Small UK study into reasons for choosing freebirth.

http://blogs.biomedcentral.com/bmcseriesblog/2016/04/12/giving-birth-going-alone-choosing-freebirth-uk/

Just a small study and the findings - negative experiences, loss of faith in maternity services, desire to avoid interference and feel safe, the disconnect between midwifery philosophy and the actual experience of care, as well as a positive choice of freebirth - come as no surprise.  Anyone who looks at UK maternity care and thinks it is ok and offering choice, continuity, control or even care on anything other than an individual, occasional or serendipitous level is deluded. 

Why do we persist with our outdated ideas about due dates? Bring on the "EPB".

In 1990, Mittendorf and colleagues pretty much established that a first pregnancy, on average, lasts longer than the 280 days from LMP that we use to calculate due dates.
http://www.ncbi.nlm.nih.gov/pubmed/2342739

Their research showed pregnancy, on average, to last 41 weeks and 1 day for primiparous women and 40 weeks and 3 days for multiparous women.  They concluded that "one should count back 3 months from the first day of the last menses, then add 15 days for primiparas or 10 days for multiparas, instead of using the common algorithm for Naegele's rule" [Naegele's rule being count back three months and add 7 days].  Mittendorf et al.'s statistics did come from what they describe as "private-care white mothers" but, in the intervening quarter century, these findings haven't even been adopted for that demographic, with the inevitable impact on anxiety levels and intervention rates.

Roll on 23 years to 2013 and more of the same. http://humrep.oxfordjournals.org/content/28/10/2848

Not only is the average length of pregnancy 40 weeks and 2 days from LMP, according to this later research, but it also has a large natural variation, of 37 days.  The sample was a lot smaller but again brings the honesty of giving women an Expected Date of Birth (EDB) instead of an Expected Period of Birth (EPB) into question.  UM, like many midwives and doulas, has for many years preferred to talk about a rough estimate (taking into account Mittendorf and Co.'s paper) of, for example,"around the first week of May" or "the second half of June" or "the middle of November".  But even this approach falters in face of the assertive and "scientific" certainty of an Expected Date of Delivery (EDD) (sic) given at a scan or medical appointment.

Let's all stop talking about EDDs ("women give birth, pizzas are delivered"), and EDBs and replace these with EPBs. 

Of course this all begs the question of when is someone "overdue"?  But the answer is clearly "not as soon as we think".

Simple psychology for mothers and babies.

This is a nice little summary of what helps baby enjoy life and adapt to its new social and family environment, and mothers enjoy life with a baby, from The British Psychological Society.  Simple, good advice.

http://thepsychologist.bps.org.uk/volume-29/january-2016/psychologist-guide-you-and-your-baby

Free on-line attachment and baby development course looks interesting.

I have no idea what this will be like (it starts on 28th March) but the person who has set it up has done some very interesting research into attachment parenting so it might be very good indeed.
https://www.futurelearn.com/courses/babies-in-mind 

You can express interest now and presumably get access from 28th March.  It is 4 hours a week for 4 weeks.

Here is the course outline: 
 
This course will explore how the mind of the parent influences the developing mind of the child, from conception through infancy and into later life.
We will take you on a journey that begins in pregnancy, exploring the importance of the ability of the mother-to-be to think about her baby while still in utero, alongside the impact of emotions such as anxiety and depression.
We will then explore what the research tells us about the way in which the parent’s emotional and cognitive mind, can shape the interactional context of the baby during the first two years of life, and the impact of this interaction on the baby’s developing mind. This will include, for example, thinking about the parent’s ability to be ‘mind-minded’ in terms of being able to treat their baby as an individual with a mind of their own.
Throughout, we’ll seek to answer questions such as:

• How does a parent’s mind influence the development of a baby before he or she is born?
• What processes take place in the post-natal period that influence the baby’s developing mind?
• What can we do during pregnancy and the post-natal period to support parents who are experiencing difficulties?

You will get the chance to hear from expert academics and clinicians working in infant mental health, and share your views with other parents and caregivers around the world.

Requirements

This free online course is aimed at everyone who has an interest in promoting the well-being of their own baby, or the parents and babies they work with. You do not need any prior knowledge of infant or child development, just a desire to learn about parents and babies, and the way that early interaction shapes later development. The course is based on the latest research in the field and you will be introduced to key concepts relating to infant psychology and attachment.

Comfortable Upright Birth (CUB)

http://www.cub-support.com/

I love the animation on this site and coming across a piece of useful gear at a reasonable price.  Also a great resource list for any midwifery student doing a project on birth positions.  I think an inflatable support like this will have limited appeal to many units (over and above birth balls for labour and solid birth stools for birth) but a great thing for homebirths. 

Proud to be breastfeeding her toddler.

It isn't often that the Mail comes up with anything that is a) good news or b) worth reading, but this is a great story from yesterday's Mail On Line http://www.dailymail.co.uk/femail/article-3270403/WAG-Melanie-Walcott-reveals-breastfeeds-18-month-old-son-Finley.html
For non-UK readers, Theo Walcott is a football/soccer player for Arsenal and England so about as famous in UK Man-World as they come.  A great use of celebrity to promote attachment parenting and long-term breastfeeding, well done Melanie Walcott.

Shoe size and risk of Caesarean section

In 1985 some midwives and doctors (Frame S et al.) from St Mary's in London published a beautifully simple and interesting study in the British Journal of Obstetrics and Gynaecology called "Maternal height and shoe size as predictors of pelvic disproportion: an assessment".

They found a clear correlation between foot size and giving birth by Caesarean section, that is they took shoe size to be an indicator of pelvic capacity.  Of course even in 1990, the CS rate in England was "only" 12% and BMIs were lower than they are 30 years on.  I think any replication of this study would have to see how much BMI affected the CS rate.  Whilst Frame and colleagues found that CS risk was poorly related to height, this may not hold true for BMI.

The findings are summarised below and give European shoe sizes with US shoe sizes in square brackets [...] (the original paper gives old British shoe sizes):

351 women who gave birth in the Paddington and North Kensington Health District were studied in order to establish a factual basis for recording height and shoe size as indicators of pelvic adequacy. Because only 19 women had radiological pelvimetry assessment, type of delivery and length of labour were used as proxy measures of disproportion. 

Of the 57 women with a shoe size less than 37.5 [7],  21% were delivered by caesarean section compared with 10% of the group with shoe size between 37.5 [7] and 39 [8.5] and only 1% of the group with shoe size of or greater than 39.5 [9].  Similar relations with height were not generally found. 

The data were further examined using logistic regression models of the expected percentages of mothers having an adverse delivery. The models confirmed and extended the more simple analysis.

This is such a simple finding and with risk screening for CS becoming quite the In-Thing, this is a piece of work worth revisiting.  Of course, whilst there is a significant linear trend in the percentage of women giving birth by CS and their foot size, the relationship is not a causal one and if we used foot size alone as a predictor of CS, we would be wrong most of the time, even in these days of The Great Caesarean Epidemic, although if you have size 39.5+ feet, I think you can be fairly confident that your pelvic diameters are very baby-friendly!

This interesting piece of work can still be found here:

https://epilab.ich.ucl.ac.uk/coursematerial/statistics/PDFfiles/maternal%20height%20and%20shoe%20size.pdf

More on Paracetamol (Acetaminophen) in pregnancy

Another study has confirmed earlier Danish findings that paracetamol use during pregnancy can have an adverse effect on male reproductive function.
FOR MORE ABOUT PARACETAMOL (ACETAMINOPHEN) PLEASE SEE MY POST OF 28TH MARCH 2015.

A team in Edinburgh have found that prolonged paracetamol use (aka acetaminophen or Tylenol) by pregnant women may reduce testosterone production in unborn baby boys.  The authors advise taking paracetamol only for the shortest time and the lowest dose during pregnancy.

This confirms earlier suggestions that the inhibition of prostaglandin synthesis caused by paracetamol has wider hormonal impact than has been thought.  The doses used by the Edinburgh team were close to the normal therapeutic dosage and this again suggests that paracetamol use in pregnancy and labour warrants more investigation.  So far scientists have looked at the effects on the unborn baby, but scrutiny of the effect on the mother and her labour is also overdue.

The Medical Research Council's press release can be found here: http://www.mrc.ac.uk/news-events/news/paracetamol-in-pregnancy-may-lower-testosterone-in-unborn-boys/

S. van den Driesche, J. Macdonald, R. A. Anderson, Z. C. Johnston, T. Chetty, L. B. Smith, C. McKinnell, A. Dean, N. Z. Homer, A. Jorgensen, M. E. Camacho-Moll, R. M. Sharpe, R. T. Mitchell. Prolonged exposure to acetaminophen reduces testosterone production by the human fetal testis in a xenograft model. Science Translational Medicine, 2015; 7 (288): 288ra80 DOI: 10.1126/scitranslmed.aaa4097

Anterior cervical lips and early pushing.

Rachel Reed, an Australian midwife, has written an excellent analysis of cervical lips - that is when there is a small (c. half to one cm) rim of cervix to the anterior of the baby's head.  It can be found at Rachel's blog, complete with pictures /http://midwifethinking.com/ and there is a pdf file of the same article at http://research.usc.edu.au/vital/access/manager/Repository/usc:7464?queryType=vitalDismax&sort=ss_dateNormalized\&query=Reed&f0=sm_creator%3A%22Reed%2C+R%22

This common scenario often results in women wanting to push but being urged not to do so.  In my personal experience, no multiparous woman who feels an overwhelming urge to push should be discouraged from doing so.  Rachel has also found this to be so, and has written a very useful summary of the whole phenomenon of anterior cervical lips.

However just in case the links don't work I have it quoted below minus the pictures and diagrams:

"Here is a scenario I keep hearing over and over: a woman is labouring away and all is good. She begins to push with contractions, and her midwife encourages her to follow her body. After a little while, the midwife checks to see what is happening‘ and finds an anterior cervical lip. The woman is told to stop pushing because she is not fully dilated and will damage herself. Her body is lying to her – she is not ready to push. The woman becomes confused and frightened. She is unable to stop pushing and fights her body creating more pain. Because she is unable to stop pushing, she may be told to have an epidural. An epidural is inserted along with all the accompanying machines and monitoring. Later, another vaginal examination finds that the cervix has fully dilated and directed pushing begins. The end of the story is usually an instrumental birth (ventouse or forceps) for an epidural related problem – directed pushing = fetal distress; failure to progress‘; mal-positioned baby due to supine position and reduced pelvic tone. The message the woman takes from her birth is that her body failed her, when in fact it was the midwife/system that failed her. Before anyone gets defensive – I am not pointing fingers or blaming individuals, because I have been that midwife. Like most midwives, I was taught that women must not push until the cervix has fully dilated. This post is an attempt to prompt some re-thinking about this issue, or rather this non-issue.
Anatomy and Physiology
Birth is an extremely complex physiological process but very simplistically three main things occur:
1. Dilatation of the cervix
2. Rotation of the baby through the pelvis
3. Descent of the baby through the pelvis
But this is not a step-by-step process – it‘s all happening at the same time, and at different rates. So, whilst the cervix is dilating the baby is also rotating and descending.
1. Dilatation of the cervix
The cervix does not open as depicted in obstetric dilatation models i.e. in a nice neat circle (Sutton 2001). It opens from the back to the front like an ellipse. The os (opening) is found tucked at the back of the vagina in early labour and opens forward. At some point in labour almost every woman will have an anterior lip because this is the last part of the cervix to be pulled up over the baby‘s head. Whether this lip is detected depends on whether/when a vaginal examination is performed. A posterior lip is almost unheard of because this part of the cervix disappears first. Or rather, it becomes difficult to reach with fingers first.
The cervix dilates because the muscle fibres in the fundus (top of the uterus) retract and shorten with contractions and pull it open (Coad 2005). This does not require the pressure of a presenting part i.e. baby‘s head or bottom (let‘s stick to heads for now). However, the head can influence the shape of the cervix as it dilates up around it. For example, a well flexed OA baby (see pic A above) will create a neater, more circular cervix. An OP and/or deflexed baby (see pic B) will create a less even shape. For more about OA and OP positions see this post. Most babies will be somewhere between these two extremes whilst the cervix is opening and will be changing their position as they rotate.
2. Rotation
Babies enter the pelvis through the brim. As you can see from the pictures below. this is easier with their head in a transverse position. As the baby descends into the cavity their head will be asynclitic – with the parietal bone/side of the head leading. This is because the angle of the pelvis requires the baby to enter at an angle – see the picture on the left. Once in the cavity the baby has room to rotate into a good position for the outlet which is usually OA. Rotation is aided by the pelvic floor and often by pushing.
3. Descent - the urge to push
The urge to push… and I‘m talking spontaneous, gutteral, unstoppable pushing… is triggered when the presenting part descends into the vagina and applies pressure to the rectum and pelvic floor. This is called the Ferguson reflex‘ – probably after some man. This reflex is not dependent on what the cervix is doing, but where and what the baby‘s head is doing. So, if the baby‘s head hits the right spot before the cervix has finished dilating the woman will spontaneously start pushing. An alternative but common scenario is when the cervix is fully open but the baby has not descended far enough to trigger pushing. Unfortunately, some practitioners will tell the woman to push and create problems instead of waiting for descent and spontaneous pushing.
Pushing before full dilatation
Because we are not telling women when to push (are we?!) they will push when their body needs to. If we are directing pushing we risk working against the physiology of birth and creating problems (see previous post). Spontaneous
pushing before full dilatation is a normal and physiologically helpful when:
1. Baby’s head descends into the vagina before the cervix has dilated. In this case the additional downward pushing pressure assists the baby to move beyond the cervix whilst pulling the cervix out of the way.
2. Baby is in an OP position and the hard prominent occiput (back of head) presses on the rectum. In an OA position this part of the head is against the symphysis pubis and the baby has to descend deeper before pressure on the rectum occurs from the front of the head. In the case of an OP position, pushing can assist rotation into an OA position.
I am yet to find any evidence that pushing on an unopened cervix will cause damage. I have been told many times that it will but have never actually seen it happen. I have encountered swollen oedematous cervixes – mostly in women with epidurals who are unable to move about. But, this occurs without any pushing. I can understand how directed, strong pushing could bruise a cervix. But, I don‘t see how a woman could damage herself by following her urges. In many ways the argument regarding pushing, or not, is pointless because once the Ferguson reflex takes over it is beyond anyone‘s control. You either let it happen or start commanding the woman to do something she is unable to do i.e. stop pushing.
Telling women to push or not to push is cultural and not based on physiology or research. For example, in some parts of the world e.g. Central Africa, women are told to push throughout their entire labour (on an unopened cervix!). This is often accompanied by their midwife manually stretching the cervix, too – ouch. Alternatively, in other parts of the world e.g. the US, women are told not to push until a prescribed point in labour. It seems midwives are bossy worldwide.
When left to get on with their birth, occasionally women will complain of pain associated with a cervical lip being nipped‘ between the baby‘s head and their symphysis pubis during a pushing contraction. In this case the woman can be assisted to get into a position that will take the pressure off the cervical lip (e.g. backward leaning). When undisturbed, women will usually do this instinctively. At a recent water birth, a mother (first baby) who had been spontaneously pushing for a while on all fours floated onto her back. A little while later she asked me to feel where the baby was (for her not me) – baby was not far away with a fat squishy anterior lip in front of the head. The mother also had a feel, then carried on pushing as before. Her daughter was born around 30 minutes later.
Suggestions
Avoid vaginal examinations (VEs) in labour. What you don‘t know (that there is a cervical lip) can‘t hurt you or anyone else. VEs are an unreliable method of assessing progress, and the timelines prescribed for labour are not evidence based (see this post).
Ignore pushing and don‘t say the words push‘ or pushing‘ during a birth. Asking questions or giving directions interferes with the woman‘s instincts. For example, asking, Are you pushing?‘ can result in the women thinking, Am I? Should I be? Shouldn‘t I be?‘ Thinking and worrying is counterproductive to oxytocin release and therefore birth. If she is pushing, let her get on with it and shush. For more about pushing in general and a link to a great audio by Gloria Lemay see this post.
Do not tell the woman to stop pushing. If she is spontaneously pushing (and you have not coached her), she will be unable to stop. Pushing will help, not hinder the birth. Telling her not to push is disempowering and implies her body is wrong‘. In addition, after fighting against her urge to push she may then find it difficult to follow her body and push when permitted to do so (Bergstrom 1997).
If a woman has been spontaneously pushing for a while with excessive pain (usually above the pubic bone), she may have a cervical lip which is being nipped against the symphysis pubis. There is no need to do a vaginal examination to confirm this unless she wants you to.
If you suspect or know there may be a cervical lip:
- Reassure her that she has made fantastic progress and only has little way to go.
- Ask her to allow her body to do what it needs to, but not to force her pushing.
- Help her to get into a position that takes the pressure off the lip and feels most comfortable – usually a reclining position.
- If the situation continues and is causing distress – during a contraction, apply upward pressure (sustained and firm) just above the pubic bone in an attempt to lift‘ the cervix up.
- If the woman is requesting further assistance, the cervical lip can be manually pushed over the baby‘s head internally. This is extremely uncomfortable!
Note: This nipping situation is rare and usually a cervical lip will simply move out of the way without causing any problems.
Summary
An anterior cervical lip is a normal part of the birth process. It does not require management and is best left undetected. The complications associated with an cervical lip are caused by identifying it, and managing the situation as though it problem." [The Anterior Cervical Lip: how to ruin a perfectly good birth
— posted 22 January 2011 by Rachel Reed: independent midwife, educator and birth nerd.]

Wondering where to give birth?

https://kclpure.kcl.ac.uk/portal/files/33242518/Birth_place_decision_support_Generic_2_.pdf

This leaflet, from Kings College London, is based on this biggest UK study of place of birth - the Birthplace Study.  It is an excellent, easy-to-read and illustrated discussion of the risks associated with place of birth, and some of the key factors to take into consideration when making this decision.  It explains what is meant by "risk" and it also has excellent links to other useful resources and websites.

Wherever you are thinking of giving birth - home, hospital or birth centre - this will help you make and understand your decision and explain it to other people.