Sharing the Skills: Supporting birth without the use of vaginal examinations

I have struggled to write this particular post for the past week or so; do I reference, don't I reference. Am I trying to be the 'expert'?  Is this formal, informal.  Argh - round and round I go!  Until a colleague reminded me this is a BLOG post, meaning it's an informal piece of my opinion (see disclaimer thingy).    and breathe........

I can still remember the first Vaginal Examination (VE) I preformed as a student midwife.  I remember two things mainly:

1. I had no idea what on earth I was feeling!

2. That this was a very invasive procedure.

Many units have a 4-hour guideline for VEs to asses the progress of labour; this routine assessment has no real evidence to support it and is still of unproven value in routine midwifery care, despite being recommended by NICE (it is important to acknowledge, that NICE states women should be offered a VE).  VE's can be a very helpful tool in understanding a labour when perhaps midwifery intervention may support the woman in keeping her labour normal, when clarity around labour progress is appropriate, and / or if it will affect the plan of care.  When used as the marker for progress in labour only, VEs can cloud the midwives understanding of what is happening in the woman's birth story and cause the woman to doubt her own body.

The art of Midwifery is the 'big picture', and it is through many different signs that a midwife may recognise where a woman is in her labour.  This awareness is not 'taught', but learnt: learnt from the women as you observe undisturbed birth, learnt from sitting and quietly absorbing the behaviours unfolding in front of you, and learnt from not starting from a place of 'knowing best'.  As a result of this, the thoughts below are not a 'check list' of progress in labour, simply prompts to help you consider the physiology of what may be unfolding before you.  Remember also that all women are different, and every woman and birth can unfold in a way that is unique for them.

Let us consider then, alternative ways of recognising a labour that is progressing:

How low can you go?
When I was a student midwife, I heard the wonderful Jane Evans speak on Breech birth.  In her talk, she described how women get 'closer the the ground' as their labour progressed.  In labour, as those powerful surges increase in intensity, the woman finds it harder to be upright and conserves her energy by moving into positions that bring her down - usually into the all fours, or leaning over a sofa etc.  As a guide, the closer she is to the ground and needs to stay 'grounded', the further along in her labour she is likely to be.

Those wonderful noises
Experienced midwives can often tell where a women is in a labour from those lovely noises she omits; Liz Nightingale wrote an excellent article in Midirs on noises in labour which is well worth getting your hands on. Women, under the influence of Oxytocin in labour, start to withdraw into themselves.  Talking and conversation dwindles (and so too should birth workers!), but the woman will naturally start to moan and groan through those surges; those noises come from deep within her and she has little control over them.

The 'purple' line
If you google this term you will find lots of excellent blogs reflecting on this phenomena, pictures on what you may see and so forth.  My favourite post is in Birth Without Fear which is beautifully written: just read that for a great explanation on the purple line.  I love the purple line; once you recognise it you can't fail to notice it.  Just wish bottoms came with a little gauge - you know, when it's this height the cervix is x-cms etc!

This is a woman who smiled
most of the way through her labour!

Sense of humour failure
When the woman is no longer smiling, then we are in serious business (except for those women who are having serene, orgasmic births - they smile a lot).  Humour can really help a woman in labour as it can ease tension.  If you follow her guide however, the more serious she becomes the less she may appreciate wise-crack jokes from her supporters, and the more likely her labour is advancing well.



It's all a bit sticky down here
Around 8-9 cms, women will discharge a sticky, blood-stained mucousy plug as the cervix really opens. Yay!  Even better still, as the cervix becomes fully open, the waters will spontaneously release if they have not done so already.  There is NO NEED to do an ARM if a women is 9 cms and membranes are intact (and yes I have seen midwives do this, because otherwise how will the baby get out?).

Cold Feet
As the uterus continues to work beautifully, the blood circulation will move more and more towards to uterus: this is why women get cold feet as labour progresses.  A German midwife (when I was a student) also taught me that the heat will move 'up the woman's' legs.  At around 5 cms, the heat will start from just above her knees, 8 cms the thighs feel cold, at 9cms, only a small amount of heat is left at the top of her thighs.  We used to have guessing games by gently placing a hand on the woman's thighs to see 'where she was'.  It doesn't always work, but is gentle and non-invasive.  Use the back of your hand to gently asses the coolness of the legs.

Pushing on through
Why, oh why, oh why on earth do some midwives feel the need to 'confirm' the onset of second stage with a VE?  Really?  As a woman moves into second stage, she will start to make grunting / expulsive noises.  These will intensify as the baby moves further down, triggering further expulsive urges.  The woman's body will start to 'open' as the rhombus lifts.  The purple line will be highly visible and prominent.  She will probably poop.  All of this will happen either quickly (as with the foetal ejection reflex), or for the vast majority of women, s-l-o-w-l-y!  Women can tell when they are 'moving' their baby and will often remark they can feel the baby moving down.  If after a period of time of strong expulsive urges, there are no external signs of descent, then a VE may be appropriate.  That time depends on the whole clinical picture.  And No, 10 minutes is not long enough.


There are many other ways of recognising progress in labour without the use of VEs (and please do share them); these are the ones I use to help me recognise that labour is progressing without needing me to 'do' anything other then keep the mother and baby safe and hold the space for the birth.  Observing the woman in a non-invasive way (i.e. not staring at her and 'drinking tea intelligently') normally enables the midwife to sense if something is not 'quite' right and provide the appropriate care to help the mother birth her baby as she needs to.  And this is usually herself.

Midwife angela 

“There is no other organ quite like the uterus. If men had such an organ they would brag about it. So should we” ― Ina May Gaskin

Birth Works

There have been some awesome blogs this week from Midwives and from Women, as well as some interesting news headlines; I love reading blogs that inspire me, challenge me, and get more women and midwives thinking about birth and midwifery skills.

Last week I facilitated an 'Inspirational Birth' Study day, covering physiological birth: I have wanted to run this study day for a while, but when it came to planning the actual content for the day, I found myself procrastinating.  Fear in part; worry that I didn't know enough to fill a 6 hour day; concern that I wouldn't convey the message I was hoping too.....as it turned out it was a great day: I had forgotten actually just how much I have learnt in my journey as an Independent Midwife, and watching the 'light bulb' moments was very rewarding for me as a facilitator.  

In the current midwifery climate, there is little scope for physiological birth - and I don't state that lightly, as I know that is a direct criticism of maternity services.  How do I justify that statement?  Women are designed to give birth; sometimes, in some circumstances, some women may need some help (thank you Mary Cronk for that beautiful phrase), BUT we know that the vast majority of women are NOThaving normal, straightforward births - and even fewer are experiencing physiological birth  (there is a difference).  Birth Works, but it needs certain conditions, support and understanding for that to happen.  Maternity services in the UK are at breaking point: a rising birth rate and too few midwives (or cuts in services) means that women are not guaranteed one-to-one care in labour; women do not have time to build a relationship with a midwife that facilitates trust; hospitals have policies that are not conducive to physiological birth - but are conducive to intervention and time management; and midwives are not challenged on practise that is outdated and not evidence based (valsalva for one).

In my mind, there are a few issues that continue to confound and prevent change;

1. The demise of midwifery care outside of the NHS institution
2. The continued attack on women and midwives who choose to work with physiological birth
3. That we are no longer teaching our daughters to be feminists (a dirty word in modern society)

Take for example the Daily Mail article this week on women's experience of traumatic birth; then read the comments.  Women attacking women, men attacking women, women sharing very distressing experiences - and many comments indicating 'doctor knows best and women should be grateful' .

Birth is hard work; it is not perfect, sometimes it is not 'beautiful', sometimes it is down right mean; that is birth.  This is NOT however the 'care' that may be inflicted, the unkindness of medical staff or the paternalistic attitude of doctors.  What women want is a positive experience of birth - however that birth may unfold, and having a midwife by your side who understands, supports and believes in birth and whom the woman knows and trusts can make a huge difference to that experience.  That is not too much to ask.

Birth Works - but we have forgotten this.  Instead, we focus on the 'what if's', how to 'manage' birth, how to 'save' women from pain; we have lost trust in birth and have made hospitals and the NHS the saving grace of birth - as opposed to utilising it as and when is necessary - ensuring resources and first rate care are available for women who need it (I for one have been grateful for their expertise when women in my care have needed it).  We have also de-skilled midwives and on a global level we continue to allow midwifery to be quashed, undermined, de-valued and not recognised for the amazing profession it is.  Midwifery and women are controlled -  Freedom for Birth highlighted some of these issues.

Independent Midwifery has enabled me to hone and develop my skills in physiological birth; I already had the belief and passion for normal birth, but had to work very hard in my NHS training to fully experience it.  As an IM, I want to share my passion, my knowledge, my skills (and I still have much to learn and hopefully will never stop learning) - but come October my right to work as an IM will be outlawed - another blog to follow on that.  For now, I shall continue to work outside of the NHS, I shall continue to support physiological birth at every opportunity, and I will aim to inspire my own daughters to be proud to be a feminist.

Birth Works; Women Work; Midwifery Works.

angela xx

One Born Every Minute

Last night, for the first time in very, very long time, I sat and watched 'OBEM'.  It wasn't a concious choice - we had watched the great classic movie 'Stand by Me' (oh River Phoenix, what a loss) as a family, and when the DVD had finished the TV returned to OBEM just as it started.  And I was hooked; mesmerized; drawn-in and unable to move despite my intentions to get to bed as I am feeling quite unwell of late.  But there I was, one hour later, as the credits rolled.

There are lots of reasons I don't watch programmes such as this one; firstly, my family don't allow it.  They feel it's detrimental to my health as I am unable to watch without large amounts of steam coming from my ears.  Secondly, it reminds me of the fact that the way I practise as a midwife is at risk, and frankly the thought of returning to work in a large, consultant unit, fills me with dread and fear.

So what was wrong with last night's programme?  Let's start with the fact that both labours, both healthy, first time mothers, both considered 'low risk' (hate that phrase), ended with unnecessary intervention:

'Mother one' was already in early labour; as she was 12 days over, she requested to have her labour 'induced' and just get on with it.  "Good news", hails the midwife, "we can break your waters and get you going."  A birth that was starting physiologically is now having a helping hand with an intervention that brings it's own risks (which I did not see being discussed), or other options given (such as go home - you shouldn't be anywhere near a labour ward at present) and is presented to an audience of viewers as the norm (which it probably is on a consultant unit).  Mother one did give birth vaginally - on her back, epidural in-situ and an episiotomy.

'Mother two' arrives in spontaneous labour, but she stalls and after a few hours it is decided her labour must be accelerated.  And when I say decided, this was the conversation:
Midwife "You've been stuck at 4-5cms for a while, so I need to talk to the doctors to decide what to do"........  "The plan is the get you going and put a drip up to get some oomph behind those contractions".  Interesting use of language, a really great way of not demonstrating informed CHOICE and decision making - the mother was not even included in that, the midwife and doctor decided - and another birth that needed a 'helping hand'.  It was however really fantastic to see the mother using an 'alternative position' and standing as she birthed her baby.

After watching the programme I am now aware of several things: Midwives are in charge and know best; women are clearly malfunctioning when it comes to labour; physiological birth doesn't work.  I am so grateful to have had those points clarified and to recognise that it must be time to change my practice as I am very outdated in my beliefs that birth is normal; that labour has it's own rhythm; that women should be involved in all aspects of the decision making; that the amniotic sac provides a safe, protective barrier in labour; that vagina's are designed to stretch to birth a baby; that facilitating a safe, warm, quiet, environment aids progress in labour.  Thank you to the powers that be (insurance companies and eu regulations) that foolish midwives like myself, or like Virginia Howes need to be tamed and brought into line and that we are wrong.

I clearly am one of those 'born every minute' that needs to be reminded on prime-time TV that birth does not work and the NHS knows best.

angela x

Placenta Possibilites

Smoothie anyone?

This morning I made myself my usual smoothie; rice milk (300mls), a banana and a handful of frozen blueberries.  As the blender whizzed my power drink, I was reminded of the workshop I attended last week on Placenta Remedies, facilitated by Lynnea Shrief from IPEN and organised by midwifery on-line.

I recently blogged on the third stage of labour, and felt it was time to update my knowledge on the choices that women have regarding their placentas; Placenta Encapsulation is something I have heard of, know vaguely about and have read briefly around, but I did not feel I had enough information to really talk to women about consuming their placenta and the perceived benefits of this.  I also felt I had to get over my own queasiness over the idea of eating what is often viewed as a waste product.

The workshop was really interesting; doulas, student midwives and aspiring midwives made up the group of interested women - I was the only midwife on this day, although Lynnea confirmed that midwives often attend the study day.  The morning looked at why women choose to consume their placenta, testimonials from women on the benefits and an exploration of mammals normal instinct to consume the placenta (and the really cool fact that the only land mammals who don't consume their placenta is the Camel!).  Testimonials from women included:

• increase in milk production
• reduced postnatal bleeding
• faster recovery
• more energy
• less depression

These all make sense when you consider that the placenta is a power-house of hormones and an iron-rich food source that has nourished and grown a baby for 9 months.  Lynnea was clear that there is not huge scientific evidence to support placenta consumption, but as she rightly pointed out, there is no money to be earned from women eating their own products so no-one will be putting funding towards an RCT on this area!

Later on in the day we learnt about safe storage of placentas, infection control and reduction, and then had a 'hands-on 'session making placenta tinctures and essences...... and Smoothies.  We made a 'berry placenta smoothie' which looked just like my breakfast this morning.  Apparently it tastes good too! (Placenta Encapsulation is studied at a separate workshop).

As a midwife, I feel much more informed to offer this choice to client, and more importantly, I am convinced that a smoothie would benefit my clients significantly.  Of course, women need to be open to this choice, and within our culture where eating offal is considered 'yukky', this might prove a challenge!  I am however, looking forward to sharing, exploring and learning more about this with the women I care for, and to writing about this further and would be interested to hear your comments on placenta consumption.

angela x

Shhh..... I practise physiological third stage

The third stage of labour feels like a topic that is discussed in secret amongst student midwives and midwives; whispered 'what do you do?' questions and the caginess around what one actually 'does' is tangible.

Practice around third stage came up in a recent conversation I was having, and I felt it was time this subject was explored, caginess put aside, and clarity about the NORMALness of a physiological third stage heralded high and loud.

As a student midwife, I was clear about the skills I wanted to learn; I was also very fortunate to have a mentor who was skilled in facilitating physiological birth, and another mentor whose trust in me enabled us to learn together about the third stage.  I was, however, unique in being one of only a handful of students who qualified having gained this knowledge and developed this skill: most only knew how to 'manage' the delivery of the placenta.  I know this is still happening and frankly I find it worrying.

It is normal within the hospital setting for managed third stage to occur; a reason cited to me is that it takes 'too long' to wait for the placenta.

Q1. How long does a physiological third stage take? 

20 minutes is about average, maybe 30, very rarely an hour or more.  If you assume it will take around 20 minutes, even in a busy unit, this should still be the time that the mother and baby are bonding and shouldn't be 'hassled'.  Plenty of time therefore for the midwife to be quietly and attentively watching.

 Q2.  What about the risk of haemorrhage?

Firstly, in a physiological birth, the risk of haemorrhage is relatively low  (I could reference this, but am choosing to use innate midwifery knowledge here).  The clue in this statement is physiological birth, i.e. spontaneous onset, contractions regular and rhythmic, no pharmacological pain relief (okay, a little gas and air is fine), spontaneous explusive urges, no interference with the mother-baby dyad.  In other words, with absolutely no intervention - just a mother working with her body, oxytocin flowing, adrenalin reduced, trust and patience high. 

Okay, so it doesn't take as long as you might have thought, and mum might not bleed to death, but what about the shift leader who is knocking on the door asking if the placenta is out?  What about the assumption from the woman that she will have the injection?  If the shift leader is knocking, it is our job as midwives to politely, but firmly inform them that we will let them know if we have any concerns, we will update them as and when is appropriate, but will not accept people knocking on the door (you could point out that this is like trying to have a pooh with people hanging around outside, and maybe they would not be comfortable with that?).  Midwifery is an autonomous profession, you have a duty of care to the woman, not the shift leader.

Q3. What about informed choice?

It is currently bang on trend for women to choose 'delayed cord clamping'; therefore half the work is done for you.  You know the benefits of a physiological third stage - if you have supported her in a physiological birth, surely you are just continuing with that?  I'm going to put my neck out here and say why does she need to make a choice?  That would mean you are questioning her body, and getting her thinking brain to respond.  Remember, at this point its all about the oxytocin - and quiet, watchful waiting.

 In The Midwife's Labour and Birth Handbook there is a very good chapter on third stage and a clear explanation of what a midwife 'should' and 'shouldn't' be doing; Elizabeth Davis also offers a clear summary in her beautiful Heart and Hands: A Midwife's Guide to Pregnancy and Birth book (definitely recommend that one).

Q4. What do you do?

I myself have learnt FIVE key skills to supporting a physiological third stage :

1. Keep the woman warm after birth: if she is cold, it affects the physiology of the placental separation

2. Keep the room quiet: too much excitement raises adrenaline and impacts on uterine contractions

3.  Watch carefully and listen fully: you will see the tell-tale trickle of separation and mum normally notices stomach pains

4.  Use gravity to aid delivery: the mother will normally push the placena out herself.  However, toilets are magical here; help the mother to the loo, she will pee and pass the placenta all at once.  Never fails if time is passing! 

5. Do not Fear it - IT WORKS!

“Nothing in life is to be feared. It is only to be understood. “~Marie Curie

What thoughts do you have to share around the third stage?

angela xx

but that's just silly!......

Last week, and with my home-educating mummy hat on, I ran a 'morning with a midwife' workshop.  12 bright eyed children aged between 9 and 15 arrived at my home for a two-hour interactive workshop.

We started of by covering the role of the midwife, and what kind if checks we do; they played with my sonic aid and listened to each others hear rate; they guessed if one of the mum's BP would be high or low, and they giggled as they 'explored' their own pelvis - finding their coccyx and poking around their bottoms!

Children are brilliant (well mostly brilliant, unless they are annoying or I am having a bad day), but on the whole brilliant.  They see things so clearly, and haven't been dis-illusioned by adult-hood, and are still naturally thinking out-side the box - this, I am delighted to say, made teaching them great fun.

After they had labelled up some large pregnancy charts, we looked at the physiology of how the cervix opens, how the baby descends through the vagina and how the baby rotates and fits (perfectly) through the pelvis.  Having tired of the poor messages passed to children (and adults) about birth, I used positive language: I talked about the intensity of birth, and how women cope really well with this and can rest between surges, I talked about how the baby is squeezed and 'cuddled' by the uterus with every surge, I talked about how the baby is pushed out and it feels like a huge urge to pooh!  They got it, and accepted it, and asked about it, and then there was this Eureka! moment: to help the children visualise the size and weight of a growing baby, I had created a basket with different items weighing approx weights at different gestation.  I had an orange for 20 weeks (200gms) and so forth, with the final weight of the basket about 3200g (7 1/2 pounds ish in old money).  Using the pelvis, I showed how easy it was for the orange to get through when the 'mummy' was kneeling or on all fours, then I turned the pelvis into semi-recumbent and......... the Orange just sat there.  Eureka!  

..."but that is just silly!  why would you do that?!....."

asked a 9 year old.  Why would you do that?  Why would a woman give birth in the most physiologically challenging position you could choose? Why would a woman shut her pelvis and work against gravity?  Why would we do something so silly?  Well if a 9 year old can get that, then why are the vast majority of women giving birth on their backs?  Why are student midwives qualifying having NOT supported women in 'alternative' (don't get me started on that phrase) positions? Why why why? 

One for Mr Marr!

I feel there are many reasons (sadly) why this continues; the medical mode of birth, the use of pharmacological pain relief, ease for the midwife, the images of birth that are portrayed in the media?  None of these of course make it OK, or acceptable, but I do think the latter is a huge influencing factor. It's almost as if women expect to birth in that position - the children did, as that is what they have seen - until shown otherwise.  So perhaps then, it is the Film and TV producers of the world we should be talking to?  Certainly, in the opening issue of Andrew Marrs' History of the World (a brilliant programme I might add) the ancient African homosapien is seen to birth in the 'typical' semi-recumbent position.  Historically, women birthed upright; using trees, kneeling, squatting to give birth; not sitting with their bums and vagina's in the dirt.  It would have been much cooler Mr Marrs if your production team had shown that!

Perhaps it's time to remind ourselves of the Wonderful Female Pelvis, to remind women, doctors, parents, teachers, children, and the Film Industry of how perfectly designed we are to birth and how women - when well supported - will adopt the 'alternatively brilliant' birth positions that aid birth naturally.  Perhaps it's time for a new slogan:

'don't take it lying down!'..... 'knees for ease!......'using the (all) fours of gravity!......  suggestions please!

and here is a little something to share: (catch it here too http://www.youtube.com/watch?v=MswFqXdOq2U)

Enjoy!

angela xx