MAYD to Birth: At Your Doorstep

Promoting gentle, empowering mother journies…

Vaginal Birth Preparation

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You want a natural vaginal birth, but have you prepared for it?

Vaginal Childbirth Methods

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Many pregnant women are unaware that several natural vaginal childbirth methods are available. Foremost among these are Hypnobirthing, the Bradley Method and Lamaze.

Free Water Birth Video Clips

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Making a water birth video is a wonderful way to capture the moment of your child’s birth. Featured in this section is a sampling of free water birth video clips.

Guidelines for Water Births

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Water births are a safe, effective alternative to the harsh
medical setting of a hospital as long as these guidelines are followed.

What is Waterbirth?

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Waterbirth is a key ingredient to a natural childbirth for many women. Read on to learn
more about waterbirth.

I’m Moving!

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I feel like I have outgrown Momotics… and I have been working on another project for a little bit… I am in the final steps of getting it all up and running so I would really appreciate if you came over and checked it out!

 

CHECK OUT MY NEW SITE!

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10 Lessons Toddlers Can Teach Adults

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When I was at the mall with my children the other night, I started to come to a realization about the innocence of our toddlers.  They really have so many lessons they can teach us as adults.

They are fearless, friendly, and have no type of prejudice at all. It is something they learn, and experience as they grow and are truly exposed to the world around them. Whether it is their parents, other kids at school or strangers they encounter as they grow.

 

READ MORE HERE

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The Assessment of Progress

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Recruit 5000 more NHS midwives in England

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Recruit 5000 more NHS midwives in England

Responsible department: Department of Health

More babies were born in England in 2010 than in any year since 1972, whilst births to women aged 30 or older were at their highest since 1946. The NHS is desperately short of midwives, and the shortage affects every region of England. We need urgent action from the Government, including a target to recruit the equivalent of 5000 more full-time midwives. Care for women but especially babies at the very start of life should be shielded from the cuts.

This is an e petition to H M Government. I would have worded it differently, but there again I am a simple being who would just go to the heart of the problem. The whole world, literally, interprets the current staffing issue within the maternity services as being down to a shortage of  trained midwives but that isn’t the situation, there are plenty of us. The issue is the employment of midwives, and the crux of the matter is funding. The Trusts are having to budget so harshly that coal-face staff numbers are being trimmed to below the quick, and not just midwives, other professionals as well. We do need to recruit more midwives but to do this we need to improve the funding, be shielded from the cuts yes, but also improve the monies available to the maternity services, not for paper-shuffling exercises but to employ more midwives.

Anyway, here’s the link, it can’t do any harm so please sign  the e petition here.

 

In the Final Days

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I have been avoiding the computer really at all costs. I have kept up with my Babble posts, because of course I have to. But other than that when I am on twitter, or facebook … most of it is on my phone from the hospital trying to keep my mind busy so I don’t think about what is really going on. I hate seeing my sister in the condition that she is in.

My mother called me last night and told me her ex-husband and son would be staying at the hospital for the night because really we didn’t think she would make it through the night.  So I went up to the hospital and stayed late.  I fell asleep in a chair next to her bed, holding her hand with my head on the rail of the bed.   My breast milk stash I had in the freezer is gone. I used the last bag over the weekend when I was spending hours at the hospital as my husband could sit with the kids.

I feel like every time I am with my sister, I am neglecting the kids whether they are with a babysitter, or my husband. And when I am with the kids, I feel like I am missing the little bit of time I have left with my sister.  I am damned if I do, and damned if I don’t.  There is no easy way around any of it.

Keeping myself busy is the only way to keep my mind off of everything when I can’t be at the hospital at her side. Sunday when I had to come home, once the baby was fed, and back to sleep I literally washed the walls in my kitchen. Something I would never willingly do, or take time to bother with.  Yeah it has to be done, but not something I would ever take on during a Sunday afternoon when I have time that the kids are behaving.

We have all been taking shifts at the hospital so she is never alone. There is always someone with her.  Holding her hand, or laying with her in her bed comforting her and letting her know everything is ok.

I typically am not the most Godly person, but I have been in the chapel every day and last night we had the Priest in the hospital come up and pray with us.  It is what she wants, she keeps talking about the angels, and how she is going to be an angel. I told her she is going to be the best damn angel Heaven has EVER seen.

No one ever thinks their 40 year old sister is going to get a brain infection and die. EVER.

It is simply something you can never plan for. And it hurts.

Writing a bit here and there is the only way to help me get some of my emotions out.

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