely Doula friend Pernille. Her insights into this matter are interesting and I would like to share them (please let me know P if I’ve mis-interpreted you). For these women, the choice of intervention can represent the ultimate expression of motherhood. For example, allowing your own body to be cut open to save your baby is surely the epitome of mothering.

Summary

There is no correct way to birth, or to behave during birth. As women and mothers we are subjected to more than enough judgement from others and ourselves. Perhaps it is time to start nurturing and supporting ourselves and others instead.

Posted in birth, opinion and thoughts | Tagged , , , | 97 Comments

VBAC: making a mountain out of a molehill

Posted on February 23, 2011 by

VBAC (vaginal birth after caesarean) is big. A google search for ‘vbac’ results in ‘about 1,390,000′ results. Reviews, guidelines, policies and statements are being produced by every organisation with an interest in birth. Support groups and networks are growing. I am not going to add to this wealth of information. Others are doing a fantastic job and I will provide some links at the bottom of this post. This post is really aimed at putting VBAC into perspective risk-wise and discussing how we can best support women planning a vaginal birth after caesarean. I haven’t personally experienced the VBAC journey and would welcome some input from mothers who have via comments, suggestions and links. This is written from my perspective as a midwife…

With a c-section rate of around 1 in 3 (Australia) a significant proportion of women approach their subsequent birth with a scarred uterus. Of those women, 83% will have another caesarean. I can’t find the stats re. how many of these repeat c-sections are planned vs emergency. But, considering the 50-90% ‘success’ rate for VBACs, I am assuming that most repeat c-sections are planned. I wonder if more women would choose to experience a vaginal birth if they had adequate information and support from care providers who believed in them?

Guidelines suggest that women should be counselled about the risks of VBAC, and they should have additional monitoring and intervention during labour. The big concern is uterine rupture and this is what I am going to focus on. By the way – unless I provide a reference/link you can assume I am getting my numbers from the NIH Consensus Statement (US) or Having a Baby in Queensland (Aus). Both of these resources are based on the current research evidence. So, if you need the original research sources check out their reference lists.

What happens during a uterine rupture?

Considering this is the risk associated with VBAC is worth briefly describing what is involved. Uterine rupture can happen at any birth, even when no scar is present (particularly if syntocinon is used). There are two types of uterine rupture associated with VBAC (Pairman et al. 2010):

  1. Catastrophic (symptomatic) – the old scar separates long its length, the amniotic sac ruptures and the baby is pushed into the abdominal cavity. This results in significant bleeding, shock and the baby is in grave danger.
  2. Asymptomatic – the scar separates partway along its length, the amniotic sac stays intact and the baby remains in the uterus. Bleeding and shock is minimal and the baby usually survives. This is the most common type.

Here is a youtube clip of what happens during a catastrophic uterine rupture:

For more information about uterine rupture (including symptoms) check out this article on BellyBelly.

Risk by numbers

Risk is a difficult concept. You can have odds of 1 in a million, but if you are the 1 it is 100% for you. It is also impossible to eliminate all risk from life (or birth) and every option has risks attached. All women can do is choose the risk that feels right for them – there is no risk-free choice. There are many ways of presenting risk and some ways may mean more than others for individuals. For example, if we look at the overall risk of uterine rupture for a woman who has had 1 previous c-section. By overall, I mean without adding or subtracting factors which increase or decrease an individual’s risk (eg. syntocinon during labour, transverse scar). The risk can be presented like this:

  • 50 out of 10,000 will rupture
  • 9,950 out of 10,000 will not rupture
  • 1 in 200 will rupture
  • 199 out of 200 will not rupture
  • 0.5% will rupture
  • 99.5% will not rupture

Which of these versions would help you conceptualise risk? I know when I look at the picture versions of risk I assume I’m the ‘red person’. Personally I like the 99.5% intact uterus odds.

The risk of rupture may be even lower in labours that are not induced or augmented (the stats above are a mixture of all labours). An Australian study (Dekker et al. 2010) found that the risk of uterine rupture during VBAC was 0.15% in spontaneous labour, 1.91% in augmented labour and 0.88% in labour induced using prostin and oxytocin. In contrast a US study (Ouzouian et al. 2011) found no different in rupture rates between spontaneous and induced labours – but found a significantly greater vaginal birth rate following spontaneous labour. Another study (Harper et al. 2011) found an increased chance of rupture during induction when the woman has an ‘unfavourable’ cervix. There are also other risks associated with induction which need to be considered before heading down that pathway.

For women who have had multiple c-sections: Landon et al. (2006) suggest the risk of rupture rises to 0.9%. However Cahill et al. (2010) found that: “Women with three or more prior caesareans who attempt VBAC have similar rates of success and risk for maternal morbidity as those with one prior caesarean, and as those delivered by elective repeat caesarean.”

The story looks a little different again when you look at the mortality and morbidity caused by uterine rupture.  Guise et al (2004) conducted a systematic review of research relating to VBAC and uterine rupture. They found that uterine rupture resulted in: 0 maternal deaths; 5% perinatal deaths (baby); and 13% hysterectomy. They conclude that: ‘Although the literature on uterine rupture is imprecise and inconsistent, existing studies indicate that 370 (213 to 1370) elective caesarean deliveries would need to be performed to prevent one symptomatic uterine rupture.’

So, out of the small number of women who experience uterine rupture, an even smaller proportion will lose their baby or uterus because of it. When the uterus ruptures 94% of babies survive.

VBAC vs planned c-section: uterine rupture

Most resources and guidelines compare the risk of a VBAC with the risks of a repeat c-section. This can be a brain-twister because of the multiple and complex risks associated with c-section. Childbirth Connection cover them well, so I won’t. Having a Baby in Queensland directly compares VBAC with planned repeat c-section for a number of complications. I’m trying to stick to the risk of uterine rupture (the ‘big’ one). So, planned c-section wins with a 2:10,000 uterine rupture rate compared to 50:10,000 for a VBAC. That’s if you are happy to take all the (more frequently occurring) risks associated with c-section in exchange.

Uterine rupture vs other potential birth emergencies

A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations compares uterine rupture with other potential complications. You are more likely to experience a placental abruption, a cord prolapse or a shoulder dystocia (not associated with previous c-section) during your vbac than a uterine rupture. Your baby is also more likely to die from the placental abruption or cord prolapse than from a uterine rupture.

Anecdotes

Anecdotes hold as much power as numbers. I can guarantee that I will get a comment telling me about a poor outcome associated with a VBAC. They do happen (see the stats above). Unfortunately when care providers have been involved in a traumatic situation, it can be hard not to let that experience colour their perspective and approach. The memory of one uterine rupture will be stronger than all of the VBACs they have seen. Obstetricians in particular have to deal with the fall out of major complications because this is their area of expertise. They also miss out on seeing physiological normal births which end well because this is the realm of the midwife (I know this is different in the US/private sector). This can lead to fear-based counselling and practice, and a general fear of normal birth. Interesting that a poor outcome associated with a c-section does not seem to elicit quite the same response – ie. fear of c-section.

When parents find themselves the 1 in how ever many, it is even more devastating. their stories are powerful and need to be heard. However, it can be difficult for other parents to contextualise the story without also hearing stories with good outcomes.

The real risks of VBAC (according to me)

I am a bit confused about why such a huge deal is made about the risk of uterine rupture during VBAC. Why are these women subjected to serious (and often biased) discussions with fearful obstetricians about the dangers of attempting birth? Why are they categorised as ‘high risk’, limiting their care options and imposing additional monitoring and intervention during their labour? If we agree that this is the right approach, then we also need to treat all women like this because the risk of placental abruption or a cord prolapse is greater than the risk of a uterine rupture during a VBAC.

To be honest, as a midwife uterine rupture is the least of my worries when caring for a woman having a VBAC. I actually think the mountain that has been built out of the risk-molehill requires more energy and attention. These women do need special treatment, but not in the form of disempowering fear-based counselling or practice. They have often had a previous traumatic birth experience and are dealing with fear from family, friends, and the medical system, in addition to their own worries. They have been labelled ‘high risk’ and are constantly reminded of the potential disaster waiting to occur. They also risk ‘failing’ if they encounter any complications or end up having a repeat c-section. This impacts on their ability to trust their body, follow their intuition and allow the physiology of birth to unfold. Often these women need more nurturing, reassurance and support from their care givers.

Suggestions

During pregnancy

It is important to not only help women to prepare but also their partners and/or other close family members who may be at the birth. Often the partner was present at the previous birth which may have been traumatic to witness. For a partner their priority is the safety of the woman they love – not a particular birth experience. Winning them over may be difficult. In some cases the decision the mother makes may be that the partner should not be present. OK – some suggestions:

  • Find out the details of her previous birth experience. If she needs debriefing help her do so, or refer to someone who can. Knowing about her previous experince and her fears can help you know what she needs during her labour.
  • Offer to discuss ‘risk’ and present the statistics in a number of ways. Find out what they (mother and partner) find most useful and empowering. I could say ‘don’t mention risk’ but to be honest unless she is living in a cave she will already be aware that VBAC is ‘risky’ and will need to explore this.
  • Make sure she is aware that she has a 50-90% chance of having a vaginal birth – greater than a first time mother. She can increase this chance by choosing supportive care providers (and setting) and not having her labour induced or augmented.
  • Talk about the possibility of the pregnancy going beyond the prescribed ‘due date’. This is often a feature of VBAC pregnancy. Some hospitals or midwives consider this to be a risk factor because the chance of a repeat c-section is about 9% greater (Coassolo et al. 2005). However, the risk of uterine rupture is no greater.
  • Make sure she knows that having a c-section after labour has started holds more health benefits than a planned c-section. Her baby will have had a chance to initiate labour and make the physiological changes needed for life outside the uterus. They will be less likely to suffer respiratory distress and end up in special care. In addition both mother and baby will have the important cocktail of hormones that assist with bonding. Even if she chooses a repeat c-section she can insist on going into labour first.
  • Talk to her and her partner about what actually happens if the uterus ruptures. They may be imagining all kinds of horrific scenes such as the baby bursting out of the woman’s abdomen.
  • If she is worried about ‘failure’ reassure her that she doesn’t need to tell anyone she is planning a VBAC. She can say she’s not sure and will decide in labour. Some mothers planning a homebirth after c-section book into the hospital and pretend they are planning a hospital birth. Then if they transfer in they don’t have to deal with the ‘failed home VBAC’ situation. She needs to do whatever takes the pressure off even if that’s lying.
  • If she is planning to birth in hospital she needs to know what the hospital policies are and decide what she will or won’t go along with. This means talking about the risks of the usual interventions such as CTG monitoring. A very clear birth statement can help the staff to support her wishes.
  • Encourage her to talk to other women about their experiences of VBAC, read positive birth stories and watch beautiful VBAC birth movies.
  • Do not use disempowering language such a ‘trial of scar’ or constantly refer to her birth as a VBAC. She is a woman having a baby, not a disaster waiting to happen.

During labour

The physical care of a woman having a VBAC should be no different (although I know it is in hospital). Yes, I’m watching for signs of a uterine rupture: unusual pain, fetal heart rate abnormalities, unusual bleeding, a change in maternal observations etc. But, those symptoms in any birthing woman would be concerning, so this is not different care. In addition if a woman is unmedicated and connected to her body/baby she will be the first to notice a problem. I have noticed that women having a VBAC may have additional psychological needs. For example, they may request vaginal examinations, particularly if their c-section was for ‘failure to progress’ (aka failure to wait). Even with information about how poor VEs are at indicating progress they may want that dilation number – some non-VBAC women do too. They may also want more frequent fetal heart rate auscultation and need you to reassure them the baby is well. In general these women, and even more so their partners need reassurance and a care giver who believes in them. Of course some women don’t need any of this and choose freebirth.

Personally I love attending VBACs. These births are usually immensely healing and empowering for a woman and her partner. I wonder whether this aspect of birth is discussed at the ‘risk consultations’ along with the numbers.

Here is one couple’s VBAC journey (have a tissue handy). This is the most likely outcome of a VBAC – particularly a homebirth:

Further Reading/Resources

Posted in birth, intervention, midwifery practice | Tagged , , , | 176 Comments

Cord Blood Collection: confessions of a vampire-midwife

Posted on February 10, 2011 by

http://www.isu.edu/cls/shields09wikis/cordblood.htmlWhen I was a bright-eyed and bushy-tailed student midwife I was awarded with a certificate and a box of chocolates. My achievement was collecting the most cord blood in the hospital. At that time the Local Health District was trialling a cord blood bank. The collected stem cells were to be used for treating leukaemia and for research. Every woman birthing in the hospital was asked to donate cord blood for the good cause, and many generously agreed. I was exceptionally good at collecting the blood. This post is a small attempt to repent for my sins.

In recent years cord blood collection and storage has become popular, particularly in the private sector. Cord blood contains magical stem cells, and the idea is that if your baby becomes ill in the future you may be able to use these cells as treatment. My concern with cord blood banking is the inadequate and misleading information given to parents. This misinformation raises both ethical and legal issues. The procedure involved in collecting cord blood is sold as ‘simple, safe and effective’. When it comes to decision making about cord blood only three options are presented: keep it (pay for storage), donate it (to a public initiative) or throw it away. What about letting it finish its journey up the umbilical cord and into the baby?

Even the term ‘cord blood’ is misleading – blood is merely collected via the cord. In addition the promotional materials talk about collecting ‘blood from the placenta’ without acknowledging that the baby/placenta are one blood circulation unit. After birth the blood from the placenta transfers to the baby, assisting transition to breathing. Knowledge about the short term and long term health benefits of allowing placental circulation to complete the job is becoming widespread. See this post for an overview of the physiology of newborn transition to breathing, and for links about the health benefits of full blood volume for babies. With further research one of the long term benefits may actually turn out to be protection against some of the illnesses stem cells are being collected to treat.

Parents need to be informed that cord blood collection requires premature cord clamping, and that the blood being collected belongs to their baby.

In the procedure guide for collection there is no mention of when to clamp the cord. This may lead parents to believe they can delay cord clamping and still collect cord blood. This is not an option. After the placenta has finished transferring blood to the baby it is difficult to collect even the few mls needed for blood group testing (Rh neg). The large umbilical vessels are empty and by the time the placenta has been birthed the blood in the small vessels has begun to clot. You have to faff about trying to scavenge enough un-clotted blood from the small vessels covering the placenta. The minimum required for cord blood collection is 45mls. Take a look at the photograph of a placenta that finished its circulation before being clamped. If you reckon you could get 45mls out of that, you deserve a certificate and some chocolates.

http://www.bmj.com/content/333/7575/954/F1.large.jpg

This diagram from the British Medical Journal shows the transfer of blood volume from placenta to baby after birth

Paediatric guidelines state that ‘blood draws in infants and children should not exceed 5% of the total blood volume in any 24 hour period’. A 3.6kg newborn has a blood volume of around 280mls – so the maximum blood draw would be 14mls. How come these rules don’t apply immediately following birth? The collection bag for cord blood holds 250mls (35mls already taken up with anticoagulant fluid). The minimum amount of blood acceptable for collection is 45mls, and the maximum possible is 215mls. During my vampire-midwife days I reckon I generally filled at least half of the bag – so around 90mls. In the photograph at the top of this post the bag looks more than half full. This amount of blood represents a significant proportion of the newborns blood volume.

I wonder how many parents would consent to someone coming onto the postnatal ward and sticking a needle into their baby to collect around a third of their blood volume? It’s the same thing… only the needle is in the baby not the umbilical cord.

I am not saying cord blood banking shouldn’t be an available option. All I am suggesting is that parents need adequate information before they make a decision to withdraw a significant amount of their baby’s blood volume. They need to be able to weigh up the definite benefits of full blood volume at birth vs a possible treatment for an unlikely future illness. Cord blood is baby’s blood.

PS: I no longer participate in stealing babies blood. We live and learn.

Further information

Penny Simkin provides a graphic illustration of blood re-distribution after birth:

You can listen to a very interesting interview with Dr Mercer about delayed cord clamping, including her thoughts on cord blood collection.

Access a journal article (Waller-Wise 2011) discussing the use of stem cells which includes some information about the limitations the cord blood banks don’t share.

Royal College of Midwives and Royal College of Obstetricians and Gynaecologists (UK) joint statement on cord blood collection

Posted in baby, birth, intervention | Tagged , , , , , | 88 Comments

The Anterior Cervical Lip: how to ruin a perfectly good birth

Posted on January 22, 2011 by

Here is a scenario I keep hearing over and over: A woman is labouring away and all is good. She begins to push with contractions, and her midwife encourages her to follow her body. After a little while the midwife checks to ‘see what is happening’ and finds an anterior cervical lip. The woman is told to stop pushing because she is not fully dilated and will damage herself. Her body is lying to her – she is not ready to push. The woman becomes confused and frightened. She is unable to stop pushing and fights her body creating more pain. Because she is unable to stop pushing she may be told to have an epidural. An epidural is inserted along with all the accompanying machines and monitoring. Later, another vaginal examination finds that the cervix has fully dilated and directed pushing begins. The end of the story is usually an instrumental birth (ventouse or forceps) for an epidural related problem – directed pushing = fetal distress; ‘failure to progress’; baby mal-positioned due to supine position and reduced pelvic tone. The message the woman takes from her birth is that her body failed her, when in fact it was the midwife/system that failed her. Before anyone gets defensive – I am not pointing fingers or blaming individuals, because I have been that midwife. Like most midwives I was taught that women must not push until the cervix has fully dilated. This post is an attempt to prompt some re-thinking about this issue, or rather this non-issue.

Anatomy and Physiology

Birth is an extremely complex physiological process but very simplistically 3 main things occur:

  1. Dilatation of the cervix
  2. Rotation of the baby through the pelvis
  3. Descent of the baby through the pelvis

But this is not a step-by-step process – it’s all happening at the same time, and at different rates. So whilst the cervix is dilating the baby is also rotating and descending.

1. Dilatation of the cervix

The cervix does not open as depicted in obstetric dilatation models ie. in a nice neat circle (Sutton 2001). It opens from the back to the front like an ellipse. The os (opening) is found tucked at the back of the vagina in early labour and opens forward. At some point in labour almost every woman will have an anterior lip because this is the last part of the cervix to be pulled up over the baby’s head. Whether this lip is detected depends on whether/when a vaginal examination is performed. A posterior lip is almost unheard of because this part of the cervix disappears first. Or rather it becomes difficult to reach with fingers first.

The cervix dilates because the muscle fibres in the fundus (top of the uterus) retract and shorten with contractions = pull it open (Coad 2005). This does not require the pressure of a presenting part ie. baby’s head or bottom (lets stick to heads for now). However, the head can influence the shape of the cervix as it dilates up around it. For example, a well flexed OA baby (see pic A) will create a neater, more circular cervix. An OP and/or deflexed baby (see pic B) will create a less even shape. For more about OA and OP positions see this post. Most baby’s will be somewhere between these two extremes whilst the cervix is opening and will be changing their position as they rotate.

2. Rotation

Babies enter the pelvis through the brim. As you can see from the pictures above this is easier with their head in a transverse position. As the baby descends into the cavity their head will be asynclitic – with the parietal bone/side of the head leading. This is because the angle of the pelvis requires the baby to enter at an angle – see picture on the right. Once in the cavity the baby has room to rotate into a good position for the outlet which is usually OA. Rotation is aided by the pelvic floor and often by pushing.

3. Descent - the urge to push

The urge to push… and I’m talking spontaneous, gutteral, unstoppable pushing… is triggered when the presenting part descends into the vagina and applies pressure to the rectum and pelvic floor. This is called the ‘Ferguson reflex’ – probably after some man. This reflex is not dependent on what the cervix is doing, but where and what the baby’s head is doing. So, if the baby’s head hits the right spot before the cervix has finished dilating the woman will spontaneously start pushing. An alternative but common scenario is when the cervix is fully open but the baby has not descended far enough to trigger pushing. Unfortunately some practitioners will tell the woman to push and create problems instead of waiting for descent and spontaneous pushing.

Pushing before full dilatation

Because we are not telling women when to push (are we?!) they will push when their body needs to. If we are directing pushing we risk working against the physiology of birth and creating problems (see previous post). Spontaneous pushing before full dilatation is a normal and physiologically helpful when:

  1. Baby’s head descends into the vagina before the cervix has dilated. In this case the additional downward pushing pressure assists the baby to move beyond the cervix whilst pulling the cervix out of the way.
  2. Baby is in an OP position and the hard prominent occiput (back of head) presses on the rectum. In an OA position this part of the head is against the symphysis pubis and the baby has to descend deeper before pressure on the rectum occurs from the front of the head. In the case of an OP position, pushing can assist rotation into an OA position.

I am yet to find any evidence that pushing on an unopened cervix will cause damage. I have been told many times that it will but have never actually seen it happen. I have encountered swollen oedematous cervixes – mostly in women with epidurals who are unable to move about. But, this occurs without any pushing. I can understand how directed, strong pushing could bruise a cervix. But I don’t see how a woman could damage herself by following her urges. In many ways the argument regarding pushing, or not is pointless because once the Ferguson reflex takes over it is beyond anyones control. You either let it happen or start commanding the women to do something she is unable to do ie. stop pushing.

Telling women to push or not to push is cultural not based on physiology or research. For example, in some parts of the world eg. Central Africa, women are told to push throughout their entire labour (on an unopened cervix!). This is often accompanied by their midwife manually stretching the cervix too – ouch. Alternatively in other parts of the world eg. the US women are told not to push until a prescribed point in labour. It seems midwives are bossy worldwide.

When left to get on with their birth, occasionally women will complain of pain associated with a cervical lip being ‘nipped’ between the baby’s head and their symphysis pubis during a pushing contraction. In this case the woman can be assisted to get into a position that will take the pressure off the cervical lip (eg. backward leaning). When undisturbed women will usually do this instinctively. At a recent waterbirth a mother (first baby) who had been spontaneously pushing for a while on all fours floated onto her back. A little while later she asked me to feel where the baby was (for her not me) – baby was not far away with a fat squishy anterior lip in front of the head. The mother also had a feel, then carried on pushing as before. Her daughter was born around 30 mins later.

Suggestions

Avoid vaginal examinations (VEs) in labour. What you don’t know (that there is a cervical lip) can’t hurt you or anyone else. VE’s are an unreliable method of assessing progress, and the timelines prescribed for labour are not evidence based (see this post).

Ignore pushing and don’t say the words ‘push’ or ‘pushing’ during a birth. Asking questions or giving directions interferes with the woman’s instincts. For example, asking ‘are you pushing’ can result in the women thinking… am I? Should I be? Shouldn’t I be? Thinking and worrying is counterproductive to oxytocin release and therefore birth. If she is pushing let her get on with it and shush. For more about pushing in general and a link to a great audio by Gloria Lemay see this post.

Do not tell the woman to stop pushing. If she is spontaneously pushing (and you have not coached her) she will be unable to stop. Pushing will help not hinder the birth. Telling her not to push is disempowering and implies her body is ‘wrong’. In addition, after fighting against her urge to push she may then find it difficult to follow her body and push when permitted to do so (Bergstrom 1997).

If a woman has been spontaneously pushing for a while with excessive pain (usually above the pubic bone) she may have a cervical lip which is being nipped against the symphysis pubis. There is no need to do a vaginal examination to confirm this unless she wants you to. If you suspect or know there may be a cervical lip:

  • Reassure her that she has made fantastic progress and only has little way to go.
  • Ask her to allow her body to do what it needs to, but not to force her pushing.
  • Help her to get into a position that takes the pressure off the lip and feels most comfortable – usually a reclining position.
  • If the situation continues and is causing distress – during a contraction apply upward pressure (sustained and firm) just above the pubic bone in an attempt to ‘lift’ the cervix up.
  • If the woman is requesting further assistance the cervical lip can be manually pushed over the baby’s head internally. This is extremely uncomfortable!

Note: This nipping situation is rare and usually a cervical lip will simply move out of the way without causing any problems.

Summary

An anterior cervical lip is a normal part of the birth process. It does not require management and is best left undetected. The complications associated with an cervical lip are caused by identifying it, and managing the situation as though it is a problem.

This post is also available in French


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Stages of Labour and Collusion

Posted on December 22, 2010 by

My New Years resolution is to stop colluding in the myth of stages of labour. Will you join me? This may be a little difficult as a midwife and an educator but I’ll give it a go – will you?

The stages of labour

In current midwifery texts labour is divided into three distinct stages, and further divided into phases within those stages. The first stage of labour involves regular and coordinated uterine contractions accompanied by cervical dilatation. This stage includes three phases: latent, active and transitional. The second stage of labour begins when the cervix is fully dilated and ends when the ‘fetus is fully expelled from the birth canal’ (Stables and Rankin 2010, p.533). Again, the second stage is further broken down into three phases: latent, active and perineal. ‘The third stage of labour is the period from the birth of the baby through to delivery of the placenta and membranes and ends with the control of bleeding’ (Stables & Rankin 2010, p.547).

This concept of birth reflects the scientific, mechanistic model of how the body works (see ‘a quick history lesson’ ). It does not reflect women’s experience of birth or the physiology of birth.

Problems with assessment and categorisation

The idea of stages of labour contradicts what we know about the physiology of birth. Physical changes in the cervix and uterus occur during pregnancy and the onset of labour is a gradual happening without a distinct start time. The definition of ‘established labour’ includes regular rhythmic contractions (3:10 or more, lasting 45 secs or more) and progressive dilatation of the cervix (1cm per hour). However, women’s natural contraction patterns vary, and the idea that a cervix will follow a graph is outdated – see ‘the effective contraction’. What about a woman who only ever has contractions 2:10 but births her baby? Did she skip the first stage of labour? Women with OP babies often have different labour patterns that will not fit this definition.

The definition of the first and second stages of labour also assumes that a vaginal examination will be carried out because everything hinges on what the cervix is doing. However, this doesn’t quite work. If I examine a woman at 3pm and find out her cervix is fully dilated does that mean her second stage started at 3pm? What if her cervix had been fully dilated at 2pm but I didn’t know? The only time measurement we can know for sure is the end of the second stage of labour – because the baby emerges (assuming we remember to look at the clock). We could get a time for the birth of the placenta, but the end of the third stage ends with ‘control of bleeding’ which is open to interpretation.

The impact of collusion

Care providers have accepted this categorisation despite the lack of evidence or sense to support it. The stages of labour are like the emperors new clothes. We educate women on the stages of labour; we assess their progression through these stages; and we fill in documentation about their progression through the stages (eg. time of 2nd stage). Perinatal data forms require the precise hours and minutes that a women spends in each stage of labour.

How this translates into practice is that midwives basically make it up. There is a box to fill, so we fill it. This results in some comical paperwork conversations between midwives/midwifery students eg.: ‘What time would you say second stage started?’ ‘Umm not sure – she was making grunty noises around 5.30pm…’ ‘OK, I’ll put 6pm.’ Midwives also massage the paperwork to fit policies eg. ignoring that the woman was actually ‘pushing’ for 3 hours and only documenting a 1 hour second stage to avoid trouble.

These made up times are carefully recorded and then sent to organisations that collect and analyse the stats to provide information about labour and birth. By making our records fit the myth, we are colluding in maintaining the myth that labour can be compartmentalised into distinct stages and measured accurately.

Perhaps more importantly by colluding we are re-defining women’s birth experiences – often in contrast to their own experience. Have you tried explaining to a woman why we only record ‘established labour’ and disregard the hours or days that she experienced contractions before being assessed as in established (real) labour?

The future

I guess I have it easier than those working in hospitals with hospital documentation. I’m in control of my own paperwork and have already excluded the stages of labour from the birth notes I write at homebirths. However, I still have to complete perinatal data forms. So, the question is do I put a ‘?’ in the box or draw a line through it?

Merry Xmas readers and thanks for following my blog in 2010

*Update: This post has been expanded into an article for AIMS. You can read it here.

This post is also available in French

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Shoulder Dystocia: the real story

Posted on December 3, 2010 by

kytriallaw.comRecently the media have been demonstrating ignorance and lazy journalism with a scattering of items about shoulder dystocia. Apparently doctors are having to attend special classes to learn how to break babies bones because mothers are fat and make their babies too big. At least that is the story – women are creating a problem and doctors have to solve it. The reality is that almost half of shoulder dystocia occurs with babies who are not ‘big’. This post will discuss how to avoid a shoulder dystocia and deal with the situation if it occurs. There is plenty of great information available on the internet about shoulder dystocia. So, I will indulge in some lazy blogging and link where I can.

Resources: You can download an information leaflet from midirs, and CETL learning have a slide presentation available online. Both of these resources give a comprehensive overview of the incidence, risk factors and the standard approach to shoulder dystocia. In addition references are provided for those who want/need them.

What happens during a shoulder dystocia?

Basically the baby’s shoulder/s get caught on the pelvic brim (more info about the pelvic brim, cavity and outlet in this previous post)

Avoiding shoulder dystocia

A lot of midwifery and obstetric learning resources focus on how to manage particular complications or problems. I prefer to avoid the situation in the first place, if at all possible. Although in some cases shoulder dystocia is unavoidable, there are a number of ways to reduce the chance of it occuring:

Undisturbed birth

When women are able to birth instinctively without direction or intervention they are capable of magic. I have seen some bizarre birth positions and movements that made perfect sense once the baby emerged. And in the case of a stuck shoulder, instinctive pelvic movements can release the baby without drama.

Patience

The baby needs time to get into the best position to move through his/her mother’s pelvis. When we try to hurry birth, the baby may be unable to make these adjustments. Induction augmentation of labour and instrumental delivery increase the chance of a shoulder dystocia happening (Gherman 2002). Directed pushing can force the baby into the pelvis without allowing time for subtle adjustments to happen.

I am also convinced (but have no research to back me up) that pulling babies out can wedge their shoulders against the pelvic brim. Waiting for a contraction when the head is out can feel like forever (could be 5+ minutes) and it’s tempting to tell the mother to push or give a gentle pull on the head. But, the baby may be using this time to make the adjustments necessary for the shoulders to birth. As long as there is some change with each contraction and the baby is well (pink/bluish), you can wait – bite your tongue and sit on your hands if you have to. Usually the shoulders will be born with the next contraction following the head but not always. The next contraction may rotate the baby, then the next contraction birth the shoulders. Watch and see.

Being proactive with epidurals

An epidural will completely alter the physiology of birth and the instinctive behaviour of the mother. Once an epidural is inserted ‘active birth’ often goes out the window. In my opinion ‘active birth’ is not necessary when a woman is undisturbed – she will instinctively get into positions that work for her without prompting. However, active birth becomes essential for a woman who has an epidural. Looking after a woman with an epidural should be hard work. As a care provider you now have to help the baby through the pelvis by prompting and assisting maternal movement and position. This is where the ‘creating space’ tricks become important.

Birthing in a semi-recumbant position increases the chance of shoulder dystocia because the pelvis is unable to open ie. sacrum move back and coccyx uncurl. This is often the default position for women with epidurals. However, most women are able to get into an alternative position with assistance, and most hospital beds are adjustable. It is possible to get into a squat using a bar attachment to hold, and women can kneel up and lean over the back of the bed despite a lack of feeling in their legs. A lying lateral position is always available if movement is really difficult. Lots of position changes during pushing may be difficult but can make a huge difference to the outcome.

Management of a shoulder dystocia

Despite anything and everything mothers and care providers do – some babies will still get stuck. Even though shoulder dystocia is relatively rare (1:200), knowing what to do is useful. Firstly it is important not to make a bad situation worse, therefore:

  • Do not pull the baby as this will impact the shoulder further. This is the most common mistake people make because they panic. Traction can result in brachial plexus injury to the baby (see movie above). Unfortunately the care provider can then find themselves facing litigation. An article by Johnson outlines the medico-legal perspective ‘…for many years it has been accepted that OBPP [obstetric brachial plexus palsy] is an injury caused by excessive traction on the head when the anterior shoulder is impacted above the symphysis pubis.’
  • Do not cut the umbilical cord if it is around the baby’s neck. While the cord is intact there is still a chance that the baby is receiving oxygen which gives you more time and assists with resuscitation afterwards.
  • Communicate with the mother. You always have time to explain what is happening and why you are doing what you are doing, or asking her to do something.

Here is a video illustrating why pulling babies out is bad practice:

We all learn and retain information differently. As a lecturer I teach two different approaches for different reasons:

HELPERR – A STANDARD APPROACH

I’m sorry, but I have a strong aversion to mnemonics. I get particularly frustrated by mnemonics that don’t fit the letters to actions = actions being crow-barred into the word, or another letter being added so it is no longer an actual word. In the case of HELPERR the first E is for ‘evaluate for episiotomy’ – which I am yet to see anyone seriously do in real life. Firstly, you would have to be very brave to attempt putting scissors in such a tight space next to a baby’s head/face. Secondly, if you really need to get your hands in – you will, and a tear will be the least of your worries in that moment. In addition, HELPERR assumes the woman is on her back – which I guess she usually is if the baby is stuck.

OK, rant over. I know that some people find mnemonics assist them to remember sequences, and that hospital staff are expected to follow them. In addition, for legal purposes (see above article) it looks good if you have documented evidence of working through the HELPERR sequence. Because HELPERR is the standard approach I will not list ‘how to’ here – the links provided at the beginning of this post give instructions to follow. However, I have added a movie showing how McRoberts works (with classical music!?):

A HOLISTIC APPROACH

The limitations of the HELPERR approach become apparent when assumptions about position (reclining/on back) and environment (on a hospital bed) are removed. If a shoulder dystocia occurs in a small toilet cubical with an upright woman – how do you perform McRoberts?

So, considering the range of positions, environments and situations birth takes place in, we need to be able to think and act beyond the mnemonic. When a shoulder dystocia occurs one or both of 2 things need to happen to release the shoulders:

1. Change the size and position of the pelvis (mother)

This can be done by encouraging the mother to move and change position. The best option will depend on the position she is already in. Often just the movement of getting into a position will release the baby. You can ask or assist a mother to change her pelvis by:

  • Lifting a leg up and/or outwards eg. onto the side of the birth pool or chair. This can be accompanied by a rocking back and forward of the pelvis (thrusts).
  • McRoberts is easy if the mother is already reclining. If on all fours, flipping over onto her back might be possible and the baby may release during the movement.
  • Gaskin manoeuvre – rotating onto all fours from a reclining position (a bit like a reverse McRoberts). If upright, dropping to all fours might work.
  • German approach – a German midwife friend sent me an interesting article about maternal movements for shoulder dystocia. A German midwifery student has kindly translated/explained the text and provided more pictures. I’ve made a pdf of the information.

2. Change the size and position of the shoulders (baby)

Adducting the shoulder/s will make the diameter of the shoulders smaller. Rotating the shoulders into the oblique diameter of the pelvis will make use of the extra space available (see pelvis info in previous post). Again you can find explanations of the following manoeuvres in the links provided at the beginning of this post.

  • Suprapubic pressure (sometimes called Rubin’s I)
  • Rubin’s manoeuvre (sometimes called Rubin’s II because it is attempting to do the same as the above manoeuvre only internally)
  • Woodscrew manoeuvre
  • Reverse Woodscrew manoeuvre
  • Removal of the posterior arm
  • Axillary traction (described in Ansell 2009 Chp5 of thesis)

There is no particular order in which you can try the above positions and actions. It will depend on how well the mother can move; the position she is in; and the access you have into her pelvis ie. how and where you can get your fingers in (if needed). For example, Rubins (II) will be easier to do than suprapubic pressure on a forward leaning mother.

A holistic approach means taking in the situation and using the appropriate movement or action at the time.

FlipFLOP

Gail Tully has devised an approach to shoulder dystocia that changes the size and shape of the pelvis and of the shoulders. It also comes with a mnemonic for those who like them – FlipFLOP. You can find information, pictures and a movie on the spinning babies website.

DRASTIC APPROACHES

There are options if all else fails which usually involve damage to the baby or mother (again, see links provided). These desperate measures have their place – after attempting everything else. I know a healthy 2 year old who’s mother had a c-section following a successful Zanvanelli manoeuvre. In this case the umbilical cord was most likely intact and functioning. Unfortunately sometimes regardless of what is done a baby will not survive.

MOVIE

You can watch a movie of a shoulder dystocia occurring during a home waterbirth here

Posted in birth, intervention, midwifery practice | Tagged , , , , , | 56 Comments