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

Shiney New Blog

I am so excited to feel my bloging fingers return to the keyboard, and am bursting with new ideas for midwifery and birth related posts!  It's been too long.....

I am planning to start 'what I have been reading' posts, sharing what's on my book shelves with you, as well as 'how to 'posts on midwifery skills (primarily aimed at students) and of course my usual reflections on current topics.

Speaking of which, we are in October.  October.... the impending end of Independent Midwifery as we know it.  Of course, as with all things in life, the goal posts have changed and the NMC confirmed this week that there is a delay in the implementation of the new legislation and we now have until February.  In the meantime, IMUK, who have been working incredibly hard over the summer months and have found a product that is a solution to the insurance fiasco, continues to beaver away at getting insurance in place long before that deadline (we very much hope that the dear DoH do their bit and help us on our way) .  You can keep up to date here.

Pretty knitted things

Exciting, turbulent, history changing times lay ahead; and it is down to the passionate and strong midwives and supporters that there is light at the end of the tunnel.  Women have always had a strong influence in the course of history; this year was the 100th anniversary of the death of Emily Davison, the suffragette who threw herself under a horse; I feel I am part of a modern suffragette movement (although I am not throwing myself under a horse), not one working to get the vote, but one to get a basic human right to know and choose your midwife as a normal part of the childbearing continuum.  I am a feminist - and rightly proud.  Okay, I am a knitting feminist, and rightly proud.  Okay, I am a knitting, mascara wearing, girl-who-likes-pretty things feminist, and rightly proud.

Mascara wearing midwife on a mission

Anyway world, watch out.  Or you may have a bunch of media wielding, modern suffragettes playing havoc with your his(her)story; and it might not be pretty or knitted.

angela x

Independent Midwifery: Dispelling the Myths

"I bet your clients are really demanding?".  Sigh.  Nope, not usually.  In fact, I find the hardest bit of being an IM is dealing with such misconceptions and answering questions (from an NHS midwife) as that one.  I wrote previously about 'what we do', now however, it is time to dispel some myths about Independent Midwives (IM's):

IM's are Maverick and Risky
On the contrary; IM's have a large number of women who would be considered 'high risk' within the NHS and as such are seeking a midwife who will support them in their informed choices.  This means careful thought and planning, often involving a Supervisor of Midwives to help arrange the appropriate care.  It means being up-to-date with the latest research so that we can provide safe, effective practice.  There are risks to our job; but we work hard to keep these to a minimum whilst supporting women fully in their choices.

Women who use IM's are wealthy
Different women, from different backgrounds and with differing levels of personal income book with IM's.  Yes, I have had clients whose disposable income is enviable, however the vast majority of my clients have to work hard to find the money for my fees.  Or they simply can not find the money and then we try to work something out.  For most clients, their priority is to book with a midwife whom they know and trust  - and this often means making huge personal sacrifices.

IM's earn 'loads of money'
You can see that in the shiny 2005 Citroen Picasso I drive, and all the holidays I take - NOT!  Out of my fees I have to pay for my equipment, administration costs, petrol, training updates, tax, holiday 'pay' (being self-employed means when I am not working I am not earning), journal subscriptions,  etc etc.  IMs really do not earn huge sums - and we really do earn our money!  24-on call is not an 'easy' option and can take it's toll on family, friends and day-to-day life.

IM's Clients are demanding
If wanting to have one-to-one care with a midwife you know and trust, appointments in your own home, and feeling supported in your choices is considered 'demanding' then yep, my clients are very very demanding.  I do find however that this standard of care pays dividends in normal outcomes, high breastfeeding rates and family satisfaction.  And I always get tea and cake (hence my expanding waist line).  Women are really so demanding!

IM's don't want insurance
We do, we do, we do!  We just can't get it!  Honestly, every time you go to a birth, to hear the little voice on your shoulder saying 'this could be the one that costs your home' is not fun!  We do it because we can (not for much longer), we do it because we care, we do it because midwifery services should not be a 'one size fits all' option.  I do it for myself (terribly selfish), but knowing who I am going out to when I get called to a birth makes me feel like a safe practitioner.  Plus, I don't have to get to know the woman and her family, instead I can just offer my full attention and be 'with woman'.  It's fantastic.

Independent Midwifery is not for everyone, just as being a labour ward midwife, or a consultant midwife is not for everyone.  The important thing is that just as women should have choice, so too should midwives.  

There are many myths around Independent Midwifery and IM's, and the one that is most concerning is that is does not matter if we are no longer able to practice.  The demise of IMs will have catastrophic affects, and midwives within the NHS will find that their autonomy will be significantly threatened - the RCM know this and just continue to play footise with a government that is calling the shots.   Just look to countries where midwifery has been persecuted in this way, and then see how many midwives there are.  It is worrying.

Independent Midwifery must survive - and you can help.  You can share this blog with everyone and anyone who has an interest in midwifery or birth.  You can tell people the TRUTH about IM's.  You can watch 'Home Delivery' on March 21st and see how we work.  You can join our facebook page and learn more.  Women matter - IM's do too.

angela xx

Even a future Queen to be is still ‘just’ a Mother to Be.

The exciting news was announced that The Duke and Duchess of Cambridge are expecting their first baby; whilst the Duchess recovered from Hyperemesis Gravidarum (a debilitating acute from of morning sickness) and amidst all the excitement and media hype, was the devastating outcome of the ‘prank call’ and the everlasting ripples from the fall-out:  not the most positive start to a pregnancy for any couple, yet alone a couple who are prominently held in the public eye.

So what next for the Royal Couple? Well, just like any other new parents-to-be, before any of the screening, bloods, ultrasound, place of birth, type of birth choices they make, they might like to consider who they invite to care for them; they may choose to have their care with a private obstetrician, or they may choose to use their local NHS system, or they may seek a known midwife to support them in their pregnancy; but they do have a choice over all of these.   Essentially, having someone to talk to might make negotiating all those choices a little easier!

If I was Kate’s midwife (as her midwife, I would call her Kate, and she may call me Angela), I would spend time with her talking through her options; in-between appointments (that would be in her own home, and at convenient times, with appointment times that William could also come to) I would encourage her to read widely; some books I might suggest to her would include ‘Ina May's Guide to Childbirth’, Childbirth without Fear: The Principles and Practice of Natural Childbirth ’ and ‘What Every Parent Needs to Know: The incredible effects of love, nurture and play on your child's development’, as well as giving her up to date information on nutrition, screening and normal pregnancy ailments.   (I did google pregnancy books for Royalty, but it just found the Royal Free in Hampshire!)  We would drink tea together, share concerns, and build a trusting relationship, and she would feel secure in knowing that she would be well supported in her choices, and that on the big-day, someone she knew would be at her side when her baby was born.

This type of midwifery care enables women to really make choices; we also know that they are more likely to have a normal healthy pregnancy, a  normal straightforward birth, more likely to establish breastfeeding, and less likely to experience postnatal depression.   Pretty compelling reasons as to why one-to-one midwifery care is so important, and why it is essential that women know that this is the care they should receive as the norm, that they should be shouting loudly for, and that shouldn’t only be open to those whose NHS trust is forward thinking, or those who can engage an Independent Midwife like myself, and whose way of working is under threat.

The hype around the beginning of The Duke and Duchess’s pregnancy will hopefully settle and they will be able to look forward to the next 8 months or so (albeit it being very much the talk of the nation).   Expecting a baby, is for most people, a joyful, exciting event;  but every woman, whether it’s her first, second or subsequent baby, may still have the same anxieties, the same pregnancy complaints’ and may have to make some of the same choices that other mothers will – even if she is a future Queen!  

It's in the words

Two weeks ago, I took my three home-educated children along to the Science Museum to enjoy The Human Body film on their IMAX screen.  The film was really interesting, with lots of amazing facts, clever imagery and clear explanation.

Then, we get to the 'birth bit'; I am an experienced 'TV birth' avoider now, having wasted too much energy shouting at rubbish programmes (OBEM is right up there in my list of hates), so I tried not to get too excited, so as not to be disappointed   That was the right decision, as four-hundred children of varying ages were presented with the typical birth scene I strongly feel should not be broadcast: the woman, on her back, full epidural, stirrups, a team of people (I think they edited out what was clearly an assisted birth), baby taken away, wrapped and returned to the proud mother.  And the icing on the cake..... the midwives phrase that makes me want to want to jump up and down like a raving bloody looney (and that is being tame on what I really want to say):

"come on, push, push, push, push, push,....

get ANGRY (with your baby?)".

Get Angry?  Angry....... so is what we're really saying, is that we want the woman to be this:

and then expect to her be this:

A diametrical concept to the extreme.

And it's not just here that the language of midwifery needs addressing;  how many times do we need to remind women and midwives that pizzas are delivered, shopping is delivered, parcels are delivered.  Babies are BORN. I do not deliver babies; I facilitate birth, I support, I catch, I guide.  I am in awe as a woman delivers her own baby.  Not me.

To empower women, we need to think carefully about the language we use: midwives are in a very powerful position.  Women listen to us, they value us, they (hopefully) respect us: what we say and how we say it sticks.  Let's look at some other examples:

"ohh.... that's a big baby your growing there."  ( Woman hears "oohh, I ain't ever gonna get this baby out of my vagina.")

"would you like some pain-relief?"   (Woman hears "midwife thinks I can't cope; better get some drugs before this gets worse")

"just pop up here on the bed, there's a good girl"   (Woman hears "I better stay here where I am told")

In a recent issue of the Midirs Essentials, there was an interactive section encouraging the reader to reflect on some of the common phrases used and often said to women;  I, even as a student, have never told a women to get angry, have never asked a women to "take a deep breath and push", and have always encouraged women to listen to their body.  I have seen students swiftly adopt these 'standard phrases', as if these mantras somehow make them a midwife, a part of the 'gang', or somehow more competent in their mentors eyes?

As a midwife, my aim and hope is to empower a woman to feel like this:

because, I believe, that only when she has released her inner-lioness, only when she has birthed her baby (in her own unique way), only when she has felt that she did it (even with an assisted birth), that she is the woman, the mother, the strong-one, can I expect her to be this:

Words are powerful.  Women should be central to that power.

The most common way people give up their power is by thinking they don’t have any. – Alice Walker.

angela x

How it feels to be a midwife

Sometimes, I hate being a midwife, and consider on a fairly frequent basis that I might leave the profession.  My problem is however, that midwifery is an intrinsic part of who I am; it is my calling;  my vocation; my life.  And as much as I hate it, I also love it passionately and I know there are midwives out there who will be nodding in agreement to these thoughts.

I remember so vividly the day I actually qualified as a midwife and the day my NMC Pin number dropped through the letter box.  I spent the next few weeks like a small child telling anyone who would listen that 'I'm a midwife'; I sang it round the house (albeit out of tune), I danced around my garden, and I posted it on facebook.  I really wanted to skip down the road shouting it too, but managed to restrain myself from actually doing that.  Still, there's time.

Anyway, after three years of blood, sweat and lots and lots of tears (a bullying NHS culture and colleagues ensured that) I had finally made it to the other side.  Alive, sadly not well (it took a long time to recover emotionally), but I had made it!!

I never practised in the NHS, but chose to go straight into Independent Practice; I had a midwifery partner and mentor to support me, and despite others doubts, I felt confident and competent to practice autonomously.  I had ensured throughout my training that I had gained a good understanding of the knowledge and skills I wanted under my belt (suturing, home birth, water birth, physiological third stage) etc..  Not always easy, and one of the few in my cohort qualifying with such experiences (that's a whole other issue in it-self!), but with some fantastic mentors and a lot of effort on my part, it had paid-off.

Midwifery is such an amazing profession; but there are so many politics involved, so many issues, so much angst that, at times, it's hard to remember that.  I can only write about midwifery from my view point as an IM; I have a deep respect for my NHS colleagues who work to be the best midwife they can, often under difficult conditions, and although I have worked a few 12-hour shifts on a busy labour ward, I am not in a position to comment about how it feels to be part of the system.

So, how does it feel to be a midwife?...........

When you are invited to care for a family during her pregnancy and for the birth of her baby, you are given a great gift: you are given the gift of Trust, of Respect, of a deeply personal Relationship at a vulnerable time in a woman's life.  You are asked to ensure the well-being of the Mother and her baby, to work in partnership with her, to empower her to make decisions and choices that will affect her health, her baby's health, and eventually her potential to labour and birth with confidence and self-belief.  

This feels like magic; like warmth filling your every cell; like the last piece of chocolate cake nestled on your plate.  It feels like a weight on your shoulders; have I done enough? have I put into place the appropriate advice, plans of care, evidence based information? have I documented it?! Do I convey my belief in her and in birth at every given opportunity?

When you are called to a birth, there is no feeling like it; the wait is over; but the work is just beginning.  Finally, she is labouring; you have put your life 'on-hold' for the past few weeks, you have kept your phone by your side, you have turned down that glass of wine, the invite to a trip that is just a little too far away in case 'the call' comes.

This can feel like coffee when its been burnt - looks amazing but the taste that lingers can be bitter.  It can feel like being invited to the party of the year, but then being grounded when they day arrives! It can feel like your life is passing as you watch from the side; like you are present but not fully participating; like a small shadow lingering over your shoulder.   

In the dark, small hours, I stumble from my bed to reach for the phone; I know it is my client and I hear her husband speak to me: "she want's you to come".  I check she is well, baby is moving, any concerns?  All good, her husband confirms.   I prepare.  Wash, brush teeth, dress - I pretend I am quiet, my husband tells me other-wise.  I breathe.  Deeply. And centre myself before I climb into the car.  I know where I am going as I have been there many times, my equipment is already in the car - always ready in the car.  I think; what do I need to be aware off, will my children be OK, how long might I be gone?  I hope and trust all is well.  You never stop thinking as a midwife; it's just you learn to do it quietly and calmly - that art of 'drinking tea intelligently'.

As labour unfolds, you appear calm, confident and relaxed.  You trust in the process - this is essential: if you do not trust the mother, her labour, her body, then your emotions will affect the birth and the potential outcome.  Without this innate belief you can not be a midwife.   Inside, you are quietly noting where she is in her labour, what you might need to do - or not do - to help and support.  Birth approaches; you breath.  Deeply.  Emergency equipment to hand (just in case); you watch.  Patiently.  And you lovingly encourage the mother to work with her body; you do not tell her what to do.  Her body knows, her baby knows.  As her baby enters the world, and the mother reaches for her child, you calmly, quietly check all is well.  You breathe. Deeply.

And you remember; you remember why you love midwifery, why you answered the calling to be 'with woman'; why birth is the most amazing event to witness, and why women are courageous and inspiring.  You remember why you do this.  It feels like Christmas morning; like the first sparkling frost of winter; like tasting your first bubbles of champagne; like nothing else on earth.  It fills your heart and soul.

A mother meets her baby after an emotional birth;
I was honoured to welcome two of her babies into the world

Midwifery is a roller-coaster of feelings; it is good, bad, beautiful, challenging.  It is rewarding beyond belief, and frustrating beyond measure.  It is a battle of wanting to be the best that you can, in a climate of fear and control and politics.  Midwifery is a way of life; it's not a job to come into because you like babies, or because you're good with people, or because you need a change.

Sometimes, I hate being a midwife, and as much as I hate it, I also love it passionately;  so, for as long as I still love it, and the women I serve, I shall continue on my midwifery journey.




Ask yourself this; how do you feel about midwifery?


angela x

Celebrating Normal Birth

I am off-call!  After attending and supporting 8 beautiful, strong, wonderful mothers since April, I am now due a short break.  I have learnt so much and had the immense honour of attending:

• a home 'land' birth
• a home VBAC in water
• a breech hospital birth
• a caesarean birth
• 4 home water births

I am taking my short sabbatical from being on-call in order to rest, reflect and regather my energy.  

In the mean-time, I am planning a workshop for Student midwives and doulas on Physiological Birth: birth is a normal process, a part of life and something that women should be well supported through.  Marsden Wagner writes eloquently and honestly about the dehumanisation of birth here - food for thought indeed. 

Mothers and midwives we need to reclaim birth, we need to honour the strength and courage of all women and we need to do it now.  A fantastic new website has been created for women to share their experiences of birth and midwifery - and to campaign to improve the care that women receive.  Take the time to visit the site and make your own entry....   birth is 'uniquely normal' and we need to celebrate this!

Revealing the Lioness!

I have been very fortunate over the past few weeks to have attended two wonderful home births. The women who let me into their homes and hearts both had personal challenges and fears to overcome in order to face and meet their labours and births; both needed to regain belief and confidence in their bodies, and to trust in the power of birth.


As I watched these amazing women dig deep, bare their souls, and allow nature to release it's full force, I couldn't help but feel I was part of something more than the birth of a baby; I was also present at the birth of a mother..... and the birth of a strong, fearsome Lioness!


I haven't cried at a home birth for a while; of course I shed tears of joy, but during both these births I shed soul tears for the courage, love and bravery that unfolded before me, and I was reminded that Women really are incredibly amazing. Wow!

Is having a home birth selfish?

This was a question posted on the popular 'Mumsnet' website and caused a lot of response. I have thought about this question a lot (insomnia gives you time to think!), and I guess my response to that would be that there are many decisions we have to make as parents that are life changing, for example:

• is it selfish to vaccinate / not-vaccinate?
• is it selfish to place a child in full-time nursery care / be a full-time parent?
• is it selfish to home-educate / use state schooling?
• is it selfish to have one child / have 4+ children?

All of the decisions we make as parents are difficult ones: all we can hope to do is make the best decision, based on the information and evidence we have, at that time. Choosing to give birth at home does involve risks, but so does choosing to give birth in hospital and contrary to popular belief; hospital does not guarantee a safe outcome.

Planning a home birth based on the evidence available, is shown to be a safe, normal choice and is nothing new; Women have birthed, and will continue to birth in the place that feels right for them. The question of being selfish is therefore an unnecessary and judgemental one to pose. We are all individuals who have to make choices - as with the examples above they may not be the same choices that other parents may make, but they are no less valuable or 'right'. Birth and parenting is not 'black & white' but is made up of many shades, and every day brings new challenges and choices. I know I don't always get it right, but when it comes to important, life influencing decisions, I try to make the best decision I can at that time!

Selfishness aside, having a baby is a unique, life-changing experience; for some women they will need all the interventions that high-tech birth can offer, for some women they will choose to give birth in their local hospital, and for some women they will choose to give birth in the comfort of their own home. All choices should be respected, all women should receive the best care they can, and all women should feel supported in the decision they have made, rather than bullied, coerced or belittled into doing something that is not right for them.