Feel the Fear and Birth Anyway

Posted on March 27, 2013 by

http://keepcalmandloveon.wordpress.com/2011/08/09/keep-calm-and-fill-in-the-blank/

This is just a little post to ease me back into the blogging world (thesis finally submitted). As usual, the content is in response to a reoccurring issue and discussions with mothers and midwives. And I welcome your experiences and comments on this topic…

In a backlash against the medicalisation of birth women are beginning to reclaim birth (yay!). Partly thanks to the availability of information via the internet, a counter culture has emerged. Movies, images and stories of empowered birthing mothers circulate through social media – women birthing in beautiful calm environments (usually in water, surrounded by candles), looking like Goddesses whilst gently and quietly ‘breathing’ their baby out. Women are able to see how birth can be, and many are inspired and driven to create a birth experience like those they watch.

Whilst these images can assist in building self-trust for mothers as they approach birth, they do not tell the whole story.

Fear, losing control, and the birth process

Labour is hard work – hence the word ‘labour’ (and I know some people don’t like the word… neither do I). But the work is not just physical, as women birth their babies, they are journeying through a life changing rite of passage into motherhood. At this time a woman is at her most powerful, and her most vulnerable. Historically and globally, childbirth is a time of danger for both mother and baby. Rituals are enacted in an attempt to ensure the safety of mother and baby. The nature of these rituals reflect the culture in which they are enacted. In medicalised cultures these rituals are technological and medical, focussing on surveillance and intervention (Davis-Floyd 2003) – which often create danger but that is a whole other post/s. Regardless of attempts to ensure safety, deep down, like our ancestors we know we step into the unknown during birth. Fear is a normal part of birth. It is normal to fear for yourself and your baby. It is normal to fear the changes that will come when this new person enters your life. It is normal to fear how you will cope/are coping with the enormous physiological changes and sensations in your body.

It is unusual and unhelpful to be extremely fearful throughout labour, and prolonged high levels of adrenaline can reduce contractions and placental blood flow. However, most women experience a point in their labour where they feel out of control, frightened and overwhelmed. Some call this ‘transition’, and it is usually a sign that birth is close. Victor Turner (1987, p.9) described the middle phase of a rite of passage as an ‘undoing, dissolution’ and a ‘decomposition’ [of the self] which is accompanied by the ‘processes of growth, transformation, and the reformulation of old elements in new patterns’. I think this is a good description of the transitional phase of labour. In addition, Michel Odent suggests that the intense fear and sense of ‘losing it’ experienced near the end of labour facilitates the physiological process of birth.

Most women will verbalise their fear, reaching out for reassurance, becoming loud and/or angry… often later apologising for their behaviour. Others remain externally calm, and those around them are oblivious to their turmoil. I have previously written about how women are judged by how they behave in labour. Women who manage to remain calm and serene whilst birthing are admired for maintaining control. In contrast, those who are loud, and appear to ‘lose it’ are considered to be out of control. However, appearing calm, and feeling calm are entirely different things. Only the woman knows what is going on inside her head – and body.

We have created a culture (and birth culture) that seeks to avoid and minimise extreme emotion and pain, and encourages being in control. We use medications and/or skills, methods and techniques to remain in control and dampen the emotions – or at least the expression of those emotions. In some cases women are told that they should not experience fear, or pain, during birth… that these are conditioned feelings and you can control them. I think it is a shame that this powerful aspect of the birth experience remains hidden and suppressed. Birth movies rarely include footage of women visibly ‘losing control’ (are these scenes edited out?). Women rarely share with others their experiences of feeling fearful and out of control – possibly they are worried about being judged, or think that they are unusual.

Getting real – acknowledging fear

I realise that my perspective/suggestions go against many childbirth preparation programs which aim to give women skills and techniques to control their fear (and behaviour). Whilst these techniques can be helpful… particularly during early labour… they are unhelpful for some… particularly during the intense transitional phase of labour. Women have told me they felt like failures because the techniques stopped working for them and they ‘lost it’. One woman recently told me that the practitioner who had taught her the techniques told her she had not done them properly because she felt pain and fear! In addition, suggesting that the baby suffers long-term emotional issues if fear is experienced during labour is unhelpful (seriously, women are told this).

An alternative approach is to open up the discussion about fear and losing control during birth.  Rather than trying to eliminate fear, it seems more helpful to acknowledge it is part of birth (for most) and to embrace it. Some suggestions:

During pregnancy

  • Explore fear – What are you afraid of? Is there anything you can do to help alleviate specific fears (eg. researching, talking, planning)?
  • Reinforce that it is OK if fear surfaces during birth… even if you think you have ‘worked through’ a specific fear during pregnancy it may resurface.
  • If you want to, learn relaxation/coping techniques – these may help, particularly in early labour – but don’t rely on them to work throughout (they might if you are lucky). Also don’t be persuaded that you need to master particular skills to birth well… you already have everything you need within you.
  • Create/plan a safe birth environment where losing control and feeling fear will be OK. Anyone who you plan to have in your birth space should be able to ‘be with’ your fear, and support you through it. You should feel comfortable about losing it in front of them without being judged.

During labour

Get on with birthing – as fear arises let it come, feel it, accept it, and deal with it however you need to (be loud, be angry, be quiet, reach out for reassurance, shut yourself in the toilet, breathe, whatever). It will pass, and you will birth.

Posted in birth, opinion and thoughts | Tagged , , | 70 Comments

Early Labour and Mixed Messages

Posted on September 22, 2012 by

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

This post is about early labour and the mixed messages women are given about this important part of the birthing process.

Defining the indefinable

The concept of ‘early’ or ‘latent’ labour emerged as a result of the birth process being broken down into stage and phases – the diagnosis of which relies on clinical assessments of contraction pattern and cervical dilatation. The notion of being able to determine the future progress of labour from such clinical assessments is not supported by research, yet it underpins maternity care. What research does show is that concepts of stages and phases of labour does not align with women’s perception and assessment of their own birth process (Gross et al. 2009; Low & Moffat 2006; Dixon et al. 2012).

In addition ‘early’ is only ‘early’ with hindsight. At one point in time (the clinical diagnosis of early labour) there is no way of knowing if labour will result in a baby in 30 minutes or 24 hours. If a labour is 2 hours long… when did early labour occur? As previously discussed an individual woman’s body is unique and so is her labour pattern.

Labour is basically the process by which a baby moves from the inside of a woman to the outside of a woman. Sounds simple, but it is incredibly complex and involves a complicated interplay of physiological, psychological and emotional factors. Women’s experience of labour often involves a sense of separation from the external world, focussing within, and becoming immersed in the act of giving birth. The hormones released during birth support this ‘altered state of consciousness’ (see the work of Sarah Buckley). During early labour the woman is beginning to move into this birthing state. Many midwives, including myself use the changes in behaviour displayed by women as they move into, and through the ‘birthing state’ to estimate how close the birth is. Of course, just like clinical assessments this is not entirely reliable as some women do not follow the usual scenario.

Despite the fact that concepts such as ‘early labour’ and ‘established labour’ are constructed, and not very helpful… I need to use these terms in this post because they are used consistently in the literature I am discussing (apologies).

Hospital perspective: early labourers are not welcome

Women admitted to hospital in early labour are more likely to end up experiencing complications and interventions, including caesarean section (Klein et al. 2004; Bailit et al. 2009; Rahnama et al. 2006). There are two explanations for this:

  1. That these women already have a dysfunctional, prolonged labour which is why they are coming to hospital in early labour. This explanation is favoured by a local hospital, and their response is to augment (ARM and IV syntocinon) all women who are admitted in early labour who do not establish labour within 2 hours. The rationale is to avoid a prolonged, complicated labour… and according to the obstetrician ‘women don’t want to be in labour for a long time’. I wonder if the women are consenting to these procedures based on adequate information… or just being asked if they want a shorter labour (hands up!)
  2. That exposure to the routine interventions involved with care in a hospital setting increase the chance of complications occurring (Bailit et al. 2009) ie. the longer the woman is in the system, the more opportunity there is to ‘do stuff’ to her.

Women admitted to hospital in early labour also cost the institution more money because they are on the ward for longer which increases demands on services and staffing. Therefore, great efforts are made to deter women from settling themselves into hospital during early labour. Antenatal classes warn women to stay away from the hospital for as long as possible to avoid intervention. When women ring hospital to enquire about coming in they are advised to ”take a paracetamol, have a bath the ring back in an hour” (guilty). Women are also told to only come to hospital when their contractions are coming every 5 minutes or less – which is concerning because the pattern of contractions is not necessarily an indicator of when the baby will be born. Entire services have been devised (phone support/home visits) to support women to stay at home during early labour (Janssen et al. 2009). When women arrive at hospital they are subjected to invasive clinical assessments to diagnose ‘established labour’ before they are ‘cleared’ for admission to labour ward (Cheyne et al. 2008).

If a woman does manage to get admitted whilst in early labour she is considered a burden by staff. She is likely to be put in a room and checked on occasionally and referred to as ‘not doing anything’, ‘niggling’, ‘she should go home’, etc. The midwife who admits her will be questioned and ridiculed at handover. The midwife allocated to her will most likely also be caring for a woman in ‘real labour’, and that woman will take priority. This is not to bag hospital midwives… I’ve been there myself, and it is very frustrating dealing with a woman in early labour whilst also caring for 1 or more women in ‘advanced’ labour. Whilst not condoning the hospital perspective on early labour – I can understand it from a cost/staffing perspective.

Women’s perspective: seeking reassurance and safety

Findings from qualitative studies suggest that staying away from hospital during early labour can be challenging for women. It seems that women want to be in hospital. And the experience of being assessed as ‘not in labour’ and sent home can be distressing and result in women feeling unsupported (Baxter 2007; Barnett et al. 2008; Scotland et al. 2011). A study of first time mothers found that women experienced embarrassment when they arrived at hospital too early to stay (Eri et al. 2010). They also felt vulnerable when negotiating with midwives to stay. The need to be in hospital is not necessarily about needing pain relief or support. Cheyne et al. (2007) found that women wanted to be in hospital during early labour despite feeling that they were coping well at home. Some participants reported feeling uncertainty about the safety of their baby whilst at home. Carlsson et al. (2009) also found that women were concerned for the wellbeing of themselves and their baby whilst labouring at home. They identified the theme ‘handing over responsibility’ as the core category emerging from their data. Women were keen to transfer to hospital in order to hand over the responsibility for safety to midwives.

Another concern associated with staying at home during early labour is uncertainty about identifying when established labour begins. Women in Cheyne et al.’s (2007) study expressed concern about not knowing how advanced their labour was while at home. Beebe et al. (2006) also found that first time mothers struggled to identify the onset of active labour themselves. Women worried about going to hospital too soon or too late, and were unsure of how to know if their labour was ‘the real thing’. Their main concern about staying at home was not being able to have their labour assessed by hospital staff. In Eri et al.’s (2010) study women perceived midwives as ‘gatekeepers’ with whom they had to negotiate their credibility with in order to gain access to the hospital. Gross et al. (2009) found that women’s own assessment of how and when their labour began was varied and did not match midwives’ clinical diagnosis of labour onset. A study of first time mothers by Low and Moffat (2006) found that women were perceived as abnormal by hospital staff if their experience of labour onset did not fit clinical definitions. Themes identified from the data included ‘this is not right’ and ‘don’t trust your body, trust us’

Physiology and contradictory messages

Let’s take a look at physiological explanations for early labour behaviour. Like all other mammals, labouring women seek a private and safe place where they can avoid distraction and immerse themselves in the act of birthing. During early labour women seek a place to settle and ‘nest’. This makes perfect sense because the neocortex is still engaged and can slow contractions (by reducing oxytocin) in response to thinking, talking, etc. - the woman can think clearly and do the practical things involved in a physical move. Once the woman is settled and her neocortex is not being stimulated, increased oxytocin release re-establishes contractions. This explains why labour often slows down in response to the move to hospital. However, as labour progresses the limbic system takes over and it becomes more difficult – and dangerous from an evolutionary perspective – to move from place to place. The neocortex is suppressed and the woman is deeply in an altered state of consciousness. This is the women who arrives at hospital already ‘separated’ from the external world, nothing stops her contractions, and she is often unaware of those around her until after the birth. So, the need to settle into the birth place during early labour is a normal response to the physiology of the birth process. It is also common for women to call on the support of other women during labour – women they know and who they feel safe with – relatives, friends, midwives, doulas. Early labour is a woman’s signal to get settled somewhere safe and to gather her ‘women-folk’ around her.

What is considered a ‘safe place’ is influenced by the culture in which the birth is taking place. I am not getting into the debate of hospital vs home re. safety. One, because I am totally over it, and two because I am a slightly biased homebirth midwife. Here is a Cochrane Review if you feel the need to head into the debate. Women in Australia (and many other parts of the world) are urged to birth in hospital because the cultural concepts of ‘safe’ involve medicine and technology. The experts in birth are the people who know how to use the medicine and technology, and who can carry out clinical assessments to determine wellness and progress (Davis-Floyd 2003). This message begins in pregnancy as women undergo routine clinical assessments with an emphasis on professional experts providing reassurance of wellbeing. Women are also bombarded with fear-based media about the dangers of birth, and the hospital-based Knights in Shining Armour who will gladly rescue any Damsel in Distress (and her baby). Therefore, it is not surprising that women head for the safety of the hospital when they are in early labour. Our culture has replaced the home/birth hut + well known women-folk with the hospital + unknown medical staff.

The emphasis on hospital as a place of safety whilst also encouraging women to stay away results in some very contradictory messages and ideas (please note these statements do not represent my own views):

  • We are the experts in your labour progress, only our clinical assessments can determine what is happening… but we’d rather you do not come in to be assessed, and instead stay at home not knowing what is going on.
  • Trust us – we want you to have a good birth experience… but if you come in too early we are likely to create complications which will require intervention… so keep away from us as long as you can.
  • We are the experts in your labour progress, our clinical assessments can predict your future labour progress… we will send you home if you are found to be in early labour… if you then birth your baby in the car park it is not our fault as birth is unpredictable.
  • This is a safe place to labour…. but you can only access this safety when you reach a particular point in your labour… preferably close to the end of your labour i.e. you should do most of it on your own away from safety. This contradiction results in a very annoying double standard: A women who labours at home and comes into hospital ‘fully and pushing’ is praised – ‘she did a great job’. However, she laboured (perhaps for many hours) without the attendance of a professional and without any monitoring (eg. fetal heart rate auscultation, etc.)…. On the other hand, a woman who homebirths intentionally is considered to be doing something unsafe despite the constant attendance and monitoring of her midwife.

Suggestions

Rather than considering ‘how to prevent women in early labour being admitted to hospital’, instead it may be better to explore how women’s needs during early labour can be accommodated by the maternity system. I would be interested to know what your experiences and/or suggestions are. Here are some thoughts, as usual I’m ignoring constraints of the system and money in favour of fantasy:

  • Antenatal care should centre on building self trust and reinforcing the woman’s own expertise in birthing her baby. If she relies on herself to determine wellbeing and progress she may be less likely to head to hospital early for reassurance. A study by Carlsson et al. (2012) found that first time mothers who managed to remain at home during early labour expressed a sense of power. Maintaining power was the central focus for these women and involved a sense of authority over their own body. Something to be encouraged I think!
  • Give early labour respect. It is an important part of the birth process and women deserve recognition for it… ie. don’t use the term ‘latent’ or ‘not in established labour’. The woman has begun the birth process. She has her signal to seek a safe place – help her do this.
  • Women’s access to their birth space should not rely on them meeting arbitrary measurements which involve invasive clinical assessments. They should be able to use early labour to get to their ‘safe place’ and settle for birth.
  • If you are planning to head to hospital while deeply in the altered state of labour – it might be useful to take along a doula who can advocate and use her neocortex while yours is suppressed.

Of course if a woman is birthing at home with a known and trusted care provider it is a different kettle of fish. She doesn’t need to concern herself with ‘when to go to hospital’ – and her care provider can (should) attend based on when the woman needs her…  not when she meets particular criteria. Then again in the real world not all women want to birth at home, or can get the support to do so. Therefore, the systems in which they birth need to change. The essential problem is that maternity care has developed in response to the needs of institutions – not the needs of women. More research is being done… and reports published about what women want from their maternity system. Unfortunately what they want (woman-centred, continuity of care) is the opposite to what is already deeply embedded in our society (hospital-based, fragmented care). To turn this around is a huge undertaking… and change will undoubtedly meet resistance from those who benefit from the way things are.

Posted in birth, intervention, midwifery practice, uncategorized | Tagged , , | 63 Comments

An actively managed placental birth might be the best option for most women

Posted on May 5, 2012 by

The birth of the placenta is my least favourite part of the birth process. I know I have ‘issues’ and I’m working on them. Hopefully writing this blog post will be therapeutic as well as informative. I am going to refrain from referring to the birth of the placenta as the ‘third stage’ of labour because I don’t believe in the concept of stages of labour.

What’s the big deal?

Postpartum haemorrhage is historically and globally the leading cause of maternal death (World Health Organization). The most dangerous time for a woman during the birth process is after her baby is born, around the time the placenta is birthed. Whilst the mother and baby meet face to face, and the family greet their new member, there is a lot of important work going on behind the scenes (ie. inside the woman).

The physiology of placental birth

This is an overview of what happens to ensure the placenta is born and the blood vessels feeding the placenta stop bleeding. If you want references, the information is available in any half decent anatomy and physiology text book (eg. Coad & Dunstall 2011; Rankin & Stables 2010)

Before the baby is born

Birth does not happen in distinct stages and the birth of the placenta is part of a complex process that begins before the baby is born. Oxytocin makes the uterus contract. Oxytocin is released by the posterior pituitary gland (in the brain) during labour to regulate contractions. It is one of the key birthing/bonding hormones. I really don’t have the space here to get into any depth about birth hormones, so check out the work of Sarah Buckley to find out more. As the birth of the baby becomes imminent, high levels of oxytocin are circulating in the mother’s blood stream. This creates strong uterine contractions which move the baby through the vagina, and prepare the mother and baby for post-birth bonding behaviours.

Separation of the placenta

 After the birth of the baby the contraction pattern is interrupted. The placenta transfers it’s blood volume to the baby ‘handing over’ the job of oxygenation to the lungs – the placenta is now emptier and less bulky. Instinctive mother-baby interactions stimulate further oxytocin release and the uterus responds by contracting. These interactions involve smell, touch (skin-to-skin), taste, sound… the baby ‘crawls’ on the mothers abdomen, his feet stimulating her uterus to contract. He may attach to the breast and feed, however this is not essential. The placenta is compressed and the blood in the intervillious spaces (the interface between mother’s blood system and the placenta/baby’s blood system) is forced back into the spongy layer of the decidua (uterine lining). Retraction of the uterine muscle fibres constrict the blood vessels supplying the placenta, preventing blood from draining back through the maternal vascular tree (mother’s blood vessels feeding the placenta). This congestion results in the veins rupturing and the villi shearing off the uterine wall. A clot forms behind the placenta. The non-elastic placenta is unable to remain attached and peels away – usually starting from the middle.

At this point you may notice a small gush of blood as the placenta separates and the umbilical cord lengthen as the placenta moves downwards.

After separation

The placenta leaves the upper segment of the uterus and further strong contractions bring the walls of the uterus into opposition – compressing the blood vessels. At the same time the contracted uterine muscle fibres act as ‘living ligatures’ to the blood vessels running through them preventing further blood flow. An increase in the activity of the coagulation system means that clot formation in the torn blood vessels is maximised and the placental site is rapidly covered by a fibrin mesh.

As the placenta leaves the uterus the mother may feel the urge to push again and birth her placenta. Or, she may be far too busy with her new baby and the placenta will sit in her vagina until she moves.

A mother birthing and catching her own placenta

This process is usually complete within an hour of the baby’s birth. However, sometimes it takes longer ie. hours… and hours. If you waited a long time to birth your placenta please post your story in the comments.

Pathology – when it doesn’t work

The bottom line is that the birth of the placenta and haemostatsis (prevention of excessive bleeding) relies on effective uterine contraction. Ineffective uterine contraction is the main cause of post partum haemorrhage (PPH). The other causes are perineal/cervical damage, or even more rarely clotting disorders.

There are 2 main causes of ineffective uterine contraction after birth:

  1. Hormonal – Inadequate circulating oxytocin or inadequate uterine response to oxytocin. Inadequate response is often because the oxytocin receptors in the uterus have become saturated eg. by large doses of syntocinon over a long period of time during an induction (Belghiti et al. 2011; Phaneuf et al. 2000).
  2. Mechanical – something is in the way and the uterus cannot contract. Most often this is a full bladder taking up space in the pelvis and stopping the uterus from contracting down. It can also be a large clot in the uterus or a partially detached placenta.

Most PPHs occur after the placenta is out. PPH can and does occur after a c-section too. In a future post I will discuss the management of bleeding, however this post focuses on physiological vs active management of placental birth and how this relates to PPH.

Another complication can be a retained placenta ie. the placenta remains attached. The definition of a retained placenta varies – and I’m not game to put a timeframe on it. However, once you have done something (such as given an oxytocic drug – see below) you need to finish the job and get the placenta out. If you have not, and there is no bleeding then… how long is a piece of string?

Active management of placental birth

In the 1950s syntocinon (pitocin) hit the birth scene. Syntocinon is an artificial version of oxytocin and is now used extensively for induction of labour, augmentation of labour and to ‘actively manage’ the birth of the placenta. It differs from endogenous oxytocin in the way it is released into the blood stream – ie. in a consistent dose rather than in pulse like waves. Syntocinon is also unable to cross the blood-brain barrier and influence instinctive bonding behaviour (check out Moberg’s book about how oxytocin influences behaviour).

When used to actively manage placental birth, syntocinon mimics the physiology described above by initiating uterine contractions. How active management is carried out varies considerably and this drives student midwives mad. Different practitioners do their own thing, and the literature is also inconsistent. Essentially syntocinon (10iu) is given to the mother by injection after the birth of the baby. The cord is clamped and cut, and the placenta is usually pulled out using controlled cord traction – see the horrible picture above. The order and timing of these interventions varies, although obviously pulling the placenta out comes last. The areas of debate/negotiation are:

  • Timing of injecting syntocinon: Originally syntocinon was given with the birth of the baby’s anterior shoulder. Nowadays it seems to be given after the birth of the baby. There is no research determining the best time. Syntocinon takes around 3 mins to work when given IM (into muscle) – so in theory to mimic physiology it probably should be given soon after the baby arrives.
  • Timing of clamping and cutting the cord: The risks of premature cord clamping are now well know. Most midwives I know (regardless of where they work) wait until the cord has stopped pulsing before clamping. This may have implications if the cord is not clamped before the syntocinon works… there is a theory that the strong contraction will shunt excess blood from the placenta to baby… I’m not so sure. Some midwives wait until after the cord has stopped pulsing before giving syntocinon to avoid this.
  • Whether to ‘drain’ the placenta: If the cord has been prematurely cut, some of the baby’s blood is trapped in the placenta – this makes the placenta bigger and more bulky, and in theory/experience more difficult to get out. There is no research to support this… but many midwives will leave the placenta end of the cord unclamped and drain the trapped blood prior to attempting to delivery the placenta. Personally, this is my preference as I notice it is much easer to get an empty placenta out. Something I learned while collecting cord blood.
  • Whether or not controlled cord traction is used and when: It is standard practice to pull the placenta out after syntocinon has been injected, and the umbilical cord has been cut. Some midwives wait until they have seen signs of placental separation before pulling. I think it is this part of active management that causes the most problems. If you pull on a placenta that has not yet separated you can partially detach it = some blood vessels are ‘torn and open’ but the uterus cannot contract because the placenta is in the way. Or, you can detach it before the syntocinon is working i.e. no contractions to stop the bleeding. Or worse case, and very rare scenario you can pull the uterus out! You can also, more commonly snap the umbilical cord – which often freaks everyone out. But a snapped cord is not a big drama. It just means the mother will have to get up and push her placenta out… Which brings me around to the idea of not pulling at all. A study by Gülmezoglu et al. (2012) found that the ‘omission of controlled cord traction’ did not increase the risk of severe haemorrhage (they only looked at severe). So, women should have the option of getting upright and pushing, or having someone pull their placenta out for them. Or even perhaps pulling their own placenta out?

Active management is usually (not always) quicker than physiological. This is probably another reason it is favoured in hospital settings. Less time waiting for a placenta = less time stressing out about a potential PPH, and you can get the woman to the next station (postnatal ward) quicker.

Occasionally syntometrine is used for active management. This is a mix of syntocinon and ergometrine. It is not generally used nowadays because the ergometrine acts on smooth muscle – all smooth muscle. Therefore the side effects are vomiting, raised blood pressure and potentially a retained placenta due to the cervix shutting… although I’m not convinced about the cervix closing firmly enough to trap a squishy placenta.

What the research tells us – and doesn’t tell us

The physiological vs active management of the ‘third stage’ has been going on since I was a student midwife (I did a literature review on it as an assessment). Today I am doing it the easy way and relying Cochrane to review the studies for me (Begley, et al. 2011; Cotter, Ness & Tolosa 2010). In summary the reviews note that there is a ‘lack of high quality evidence’ but conclude that active management reduces the risk of haemorrhage. They also raise concerns about side effects – increased blood pressure, afterpains and vomiting (probably due to the use of syntometrine in some studies); reduced birthweight for baby (probably due to reduced blood volume following premature clamping); more women returning to hospital with bleeding (?). In regards to the last side effect – anecdotally midwives report greater blood loss on the post natal ward after the syntocinon or syntometrine has worn off but this is not measured in studies.

The important thing to remember when interpreting these findings is that all of the studies included were conducted in a hospital setting. The experimental group were those having ‘physiological’ management. The practitioners attending the ‘physiological’ placental births were most likely doing something that was not their usual practice, and they may have been unprepared for, or uncomfortable with this approach. A study that compared active vs holistic physiological care had very different findings (Fahy, et al. 2010). In this study the midwives attending the physiological placental births were familiar and comfortable with this approach. In contrast to previous studies active management was associated with a seven to eight fold increase in PPH rates compared to a holistic physiological approach. Another retrospective study (Davis et al. 2012) found a twofold increase in large PPHs (1000mls+) for low risk women having an actively managed placental birth in New Zealand compared to those having a physiological placental birth.

Back to my initial title statement

A safe and effective physiological placental birth requires effective endogenous oxytocin release. This is generally facilitated by:

  • A physiological birth of the baby: No interventions during the birth process eg. induction, augmentation, epidural, medication, instructions or complications.
  • An environment that supports oxytocin release: Privacy, low lighting, warmth and comfort. No strangers entering the birth space eg. paed or extra midwife.
  • Undisturbed skin-to-skin contact between mother and baby: others must not handle the baby or engage the mother in conversation (no patting, no chatting and no hatting – Carla Hartley). These interactions may result in breastfeeding, but this should not be ‘pushed’ as not all babies want to breastfeed immediately.
  • No fiddling: No feeling the fundus. No clamping, cutting or pulling on the umbilical cord. No clinical observations or ‘busying’ around the room.
  • No stress and fear: Those in the room must be relaxed. The midwife needs to be comfortable with waiting and have patience. The mother must not be stressed as adrenaline inhibits oxytocin release. This is why a PPH often occurs after a complicated birth (eg. shoulder dystocia) and when the baby needs resuscitating.
  • No prescribed timeframes: Many hospital policies require intervention within half an hour if the placenta has not birthed. This is not helpful and generates anxiety which is counter productive.

Of course this is a general list and some women are perfectly capable of birthing their placentas amongst the chaos of siblings and noise etc. Probably because it is their own, familiar chaos and they are relaxed in the midst of it. Others want the cord cut after it has stopped pulsing eg. if it is short. I think the most important factor in ensuring a safe physiological birth of the placenta is a physiological birth of the baby.

However, in Australia (AIHW 2011) only 21% of women go into spontaneous labour and continued to labour without augmentation. Out of that % how many labour without an epidural or other medication? Out of that % how many are birthing in the conditions described above? I pose the question because these stats are not presented. I don’t need to ask the question because I am familiar with hospital practice… and most women are birthing in hospital.

Until hospitals are able to provide care that facilitates a physiological birth process, women choosing to birth in them may find that the safest option is active management of their placental birth. There are further options within this that can be negotiated (see above). Physiological placental birth is an option and possible if you manage to avoid induction, augmentation, an epidural or complications – but be aware of how difficult it may be, and don’t beat yourself up if it doesn’t happen.

Further reading/resources

Belghiti J, Kayem G, Dupont C, et al. Oxytocin during labour and risk of severe postpartum haemorrhage: a population-based cohort-nested case-control study. BMJ Open 2011;1: e000514. doi:10.1136/ bmjopen-2011-000514

Hastie C, Fahy KM. Optimising psychophysiology in third stage of labour: Theory applied to practice, Women Birth (2009), doi: 10.1016/j.wombi.2009.02.004

On Birth and Bleeding – Science & Sensibility

Posted in birth, intervention, uncategorized | Tagged , , , , | 133 Comments

Asynclitism: a well aligned baby or a tilted head?

Posted on April 25, 2012 by

This post is a quickie. I am compiling a list of suggestions for future posts via Facebook and Twitter which I will start working through. In the meantime this little topic has been cropping up a lot so here goes…

Asynclitism is when the baby’s head is moving through the pelvis ‘tipped’ to one side. This is usually diagnosed by a vaginal examination in labour. However, asynclitism is rarely caused by the baby having his/her head tilted to one side and rarely a real problem. Instead, like the anterior lip, it is a normal part of the physiological process of birth.

Disclaimer: Routine vaginal examination has NO place during a physiological birth. Unfortunately vaginal examinations continue to be commonly used to determine progress despite the lack of evidence supporting this invasive intervention. In addition, most women do not experience a physiological birth and instead have their labour induced or augmented. Once an intervention is implemented it’s effects need to be monitored ie. assessment of cervical dilation. Therefore, the following explains what is felt during an examination in relation to what is happening as the baby descends and rotates through the pelvis.

Asynclitism: normal birth physiology

The baby enters the pelvis through the brim/inlet. The easiest way to do this is with the head in the transverse position (facing sideways to mother). However, the baby is not lying in a perfecting vertical position. The woman’s pelvis is tilted and her uterus/baby are also sticking out at an angle – check out a pregnant woman for confirmation. If at this point in the birth process you put your fingers into her vagina, you will feel the side of the baby’s head near the symphysis pubis. If you dig further you will feel the saggital suture towards the back of the pelvis. The baby’s head is not tilted… it is perfectly aligned with the baby and the pelvis.

Once the baby has descended into the cavity/mid-pelvis he will use the space and the counter pressure of the pelvic floor (unless the muscle tone is reduced by an epidural) to rotate an anterior position (facing towards mother’s back) to fit the shape of the pelvic outlet. It is not until the baby has made this rotation that you will feel the centre of the head in the middle of the pelvis. If the baby’s head is well flexed, you will also be able to feel the occiput, the posterior fontanelle and the lambdoidal suture (I love that word – lambdoidal).

As usual the text book depictions of a perfectly central saggital suture reflect our cultural need to keep birth neat and orderly. It fits in with the clean and clinical depictions of birth in which the woman is replaced by diagrams and graphs. The reality of a vaginal examination is very different and involves bodily fluids, squishy bits, hair, caput (swelling on baby’s head), moulding, the amniotic sac, difficult to distinguish parts of the head… and is usually an unpleasant experience for the woman (yes, she is involved). When birth becomes complicated there may be an indication for a vaginal examination (eg. to determine position), but in the absence of a complication there is no point. Telling a woman that her baby is asynclitic is at best pointless and at worst stress inducing… OK I’ll shut up about VE’s and save it for dedicated post later on. Moving on…

Asynclitism: a variation or complication

Occasionally the baby enters the pelvis with his/her head tilted down towards their shoulder (a variation). If the baby continues to descend in this position it can alter the progress of the birth process. The woman may experience irregular contractions without change over many hours. Most of the time the baby will sort themselves out, particularly with an actively mobile mother. Techniques to create more space in the pelvis may help to provide additional room for head wriggling and repositioning. Unfortunately a common response to this situation is to put up syntocinon (pitocin) and create stronger contractions. It doesn’t take a genius to work out what happens if you have stronger contractions pushing the baby through the pelvis even harder and faster. The baby needs space to realign his head rather than more pressure and compaction (and the additional risk of syntocinon). Very occasionally the baby is unable to adjust his position and the birth becomes complicated – the baby becomes increasing compacted in the pelvis and begins to show signs of distress. In this situation the woman may require assistance to birth (instrumental birth or c-section).

Summary

Asynclitism is a normal part of the birth process. When it is caused by a tipped head it can alter the pattern of labour and may require additional work and support. It can be difficult to work out which type of asynclitism is happening via a vaginal examination (normal or a tilted head). Therefore it is best to keep fingers out of the vagina and focus on the woman and what she does or does not need from you.

Further resources

Spinning babies

I would love to hear your experiences of asynclitism.

Posted in birth, midwifery practice | Tagged , , , | 58 Comments

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 , , , , , , , | 65 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 , , , | 33 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 , , , , , , | 117 Comments