Birth as we know it - a film about oxytocin

I have just watched a birth film that I love (although I loved the previous version called Birth into Being more).  It is filmed mainly in Russia and what is so lovely about this film is you can almost see oxytocin, it is visible in the faces and expressions of the women filmed, it is almost palpable.  I wish they would show this sort of film more on TV.   

Oxytocin - the hormone that makes life possible, that makes us all tick, that makes the world go round, that mediates love and happiness - it really warrants a whole David Attenborough series, especially as other mammals show its importance too. Oxytocin is excreted by the posterior pituitary gland in situations of calm, joy, relaxation, love, sexual stimulation etc.  But it almost seems to me that is is a physical outpouring of our soul life.  It helps build the soul forces of our children too, in labour, at birth, and during breastfeeding.

For anyone who doubt the impact that good oxytocin secretion has, Birth As We Know It will soon put you right!!

Birth furniture

I have in my bedroom an old oak birth stool.  I think it is  early 20th century Spanish.  It is basically three legs that bolt to a seat.  The seat is narrow, curved and has hand grips, and there is a back-rest.  It is a bit like this one (which is also Spanish) but is carved.  The whole thing can be unbolted, tied together and left to sit in the back of a cupboard until needed.  It is perfectly usable and simple.

There are a variety of birth stools, birth balls and birthing beds on the market.  They must comply, of course, with "health and safety" requirements and are generally rather expensive.  The NCT, for example, sells a fibre glass birth stool for £1,000 (not sure whether that says more about the stool or the NCT).  However, most birth furniture is German and sells for German prices, and the UK seems not to either design or manufacture much decent birth furniture at all.  The NCT birth stool for example is almost the only one readily available in the UK.  But with 5,200,000 babies born annually in the EU, the market should surely be doing more?

Most birth beds are expensive, heavy, complicated and pretty uncomfortable, especially to sleep on.  They are also quite hard to move around on and mobility is crucial in labour.  Birth balls are popular because they are cheap (hence most maternity units have them and many people can afford one) and do a reasonable job especially in aiding pelvic movement.  Most birth stools are pretty uncomfortable after any length of time and they can be hard to get down onto or up from.  Few women want to spend much time on them and it is probably best if they don't, however great they can be for birth.

Enter the Osborne Chair!!  This is a chair designed to aid mobility, be comfortable, be easy to get on and off, and comply with regulatory requirements.  It particularly does what few other birth furniture does - cater for the need of labouring women to hang over things, to lean and kneel and rock and roll their pelvis.  It is still in the development stage but looks good.  Undercover Midwife looks forward to its launch and hopes it leads to the development of much more furniture designed for pregnancy, labour and breastfeeding.
http://www.birthupright.co.uk/
FOR AN UPDATE ON THE OSBORNE CHAIR, SEE MY POST OF OCTOBER 2017

Good article in The Guardian about free-birth.

At last, a balanced presentation and discussion about free-birth in the mainstream media!

http://www.theguardian.com/lifeandstyle/2013/sep/14/freebirthing-birth-without-medical-support-safe

Lots of information and some useful links.  Worth reading because it gives context to the free-birthing women's decisions and balances the autonomy-responsibility dyad well by not presenting them as conflicting as so many discussions do.  Also covers many of the issues that need to be thought through when planning free-birth.  Well done Joanna Moorehead.

Facing Baby

Over the past 30 years there has been a sorry trend in baby carriers and especially prams whereby our babies are left without visual contact with their carers.  This is the sort of thing I mean:

Young children cannot learn from the endless stimuli that they are exposed to except through the mediation of their mothers, fathers and other carers who interpret, repackage, censor and explain phenomena to them.  It is the three-way interaction between the world, the baby and its carer that allows the child to make sense of it all.  Simply exposing the baby to stimuli without the input and constant filtering of the stimuli by the carer over-stimulates and confuses the baby and, at worse, makes it anxious.

Where has this come from?  Surely pram manufacturers are capable of making prams that enable inter-action with the baby as he or she grows?  Slings that enable baby to face mummy or daddy are certainly available.

The second photo above was used to illustrate a story about Pullitzer prize-winning author Jared Diamond advising parents to boost their babies' confidence by carrying them facing outwards.  Jared is an advocate of baby wearing which is great and points out that babies have been carried rather than pushed from time immemorial and that this is beneficial.  My issue is where does this facing outwards idea then come from?  Traditional societies cited by Diamond do not wear their babies facing outwards.  To illustrate his point about traditional parenting wisdom, the article uses this picture:

A mother in face-to-face contact with her child!

Personally I have nothing against prams, especially as the baby grows heavier, though baby-wearing is wonderful.  What concerns me is the relative isolation of the babies in the first two pictures compared with these:

Research has shown that when parents are facing their babies in this way in prams, they are twice as likely to talk to them as when they are facing away.  You can read this research here: http://www.literacytrust.org.uk/research/nlt_research/5313_whats_life_in_a_baby_buggy_like
and here:
http://www.literacytrust.org.uk/talk_to_your_baby/news/1553_do_baby_buggies_affect_development 
As far as slings go, Elizabeth of Boba products (a baby sling maker) gives 9 good reasons why you shouldn't carry your baby facing outwards and here they are:
http://www.bobafamily.com/blog/2011/10/11/nine-reasons-not-to-carry-your-baby-facing-out/
Buying a pram, or even a good sling, is a costly business.  They are important bits of kit, allowing us to get out and about, protecting baby from the elements, giving the opportunity for fresh air; but they are also about time spent together, introducing baby to the park, the shops, your locality and sharing your experience of those places with him or her.  "Look, duck!", Look at the doggy run", "See the big red lorry", "Here's Grandma" and similar are ways of making sense of the world for the baby, of learning language and the association of word and object.  They can't happen when you can't even see your child.

 

Undercover Midwife's Hats for Babies Campaign

Update!
The same advice albeit for different reasons goes for winter too.  Here is a link to a simple autumn/winter bonnet that you may enjoy making for your little person.
http://www.ravelry.com/patterns/library/norwegian-sweet-baby-cap---djevellue 
Thanks to Carol for supplying the e-address.
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Oh dear, oh dear I am in moaning old bag mode here, be warned!  My grouse is about the number of babies and toddlers who go hatless in hot weather. 

Thin skulls, soft fontanelles, no or next-to-no hair and full hot sun shining on their little heads!  Babies and toddlers who are not protected from the sun are at risk of sunstroke and that is a serious condition.  A hat is an absolute must, no baby or toddler should be out in hot sun without head protection.  Last week, hatless babies of just a few weeks old were being exposed to sun and temperatures in the high 20s almost everywhere I looked. 

If you must take your baby out in the sun:

• Always have your baby shaded - you can use a sheet or wrap over her pram to protect her.
• Ensure that all exposed skin is covered, either by lightweight, loose-fitting clothing or with the shade cast by a wide brimmed hat or bonnet.
• Try to keep your baby in the shade when you take him outside.
• Check to make sure that your baby's staying cool during car rides. 
• Give your baby more breastfeeds or fluids than usual on hot days.
• Protect the parts of your baby's skin that can't be covered with a suitable sunscreen (though it is best to protect using the steps above).

Here are some links to some sunhats you can knock up in a jiffy!
http://www.youtube.com/watch?v=qHIobBoFuKg

http://www.make-baby-stuff.com/baby-sun-hat.html

and a link to a good website with advice re sunstroke -

http://www.globalappointments.com/ARTICLES-JULY06/sunstroke-july06/Sunstroke.htm

No ifs, no buts, put a hat on your baby.  And pass on the message!

Intermittent auscultation

Intermittent auscultation: the practice of listening to the baby's heartbeat at intervals either by a handheld ultrasonographic device (aka a Sonicaid) or a wooden or plastic fetal stethoscope known as a Pinard's stethoscope.  Current NICE guidelines state that this should be done EVERY 15 MINUTES during established labour.  The alternative is continuous monitoring of the baby's heart via a cardiotocograph (CTG machine).

A very interesting article by Ruth Martis in "Essentially MIDIRS" (Vol 4, no 5, May 2013) about the intrusiveness of intermittent auscultation and the lack of evidence regarding the efficacy of listening to baby's heartbeat in an otherwise normal labour/healthy woman.  A woman quoted describes the experience of intermittent auscultation as being intermittently "ripped away from my peaceful place".

The level of evidence for NICE's 15 minute guideline is C, effectively nothing more than personal opinion.  As obstetricians dominate the NICE maternity guidelines, this means obstetric opinion, and not scientific evidence.  It is actually as near to continuously monitoring as they could get without actually opting for continuous monitoring by CTG machine, undoubtedly their favoured option if not for the presence of lay members and midwifery representatives pointing out that the evidence pointed against that.  (Someone in the know told me this was the situation shortly after the intrapartum guideline was published.)

If some women (and of course many will want their midwife to listen to the baby's heart, whether at 15 minute or longer intervals) find it obtrusive, it also interferes with watchful midwifery.  Having to fiddle around with a sonicaid or Pinard every 15 minutes, changing the woman's position to get a clear reading, interfering with clothing, having to talk to or touch her, as well as the noise of the sonicaid which is intrusive even at low volume.  So called low-intervention care contains many interventions - pulse, blood pressure, palpations, FH auscultation, temperature-taking, asking questions, making records, noting times, offering drinks, massaging backs, even being in the same room ......they can all be intrusive and some women do not want or benefit from any of it.  Especially those who are using hypnobirthing techniques or who are most emotionally and therefore physiologically comfortable in private peace and quiet, who need a deeply mammalian experience and environment.  And there are far more women who need and want this than currently get it.

The Essentially MIDIRS article isn't available online but here is a link to Ruth Martis' proposal to undertake a review of auscultation and the frequency it may or may not be efficacious.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008680/full

and a link to her other work which includes the use of music during caesarean section:
http://scholar.google.com/citations?user=73RnpAEAAAAJ&hl=en

I am quite sure the questions Ruth is asking are important for women and midwives as she is asking questions about the nature of intervention itself in low-risk labour or where women do not want it regardless of risk.  Undercover Midwife looks forward to reading more when she and her colleagues publish their review.

Induction of labour and the risk of Caesarean section in low risk parous women.

A Swedish study has looked at the risk of CS in low risk PAROUS women who are induced (women who have had a baby before).  The Caesarean section rate in this group is doubled following elective induction of labour and tripled if a cervical ripening method (eg Propess or prostaglandin gel) is used.

This research is very significant and urgently requires to be replicated to make sure its highly significant findings are confirmed in other settings.  Any low-risk parous woman faced with elective induction should be made aware of the findings if she is to make an informed choice.

The paper can be found here:

http://www.ncbi.nlm.nih.gov/pubmed/23157554

Bounty (sic) and the child benefit form

Update 26.9.13
Good old Jane Martinson in The Guardian, she does seem to "get it"! 
http://www.theguardian.com/lifeandstyle/the-womens-blog-with-jane-martinson/2013/sep/26/kick-bounty-out-maternity-wards-parenting-clubs

Update 18.6.13
This appeared in the Telegraph today! 
http://www.telegraph.co.uk/health/healthnews/10049918/NHS-cash-for-access-mothers-targeted-by-salespeople-just-minutes-after-giving-birth.html

Boom boom!

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One of the most irritating things about being in a maternity unit is being accosted by Bounty (sic) "ladies" (salespersons) and being given numerous plastic bags full of advertising and samples of various toxic substances.  Even hand-held maternity notes come in plastic "Bounty" envelopes.  In fact, if you are left in any doubt as to the value of your pregnancy to global commerce at the beginning of pregnancy, even the most ardent advocate of free enterprise must be pig-sick of the rubbish being thrown at them by the time they qualify for the final samples which are usually waiting for them by their postnatal bed or in the baby's cot!!  Of course, it doesn't end there.  Once you are on the Bounty mailing list, a small forest of snail-mailings will be sent and your inbox will be full of junk from Bounty every time you manage to find a few minutes to sit at your computer in the first year of motherhood.   And this barrage of crap is justified on the grounds of "information-giving".  As far as maternity units are concerned, the dosh they get for allowing this rampant commercialisation of birth is all that interests them.  They even have to constantly check that the stuff in the packs doesn't run counter to evidence-based maternity care, especially as regards breastfeeding, and have said reps in to remonstrate with them when it doesn't. 

Why does the NHS allow such access to its clients?  It doesn't allow it for other groups, just pregnant women.  It justifies it, or allows Bounty to justify it, on the grounds that the Bounty Packs contain the child benefit claim form and this charade is therefore providing a public service.  Utter tosh.  You do not need to fill your recycling bin with rubbish just to get your child benefit form.  Here it is:

 http://www.hmrc.gov.uk/forms/ch2-online.pdf

Instructions for completion are here:

 http://www.hmrc.gov.uk/forms/ch2-online-stubb.htm

and the link to the petition trying to get this sorry state of affairs changed is here!!

http://www.change.org/en-GB/petitions/health-minister-dr-dan-poulter-mp-put-an-end-to-commercial-parenting-club-reps-in-maternity-units-2

As I write, over 14,500 people have already signed!

Registering births.

I read a truly awful account in the AIMS Journal (Vol 25, No 1, 2013) about a free-birthing couple who were horribly bullied by the health service and social services in South Tees.  One of the bullying tactics was the with-holding (by the midwives) of the notification of birth which delayed the baby's registration and caused problems with the issuing of her NHS number.  Quite how the midwives have been allowed to get away with this is beyond me.  

However, as AIMS points out in relation to the 1907 Notification of Births Act, found here: http://www.legislation.gov.uk/ukpga/Edw7/7/40

"it shall be the duty of the father of the child, if he is actually residing in the house where the birth takes place at the time of its occurrence, and of any person in attendance upon the mother at the time of, or within six hours after, the birth, to give notice in writing of the birth to the [Registrar] .........."

The Births and Deaths Registration Act of 1953 is quite clear:

"The following persons shall be qualified to give information concerning a birth, that is to say—
(a) the father and mother of the child;
(b) the occupier of the house in which the child was to the knowledge of that occupier born;
(c)any person present at the birth;
(d) any person having charge of the child."

The Act can be found here:
http://www.legislation.gov.uk/ukpga/Eliz2/1-2/20

Basically, the notification of birth is usually signed by the attending midwife and this automatically alerts the registrar and the parents turn up some time later and sign and collect the baby's birth certificate.  So it is a 2 phase process - notification and later registration, either of which can be done by the father.  A letter notifying of the birth should suffice as this is essentially what has passed between hospitals and registrars.  Of course nowadays it is all automatic via computer link but that is not a pre-requisite for registration.

The NHS number is issued as part of this process but the LSAMO (see website below) should be able to obtain an NHS number for the baby if the midwives will not oblige.  http://www.lsamoforumuk.scot.nhs.uk/

So the NHS number is really a separate issue and can be dealt with over a period (hospitals have a way of accessing an NHS number in an emergency e.g. for visitors arriving from overseas and being rushed straight to A & E with a DVT for example).  My advice would be:

a) see if a local midwife or Supervisor of Midwives will notify the birth if you are happy to contact one within the 6 hours mentioned (this will sort the NHS no issue too); or

b) write a simple letter to the local registrar advising of the birth (date, time, sex etc); and 

c) wait a week of two to see if the registrar writes back and then visit to register in the usual way.  In theory you should be able to sign the register and obtain a birth certificate; and

d) ask your GP or health visitor to sort out the NHS number or contact the LSAMO.

Group B Streptococcus

To have or not have intrapartum antibiotic prophylaxis (IAP) if you have been found to have Group B Streptococcus (GBS)?

A recent Cochrane review of IAP found insufficient evidential support for IAP in terms of reducing early-onset GBS in the baby, that is infection in the first week.  This review can be found here.
http://www.ncbi.nlm.nih.gov/pubmed/23440815
90% of GBS infection in babies occurs in the first week.

What about later onset GBS disease in babies (that 10% which occurs between 7 days and three months of age)?  IAP has been found to lessen the severity of later onset GBS disease in babies in a recent retrospective cohort study.  However later onset GBS is rare, affecting around 1 in 4000 term babies.  The authors of this paper agree that GBS transmission is poorly understood and that IAP is insufficient to prevent mother-to-baby transmission.
http://www.ncbi.nlm.nih.gov/pubmed/23296441

It is a personal decision whether to have IAP but the evidence supports a decision to decline IAP every bit as much as it supports the decision to go along with it.

What is important is the recognition of GBS disease in a baby and an effective response to that by parents and healthcare services.  GBS is not a contra-indication to homebirth whatever the parents' decision is about IAP.

Signs of GBS in a baby:
- Poor feeding
- Lethargy
- Irritability
- High or low temperature
- High or low or irregular heart rate 
- Anxious or stressed appearance
- Blue appearance (cyanosis) or paleness (pallor) with cold skin
- Breathing difficulties such as flaring of the nostrils, grunting noises, rapid breathing, short periods without breathing

Choose your midwife choose your birth

Excellent demonstration outside parliament today, and meeting with MP for Shipley. Midwives, doulas, mothers, fathers, babies, siblings, hypnobirthing teachers, AIMS, ARM, IMUK, RCM, all making themselves heard.  Not sure who was listening but it had to be done.  

The threat to independent midwifery is serious and looks insurmountable.  The insistence that registration will be dependent on adequate indemnity insurance has recently been reiterated by Dan Poulter, Minister for Health in a letter to IMUK.  It doesn't look like the DoH is prepared to find a compromise.  Next step is the joint manifesto for maternity care co-written by NCT, AIMS, ARM, IMUK and The Birth I Want.  This is called "A Midwife For Me and My Baby" and will be launched at the beginning of May with an action that will see a cardboard baby (or a charity shop doll) delivered to every MP with a message calling for continuity of care from a known midwife and choice, including an independent midwife. 

How will midwifery skills and practice develop if there are no midwives practising outside the constraints of NHS "policies"?  I can think of no midwifery skill and practice development in relation to normal birth over the last 30 years that has developed within the NHS.  All practice and skill development with regard to normal birth has first been conceptualised, explored, discussed and written about in independent practice and thence wound its way into wider practice (physiological third stage, waterbirth, complementary therapies, the purple line, vaginal breech birth, milking the cord, lotus birth, parameters of normal labour, birth stools......).

Birthing outside the system - perceptions of risk

http://www.ncbi.nlm.nih.gov/pubmed/22300611

The authors interviewed women (in Australia) who had free-birthed or had homebirths despite being "high-risk" to explore their perceptions of risk.

The women interviewed described their understanding of the risks of giving birth in hospital, particularly regarding interventions and lack of privacy, and sought to protect themselves and their babies from those risks through choosing to give birth at home.  They were found to have given this matter considerable thought.

The same considerations were found in Iran where women also perceive that there are risks attached to hospital birth.

http://www.ncbi.nlm.nih.gov/pubmed/22172740

Perhaps the DoH would like to produce one of their nice little leaflets (see their annual flu vaccine leaflets for example of same) expounding the risks of hospital birth to women?  Doubtless midwives would be required to tick a box in triplicate to confirm the leaflet had been given but it would be worth it for once.  It isn't just women's perceptions - both the Birthplace study and the PPH study done by the University of Southampton (see last posting) give quantifiable examples of the actual risks.

Postpartum haemorrhage

A review of 273,872 births by a team at the University of Southampton has shown that the rate of PPH is lower for women having homebirths, and concludes that the excess PPHs in hospital births is in part caused by medical intervention (e.g. use of syntocinon to speed labour, episiotomies, Caesarean sections).

The researchers advise "Women and their partners should be advised that the risk of PPH is higher among births planned to take place in hospital compared to births planned to take place at home."

And this is despite there being likely to be more physiological third stages at homebirths!  Once again, a clear demonstration that women's bodies nearly always do the job best if left to get on with it in their own time in a supportive and calm environment, and the hospital maternity services are unable, for the most part, to improve on physiology. 

The article can be found here:

http://www.biomedcentral.com/content/pdf/1471-2393-12-130.pdf

Tying and cutting the cord

For those who do not want a lotus birth (more of that on a later post maybe), what to do with the cord?  A plastic clamp?  A sterilised piece of string or plaited embroidery thread?  I much prefer the latter, the cord seems to dry out better.  Of course, the ties may become loose during that process and at this stage may need to be replaced (or not).  Clamps used to be cut off after 2 or 3 days but the clamp-cutters, at that point re-usable, were thought (probably rightly) to be an infection-risk.  Disposable clamp-cutters are available but are costly and unecological. This means that once a plastic clamp is on the cord, it can rarely be removed whilst the cord remains attached (4 to 10 days).

Cutting - scissors or knife or razor blade?  All should be sterilised as well as possible, usually by sterilisation tablets, baking or boiling, depending on what is being sterilised - see http://www.ific.narod.ru/Manual/Clean.htm  for useful discussion of the various methods.

Of course NHS midwives are supplied with sterile supplies and independent midwives also have their own supplies, also usually sterile pre-packed.   Animal suppliers also sell sterilised plastic cord clamps in small amounts.  These can be ordered via the Internet.  Paramedics have fantastic little birth packs which also contain a plastic clamp and sterile scissors (disposable).

If the cord is left until after the birth of the placenta, it is thin, its vessels have collapsed, and it is easier to cut through.  To those who haven't cut a cord before, it can occasionally feel quite hard to cut through.  Definite and determined cutting will always succeed.

I am quite sure that thinner cords would stay tied if simply knotted.  But I have never done this.  Has anyone?

Update 8.1.14 - here is a link to a lovely You Tube photo-montage showing cord-tying following a ?freebirth: http://www.youtube.com/watch?v=1lOden_xbt4&feature=youtu.be

Welcome to The Undercover Midwife's blog.

Welcome to my blog which is primarily for women making radical and difficult choices in the face of the demise of independent midwifery, the absence of services that meet their needs and preferences, and the inability of maternity services to approach birth from other than a medical viewpoint.

I am a midwife with more than 30 years experience and believe women and families need support to give birth and raise their babies within the context of their lives, relationships, beliefs and path through life.  Homebirth, attachment parenting, a community and familial approach to birth such as local birth centres and breastfeeding support, and the right to choose and get to know your birth attendant(s) are all important to me.  

Many women are choosing to "freebirth" too, often as a last resort rather than a first preference, though this choice is also a positive one for many too.  I hope that this blog will enable me to give some e-midwifery support to freebirthing women especially, and enable us to explore issues together.

Below is a link to an Australian news item:

http://www.abc.net.au/news/2013-02-08/free-birthing-on-the-rise-despite-danger-warnings/4509420