Come on Mr NICE guy, be nice!

•October 31, 2011 • Leave a Comment

It was going to take a handsome prince to wake me from my blogging slumber. Alas though there’s no such thing in cyber land. Instead, though, Mr NICE guy has thrown a bucket of cold water over me while I blissfully ignored all the controversy that’s been swilling around birth for the last couple of months.

What are we to make, then, of this guideline, that anyone who would like one, should be allowed to have a caesarean. Is this a shot in the arm for feminism, or a blow to it? And similarly, to the NHS?

I saw the headline yesterday and avoided the article in order to protect my blood pressure. I have continued to avoid much of the media debate today because I fear it will be misinformed and simplistic.

I suspect that the back story for guideline is avoidance of birth trauma, and facilitating birthing women to give birth in a way that is as meaningful and unstressful as possible for them. But if my suspicion is correct, I feel very deeply that NICE has missed the point rather spectacularly. Because actually the evidence tells us pretty clearly that what makes people feel good about their experience of birth is being listened to, nurtured, loved, even. Of exploring their fears and perhaps facing them, and coming out of that experience feeling strong and powerful.

Now, for some women that is a very low-tech homebirth, for others that is an elective caesarean – and for many it is somewhere in between the two. Naysayers on both sides of the caesarean versus homebirth debate will state that the other is fraught with danger and an inefficient use of resources (quoting my friend Charlotte Morbey). But where one is to be offered without prejudice or judgement, surely the other should, too? Each with their own open, kind and loving conversation to accompany it, so that a woman and her family can truly understand the implications of whichever way she choses to give birth.

As an antenatal educator, if someone comes to me (as they do reasonably often), saying they want a caesarean, it opens up a conversation, and an opportunity to explore a host of feelings and options. If this guideline provides that opportunity to more women, who then genuinely feel that they have made the right decision for them and their family, then it is a good thing. But if the associated conversation – the TLC – doesn’t happen – if it’s just ‘hello doctor, I’d like a section please.’ ‘Fine, I’ll put you in for the 21st at 9am. Next!’ then it could well be there is a growing population of women who are feeling at the very least emotionally and physically unsatisfied with their experience of birth, and possibly even traumatised by the passive, non-participatory way in which their child was brought into the world.

We know what makes women feel good about their birth experience. It’s TLC and love. And if NICE could rustle up a guideline which gave birthing women continuity of carer, and empathy – however the birth unfolds on the night – then quite honestly a whole lot less women would opt for major abdominal surgery in order to become mothers. And those for whom it became the only option would feel far more accepting of it. I promise.


I caught a baby!

•August 7, 2011 • 4 Comments

As a doula – a birth companion – it states very clearly in my contract that I will not, and in fact it would be illegal for me to act as a midwife. My job is to provide emotional and physical support during labour, and to leave the clinical aspects of the birth to the medically qualified ones.

Natalie made contact to ask whether I would be able to be present at her baby’s home birth.

Just shy of a week overdue, I got a message to tell me she thought things were kicking off. I had had an ongoing worry that the baby in the back to back position, which can slow down and complicate a labour – but clearly we were now ready for the off.

The next call came around 4.30am, from Chris, telling me that Natalie was having contractions every three minutes and she’d like me there. I still had in the back of my mind that this was a first baby, and potentially poor positioning, so I didn’t rush.

When I got there – around five thirty, I expected a birthing boudoir – I was really surprised when Chris opened the door and Natalie called out cheerfully, ‘Up here!’ I went into their bedroom to find all the lights on, and Natalie sitting on the bed, making eye contact, and acting normal. The labouring woman in her appeared to have left the building. ‘It’s all stopped,’ she complained, ‘we’re down to every fifteen minutes.’

We had a chat, and I watched her have a contraction or two. They didn’t seem that intense, or long, and I yawned with frustration at being out of bed three hours early for nothing! ‘I’m really frustrated,’ Natalie complained, ‘I don’t know what’s happened.’ Neither did I, really – although I knew that interruptions to the atmosphere when in labour could play havoc with its progress. Natalie was also worried that there was no food in the house, and they were down to a single roll of toilet paper.

I took this as an opportunity to leave Natalie and Chris to their own devices to do whatever they could to get lovey-dovey, to get labour started, while I went to the 24 hour supermarket, with their shopping list.

Again I didn’t rush and I drifted back by about 6.30, wondering what I would be met with.

And hey presto, I got the scene I had anticipated an hour and a half earlier. Now the lights were down, Natalie was on all fours, moaning gently to herself. To my eye – experienced but untrained – she was now looking like she was in established labour.

‘How are you feeling?’ I asked gently, to which the response was ‘I think we should call the midwives.’ Chris got straight on the phone to the local delivery suite and painstakingly explained to a receptionist that yes, this was a planned home birth, yes, this was a first baby, yes the doula was already there, and yes, we’d like the midwife to come. And repeated Natalie’s name again.

Less than ten minutes later Natalie felt like she needed the loo – so the three of us trooped off to the bathroom and she sat. In the next contraction her waters went and instantly her behaviour changed. ‘Did that one feel a bit pushy?’ I asked. She nodded.
‘Chris, get back on the phone and tell labour ward her waters have broken and she’s pushing,’ I ordered.

I had a rush of adrenalin as it occurred to me that I was the most experienced person here and it might fall to me to catch the baby. I could feel my heart beating as I silently urged the midwives to hurry up and get here – not only would this be a massive responsibility for me, I had no kit – no plastic sheeting, no sterile gloves – and in fact technically it would be illegal for me to act as a midwife. But what else could I do? I wasn’t going to leave this couple on their own now.

‘OK, Natalie, I’d like you to move back to the bedroom. I don’t want to be fishing your baby out of the loo,’ I requested. She slowly made it back to her double bed, which I spread with the shower curtain and a pile of towels, and resumed her all-fours position.

I could see all the signs that the baby was on its way down – signs that I’d seen before, but not that close up – usually as a doula I’m at the ‘head end’, hugging the woman, mopping her brow and reminding her to breathe. This time I was in the midwife’s position as I saw first a tiny slither of the baby’s head, and with each push, a little more. I went off to wash my hands thoroughly, mimicking the ‘scrubbing in’ I’d seen in hospital documentaries.

I imagined I heard a knocking downstairs. I ran down and opened the door – but there was no-one there. I rushed back upstairs to see more and more of the baby’s head emerging.

Then suddenly the whole of the baby’s head was out. She did me the good service of making chewing motions, which told me she was alive. (We had had no way of checking the baby’s heartbeat through the labour, although Natalie had reported she’d felt the baby move regularly, which had reassured me when I first got there.)

A final push, and I guided this tiny newborn down onto the bed in between her mother’s legs, and she cried. Natalie then sat back and picked up her baby, who was already pinking up. We wrapped the pair of them up warm, checked the time (8.03am) and laughed in incredulity that the midwives still weren’t there – an hour and a half after our first call, and an hour after we had called back!

About fifteen minutes after Eloise was born, a midwife appeared. Fortunately she was able to do all the clinical bits and pieces including delivering the placenta, checking whether Natalie needed stitches, while I went downstairs and made tea and toast for everyone, although I felt like I wanted something a whole lot stronger!

There was no follow-up to my dalliance with midwifery – once the midwives were assured that we hadn’t planned it this way, I think it was accepted that sometimes labours are difficult to read, and we were all delighted that it all went so well.

It should be about informed choice, not coerced compliance

•July 29, 2011 • 1 Comment

Two things have been going on in my life recently:

Firstly, I teach antenatal yoga on a Thursday night, and usually I come home feeling wonderfully zen, at one with the world.

Secondly, through many conversations with two friends who are student midwives, and through a lot of birth companion jobs this year, my respect for midwives has grown enormously. I understand that they are working under enormous pressure and fundamentally want the same as most pregnant women want: a gentle straightforward birth with minimal intervention.

Last night that all changed, and I drove home ranting loudly at my passenger about why on earth people go into the ‘caring professions’ when they just don’t seem to care about bedside manner, the way in which they deliver news or advice. And when you get incredibly fond of may of your clients, in the way I seem to, it’s inevitable that you get pretty defensive when you feel they are not being looked after.

So in the last few days I have encountered a wealth of horror stories which only serve to disempower pregnant and birthing women, and which I just can’t see helping anyone. There are several mums who’ve been told they ‘have to have’ x, y, or z – no debate, no consideration of the pros and cons, and certainly no acceptance that these women might have other opinions. There is another who was ‘treated’ to the story of the midwife’s mother’s death, with a strong implication that the same could happen to her. There’s the obstetrician who gave a woman drugs in labour (I was there – I saw it), with no chat about it – when I pushed her, all she said was ‘medical advice recommends this’. Guess what? The drugs caused a cascade of intervention, baby’s heart rate dropped and the mum had an episiotomy in order to rush the baby out.

I know that there are 20% cuts within the health services, and whatever anyone says, maternity services are not exempt. I really do understand that means that the professionals have to deal with more people, more quickly, and that there’s a double whammy in that the birth rate continues to rise. I know profoundly how hard it is as a midwife to keep one’s morale in a very difficult working environment – honestly, I do know all these things and it’s the reason why I have resisted applying for midwifery training for so many years.

But a kind word and an acknowledgement of a woman’s autonomy costs nothing. I can’t even see that it should take any more time at that rushed appointment. Because I’ve seen that in action too. A very gentle ‘our policy says that we recommend a certain course of action, but if you feel that you would like to do differently, that’s fine and I’ll support you’ is wonderfully empowering. And I believe that it works in everyone’s favour: the woman trusts the midwife then, and the relationship becomes mutually satisfying, even if it’s only for 10 minutes.

One of the stories I was told last night was hair-raising in its careless dismissiveness. We currently have two doctors in the group, and both of them acknowledged to me what I already knew – that what this woman was being told was inaccurate at the very least.

Surely it can’t be that hard to suss out which inviduals would like to have some say in their care, and which ones are happy just to be told what to do?

95% of the time I am so careful that I don’t remove the trust women have in their care-givers during pregnancy and labour. I don’t believe that that would be a constructive thing to do. But in the cases that I heard last night, the care-giver did that very effectively themselves – leading to a woman going into the birth of her baby frightened and insecure – and thus increasing the chances of labour not going well.

And we’re in a very bad place when the care-givers might give care in a physical sense, but they don’t care. And that makes me really, really sad.


Seven cheers for the Beckhams!

•July 11, 2011 • 1 Comment

OK, so she’s finally got her girl. And surprise surprise, the little girl has an unusual name. Well you would hardly have expected anything mainstream, would you, afterBrooklyn, Romeo and Cruz?

The social networks have been buzzing all morning with comments about young Harper’s name – and particularly the choice of her middle name, which is… if you happen to have been under a rock all morning… (possibly placed there by your truculent toddler – or did you put yourself there as a result of your truculent toddler? Well, that’s another story…) Seven.

Harper Seven Beckham.

‘Oh, I quite like it’ says one comment on my Facebook friend stream. ‘not sure about Seven,’ says another.

To which I say, WHY DOES IT BLOODY MATTER? OK, so Posh and David are celebrities and there’s always the argument that they have courted that, so deserve to have every fart, every nosepick, every sneeze brought into the limelight. And to me there’s something going on here about how mums (women, maybe) can be wonderfully supportive and display heartening sisterhood – or they can be catty and judgemental.

It’s up to them what they call their child. I wonder whether anyone said to my parents’ faces ‘Oh, not sure about Kedi’ – I doubt it. Could well have been raised eyebrows behind their backs (or perhaps not – this was the early seventies, after all). Just as it’s up to them how they give birth, and how they feed their child. Just as it’s up to every single one of us how we do things.

I had a lightbulb moment once when training to be an antenatal teacher, when soemone said to me , ‘everyone wants the best for their child’. The problem is that individuals sometimes disagree what’s for the best. Some parents feel that a mainstream name is great – others feel that something unique is better. Some parents decide to live in the city centre, others in the depths of the country. Some parents chose to give birth by caesarean, others go an all natural route. But I firmly believe that every single parent genuinely wants to do best by their little one.

Whether they always succeed is another question. Actually I know the answer to that – of course they don’t. All any of us can hope for is to be a good-enough parent, rather than a perfect one. Some kids change their names – and not even from the bizarre to the normal, or vice versa. I have a friend – Steph – whose name is really Karen! But we name our kids according to what’s important to us, so I say good on them, and even though I keep typing Sven, which sounds distinctly boyish to me welcome Harper Seven Beckham.

Waiting for a baby

•July 9, 2011 • 2 Comments

I am waiting for a baby.

I saw the baby’s mum last week, and she asked me when I thought the baby was going to come. I worked on the information I had to make a few educated guesses. I said I thought Thursday night was a possibility (wrong, as it’s now late Saturday evening), and that Sunday night might also be a strong chance. She was delighted when I said I thought it was probable she would have the baby within the week.

That week’s half way through now, and no baby yet. My diary is totally clear until Thursday morning now, but after that things get a little complicated again. I know that my level of twitchiness will be increasing on a daily basis now until this baby shows up – and let’s be honest, my dates were nothing more than an educated guess, and quite honestly it could easily be another fortnight yet.

We human beings have a difficult relationship with uncertainty, and as life experiences go, waiting for a baby to arrive is a pretty uncertain one. We are always trying to second-guess, to predict when the baby might arrive, how the labour might go – and even though this is my job, I’m sometimes no better than anyone else. I’m not wanting to put a date and time in the diary, but a rough idea of when it’s going to happen wouldn’t go amiss!

It would be easy to go all hippy and wistful for some distant past, when we had a more profound understanding of nature and newfangled technology extended to nothing more than a flint arrowhead. It would be easy to suggest that these ancestors of ours accepted uncertainty, and doubt – but actually I would suggest that the very fact that they built walls to protect themselves from the weather, and learned how to move on from hunting and gathering, to farming, implies that uncertainty has been our enemy since the beginning of humanity.

So how then, when waiting for a baby, do we turn uncertainty from enemy to friend?

I think there are a few things we’d do well to consider in those last days of pregnancy (and that could be up to 30 days, let’s face it): here are some ideas:

  1. Remember that no-one has ever been pregnant forever. There is one certainty here: the baby will come out sooner or later.
  1. Revel in the uncertainty: schedule fun things to do, knowing that the reward for missing these fun things is the reward of having a very small person snuggling up in your arms instead.
  1. Aim to see it as a practice for labour. What I mean by that, is practice acceptance. Nature has her plan, and it will unfold somehow or other. By standing back from that – basing the next few weeks on the ‘serenity prayer’: (grant me the serenity to accept the things I cannot change, Courage to change the things I can, And wisdom to know the difference) you will be helping yourself in labour too.

Instead we try over and over again to second-guess how events will unfold, and even to change the things we cannot change – like the date on which our baby will arrive. (And before you say that the obstetricians CAN change that – they do do a good job, but Nature still resists a fair bit of the time!)

So it’s my job now to live in the moment. If I’m not called by my client, to enjoy the time with my family, or alone… to be utterly prepared to dash off at a moment’s notice, but to know that until I have that notice, I am right here, right now. And to remember what a great lesson that is for birth itself, whether for doula, or for birthing mother.

Genie’s out of the bag, a follow-up

•June 20, 2011 • 1 Comment

I have been thinking a lot about yesterday’s post, and I would like to tinker with it. But I’m not going to – I’m going to leave it up, as is.

But my conclusion is this. The obstetricians and the lawyers and the insurance men got the caesarean genie well out of the bag.

Now the tables have turned, and more and more of these people are becoming concerned about the ever-increasing rate of caesarean.

The problem is, it was they who pedalled the lines that caesareans were necessary for all sorts of complications in labour. And they certainly did not speak out when they heard yet another woman assert that they or their baby would have died if they hadn’t been rescued by the man with the green scrubs and the scalpel.

This behaviour led us to where we are now… and sure as hell they’re going to have a battle on their hands persuading the public that a lower caesarean rate is acceptable and safe.

But it’s a battle I hope they win. Good luck all.

Is the genie out of the bag?

•June 19, 2011 • 7 Comments

The Caesarean rate has been on my mind a lot recently. Firstly there was the news that the Irish Childbirth Trust has audited all Irish hospitals, and found an enormous discrepancy in the amount of caesareans performed, from Sligo with a rate of 18.9%, to Kilkenny general at 35.6%.

The UK figures are even more striking, ranging from Chelsea and Westminster, where 34.5% of births are by caesarean, to four units with a rate of less than 18%, including Pontefract, Staffordshire and Sutton-in-Ashfield.

Then there was this news from Sussex that local Primary Care Trusts will not pay for more than 23% of local births to be by caesarean – and also this week I came across a proper piece of academic work published in Cochrane, also about reducing the caesarean rate.

It seemed, then, it’s on the professionals’ minds, too – and indeed I was talking to a pregnant woman just yesterday, who quoted her obstetrician’s concern over the rising caesarean rate, and his reluctance to give her a caesarean unless there was no other course of action. He mentioned the cost of such an operation.

I applauded internally, then, at the Sussex PCTs, the Cochrane researchers and the anonymous obstetrician. But sometimes it seems to me that I’m a lone voice in the wilderness.

Further probing in conversation with the pregnant woman suggested she did not feel reassured at his reluctance to pick up his scalpel – quite the opposite. She worried that the management of her labour would now be dictated by cost, or some obscure target culture where she would be denied the necessary surgery to save her or her baby. Comments on the web page of the Sussex newspaper reflect this view.

Something weird has happened to our culture of birth, then, in the last 40 years or so. Because in 1970 the caesarean rate was around 5%. By 1990 it was up to 12%, and by 2003 it was at 22%. The most recent UK figures, for 2008-9, put it at 24.6% nationally.

You might think that Jo Public would have something to say about this. They might wonder what on earth has happened to women, to birth, to babies, which means that in only 20 years, it has become twice as hard? You might think that the rate of very poorly or dying mums and babies must have gone right down – especially given the frequency of the refrain ‘without my caesarean, we both would have died’.

So what if I tell you that there has been no reduction in maternal or infant mortality or morbidity to match the rise and rise of surgical birth? (That’s a posh way of saying all these extra caesareans don’t seem to be saving any more lives.) The world health organisation states that beyond a caesarean rate of 15%, there’s no improvement in illness or death rates, in fact. Even that’s contentious – some commentators would put the figure closer to about 8%. What if I also tell you that the good ole US of A, which has the highest caesarean rate in the G8, also actually has the highest rate of mother and baby death in that group of countries?

My conclusion, then, is that we’re in a right muddle. An astonishing mental shift has taken place over only 20 years or so, from ‘birth might hurt a bit, but we’re healthy and well looked after, and we’ll probably get away unscathed. Hell, we might even find it’s OK…’ to ‘birth is inherently dangerous, and we might well need rescuing from it.’

Because very few wants to look back at a serious, and scary surgical intervention and wonder whether things could have been done differently – whether it was avoidable. That means losing faith in the people and the system that have been looking after you, or will be looking after you. It means become bitter and cynical and untrusting. Hey, it means questioning, and even taking responsibility for your own care – and that’s one hell of an unsettling place to be.

But don’t tell me that women in Sligo are all that different from women in Kilkenny – or that women birthing at Chelsea and Westminster have different pregnancies from those in Ilford. Not that different, anyway.

And that means that the uncomfortable truth is that there are a whole lot of caesareans being performed out there unnecessarily. We know very well what increases the chance of caesarean – induction of labour, epidurals, augmentation with sytocinon (pitocin for my American friends), continuous montioring, fear (of a breech vaginal birth, a multiple birth, a scar rupture)… but we enter into it anyway. And that means that either explictly or implictly, a whole generation of women and their families are being lied to, because without that caesarean they wouldn’t have died, actually. Most of them would have given birth naturally, and everyone would have been fine.

There’s one last piece I came across this week on the caesarean rate, which made a big impression on me. Over to Gloria Lemay, Canadian midwife

‘everyone knows how to lose weight (eat less, exercise more) but only a few get into action. We DO know how to lower the cesarean rate, but committed action is needed.’

In the last 20 years the caesarean genie has well and truly been taken out of the bag. And the only chance we have of getting him back in, is to keep asking the difficult questions, and carry on unsettling those too complacent to question. Only that way do we stand any chance of getting back to a healthy rate of vaginal birth.