Post-Dates Induction of Labour: balancing risks

Posted on July 13, 2016 by MidwifeThinking

Updated: August 2019

In Australia 33% of labours are induced (40.5% of first time mothers). The most common reason for induction is to prevent a ‘prolonged pregnancy’. That’s an awful lot of babies outstaying their welcome and requiring eviction. I am not going to get stuck into the concept of ‘due dates’ or rather ‘guess dates’ here – I discuss estimating birth dates in my book. This post will focus on induction of labour to prevent a ‘prolonged’ pregnancy and the complexities of risk in this situation.

A quick word about risk

I don’t particularly like the concept of ‘risk’ in birth. There are all kinds of problems associated with providing care based on risk rather than on individual women. However, risk along with ‘due dates’ is here to stay, and women usually want to know about risks. Risk is a very personal concept and different women will consider different risks to be significant to them. Everything we do in life involves risk. So when considering whether to do X or Y there is no ‘risk free’ option. All women can do is choose the option with the risks they are most willing to take. However, in order to make a decision women need adequate information about the risks involved in each option. If a health care provider fails to provide adequate information they could be faced with legal action. Induction for prolonged pregnancy is not right or wrong if the choice is made by a woman who has an understanding of all the options and associated risks. As a midwife I am ‘with woman’ regardless of her choices. It is my job to share information and support decisions – not to judge.

What is a prolonged pregnancy?

Before we go any further lets get some definitions clear:

  • Term (as in a ‘normal’ and healthy gestation period): is from 37 weeks to 42 weeks.
  • Post-dates: the pregnancy has continued beyond the decided due (guess) date ie. is over 40 weeks.
  • Post-term: the pregnancy has continued beyond term ie. 42+ weeks.

The World Health Organization’s definition of a ‘prolonged pregnancy’ is one that has continued beyond 42 weeks ie. is post-term. However, induction is usually offered when a pregnancy becomes post-dates with the aim of preventing it becoming ‘prolonged’. Therefore, very few women experience a prolonged pregnancy – in Australia only 0.6% of pregnancies continue beyond 42 weeks.

The idea of a prolonged pregnancy assumes that all women naturally gestate their babies for the same length of time. However, it seems that genetic differences may influence what is a ‘normal’ gestation time for a particular woman. For example, Morken, Melve and Skjaerven (2011) found “a familial factor related to recurrence of prolonged pregnancy across generations and both mother and father seem to contribute.” Therefore, if the women in your family gestate for 42 weeks so might you. The length of gestation may also be influenced by factors such as diet (McAlpine et al. 2016).

The initiation of labour is likely caused by the baby who secretes surfactant protein and platelet-activating factor into the amniotic fluid as their lungs mature (Mendelson 2009; Science Daily). This results in an inflammatory response in the mother’s uterus that initiates labour.

The risks associated with waiting for spontaneous labour

Ageing placenta?

Some people believe that the placenta has a best before date and starts to deteriorate after 40 weeks resulting in reduced nutrition and oxygen for the baby. There is evidence that the structure and biochemistry of the placenta changes as pregnancy develops. Some scientists interpret these changes as the placenta growing and adapting to meet the changing needs of the baby: “There is, in fact, no logical reason for believing that the placenta, which is a fetal organ, should age while the other fetal organs do not…” Others argue that these changes are due to the ageing and deterioration of the placenta. However, tests of placental function show no changes in post-dates pregnancies (Madruzzato et al. 2010). In practice, I have seen signs of placental shut down (ie. calcification) in placentas at 37 weeks and I have seen big juicy healthy placentas at 43 weeks. Sophie Messenger write more about ‘the myth of the ageing placenta’ here.

Big baby

People also have concerns that the baby will grow huge and therefore be difficult to birth. There is evidence that babies continue to grow bigger the longer they gestate, and this contradicts the above theory about the ageing placenta. If the placenta stops functioning, how does the baby continue to grow so well? Big babies are pretty good at finding their way out of their mothers expandable pelvis. The research about complications relating to big babies suggests that it is the interventions carried out when a baby is assumed to be big – rather than the actual size of the baby – that mostly contributes to complications (Sadeh-Mestechkin et al. 2008; Blackwell et al. 2009; Peleg et al. 2015).

Meconium liquor

There is an increased chance that the baby will pass meconium as his/her bowels mature. I have written about this scenario in another post.

Perinatal death

The general rate of perinatal death (stillbirth + newborn death) increases as pregnancies advance beyond term. The rate remains small but is statistically significant. For example a systematic review and meta-analysis (Muglu et al. 2019) reported that: “The overall gestation-week-specific prospective risk of stillbirth steadily increased with gestational age, from 0.11 per 1,000 pregnancies at 37 weeks to 3.18 per 1,000 at 42 weeks gestation… The risks of newborn death remained constant between 38 and 41 weeks, and only increased beyond 41 weeks” .

Post-dates induction of labour reduces the general rate of perinatal death. A Cochrane Review summarises the research examining induction vs waiting: “There were fewer baby deaths when a labour induction policy was implemented after 41 completed weeks or later.” However, it goes on to say: “…such deaths were rare with either policy…the absolute risk is extremely small. Women should be appropriately counselled on both the relative and absolute risks.” Hands up all the women who had a discussion with their care provider about the relative and absolute risks of waiting vs induction…

Essentially, according to the available research, if you are induced at 41 weeks your baby is less likely to die during, or soon after birth. However, the chance of your baby dying is small either way – less than 1%… or 30 out of every 10,000 for those waiting vs 3:10,000 for those induced. This research article reports the relative and absolute risk of stillbirth at various gestations with waiting vs induction. The authors state that 1476 women would need to have an induction to prevent 1 stillbirth at 41 weeks gestation.

Reviews are only as good as the research they review and there are some concerns about the quality of the available research. The World Health Organization recommends induction after 41 weeks based on the Cochrane Review above but acknowledges the evidence is “low-quality evidence. Weak recommendation”.  Another review of the literature in the Journal of Perinatal Medicine (Mandruzzato et al. 2010) concluded: “It is not possible to give a specific gestational age at which an otherwise uncomplicated pregnancy should be induced.”

One of the main problems with quantitative research is that it rarely answers the question ‘why’, and rather focuses on ‘what’ (happens). For example, congenital abnormalities of the baby and placenta are associated with post-term pregnancy and this may account for the increased risk in some cases, rather than the length of gestation (Mandruzzato et al. 2010). Quantitative research also takes a general perspective rather than addressing the risk for an individual woman in a particular situation. For example, is the prolonged pregnancy as sign of pathology, or does this woman come from a family of women who have a longer gestational timeframe? For a woman who has previously gestated to post-term without complications, there is no increased chance of an adverse outcome (Kortekaas et al. 2015).

The risks associated with induction

It can be difficult to untangle and isolate the risks involved with induction because usually more than one risk factor is occurring at once (eg. syntocinon, CTG, epidural). In addition, there are differences in outcomes and risks between women who have previously laboured, and women having their first baby. It is important for women to consider their own individual factors and how they alter their individual risk profile. Care providers should also share individualised information when discussing induction options.

General risks associated with the induction procedure and medications

The induction process is a fairly invasive procedure which usually involves some or all of the following (you can read more about the process of induction here). There are a number of minor side effects associated with these medications/procedures (eg. nausea, discomfort etc.) There are also more significant risks:

The most extreme of these risks are rare, but fetal distress and c-section are fairly common. The potential effects of uterine hyperstimulation on the baby are well known (Simpson & James 2008)- which is why continuous fetal monitoring is recommended during induction. This may also explain the association between induction and cerebral palsy (Elkamil et al. 2010)

Induced contractions are usually more painful than a physiological contractions. Syntocinon (pitocin) produces strong contractions without the gentle build up and endorphin release of natural contractions. The National Institute of Clinical Excellence (UK) state that health care professionals should discuss this with women when offering induction “recognising that women are likely to find induced labour more painful than spontaneous labour”.

Most research comparing induction with spontaneous labour combines populations of ‘experienced’ labourers with first timers. These studies report conflicting findings. For example, some studies report a lower chance of c-section with induction for this mixed group (Gülmezoglu et al. 2012; Mishanina et al. 2014; Wood et al. 2014). In contrast, more recent studies have found increased rates of c-section with induction (Zhao, Flatley, Kumar 2017; Ekéus & Lindgren 2016). A 2019 review compared the timing of induction for low risk pregnancies – 41 weeks vs 42 weeks (Rydahl, Eriksen & Juhl 2019). The review used stricter inclusion criteria than previous reviews to “enhance the methodological quality and increase the relevance for contemporary maternity care”; and reported that: “Induction at 41+0-6 gestational weeks compared to 42+0-6 gestational weeks was found to be associated with an increased risk of overall cesarean section.”

Risks for women who have had a previous labour

Women who have laboured before respond more effectively to syntocinon (pitocin) because they have more oxytocin receptors in their uterine muscle. Therefore, this group of women are more likely to experience a successful induction and avoid c-section. They are likely the reason for lower or similar rates of c-section the mixed group research discussed above. However, they are at increased risk of hyperstimulation with prostaglandin medication and/or syntocinon. So doses are usually smaller and very carefully monitored to avoid fetal distress. Women who have given birth vaginally before, are also at increased risk of perineal tearing if they have syntocinon induced contractions.

Risks for women having their first labour induced

Inducing a first labour requires higher rates of syntocinon, and the length of labour is usually longer. It is not surprising that first time mothers are more than 3 x more likely to opt for an epidural during an induction (Selo-Ojeme et al. 2011); and epidural analgesia increases the chance of ending up with an instrumental birth – ventouse or forceps (Anim-Somuah et al. 2018)

The majority of research comparing induction (IOL) with spontaneous (SP) labour in populations of first time labourers report increased c-section rates:

Another US study (Ehrenthal et al. 2010) reported that after “adjusting for maternal demographic characteristics, medical risk, and pregnancy complications. The contribution of labor induction to cesarean delivery in this cohort was estimated to be approximately 20%.” This brings up interesting risk comparisons relating to c-section vs the risk of post-dates perinatal death (see above). For example, induction is recommended because there is a less than 0.3% chance of perinatal death in post-dates pregnancies (see above). However, the chance of a significant complication during c-section (eg. hysterectomy) is higher than the chance of perinatal death in a post-dates pregnancy; and after a c-section the chance of stillbirth during a subsequent pregnancy increases to 0.4% – again, a higher rate than a postdates pregnancy.

A recent study causing a stir is the ARRIVE RCT trial (US) which reported lower c-section rates in the induction group (18.6% vs 22.2%). This one study is now being used to justify recommending early induction at 39 weeks – primarily because the findings align with cultural norms and preferences (see this post re. implementation of research findings into practice). Whilst I don’t want to give this study unwarranted attention… it keeps popping up in conversations, workshops, and presentations. Like the perineal bundle – it is an unavoidable topic in the birth world. So here goes (briefly)… recommendations based on the trial are problematic in a number of ways. The findings and recommendations have been constructively critiqued by academics, midwives and obstetricians (Dekker 2018; Carmichael & Snowdon 2019; Davis-Tuck et al. 2018; Scialli 2019). In summary, the main points are:

  • Only 27% of eligible women agreed to participate – Findings can only be applied to women who are willing to have a medically managed birth.
  • 94% of the woman were cared for by private obstetricians in US medical settings – Findings cannot be applied to other types of care providers and settings which have much lower rates of c-section and higher rates of spontaneous vaginal birth.
  • Care providers were not blinded – Knowing about the trial my have altered their practice.
  • IOL reduced c-section rates by 4% – This cannot be used to recommend IOL to prevent c-section. Other factors have a much more significant effect on c-section rates eg. continuity of midwifery care; place of birth; intermittent auscultation in labour; etc.
  • The primary outcome measure for this study was perinatal outcome (ie. the baby) – IOL made no difference to the immediate outcomes for the baby, and the study did not address the long-term harm of early birth for the baby (eg. brain development).

In relation to the primary outcome measure – perinatal outcomes. Another study (Selo-Ojeme et al 2011) found that outcomes for the baby were worse when a first labour was induced: “babies born to mothers who had an induction were significantly more likely to have an Apgar score of <5 at 5mins and an arterial cord pH of <7.0“. 

The experience of induction

Research into induction tends to focus on physical outcomes rather than women’s emotional/psychological experiences of the process.

Choosing induction will totally alter the birth experience and the options open to you. Women need to know that agreeing to induction means agreeing to continuous monitoring and an IV drip, which will limit movement. Induced contractions are usually more painful than natural contractions and the inability to move and/or use warm water (shower or bath) reduces the ability to cope. The result is that an epidural may be needed. An induced birth is not a physiological birth and requires monitoring (vaginal exams) and time frames. Basically you have bought a ticket on the intervention rollercoaster. For many women this is fine and worth the risk, but I encounter too many women who are unprepared for the level of intervention required during an induction. This does not mean you have to hand over control of your decisions or your body; and in my book I include a chapter on creating a birth plan for induction of labour.

There have been some studies examining women’s experience of induction. A UK study by Henderson and Redshaw (2013) found that “women who were induced were generally less satisfied with aspects of their care and significantly less likely to have a normal delivery. In the qualitative analysis the main themes that emerged concerned delay, staff short- ages, neglect, pain and anxiety in relation to getting the induction started and once it was underway; and in relation to failed induction, the main themes were plans not being followed, wasted effort and pain, and feeling let down and disappointed.”.  A German study (Schwarz et al. 2016) concluded that: “women’s expectations and needs regarding IOL are widely unmet in current clinical practice… and that “there is a need for evidence-based information and decisional support for pregnant women who need to decide how to proceed once term is reached.”

A recent systematic review (Coates et al. 2019) of qualitative research into women’s experiences of induction of labour concluded that induction “is a challenging experience for women, which can be understood in terms of the gap between women’s needs and the reality of their experience concerning information and decision-making, support, and environment. “

Alternatives to medical induction

Waiting for spontaneous labour

Around 90% of women who wait for spontaneous labour will give birth before 42 week, and only 1% will go beyond 43 weeks (Gülmezoglu et al. 2012). Most guidelines recommend additional monitoring of the baby – however no form of monitoring reduces the chance of complications (Gülmezoglu et al. 2012).

‘Natural’ induction?

There are a number of ‘alternative’ or ‘natural’ induction methods available (I have a chapter discussing the evidence for various methods in my book). However, trying to get the body/baby to do something it is not ready to do is still an intervention whether it is with medicine, herbs, therapies, techniques… or anything else. Interventions of any kind can have unwanted effects and consequences. Medical inductions take place with close monitoring of mother and baby and access to medical support if a complication arises. Alternative inductions do not have this level of monitoring or back up.

However, ‘interventions’ (massage, acupuncture, etc.) that are aimed at relaxing the mother and fostering trust, patience and acceptance may assist the body/baby to initiate labour if the physiological changes have already taken place.

Summary

A significant minority of babies will not be born by 41 weeks gestation. Whilst the definition of a prolonged pregnancy is 42 weeks+, induction is usually suggested during the 41st week. Women need to be given adequate information about the risks and benefits involved with either waiting or inducing in order to make the choice that is right for them. There is no risk free option. The risk of perinatal death is extremely small for both options. I know women who have lost a baby in the 41st week of pregnancy, and women who have lost a baby as a result of the induction process. For first time mothers the induction process poses particular risks for themselves and their babies. Each individual woman must decide which set of risks she is most willing to take – and be supported in her choice.

You can read more about induction in my book Why Induction Matters

Why_Induction_Matters_-_Pinter___Martin_Publishers

Further resources

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Responsibilities in the mother-midwife relationship

Posted on June 28, 2016 by MidwifeThinking

Updated: April 2020

When I facilitate workshops with midwives and students, there is always a lot of discussion and debate about professional responsibilities in the mother-midwife relationship. These debates often get heated, and the complexities of legal, professional, and ethical issues can become confusing. This post is an attempt to ‘un-confuse’ and simplify these matters a little. Please note that this post is aimed at registered midwives ie. midwives who register each year, thereby agreeing to meet professional standards. It is also about Australian midwifery and may or may not be applicable to other countries.

Midwives can get caught up in meeting the needs of the institutions they work in, and/or feeling responsible for the decisions that women make (eg. to follow or not to follow institutional recommendations). So, it can be helpful to reflect on what our core responsibilities are in the mother-midwife relationship, and how we can meet them. These core responsibilities remain regardless of the care model and/or setting.

As midwives we have guidance about our responsibilities via our professional bodies. The International Confederation of Midwives (ICM) provide a number of core documents that are reflected in national codes and standards e.g. the Nursing and Midwifery Board of Australia (NMBA). These documents are referenced when determining whether a midwife met their professional responsibilities. In this post I discuss my interpretation of these documents and the law in relation to responsibilities. I would be interested in your interpretations too so please comment.

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Midwives’ Responsibilities

“Midwifery care takes place in partnership with women, recognising the right to self-determination, and is respectful, personalised, continuous and non-authoritarian.” – ICM Philosophy and Model of Maternity Care

In essence midwifery care is ‘woman-centred’. This means that the midwife must primarily meet the needs of the woman – not the institution, or cultural norms, or colleagues, or a personal agenda.

In order to meet their core responsibilities, midwives need to be research literate. By that, I don’t mean they need to be able to conduct research or understand complex statistics. However, they do need to be able to find evidence, evaluate it, and apply it to practice. This is why university midwifery programs include research in the curriculum (and yes, students generally hate it!). The NMBA Midwife Standards for Practice state that:

“The midwife supports women’s wellbeing by providing safe, quality midwifery health care using the best available evidence and resources, with the principles of primary health care and cultural safety as foundations for practice.”

“The midwife identifies what is important to women as the foundation for using evidence to promote informed decision-making, participation in care, and self- determination”

Adequate Information

“Midwives develop a partnership with individual women in which they share relevant information that leads to informed decision-making, consent to an evolving plan of care, and acceptance of responsibility for the outcomes of their choices.” – ICM International Code of Ethics for Midwives

“Midwives provide women with appropriate information and advice in a way that promotes participation and enhances informed decision-making.” – ICM Philosophy and Model of Maternity Care

It is essential that midwives provide women with adequate information. A failure to do so not only breaches professional standards, but can also result in legal action for assault and battery (due to invalid consent) or negligence (of information giving). The legal standards for ‘reasonable information’ are listed in a previous post; and there are also professional standards about information giving.

Firstly midwives need to be clear about how they practise, their responsibilities, and their boundaries. For example, a woman needs to know that a private practice midwife is guided by the National Midwifery Guidelines for Consultation and Referral and the Safety and Quality Guidelines for Privately Practising Midwives; and what this means if her situation is categorised as a ‘consult’ or ‘refer’. In Australia, private practise midwives can withdraw care if a woman declines consultation or referral. They can also continue care if the woman declines a consult or refer. A woman needs to know her midwife’s threshold for withdrawing care before engaging their services.

When a decision is required about any aspect of care – from place of birth, to vitamin K for the newborn – adequate information must be provided about the option/procedure/intervention. In the case of a procedure – the person performing the procedure needs to gain consent ie. ensure adequate information is given. For example, if a midwife is about to start an induction process for a woman – that midwife is responsible for ensuring the woman is adequately informed. It would be nice if the person arranging the induction, or the person prescribing the medication provides adequate information… but the midwife cannot rely on this. It is her/his responsibility.

If the midwife is employed by an institution she may be obliged to offer particular options eg. a 4 hourly vaginal examination during labour. However the key word is ‘offer’. In addition to this offer, the woman needs adequate information to consent or decline the offer. If the midwife is in private practice she/he needs to inform the woman of the ‘standard’ or mainstream practise, particularly if there are state, national or international guidelines/recommendations.

For an option or intervention adequate information includes:

  • The rationale for the recommendation: why guidelines suggest the option or procedure.
  • A description of the option or procedure: what it is, how it is carried out, what it involves, etc.
  • General benefits and risks of all options: including current research, and whether guidelines are supported by research.
  • Individualised benefits and risks of all options: are there different stats/research that the woman needs to consider in regard to her individual circumstances?

Let’s take a look at some examples…

Eg. What a woman needs to know about induction of labour for post-dates pregnancy:

  • That most clinical guidelines recommend induction of labour at 41 weeks + because there is an increase in perinatal mortality (baby death) for pregnancies that continue beyond 41 weeks. I can see that some of you are already cringing, but this is the truth. You also need to quantify that risk for the woman in a meaningful way eg. 30:10,000 for waiting vs 3:10,000 if labour is induced (see this post). It is not adequate to just state ‘there is increased risk’ or to say that ‘the risk is small’.
  • What induction of labour involves and how it is different to physiological labour; and what would happen if she chose to wait eg. options re. monitoring.
  • The general risks and benefits of induction, and of waiting (see this post).
  • The individual risks for the woman i.e. factors that change her risks eg. is this her first baby? Are there other health concerns or issues (eg. VBAC)?

Eg. What a woman needs to know to consent to a routine vaginal examination during labour (as per a hospital guideline rather than in response to a situation):

  • That the hospital guidelines requires the midwife to offer a vaginal examination, for example, the midwife might say “The guideline in this hospital recommends that I offer a vaginal examination to you because you have been in birth suite for 4 hours. The reason for this is to attempt to estimate the progress of your labour.” (you must do this to meet your employee requirements if there is a hospital guideline or policy)
  • The evidence supporting (or not) the recommendation, and the risks and benefits of the intervention: “There is no evidence to support that a vaginal examination is an effective method of assessing labour progress because it can’t predict the future…” insert explanation about how all women have a different labour pattern… and the risks and benefits of the a VE.
  • Any individual factors that alter risks or benefits eg. if her membranes are not intact there is an additional risk of infection. In some cases a VE may be helpful to support decision making with regard to necessary intervention eg. if labour seems abnormal or the baby’s heart rate is concerning.

It can also be helpful to assert that it is the woman’s decision and that you will support her in whatever she thinks is best for her (many women think they have to follow recommendations).

It is particularly important to provide clear information when a woman is making decisions outside of recommendations or the norm. There is no risk free choice – the woman must decide which risk is most significant for her. In order to do this she needs to have adequate information. For example, if a woman is choosing to birth at home she needs information about the benefits, risks and other options. She needs know the difference between home and hospital, including how the setting might alter the management of any complications.

Information sharing needs to be documented. Like any aspect of care there needs to be evidence that it happened. For example, when gaining consent for a vaginal examination – rather than writing ‘VE with consent’, list the risks discussed (bullet points will do). Some hospitals are using consent forms for common interventions eg. VE and ARM with a list of risks for the midwife to read out and get the woman to sign. If you give the woman any information resources – write down what you gave her.

It is also important to be clear about your scope and abilities by “acknowledging one’s own strengths and limitations” (NMBA 2008b). This involves being honest with women about your experience and ability to meet her needs. For example, if you have limited experience in attending breech births, and her baby is breech – she needs to know. If she is wanting a physiological placental birth and you (the midwife) have limited experience in supporting this – she needs to know.

A word about words… I realise the word ‘risk’ is used a lot in this post. However, the reality is that as midwives we are expected to talk about ‘risk’. We can change the word for ‘chance’ in many cases – but not all. Like it or not, we operate in a ‘risk’ discourse and for legal purposes need to disclose ‘risk’ information with women. However, I avoid the word ‘safe’ when talking to women about their options. Safety is in the eye of the beholder – it is up to the woman whether she thinks a 1:1000 chance of something happening is ‘safe’ or ‘unsafe’. Saying something is ‘safe’ is a judgement and can be seen as an endorsement of a particular option.

Which brings us to the issue of bias. Information sharing needs to be unbiased, and this is extremely difficult because we are all biased and have our own beliefs and opinions. However, there are some strategies to avoid transmitting your bias whilst giving information:

  • Present both sides of the coin (see above) ie. risks and benefits of all options in a matter of fact manner ie. don’t share your personal opinions or experiences (with other women) about an option.
  • Avoid advising or recommending particular options unless a complication or pathology is actually occurring. For example, you wouldn’t recommend induction, or waiting for an uncomplicated post-dates pregnancy; but you would recommend a medical review if a woman’s blood pressure was abnormally high.
  • Ensure that the woman knows you are not invested in her decision, and that you do not want to influence her either way – say this to her.
  • When asked “what would you do?” – point out that you are not her , and not in her situation, and what you would do is irrelevant to what is best for her.
  • Avoid telling her what you did with your own pregnancy, birth, baby – again, this is not relevant to her.
  • Don’t create unnecessary fear about other options, for example if she is choosing to homebirth, it is unprofessional to tell her how awful the local hospital is. Not only can this influence her decision, but it can also make things problematic if a transfer to that hospital is needed.

A good way to assess whether you are providing un-biased information is to look at what women in your care choose to do. If all of the women you care for choose the same option – you need to consider if you are influencing them. Women are individuals and there should be a range of decisions being made.

Support

Woman-centred care... “enables individual decision-making and self-determination for the woman to care for herself and her family. Woman-centred care respects the woman’s ownership of her health information, rights and preferences while protecting her dignity and empowering her choices. Woman-centred care is the focus of midwifery practice in all settings.” – NMBA Midwife Standards for Practice

Once the woman has made her decision the midwife supports and advocates for her. For example, if a woman declines the offer of a vaginal examination – you simply document her decision and carry on. You may need to let colleagues know what her decision is and ensure that they respect it. In some settings, you may be questioned or pressured about her decision – but ultimately you are fulfilling your legal responsibilities regarding consent. This trumps any institutional cultural norms or expectations.

However, for a midwife in private practise responsibilities regarding support are not so clear. If a woman chooses care outside of recommendations the midwife has the choice to carry on providing support – or ‘withdraw’ care. Unfortunately this has resulted in midwives being held responsible for women’s decisions, simply by agreeing to carry on providing care.

Competent Practice

The scope of the midwife “…includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures” – ICM International Definition of the Midwife

The midwife needs to provide competent care within the constraints of the woman’s decisions. For example, competent management of an emergency situation will be different in a home setting compared to a hospital setting.

The Mother’s Responsibilities

Unlike midwives, women are not registered and regulated. Therefore, there are no guidance documents regarding women’s responsibilities in the mother-midwife relationship (and this section is a lot smaller!). However, if midwives meet their responsibilities (above), then women become accountable for their decisions and the outcome of their decisions.

Decisions

By law, women have the right to make decisions regarding what is done or not done to them. Midwifery should support women to take responsibility for their decisions.

Many factors influence decision making, and the information a midwife provides is only one piece of the puzzle. Humans are active seekers and interpreters of information. We pick and choose, using and discarding information according to internal and external constraints and considerations. Embodied knowledge, personal experiences and other people’s experiences influence the selective designation of knowledge as authoritative or not. We often start with a conclusion, then rationalise it with evidence. We surround ourselves  with people who have beliefs and opinions aligned with our own. The internet has increased our access to information and people who will reinforce our beliefs and choices. Midwives cannot, and should not take responsibility for the sources information a woman chooses to engage with.

Most women will be influenced by the mainstream risk discourse and cultural norms. Women who make decisions against this discourse must seek information and people who will support their decisions. Some do this in response to previous experiences with the medical paradigm. Some choose the support of an unregistered care provider (or no care provider) to birth away from the medical paradigm and its intervention focus and inherent discourse about risk.

Outcome of Decisions

The ICM International Code of Ethics state that women should accept responsibility for the outcomes of their choices (if the midwife met her responsibilities). This is not about blame. It is about accepting that an outcome (good or bad) directly associated with a decision is the responsibility of the decision-maker.

Whilst midwives can be affected by outcomes – they cannot take responsibility for the outcome of a woman’s informed decision. For example, if a woman chooses an induction and the outcome is fetal distress and a c-section – this outcome is not the midwife’s responsibility. The midwife’s responsibility is providing adequate information about induction, supporting the woman’s decision to induce, and competent practice (management of the induction process, identification of the fetal distress, and alerting the medical team).

Summary

Registered midwives have a responsibility to provide information, support and competent care to women. In return, women take responsibility for making decision and for the outcome of their decisions. Whilst this appears simple, it is an incredibly complex relationship and I would be interested to read your comments about these issues.

Posted in law, midwifery practice, opinion and thoughts, uncategorized | Tagged , , | 29 Comments

Information Giving and the Law

Posted on June 15, 2016 by MidwifeThinking

I was writing a blog post on induction for prolonged pregnancy but got side tracked reflecting on a recent study day I attended about law. So, I will get this out of my system before finishing the induction post.

It seems that many health care professionals are routinely putting themselves at risk of legal action in relation to information giving (or not as the case may be). Either they are unaware of the implications, or they think women will never hold them to account. This post is a very brief and basic overview of law (Australian) in relation to information giving. Although I have based the contents on McIlwraith & Madden (2010) the information is available in most law books and on the internet.

Consent

If consent is not gained prior to a procedure it could lead to an action for ‘trespass to the person’ (ie. assault and/or battery). For consent to be valid it must have at least 3 elements:

  1. be voluntary and freely given
  2. come from a competent person
  3. be specific to the treatment/procedure.

The first element is where I think most breaches take place in maternity care situations. In order for this element to be satisfied:

  • the person must not be under any undue influence or coercion
  • there must be no misrepresentation (whether deliberate or mistaken) as to the nature or necessity of a procedure.

I am sure I don’t need to list the common real life scenarios in which this element of consent is not satisfied in relation to maternity care. By the way, to sustain a civil action alleging assault and/or battery harm does not need to caused by the procedure.

Negligence – lack of information

A health care practitioner who fails to provide adequate information to a woman can be sued for negligence. In order to have a successful case the woman must demonstrate that:

  1. the health carer had a duty of care to provide the information
  2. that duty was breached by failure to provide the information
  3. the woman would not have agreed to the procedure/treatment if adequate information had been given
  4. and as a result, the woman or baby suffered harm.

What is reasonable information?

The High Court states that patients should be told of any ‘material risk’ inherent in the treatment. A material risk in relation to maternity is one:

  • to which a reasonable woman in the woman’s condition/situation would be likely to attach significance;
  • to which the health carer knows (or ought to know) the particular woman would be likely to attach significance; or
  • about which questions asked by the woman reveal her concern

Responsibilities regarding information giving are discussed in more detail in this post. And you can find more information about ‘material risk’ in this article.

What do you think?

Considering the routine use of tests and procedures in maternity care (eg. ultrasound scanning, induction, c-section, etc.) I would be really interested what readers think…

  • Are women coerced by practitioners into tests/procedures?
  • Are practitioners aware of the law, or do they rely on women not knowing the law?
  • Would common practice around information giving change if legal actions were brought against practitioners who fail to adequately inform?

Further resources/reading

Journal articles:

Goldberg, H 2008, ‘Informed decision making in maternity care’, Journal of Perinatal Education, vol. 18, no. 1, pp. 32-40.

Griffith, R 2010, ‘Giving advice and information on risks’, British Journal of Midwifery, vol. 18, no. 4, pp. 262-263.

Marshall, JE, Fraser, DM & Baker, PN 2011, ‘An observational study to explore the power and effect of the labour ward culture on consent to intrapartum procedures’, International Journal of Childbirth, vol. 1, no. 2, pp. 82-99.

O’Cathain, A, Thomas, K, Walters, SJ, Nicholl, J & Kirkham, M 2002, ‘Women’s perceptions of informed choice in maternity care’, Midwifery, vol. 18, pp. 136-144.

Websites/articles

Informed choice, consent & the law: the legalities of “yes I can” and “no I won’t” by Ann Catchlove

Birthrights

Human Rights in Childbirth

 

Posted in law, midwifery practice | Tagged , , , , , | 49 Comments

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

Posted on June 15, 2016 by MidwifeThinking

Updated: February 2022

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 advised 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 now she is coached to push. The end of the story is usually an instrumental birth (ventouse or forceps) for an epidural related problem – fetal distress caused by directed pushing; ‘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 theory has been taught to midwives since the 1930s and Ina May Gaskin herself warned against ‘early pushing’ in Spiritual Midwifery. 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 2 main things occur during labour:

  1. The uterus changes shape and pulls the cervix open
  2. Rotation and 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 being pulled open by the fundus, the baby is also rotating and descending. Here is a short overview of labour physiology:

1. Uterus changes shape and opens the cervix

The cervix does not open as depicted by obstetric models ie. in a nice neat circle. Instead, it is pulled open from the back to the front in 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 done. 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 opens because the muscle fibres in the fundus (top of the uterus) retract and shorten with contractions and pull the softer/thinner cervix open. By the end of labour the fundus is a thick powerful muscle ready to push the baby out. The opening of the cervix does not require pressure from 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 opens up around it. For example, a well flexed OA baby (see below) will create a neater, more circular cervix. An OP and/or deflexed baby (see below) 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 change their position as they rotate.

2. Rotation and descent of the baby through the pelvis

Babies enter the pelvis through the brim. As you can see from the pictures below this is easier with their head in a transverse position (facing sideways). As the baby descends into the cavity their head will be tilted – 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. 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 pelvic floor shape and tone and often by pushing.

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 sometimes 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 being pulled up, 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). There is very little research about pushing before full ‘dilatation’. Downe et al. (2008) report research conducted in the UK in 1999, and recently Borrelli, Locatelli & Nespoli (2013) published a small observational study. These studies found that the incidence of ‘early pushing urge’ EPU (as it is referred to in the literature) is between 20% to 40%. Interesting Borrelli et al. (2013) found that the sooner the midwife performed a vaginal examination in response to a woman’s pushing urges, the more likely they were to find the cervix still there. They also found that ‘early pushing’ was much more common with primips (first labours). perhaps because they are likely to take longer pushing, therefore be more likely to have a vaginal examination? And early pushing occurred in 41% of women with OP babies.

Spontaneous pushing before the cervix has been pulled up over the baby’s head is a normal variation. It is actually a healthy and helpful physiological process when:

  1. Baby’s head descends into the vagina before the cervix has been pulled over their head. In this case, the additional downward pushing pressure assists the baby to move through the cervix.
  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. The downward pressure against the shape and tone of the pelvic floor help the baby to pivot.

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. Borrelli et al. (2013) found no cervical lacerations, 3rd degree tears, postpartum haemorrhages in the women with an EPU. A recent review of the available research (Tsao 2015) concluded: ‘Pushing with the early urge before full dilation did not seem to increase the risk of cervical edema or any other adverse maternal or neonatal outcomes’. 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. Usually when I dig further into the stories of swollen or bruised cervixes the women were not having a physiological birth and/or were being directed to push.

In many ways, the argument regarding pushing, or not, is pointless because once the spontaneous urge takes over it is beyond anyone’s control. You either let it happen, or start commanding the women to do something she is unable to do ie. stop pushing. I can only find one study that examined women’s experiences of an ‘early’ pushing urge (Celesia et. al 2016). The women in this study women were told by their midwives not to push:

In coping with EPU, women found it difficult to follow the midwives’ advice to stop pushing because this was conflicting with what their body was suggesting [to] them. Throughout their attempts to stop pushing, women were accompanied by the conflicting feelings of naturalness of going along with the pushes and discomfort of going against their bodily sensation. Women were confused by the contradiction between their physical perceptions and the need to hold back pushes suggested by the midwife at the same time. Moreover, they reported difficulty in realizing what was happening. This confusion was sometimes related to the feeling of not being believed by health care professionals. (p. 23)

My research into childbirth trauma found that disregarding women’s embodied knowledge during labour was disempowering and traumatising (Reed, Sharman & Inglis 2017). One woman in the study described her experience:

I had the strongest urge to push, the midwife on staff insisted on an internal examination to check dilation, she told me if I pushed now I would end up with an emergency caesarean due to my cervix swelling. She then spent the next hour yelling at me not to push and trying to talk me into an epidural (I was trying my hardest to not push but my body kept taking over). I was begging to be allowed to push….

Telling women to push or not to push is cultural, it is not based on physiology or research. Worse, it disempowers women and reinforces the authority and expertise of the care provider.

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 her cervical lip (eg. backward leaning). When undisturbed women will usually do this instinctively.

You can listen to more discussion about pushing and cervixes on The Midwives’ Cauldron Podcast.

Suggestions

NOTE: This post and the following suggestion relate to physiological, spontaneous labour and not inducted, augmented or medicalised births.

  • Don’t do routine 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. It is like telling someone not to blink. 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 that 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. She may be in a forward-leaning position because it relieves the back pain associated with an OP presentation and be reluctant to move. This is one of the rare times a suggestion is appropriate.
  • If the situation continues and is causing distress – during a contraction the woman can apply upward pressure (sustained and firm) just above the pubic bone in an attempt to ‘lift’ the cervix up.
  • Manually pushing the lip over the baby’s head is extremely uncomfortable and may allow the baby’s head to move into the vagina before they have rotated which could create further 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 a cervical lip are caused by identifying it, and managing the situation as though it is a problem.

Learn more about Childbirth Physiology in my Online Course

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VBAC: making a mountain out of a molehill

Posted on June 15, 2016 by MidwifeThinking

VBAC (vaginal birth after caesarean) is big. A google search for ‘vbac’ results in ‘about 795,000’ 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, 84% 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 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. 2014):

  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’s 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.

As stated above these figures are the taken from the NIH Consensus Statement (US) or Having a Baby in Queensland (Aus). A more recent UK study (Fitzpatrick et al. 2012) found an even lower overall risk of rupture – 0.2%.

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. Fitzpatrick et al. (2012) also found an increase in rupture with induction and augmentation. 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%. Fitzpatrick et al. (2012) also found a slight increase in risk for women how had had 2 or more previous c-sections. 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. The RCOG guidelines state that: “Women should be informed that the absolute risk of birth-related perinatal death associated with VBAC is extremely low and comparable to the risk for nulliparous [first baby/birth] women in labour.” 

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 for mother and baby. Childbirth Connection cover them well, so I won’t. It is also important that women know a c-section increases the chance of stillbirth in subsequent pregnancies (Moraitis et al. 2015). 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 often hold more power than 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 uncomplicated VBACs they have seen. The only uterine rupture I have personally been involved with was an induction of labour – not a VBAC. So, I emotionally associate uterine rupture with induction rather than VBAC.

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 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. It is 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 practitioners 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 those involved in their birth.

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. In addition, it is a legal requirement for midwives to provide evidence based information about risk.
  • Make sure she is aware that she has a very good chance of having a vaginal birth – 72-75% if she has not previously had a vaginal birth, and 85-90% if she has (RCOG). Overall, she has a greater likelihood of a vaginal birth than a woman having her first baby and no previous c-section.
  • The RCOG guidelines state that: “Women should be made aware that successful VBAC has the fewest complications and therefore the chance of VBAC success or failure is an important consideration when choosing the mode of delivery.” Therefore it is important to consider previous birth scenarios and contexts to evaluate the chance of success for the individual woman.
  • The woman also needs information about factors that can increase her chance of VBAC eg. 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 (Senturk et al. 2015). 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 an exploding 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.
  • 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. It might be helpful to find out the VBAC rates at the hospital to gain some idea about how supportive they are likely to be during labour.
  • 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 often is in hospital). Yes, I’m watching for signs of a uterine rupture: unusual pain, unusual contraction pattern, 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 usually be the first to notice a problem. I have found 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 dilatation number – some non-VBAC women do too. They may also want more frequent fetal heart rate auscultation to reassure them the baby is well. In general, these women, and even more so their partners need reassurance and a birth attendant who believes in them. Of course some women don’t need any of this and choose freebirth.

Is homebirth a safe  option for VBAC?

No – birth is not ‘safe’ regardless of the setting. Different risks are associated with different options. In hospital there is greater risk of unnecessary intervention and associated complications. At home, if you are the 0.2% and need to transfer, there is the risk of complications due to a delay in medical intervention (including death of baby and/or mother). Bear in mind that this delay may also occur in a private hospital out of hours when theatre staff are not on site. Women also need to be aware that when it comes to homebirth, having a uterine scar places them in a ‘high risk’ category. The Australian College of Midwives classify a previous c-section as ‘B’ ie ‘Consult’ with a ‘midwife and/or medical practitioner or other health care provider’. This does not mean that a privately practising midwife cannot provide care. And the woman can decline a consultation if she wishes. Some midwives appear to be unaware of this, and tell women that they are not allowed to attend VBAC homebirths – this is not true. However, if you choose an eligible midwife, you may have problems securing a collaborative agreement from a medical practitioner so that you can claim medicare rebates for care. Likewise, homebirth services run from hospitals or birth centres may be unable to accept you as a client. Whilst VBAC homebirth is generally not supported in clinical recommendations, many women choose to birth at home. Keebler, et al. (2015) examined women’s reasons for choosing a homebirth after caesarean and the full text is available here.

VBACs 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.

You can read a birth story and watch the film here. I may be biased but this is a beautifully filmed/edited birth: Madeleine’s birth

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

Further Reading/Resources

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In Celebration of the OP Baby

Posted on June 8, 2016 by MidwifeThinking

Updated: February 2022

How many times have you heard “I had to have an epidural/c-section/ventouse/etc. because my baby was facing the wrong way”? An occipito posterior (OP) position occurs when the baby enters the pelvis facing forward with their back towards their mother’s back. The back of the baby’s head (the occiput) is in the back of the pelvis (posterior) against the sacrum. Between 15-30% of babies start labour in an OP position, but less than 5% will remain in this position at birth (Sizer & Nirmal 2000). An OP position is associated with medical intervention during labour: syntocinon infusion; epidural; forceps; ventouse; c-section. This post will discuss whether an OP position is actually a problem, or if the problem lies in our beliefs about, and ‘management’ of this common variation.

A bit of anatomy and physiology

I’m assuming that readers of this blog are midwives, doulas, and/or birth nerds who have an understanding of the pelvis. If you don’t, it doesn’t really matter – knowing the names of the bones doesn’t help you understand how the pelvis works. Basically, the pelvis is shaped in a way that requires the baby to rotate during labour. If you look in textbooks you will find diagrams with exact measurements of various pelvic diameters – this is nonsense as every woman’s pelvis is different and they don’t come in ‘types’ (Betti & Manica 2018; Kuliukas at al. 2015; Tennenhouse 2018).

I find it more helpful to consider that there are 3 areas of the pelvis: the brim, the cavity and the outlet. These areas have slightly different shapes, as I’ve tried to demonstrate below: The baby usually enters the brim with their head mostly facing sideways ie. transverse (to fit the shape). It doesn’t really matter which way the baby’s head is when entering the brim – once the head is in the cavity the baby can rotate. The downward pressure of the contractions, and the tension and shape of the pelvic muscles will guide them into a direct occipito anterior (OA) position and through the outlet. However, a very small number of babies will rotate to a direct OP position and come out facing the front of the pelvis (see below).

Usually, the baby will take the shortest rotation into a direct OA position. So, a baby entering the pelvis in a ROA (back = front/right) does this:

Whereas a baby entering the pelvis in an ROP (back = back/right) position does this:

Of course OP and OA babies may use this turning space to do all kinds of interesting things from turning OA to OP, to rotating all the way around the back of the pelvis to end up OA. The baby will work out the best way to move through their mother – even if we don’t understand it.

Being born OP

Some babies are born in the OP position either because they stay in that position, or because they rotate into that position during labour (from OA). You can watch the birth of a big OP baby in ‘The Birth of Beau‘.

The ‘problems’

OP labour patterns

Labour patterns are often different with an OP baby. This is a physiological variation and is perfectly normal. It is important to understand why and how physiology differs with this position. It is difficult enough for a woman with a baby in an OA position to fit prescribed patterns of labour progress and even more difficult with an OP position—particularly with a first baby.

Firstly, a baby who enters the brim in an OP position may not fit quite so snuggly on the cervix and this may increase the chance of variations such as ‘post-dates’ pregnancy and/or rupture of membranes before labour. Early labour (the separation phase) can take longer to build with more stops and starts. Once in strong labour, the woman’s contraction pattern is likely to be irregular.

These situations only become problematic when we apply generalised expectations about how labour should be to an individual woman/baby and situation. It becomes more of an issue if vaginal examinations are used to assess progress. With an OP labour, the fundus forms in the same way as with an OA labour. However, the cervix is not held open like it is with a well-flexed OA baby. Therefore, it appears not to be opening if you feel it – resulting in an incorrect diagnoses of ‘failure to progress.’ Instead this is a failure to understand the transformation of the uterus during labour.

Here is how the fundus/cervix function with an OA baby (once I find my lost apple-pencil I’ll create an OP version).

The key difference with an OP baby is that the cervix is not held open until the baby enters the pelvic cavity and rotates (or not). The common pattern is that the cervix appears to be not doing much while the fundus is busy forming. Then once the baby descends and rotates, the soft and stretchy cervix gets quickly pulled up. The birth is often very quick once this happens (if physiology has been supported rather than disrupted with interventions to ‘speed up’ the opening of the cervix).

An ‘early’ urge to push is also a normal aspect of OP labour. As the OP baby descends through the pelvis the back of their head puts pressure on nerves creating an urge to push. This pushing may be the body’s way of helping the baby to rotate by increasing downward pressure onto the cervix and pelvic muscles – the baby can pivot against this tension. An anterior cervical lip is also common.

Interventions

Trying to make labour patterns (women) conform

If cervical dilatation is being used to assess labour progress it is very likely that ‘failure to progress’ will be diagnosed. The medical response to this is to break the waters if they are still intact. This reduces the amount of fluid around the baby, reducing their ability to rotate. The next step is to augment the labour with syntocinon (pitocin) which increases pain (and use of epidural) and the chance of fetal distress.

The alternative approach is to use non-medical interventions to get the woman’s body to fit institutional non-evidence-based parameters of progress. Midwives, doulas and birth workers often intervene with techniques and direct women into various positions aimed at getting the baby to rotate quicker. There are no studies demonstrating these interventions are effective for women having a physiological birth ie. without an epidural (Desbriere et al. 2012).

Regardless of the type of intervention — medical or alternative — the underlying beliefs/principles are the same:

  • OP is a malposition that requires intervention (the woman’s body is wrong).
  • That women’s bodies need to be intervened with to fit medical timeframes rather than disregarding those timeframes.
  • External expert knowledge and skills are more powerful than women’s instincts and intuitive movement.

Pain?

Some women will experience pain differently when their baby is in an OP position. However, it is difficult to determine if this experience of pain is due to the position of the baby, or other factors. A study by Lee, Kildea & Stapleton (2015) into back pain in labour concluded: “The assumed relationship between fetal position and back pain in labour is a dominant discourse, albeit one which is lacking in empirical credibility.” Plenty of women with an OA baby complain of backache in labour, whilst many with an OP baby do not. Unfortunately, women are told that OP labour is ‘worse’, and are told horror stories like the one I started the post with. Given the psychological and emotional aspect of pain perception, this cannot be helpful. Every birth experience is also different. I cared for a mother during two births. Her first baby was in an OP position and she had a four-day stop-start pattern before labour established. Apart from being tired, she coped well with the pain throughout. Her second baby was OA and labour established quickly. She was shocked and distressed by how much more pain she experienced with her OA baby compared to her previous OP baby.

Women with an OP baby are more likely to opt for (or be persuaded to have) an epidural. This is not surprising, considering they are led to believe their labour will be more painful. They are also more likely to be subjected to interventions that increase pain and risk. For, example, a woman with an OP baby is more likely to be told her labour is slow and have augmentation. Both medical methods of augmentation—ARM and/or syntocinon (pitocin) increase pain. Once an epidural is inserted, the ability of the baby to rotate into an OA position is reduced (Lieberman et al. 2005). The woman is unable to instinctively move her body and work with her baby to facilitate rotation. In addition, the pelvic ‘floor’ (more like a bowl shape) is anaesthetised and loses its tone, taking away the resistance that assists rotation. In this situation (ie. non-physiological labour), positional interventions may help to rotate the baby (Bueno-Lopez et al. 2018).

In terms of back pain during labour (regardless of baby’s position), sterile water injections (into the skin of the lower back) are effective in providing relief (Fogarty et al. 2008; Lee et al. 2017).

Suggestions

Pregnancy

Women can blame themselves for their baby being in an OP position. They question what they did (spent too long in the car) or didn’t do (scrub floors). Often the advice they are given antenatally about ‘optimal fetal positioning’ implies that they have control over the position their baby is in when there is no research evidence to support this notion. In fact, the little research that has been done demonstrates that hands and knees posturing in pregnancy makes no difference (Hunter, Hofmeyr & Kulier 2009; Kariminia et al. 2004). I have even heard of women being told that their baby has assumed an OP position because of their unresolved emotional issues!

Pregnancy is a time to build and nurture self-trust, to reinforce the woman as the expert. Not a time to disempower her and reinforce fear and external expertise. Care providers should:

  • Reinforce the woman’s trust in her body and baby to birth.
  • Discuss the possibility that her labour may be different (not better or worse) and might not fit general expectations about labour patterns/progress.
  • If she wants to, she can try a variety of techniques to encourage the baby to turn (even though the research suggests it will probably be ineffective). However, if the baby doesn’t respond, it’s because they have chosen their optimal position for labour. The baby knows the shape of their mother’s pelvis better than any care provider.
  • Remind her that the baby will turn once he gets into the pelvic cavity in labour, or may even be born OP.
  • Tell her positive OP birth stories and connect her with other women who have experienced positive OP labours.

Labour

  • Trust the mother and her baby to birth.
  • Provide an environment where she can instinctively move and work with her baby to facilitate rotation.
  • Don’t do vaginal examinations. They are ineffective at determining labour progress with an OA baby, never mind an OP one.
  • Don’t tell her not to push if she is spontaneously pushing—regardless of cervical dilatation (again – don’t do a VE).
  • Back pain can be relieved by a forward-leaning position (Stremler et al. 2005); warm water; gentle sacral pressure or sterile water injections. Avoid applying strong pressure to the sacrum as this may reduce the space available in the pelvis for rotation.
  • If the woman requests help or would prefer you to ‘do’ something, there are several techniques you can use to create more space in the pelvis. I have provided a list here. Note that these techniques/positions are about increasing the space in the pelvis rather than rotating the baby – they provide an opportunity rather than making the baby move. And they are interventions.
  • Occasionally, despite everything, a baby will become ‘stuck’… and this happens to babies in an OA position too. In this situation, more invasive interventions such as digital rotation (Ray et al. 2018); instrumental birth or c-section may be necessary. However, most of the time, these interventions are carried out due to ‘failure to wait’ rather than a genuinely stuck baby.

In summary

An OP position is not wrong or a problem. It is not caused by anything the woman does or does not do. Instead, it is a common variation that occurs when a baby gets into the ‘optimal position’ for their journey through their mother’s unique body. After all, the baby has more knowledge about the interior of their mother’s pelvis than we do. If we want to improve the experience and outcomes associated with an OP position we need to rethink our approach to it. Let’s celebrate the OP baby’s wisdom and allow the birth to unfold as it needs to, only intervening if it is truly required.

Further resources:

Pushing and Cervixes – The Midwives’ Cauldron Podcast

Learn more about Childbirth Physiology in my Online Course

Posted in baby, birth, midwifery practice | Tagged , , , , , , , , | 219 Comments

The Placenta: essential resuscitation equipment

Posted on April 13, 2016 by MidwifeThinking

Updated: August 2022

Premature cord clamping/cutting

Premature cord clamping (clamping before placental transfusion is complete) has been the norm since ‘active management’ of the placenta became routine. In recent years, research has highlighted the harms caused by cutting the umbilical cord before placental transfusion of the baby. Premature cord clamping results in hypovolemia (reduced blood volume) and is associated with short-term and long-term outcomes (KC et al. 2019; Kresch 2017):

Short term (first 24 hours)

  • lower blood volume
  • lower oxygen saturation
  • higher heart rate (to compensate for low oxygen)
  • lower systolic blood pressure (ie. compromised circulation)
  • decreased renal flow, and decreased urine output ie. major organs are not optimally functioning.

Long-term

  • lower serum ferritin levels and higher rates of iron deficiency anaemia at 6 months of age
  • reduced fine motor function and social development at four years of age.

Awareness about ‘optimal cord clamping’ is increasing amongst parents and care providers (thanks to campaigns such as Wait for White). However, cord clamping during resuscitation is still an area of controversy. This post explores the practice of premature cord clamping when a baby is perceived to need resuscitation.

I was in a research team examining care provider practices during the birth of the placenta (Kearney et al. 2019). In our study, 29.1% of babies had their cord cut prematurely because of concerns for their wellbeing, either to obtain cord blood gases (13.4%), or to initiate resuscitation (15.7%). While the rate of ‘concerns for wellbeing’ was very high in this study, the practice of cutting the cord in these circumstances was not surprising. In hospital-based newborn resuscitation workshops, practitioners are taught to 1. assess the baby, 2. summon help 3. clamp and the cut cord, 4. take the baby to resuscitaire…. etc. However, this approach makes no sense if you consider the physiology of transition to extrauterine life, or the importance of the mother and the placenta in the baby’s transition and any necessary resuscitation.

The physiology of newborn transition

I cover the full physiology of newborn transition in my book Reclaiming Childbirth and in my online course Childbirth Physiology. However, here is a brief overview:

The baby/placenta has a separate blood system from the mother. The placenta does the job of the lungs by exchanging gas (oxygen and carbon dioxide) via the intervillous space between the baby’s and the mother’s blood system. Before birth, a third of the baby/placenta blood volume is in the placenta at any given time to facilitate this gas exchange. After birth, the ‘placental’ blood volume is transferred through the pulsing cord into the baby, increasing the baby’s circulating blood volume. This has two major effects:

  1. Provides the extra blood volume needed for the heart to direct 50% of its output to the lungs (8% before birth). This extra blood fills the capillaries in the lungs, making them expand to provide support for the alveoli to open. It also aids lung fluid clearance from the alveoli. These changes allow the baby to breathe effectively.
  2. Increases the number of circulating red blood cells which carry oxygen. This increases the baby’s capacity to send oxygen around the body.

The pattern and timing of the blood transfer from placenta to baby is influenced by several factors – in particular the baby’s breathing and/or crying (Boere et al. 2015). Textbooks and guidelines suggest the transfer takes 1-5 minutes, but some individual babies take longer. While the transfer takes place, oxygen continues to be provided by the placenta until the baby has established their breathing. Stem cells are also transferred into the baby during this time. There is a theory, and some evidence, that these stem cells play an important role in repairing any damage caused during birth. They may actually protect against cerebral palsy! Dr Mercer discusses this in more detail here. You can read my opinion on ‘cord’ blood collection in this post.

A study found that healthy self-breathing newborns are more likely to die or be admitted to SCN if cord clamping occurs before or immediately after the onset of spontaneous breathing (Ersdal et al. 2014). However, most babies can compensate for their lack of blood volume by readjusting their circulation to direct their blood to their major organs. The effects of reduced blood volume will be subtle but present (and long-term). If you get a chance to hear Karen Strange speak about neonatal transition to extrauterine life – take it. She shows photos of the heel capillaries of a baby who has had premature cord clamping compared to a baby who has not. The small blood capillaries are collapsed. They have shut down in order to send the reduced blood volume to the important organs.

Reasons for resuscitating a baby at birth

There are two reasons that caregivers cut an umbilical cord in order to resuscitate a baby. In both cases, their action creates difficulties for the baby. In the first, it can actually create the need to resuscitate.

1. Lack of knowledge, patience (and a bit of panic)

This often happens when a baby is slower to initiate breathing. The baby is still being oxygenated by the placenta but is waiting while the effects of an increased blood volume kick in. This is particularly common with waterbirth babies. These babies have good tone and slowly turn from bluish to pink. It can be difficult to even notice them begin to breathe. Their colour change may be the only obvious indication that they are making the transition. The cord pulses at the same rate as the baby’s heart, so feeling (or watching) it will reassure you that all is well. Unfortunately, the usual response to this situation is to clamp and cut the cord in order to resuscitate the baby. The likely outcome will be that the baby responds to the interruption of the placental flow and the stressful journey away from mother by crying. A worse outcome is that without the placental circulation, the baby is unable to complete their transition and becomes a compromised baby requiring resuscitation.

2. A compromised baby

This is a baby who has had a rough time during birth and might require a little external support to make their transition to breathing. This situation is often a result of interventions during birth such as directed pushing, artificial rupture of membranes, syntocinon/pitocin. It may also result from a tight nuchal cord reducing blood flow just before birth. A compromised baby is floppy and a blue/white colour. They may also have passed meconium during the birth, and their heart rate is slow and/or dropping. This baby could probably do with a bit of help, but most importantly, they need their placental circulation. While the cord is intact and blood is circulating, the baby is still receiving some oxygen, which is better than none. In addition, the extra blood volume and red blood cells will help to circulate any oxygen the baby gets via resuscitation.

Woman-centred, baby-centred, evidence-based resuscitation

Involvement of the mother and family

It is important that the mother, her partner and/or family members are involved in the resuscitation of a compromised baby.

For Baby: The baby has spent months inside their mother and learned her voice and smell. The baby has also learned the voice of those close to the mother ie. partner and/or other family members. To be held close, spoken to and stroked is often enough to initiate breathing. Even if further measures are needed, being held skin-to-skin with their mother is less stressful than being put on a resuscitaire.

For mother and other family members: Being able to see and touch your baby is important in minimising stress. Assisting with the baby’s transition reinforces the power of the parents rather than that of the care provider. Seeing what is happening is less stressful than ‘not knowing’ what is going on. In addition, mothers often instinctively know how to help their baby. I remember one mother telling me she felt her baby needed to be in a certain position on her chest. When she moved him, his breathing regulated perfectly.

Practical suggestions for resuscitation

Research is beginning to emerge in support of physiology and common sense. A recent randomised controlled trial concluded that resuscitation with an intact umbilical cord results in improved oxygen saturations and higher Apgar scores, with no negative consequences (Andersson et al. 2019). The discussion section of this article also cites research demonstrating that an intact cord improves resuscitation and reduces post-resuscitation complications.

However, most guidelines (and care providers) continue to recommend premature cord clamping for resuscitation. In contrast to most guidelines, WHO guidance on ‘delayed cord clamping’ states that “if the clinician has experience in providing effective positive-pressure ventilation without cutting the cord, ventilation can be initiated at the perineum with the cord intact to allow for delayed cord clamping.” Unfortunately, this is contradicted in the WHO guidelines on resuscitation of the newborn which state that “the cord should be clamped and cut to allow effective ventilation to be performed.” As usual, it will probably take many years to change a practice that was initially implemented without evidence.

Care providers often tell me they are unable to perform resuscitation without cutting the cord in a hospital setting because of how the equipment is set up (ie. fixed to a wall). However, paramedics in Queensland now resuscitate newborns without cutting their umbilical cord. If paramedics can do this in less than ideal settings, why can’t hospital staff? A simple bag and mask while baby is in their mother’s arms is all that is needed for the vast majority of resuscitations (not oxygen). On the very rare occasions that cardiac compressions are required, babies can be placed on any firm surface while still attached to their placenta eg. the floor, a small board. Hospitals need to make equipment/staff fit around the needs of the baby and mother – not the other way around.

The maternity system seems to thrive on spending money on unnecessary equipment. Then implementing staff training on how to use this equipment. There have been some feasibility trials assessing the use of a new mobile resuscitation trolley (Blank, et al. 2018; Brouwer, et al. 2019). While the commitment to supporting physiological placental transfusion is great… I’m not so sure another costly and unsustainable piece of equipment is necessary. As I mentioned above, simple equipment works well for out-of-hospital births, and could also work well for in-hospital births. And the already existing standard hospital resus trolleys also work effectively. All birth suites have mobile trolleys available in addition to any wall-fixed resus set ups. When I worked in hospitals, I avoided the wall-fixed resuscitation tables by bringing the standard trolley into the room if needed. I wheeled the trolley over to the mother and baby and plugged it into the wall. The cables and tubes are long enough to allow the IPPV mask to reach the baby-in-mother’s-arms.

One study assessing the use of the new mobile trolley found that having this option significantly increased the likelihood that the baby would be removed from their mother’s chest/arms (Sæther et al. 2020). This finding was for all babies, regardless of whether they needed resuscitation. I don’t find these results surprising. Introduce a new shiny piece of equipment, reinforce its value through staff training, and you will have staff keen to use it.

Another issue care providers bring up is blood gas analysis. This procedure is carried out if the baby has shown signs of distress during or immediately after birth (although some hospitals do this routinely!). It involves taking a small sample of the baby’s blood from the umbilical cord to measure the pH and other elements to determine if the baby was/is hypoxic. This is largely for litigation purposes – it does not alter the care of the baby or the outcome. Many care providers are under the impression that taking this sample requires cord clamping. This results in carrying out an intervention (clamping) known to compromise a baby, so that you can do a test to see how compromised that baby is – which is nonsense. However… if you really want to take a blood sample clamping is unnecessary.

“Sampling of cord blood for gas analysis may be performed on the unclamped cord right after birth without reducing the accuracy of the analysis.” (Thomasso et al. 2014)

I think that the next evolution of newborn resuscitation will be based around working with the placental circulation; and the following is my suggested approach to resuscitation – regardless of setting:

  • Try and ensure that the baby does not arrive compromised by minimising unnecessary interventions.
  • Do not clamp or cut the cord.
  • Give the baby time to transition – if the cord is pulsing, the placenta is providing oxygen… relax and reassure the mother if she needs reassurance. Keep observing the baby for signs of circulation and respiration.
  • Do not clamp or cut the cord.
  • If the baby requires assistance, start small – gentle stimulation, talking, blowing in their face (all can be done by a parent).
  • Do not clamp or cut the cord.
  • If further measures are required, take the resuscitation equipment to the baby and resuscitate them in their mother’s arms.
  • Did I mention – Do not clamp or cut the cord.

Note: Routine suctioning of the baby is totally unnecessary, invasive and could potentially create problems by stimulating a vagal response (a drop in the heart rate).

Summary

Babies are born with their own resuscitation equipment. The placenta not only helps the baby to transition, but assists with resuscitation if needed. There is no reason to clamp and cut the cord of a baby who needs help. Doing so will create more problems for the baby and mother. Anything that needs to be done can be done with back-up from the placenta, and the involvement of the mother.

Further information/resources

Learn all about Childbirth Physiology, including the placenta and transition of the newborn in my online course.

  • The Midwives’ Cauldron Podcast – placentas and cord blood
  • Mercer and Erickson-Owens (2014) – ‘Is it time to rethink management when resuscitation is needed?’ Journal article
  • Nicholas Fogelson (Obstetrician) gives a very clear presentation of the research regarding premature clamping in a lecture. The ethics of the research is questionable but hopefully the findings will help to inform a change in practice.
  • Very interesting and thought provoking interview with Dr Mercer
Posted in baby, birth, intervention, midwifery practice | Tagged , , , , , , , , , | 117 Comments

The Human Microbiome: considerations for pregnancy, birth and early mothering

Posted on April 13, 2016 by MidwifeThinking

This post was co-authored by Jessie Johnson-Cash and based on her presentation at the USC Midwifery Education Day.

The human microbiome is rather fashionable in the world of science at the moment. The NIH Human Microbiome Project has been set up to explore correlations between the microbiome and human health and disease. To date the human microbiome as been associated with, amongst other things obesity, cancer, mental health disorders, asthma, and autism. In this post I am not going to provide a comprehensive literature review – this has already been done, and the key reviews underpinning this discussion are: Matamoros et al. (2012) ‘development of intestinal microbiota in infants and its impact on health’ and Collado et al. (2012) ‘microbial ecology and host-microbiota interactions during early life stages’. Instead I am going to focus on what this means for pregnancy, birth, mothering and midwifery.

What is the human microbiome?

Based on a chart by Matamoro et al. 2013. Adapted and extended by Jessie Johnson-Cash.

Based on a chart by Matamoro et al. 2013. Adapted and extended by Jessie Johnson-Cash.

Considerations for mothers and midwives

The following are not research based recommendations – the research is yet to be done. They are more considerations/questions arising from the developing knowledge around the human microbiome.

Pre-conception and Pregnancy

The commonly accepted belief that the the baby inside the uterus is sterile (whilst membranes are intact) is being challenged. It seems that maternal gut microbiota may be able to translocate to the baby/placenta via the blood stream (Jiménez et al. 2008; Metamoros et al. 2013; Prince et al. 2014; Rautava et al. 2013; Zimmer 2013). And the unique ecosystem of bacteria in the placenta may originate from bacteria in the mother’s mouth. Women’s gut microbiota change during pregnancy and this impacts on metabolism (Koren et al. 2012; Prince et al. 2014). So ideally, women need to head into pregnancy with a healthy microbiome and then maintain it. Unfortunately our modern lifestyle is not very microbiome friendly, and many of us have dysbiosis (an imbalance in gut bacteria). Dysbiosis and too much of the ‘wrong’ bacteria has been linked to premature rupture of membranes and premature birth (Fortner et al. 2014; Mysorekar & Cao 2014; Prince et al. 2014). Gum disease (bacteria) has also been linked to pre-term birth. Suggestions:

Birth

There is a difference between the microbiome of a baby born vaginally compared to a baby born by c-section (Azad, et al. 2013; Penders et al. 2006; Prince et al. 2014). During a vaginal birth the baby is colonised by maternal vaginal and faecal bacteria. Initial human bacterial colonies resemble the maternal vaginal microbiota – predominately Lactobacillus, Prevotella and Sneathia. A baby born by c-section is colonised by the bacteria in the hospital environment and maternal skin – predominately Staphylocci and C difficile. They also have significantly lower levels of Bifidobacterium and lower bacterial diversity than vaginally born babies. These differences in the microbiome ‘seeding’ may be the reason for the long-term increased risk of particular diseases for babies born by c-section.

The environment in which the baby is born also influences their initial colonisation. A study by Penders et al. (2006) found that term infants born vaginally at home and then breastfed exclusively had the most ‘beneficial’ gut microbiota. It is likely that these babies only came into contact with the microbiota of their family during the key period for ‘seeding’ the microbiome. No one has researched waterbirth and the microbiome yet. Might it dilute the bacteria? The chance of colonisation and infection with group B streptococcus (GBS) is reduced with waterbirth (Cohain 2010; Neugeborene et al. 2007). This may be due to dilution of the GBS or additional colonisation of the baby with beneficial bacteria. Another future research topic is caul birth and the microbiome. Does a baby born in the caul miss out on colonisation via the vagina?

What we do know is that antibiotic exposure alters the microbiome in adults (see above). When a woman is given antibiotics in labour her baby also gets a dose. In 2006 a medical expert review (Ledger 2006) raised concerns about prophylactic antibiotics in labour. A study in 2011 found that antibiotics given in labour increased the incidence of antibiotic resistance when treating late-onset serious bacterial infections in infants (Ashkenazi-Hoffnung et al. 2011). A more recent study found that antibiotics given during labour or a c-section are associated with infant gut microbiota dysbiosis (Azad et al. 2016). This is concerning considering the number of women/babies given antibiotics in labour (eg. for ‘prolonged’ rupture of membranes or for ‘epidural fever’). Add to that the use of prophylactic antibiotics for c-sections = a significant proportion of women and babies being exposed to antibiotics around the time of birth. Suggestions:

  • A vaginal birth in the mother’s own environment is optimal for ‘seeding’ a healthy microbiome for the baby (Penders et al. 2006).
  • Minimise physical contact by care providers on the mother’s vagina, perineum and the baby during birth.
  • Avoid unnecessary antibiotics during labour. If antibiotics are required consider probiotics for mother and baby following birth.
  • If the baby is born by c-section… Research is currently being undertaken into the use of vaginal swabs* to ‘seed’ c-section babies. The preliminary results are that the microbiome of swabbed babies are more similar to vaginally born babies. The protocol the researchers are using is:
    1. take a piece of gauze soaked in sterile normal saline
    2. fold it up like a tampon with lots of surface area and insert into the mother’s vagina
    3. leave for 1 hour, remove just prior to surgery and keep in a sterile container
    4. immediately after birth apply the swab to the baby’s mouth, face, then the rest of the body (you can see photos of this process here)
  • If a baby is born by c-section it is even more important to encourage and support their mother to breastfeed. It may also be worth considering additional probiotic intake.

*There has been a bit of hysteria about the safety of vaginal swab seeding in the media. I will leave it to Sara Wickham to address (rant about) this one.

Postnatal

After birth, colonisation of the baby by microbiota continues through contact with the environment and breastfeeding. There are significant differences in the microbiota of breastfed babies compared to formula fed babies (Azad, et al. 2013; Guaraldi & Salvatori 2012). Beneficial bacteria are directly transported to the baby’s gut by breastmilk and the oligosaccarides in breastmilk support the growth of these bacteria. The difference in the gut microbiome of a formula fed baby may underpin the health risks associated with formula feeding. In the short term, infant colic may be associated with high levels of proteobacteria in the baby’s gut (wish I’d know this 20 years ago!). Suggestions:

  • Immediately following birth, and in the first days, baby should spend a lot of time naked on his/her mother’s chest.
  • Avoid bathing baby for at least 24 hours after birth, and then only use plain water for at least 4 weeks (Tollin et al. 2005).
  • If in hospital, use your own linen from home for baby.
  • Minimise the handling of baby by non-family members during the first weeks – particularly skin to skin contact.
  • Exclusively breastfeed. If this is not possible consider probiotic support.
  • Avoid giving baby unnecessary antibiotics (Ajslev et al. 2011; Penders et al. 2006). Again, if antibiotics are required probiotics need to be considered.
  • Probiotics may also be beneficial for babies suffering from colic.

Summary

The more we understand about the human microbiome the more it seems fundamental to our health. Pregnancy, birth and breastfeeding seed our microbiome and therefore have a long-term effect on health. More research is needed to explore how best to support healthy seeding and maintenance of the microbiome during this key period. I have discussed a number of considerations and suggestions arising from what we already know. I welcome any comments, discussion and further suggestions from readers.

Further reading and resources

Posted in baby, birth, midwifery practice, pregnancy | Tagged , , , , , , , , , , | 119 Comments

Perineal Protectors?

Posted on January 13, 2016 by MidwifeThinking

Updated: September 2019

Artwork by Dana Leggett: http://bit.ly/birthart

Most women will sustain some damage to their perineum during birth (AIHW 2018). Around 50% will have a tear or graze in the skin and/or vaginal wall (1st / 2nd degree). Occasionally (1% of non-instrumental vaginal births) significant tearing occurs that extends into the anal sphincter (3rd / 4th degree). You can find out more about types/grading of perineal trauma here. This post will discuss ‘protecting the perineum’ and was initially based on a literature review. You can find the full literature review and reference list in my thesis. I have updated the post regularly since then and have added new references in the text.

Care providers often consider themselves to be ‘perineal protectors’ tasked with preventing women from tearing. There is currently a lot of effort and money being put into trying to reduce significant tearing (see this post). And of course the approach taken to ‘protect the perineum’ reflects the birth culture in general ie. that women’s bodies are dangerous, and risk management involves carrying out interventions to minimise that risk. I think the truth is the other way around. What we do is usually the risk, and risk management should be about supporting physiology and instinct. Only intervening when there is a deviation from physiology.

Before I get off my soapbox and share the research evidence…

Bear in mind – research about birth outcomes is carried out on general populations i.e primarily on women having medically managed births. These types of births often involve interventions that increase tearing eg. syntocinon, directed pushing, etc. We really don’t have any good research on what protects the perineum during an uninterrupted, physiological birth where tearing rates are much lower.

Before birth

Fixed factors

Some factors that increase the chance of tearing are impossible or very difficult to control (Dahlen et al. 2015):

  • a big baby
  • first vaginal birth
  • high weight gain in pregnancy
  • higher socioeconomic circumstances
  • older and younger maternal age
  • ethnicity (Caucasian and Asian)
  • short perineal body
  • nutritional status
  • abnormal collegan synthesis

Preparing the perineum for birth

Suggesting there is a need to ‘prepare’ for birth contradicts the fact that women’s bodies are perfectly capable of preparing for birth without intervention. However, perineal stretching massage can increase some women’s confidence in their body’s ability to stretch and open for their baby. On the other hand, plenty of women don’t prepare in this way, and whether you have confidence in your body or not, your perineum will stretch.

A number of guidelines recommend that women should be encouraged to massage their perineums during pregnancy to reduce the chance of tearing. The reference cited to support this recommendation is a Cochrane Review. However, the review did not conclude that massage reduced the chance of tearing. It found that women having their first baby who did perineal massage were less likely to have an episiotomy – not a tear. This suggests that care providers act differently in these cases – and needs further investigation. Perhaps perineal massage helps women to fit unnecessary birthing timeframes prescribed by hospitals, therefore avoid being cut?

There is a rather scary device called an Epi-No designed to use during pregnancy to stretch the perineum. A large RCT found that “antenatal use of the Epi-No device is unlikely to be clinically beneficial in the prevention of intrapartum levator ani damage, or anal sphincter and perineal trauma.” Personally I worry about potential long term effects of repeatedly stretching the perineum to the size of a babies head. Although a woman may give birth a number of times during her life, she will usually have more than a day between each baby’s head stretching her vagina. It is also a reflection of our technocratic culture that a ‘device’ is considered to be necessary in order to prepare for childbirth.

During birth

Birth is where all of the care provider activity focuses. It was seeing all of the fussing and fiddling carried out as babies were born that sent me in the direction of a PhD. I could not understand why such a physiological and instinctive bodily process required so much directing and doing. I still don’t. I suggest that before (or after) you read this post, you read supporting women’s instinctive pushing behaviour during birth. Of course, most women do not have an undisturbed birth – therefore are not necessarily connected in with what is going on in their body. In these cases it may be appropriate to intervene (with consent).

General factors known to increase the chance of tearing during birth are (Dahlen et al. 2015):

  • position of baby – larger diameter of head presenting
  • midline episiotomy (see below)
  • instrumental birth – particularly forceps
  • ‘prolonged second stage’ – likely because this results in an instrumental birth
  • syntocinon (pitocin) use in women having their second or more vaginal birth
  • shoulder dystocia

There are two main principles involved in reducing the chance of tearing:

  1. A slow birth of the baby through the vagina – allowing time for the tissues to respond and stretch
  2. Capacity for stretch and ‘give’ in the tissues

Positions

Some birth positions assist with the principles above. The two positions that involve the least chance of tearing (side lying and hands/knees) do not involve stretched wide legs and therefore perineums. In addition the pressure of the baby’s head is towards the front of the mother rather than directly onto the perineum. In contrast, positions that make the perineum tight and stretched, and place all of the pressure of the baby’s head directly onto the perineum increase the chance of tearing: semi-supine (sitting upright and reclined – the TV/film birth position); squatting; and lithotomy.

Some women will close their legs during crowing. I have seen midwives push women’s legs back open or say ‘keep your legs open’. Closing the legs, or bringing them in from a wide-open position protects the perineum. Try it yourself… open your legs wide and bring them up towards your chest – stranded beetle position – and feel what happens to your perineum. Now close your legs a little and bring them down away from your chest – feel how much more ‘give’ there is in your perineum when it is not stretched out. It can now respond to the stretch required by the baby’s head without also being stretched out sideways. As for whether closing your legs will stop a baby from coming out… it may slow it down, but that baby is coming out. I have seen a woman birth on her side with her legs crossed – her baby came out from behind.

Standing up-right can result in a quick birth – particularly for women who have previously given birth – increasing the chance of tearing. It is not a position many women stay in to birth unless they have been directed to get into it.

Guidelines and training are reinforcing the need for the care providers to ‘visualise the perineum’ during birth. I’m not sure how that is supposed to prevent tearing. However, it does increase the chance the care provider will intervene. This approach is leading to more women being directed into positions to facilitate this – unfortunately positions that increase the chance of tearing.

Directed pushing

Guidelines recommend that ‘good communication’ is required between the care provider and woman to ensure a slow birth and minimise tearing. However, this is unnecessary if the woman is birthing instinctively. The intense sensations experienced during crowning usually result in the woman ‘holding back’ while the uterus continues to push the baby out slowly and gently. Often women will hold their baby’s head and/or their vulva. I have witnessed one mother attempt to push her baby back in (you know who you are) – it was unsuccessful but gave us a giggle afterwards. Telling a woman to stop pushing, pant or ‘give little pushes’ distracts her at a crucial moment, and suggests that you are the expert in her birth, which you are not. She is the one with a baby’s head in her vagina – leave it to her. Of course, if you have been shouting at her to ‘Puuuush’ with every contraction before crowning – she will be listening to you, not her body…

Warm water

Some women find having a warm compress held against their perineum as the baby crowns helps to ease the sensations of stretching. Others, hate it and find it intrusive. A Cochrane review found that warm compresses did not increase the chance of having an intact perineum or decrease the chance for suturing. However, it did reduce the chance of a very severe tear (3rd or 4th degree).

Waterbirth is another way of bathing the perineal tissue in warm water – and unlike warm compresses, makes it difficult for anyone apart from the birthing woman to touch her perineum or baby during birth.

‘Hands on’ techniques

Hands on techniques aimed at slowing the birth of the baby and supporting the perineal tissues are routinely used by many care providers. However, a systematic literature review concluded that: “The hands-poised [off] technique appeared to cause less perineal trauma and reduced rates of episiotomy. The hands-on technique resulted in increased perineal pain after birth and higher rates of postpartum haemorrhage.” A  Cochrane Review found that ‘hands on’ techniques did not reduce the chance of tearing and increased the chance of having an episiotomy. And a recent Australian study found that ‘hands on’ increased the chance of tearing for women having their second or more vaginal birth.

No research has explored women’s experiences of a ‘hands on’ approach. And, I am yet to hear a midwife or obstetrician ask for permission before placing their hands on the woman and baby.

Perineal massage 

Massaging the perineum as the baby is trying to be born concerns me for a number of reasons. It makes me really uncomfortable to watch lots of ‘activity’ being done to a woman’s body while she is trying to birth. I have seen some very brutal versions of ‘perineal massage’ done to women; and I am guessing/hoping that most of the women in these studies had epidurals. However, the Cochrane Review above suggests that this type of massaging can reduce the chance of significant tears (3rd and 4th degree) not the usual (1st and 2nd degree). Significant tearing is rare (around 3%) – so the intervention needs to be weighed up with the risks of additional pain and disturbance to physiology. Also, in order to perform this intervention effectively the woman needs to be in a position that increases her chance of tearing ie. on her back / semi-reclined.

Episiotomy

An episiotomy involves a deep cut into the perineal muscles and skin ie. creating perineal trauma. Episiotomies used to be rare in midwifery practice. I have carried out three in my career, and with hindsight I think two were unnecessary. However, there is a resurgence thanks to a new wave of perineal focused intervention packages, and confusing research summaries and clinical guidelines.

For example, a Cochrane Review examining ‘selective’ vs ‘routine’ episiotomy concluded that: “In women where no instrumental delivery is intended, selective episiotomy policies result in fewer women with severe perineal/vaginal trauma.” This seems to have been interpreted as ‘selective episiotomy reduces severe tearing’ rather than ‘in comparison to routine episiotomy’. Interestingly, the review does not include information about what indications are included in a ‘selective’ approach, or the evidence supporting those indications.

Clinical guidelines include indications for episiotomy without citing research to support those statements. For example, NICE guidelines state that an episiotomy should only be carried out if needed for an instrumental birth, or severe fetal distress. This was the standard when I trained and resulted in very few episiotomies. However, QH guidelines have recently added in additional indicators including ‘soft tissue dystocia’. The citation for this statement is another guideline (RANZOG) – and that guidelines includes no supporting evidence for the statement. ‘Soft tissues dystocia’ refers to a perineum not stretching ‘quick’ enough ie. lack of patience. In practice, care providers are cutting women if they think they may tear or if the birth is not quick enough – believing these are appropriate indications.

There is some evidence about outcomes relating to the types of episiotomies used – mid-line (down toward the anus) vs medio-lateral (60 degree angle). A mid-line episiotomy contributes to the risk of severe perineal trauma by increasing the chance the cut will extend (Lappen & Gossett 2014). However, a medio-lateral episiotomy cuts through more nerves and perineal structures (Patel et al. 2018). We are only just beginning to understand the complex anatomy of the clitoris  – a structure that is cut during a medio-lateral episiotomy. This type of episiotomy is associated “with a decreased sexual functioning as well as sexual desire, arousal and orgasm within postpartum five years” (Dogan et al. 2017).

Even if episiotomy does reduces the chance of severe tearing (which we don’t have the evidence for) – having an episiotomy during a non-instrumental vaginal birth would be trading a 1% chance of significant tearing with 100% chance of perineal damage via a cut.

After birth

Suturing

Tearing is a normal part of the birth process, and the body usually heals well. The vaginal wall is a mucous membrane and heals very fast (like the mouth). Suturing is the most common method of perineal repair. Whether to suture or not should be the woman’s decision. In relation to 2nd degree tears (the most common) the need to suture is debatable if the tear aligns well and is not bleeding. A Cochrane Review concluded:

“…at present there is insufficient evidence to suggest that one method is superior to the other with regard to healing and recovery in the early or late postnatal periods. Until further evidence becomes available, clinicians’ decisions whether to suture or not can be based on their clinical judgement and the woman’s preference after informing them about the lack of long-term outcomes and possible chance of slower wound healing process, but possible better overall feeling of well being if left un-sutured.”

In my own experience as a midwife I have found that un-sutured perineums heal very quickly and with far less pain than sutured perineums. Now-a-days my suturing skills are mostly utilised in teaching suturing.

In summary

There is very little care providers can do to protect women’s perineums using interventions. Instead, we need to encourage women to trust that their body has an innate ability to birth their baby; that perineal tearing is a normal part of birth; and that the body will heal itself.

Further resources

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In Defence of the Amniotic Sac

Posted on September 16, 2015 by MidwifeThinking

Updated: May 2022

Artificial rupture of membranes (ARM) aka ‘breaking the waters’ is a common intervention during birth. However, an ARM should not be carried out without a good understanding of how the amniotic sac and fluid function in labour. Women need to be fully informed of the risks associated this intervention before agreeing to alter their labour in this way.

This post will discuss how the ‘waters’ work in labour and the implications of breaking them. Most of the information in this blog is available in any good physiology textbook. I have included references and links for additional content.

Anatomy and physiology

By the end of pregnancy the baby is surrounded by around 500-1000mls of Fluid. This is mostly made up of urine and respiratory tract secretions produced and excreted by the baby. The amniotic fluid is constantly being produced and renewed – baby swallows the fluid; it is passed through their gut into their circulation; then sent out via the umbilical cord through the placenta. This process continues even if the amniotic membranes have broken. So, even when the amniotic sac has a hole in it, there is still some fluid present, ie. there is no such thing as a ‘dry labour’. You can read more about amniotic fluid volume in this post.

The amniotic sac is made up of two membranes – the amnion (inner) and the chorion (outer). At the end of pregnancy there is around 200mls of amniotic fluid and mucous between these two layers. After the birth of the placenta the two layers stick together because this fluid has gone. However, you can still tease the layers apart.

During pregnancy

The amniotic sac protects and prepares baby by:

  • Cushioning any bumps to the abdomen.
  • Maintaining a constant temperature.
  • Allowing the movement essential for muscle development.
  • Creating space for growth.
  • Protecting against infection – the membranes provide a barrier + the fluid contains antimicrobial peptides.
  • Assisting lung development – baby breathes fluid in and out of the lungs.
  • Taste and smell – the baby tastes and smells the fluid, which is similar to colostrum = helps to find their mother’s nipple after birth.

After 40 weeks gestation, around 20% of babies will pass meconium into their amniotic fluid as their bowels reach maturity and begin to work. This is perfectly normal and is not a sign of distress. This meconium is diluted and processed with the amniotic fluid as described above.

During labour and birth

Around 80-90% of women start labour with their membranes intact. This is probably because the amniotic sac plays an important role in the physiology of childbirth.

General fluid pressure

During a contraction the pressure is equalised throughout the fluid rather than directly squeezing the baby, placenta and umbilical cord. This protects the baby and their oxygen supply from the effects of the powerful uterine contractions.

diagram available here

When fluid is reduced (by escaping through a hole in the membranes), the placenta and baby get compressed more firmly during a contraction. When the placenta is compressed blood circulation is interrupted reducing the oxygen supply to baby. In addition, the umbilical cord may be in a position where it gets squashed between baby and uterus with contractions. When this happens the baby’s heart rate will dip during a contraction in response to the reduced blood flow. A healthy baby can cope with this intermittent reduction in oxygen for hours (it’s a bit like holding your breath for 30 seconds every few minutes). However, this is probably not so great for an extended period of time, or if the baby is already compromised through prematurity or a poorly functioning placenta.

Fore waters and hind waters

The sac of amniotic fluid is described as having two sections – the fore waters (in front of baby’s head) and the hind waters (behind baby’s head). A ‘hind water leak’ refers to an opening in the amniotic membranes behind the baby’s head. Often this is experienced by the woman as an occasional light trickle as the fluid has to run down the outside of the sac and past baby’s head to get out.

During labour, fore waters are formed as the lower segment of the uterus is pulled upwards and the chorion (the external membrane) detaches from it. The well flexed baby’s head fits into the cervix and blocks off the fluid in front of the head (fore waters) from the fluid behind (hind waters). Pressure from contractions cause the fore waters to bulge downwards into the cervix and eventually through into the vagina. This protects the fore waters from the high pressure applied to the hind waters during a contractions and keeps the membranes intact. The fore waters transmit pressure evenly over the cervix which helps with dilatation. When the baby is in an OP position the head may not flex as well to block off the hind waters and pressure is able to move into the forewaters and they may rupture. Early rupture of membranes is often a feature of an OP labour.

Lubrication

The forewaters usually break when the cervix is almost fully open and the membranes are bulging so far into the vagina that they burst. This ‘fluid burst’ lubricates the vagina and perineum to facilitate movement of the baby and stretching of the tissues.

Born in the caul

It is fairly common for a baby to be born in the amniotic sac when labour is left to unfold without interference. Particularly during a waterbirth where the pressure on the amniotic sac is altered by the fluid in the pool. The photograph at the beginning of this post is my lovely friend Holly birthing her baby in his caul.

Historically, being born in the caul was considered good luck for the baby. It was also believed that a baby who was born in the caul would be protected from drowning. Midwives used to dry out amniotic membranes and sell them to sailors as a talisman to protect them from drowning. You can find out more about the social history of the caul in an old journal article by Forbes (1953).

How does birth in the caul influence the baby’s microbiota?

I don’t know the answer to this question. However, increasingly research is identifying the importance of intestinal microbiota for health, including immune development and function. I have written about this topic in more detail in another post. During a vaginal birth the baby is colonised by microorganisms as they pass through the vagina. So, this raises questions about what happens if the baby does not come into contact with vaginal microorganisms because the amniotic sac is intact? In theory, during a waterbirth the pool water is likely to contain microorganisms from the mother, therefore the baby could become colonised. But on land – I don’t know.

C-section and the amniotic sac

There are photos circulating on the internet of babies in their caul during a c-section (google caul+caesarean or cesarean). I would like to know the background stories to these photographs. There has been a study supporting this practice for preterm babies (Wang, et al. 2013). However, there is no research supporting this method for full term babies.

Artificial rupture of membranes (ARM) aka amniotomy

Breaking the membranes with an amni-hook is a common intervention during labour. It is usually the second step in the induction process, and is also done in an attempt to speed up spontaneous labour. In an induced labour, intact membranes can prevent the artificially created contractions from getting into an effective pattern. There is also the theoretical risk of an induced contraction (that is too strong) forcing amniotic fluid through the membranes/placenta and into the mother’s circulation causing an amniotic embolism and maternal death. So an ARM is recommended before a syntocinon/pitocin infusion is started (although this may not be a worldwide practice).

In a spontaneous labour the rationale for an ARM is that once the forewaters have gone the hard baby’s head will apply direct pressure to the cervix and open it quicker. However, a cochrane review of the available research states that “the evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged.”

There are also risks associated with an ARM:

  • It may increase contraction intensity and pain which can result in the woman feeling unable to cope and choosing an epidural… and the intervention rollercoaster begins.
  • The baby may become distressed due to compression of the placenta, baby and/or cord (as described above).
  • Fok et al (2005) found amniotomy altered fetal vascular blood flow, suggesting there is a fetal stress response following an ARM.
  • The umbilical cord may be swept down as the fluid drains out. If ends up wedged next to the baby’s head or washout out into the vagina, this is called a ‘cord prolapse’ and is an emergency situation. The compression of the cord interrupts or stops the supply of oxygen to the baby, and the baby must be born asap by c-section.
  • If there is a blood vessel running through the membranes and the amni-hook ruptures the vessel, the baby will lose blood volume fast – another emergency situation.
  • There is a slight increase in the risk of infection but mostly for the mother (not baby). This risk is minimal if nothing is put into the vagina during labour (ie. hands, instruments etc.).

It seems that an ARM is often performed during labour without consent. The requirement for consent to be eligible includes providing adequate information about the procedure. Have any readers been given the information above prior to agreeing to an ARM?

Summary

The amniotic sac and fluid play an important role in facilitating physiological birth and protecting the baby. There is no evidence that rupturing this sac will reduce the length of labour. While every intervention has its place, including ARM, midwives need to carefully consider the risks before offering it to women. Also, women must be fully informed of the risks before choosing an ARM during their labour.

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