Author Topic: Ratbag's Reality Check - How to have a good birth  (Read 17185 times)

Bumble

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Re: Ratbag's Reality Check - How to have a good birth
« Reply #30 on: Apr 11, 2010, 11:20:56 AM »
Ratbag - what a brilliant thread, thank you.

Offline ratbag

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Re: Ratbag's Reality Check - How to have a good birth
« Reply #31 on: Apr 14, 2010, 11:35:42 AM »
Thank you - you're all welcome. 

Have been working so been too busy to add to it at the moment - hope to get back to it in the next day or so.

Am not sure of the best way to add more info - do you want me to edit the original messages so the info stays broadly at the top, or shall I just keep adding at the end of the thread - I'm not sure if people will trawl through it all...  Can answer individual questions as they occur but feel that the bulk of the info should be at the beginning - thoughts?

Offline ratbag

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Re: Ratbag's Reality Check - How to have a good birth
« Reply #32 on: Apr 14, 2010, 11:55:50 AM »
Ratbag - can you explain a bit about how things might be different if the baby is early (before 37 weeks)?

Depends how early...

Before 37 weeks generally means hospital birth, no water birth, continuous monitoring etc....
but -

no one can make you go to hospital if you don't want to, however your baby may need the assistance of modern technology - before 37/40 babies don't always keep their temperatures, or their blood sugars up, and often are slow to feed. 

Water birth may compromise an already compromised baby and prematurity is one of those situations where the baby may be compromised

Continuous monitoring has been shown to increase the caesarean section rate - I am not a fan of it simply for prematurity but every case is different.

Babies between 34-37 weeks - most of these babies will do very well - some will have feeding difficulties, a few will have some respiratory difficulties (particularly boys, and particularly if born by CS), they need to be kept warm as they can't maintain their body temperature.  Some hospitals will automatically take these babies to a NICU, others will wait and see and leave with mum under transitional care.  The best way to care for these babies (in my opinion) is kangaroo care and free access to the breast or if unable to suck regular small feeds of breast milk.

Between 28-34 weeks - most of these babies will do well if treated in an appropriate place - they will all need the care of the NICU.  Almost all will need to in an incubator for at least some of their early hours and days.  They are prone to feeding/respiratory/temperature issues.  As long as they have no other health problems, and they do not pick up an infection whilst in hospital todays modern care means that most of these babies will also survive and do well.

Between 24-28 weeks babies need to almost certainly be cared for in tertiary centre - often a distance from the parent.  Even without other health problems these babies face a lot of challenges - they are prone to gut problems, long term respiratory issues etc.

Before 24 weeks although some babies do survive the course of their early months is very challenging for them and their parents.  There are lots of ethical issues surrounding their care and whilst there are reports of babies born at this gestation surviving into childhood with no health issues these children are very rare.

I am not a neonatal specialist - I am not even a very good postnatal midwife - my speciality is labour, so please remember that this is only very general advice.  Each baby is different - some are born completely healthy, just early.  Others are born early because of infection and they are then liable to infection, some have genetic defects that mean that their body does not work as it should - so obviously I cannot do more than give a general guide.

What I can say is that the earlier your baby is born the more likely it is to be compromised at birth, and in the subsequent days, weeks and sometimes months. 

However, as a general rule of thumb, in the delivery room any baby more than 34 weeks I'm not too worried about - would have a paediatrician available but baby may not even need to be seen by them initially leaving parents to have a cuddle before (in my area) the baby is taken to NICU.  Other  areas keep babies with mum to be monitored by midwives.  Before 34 weeks I would probably (depending on the baby's condition) take the baby to the paediatrician (our resuscitaire is not in the room) for review and immediate transfer if necessary.  I would hope to have had enough time wth mum to give her an idea of what to expect.  Women in labour before 28 weeks are usually transferred out of our area to a larger hospital but if a woman did come in unexpectedly and there  was no time for transfer I would ensure not only a paediatrician but possibly aslo a paediatric consultant.

Offline ratbag

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Re: Ratbag's Reality Check - How to have a good birth
« Reply #33 on: Apr 14, 2010, 12:06:40 PM »
people's experience of pain in labour is quite varied - it seems to be talked about as if everyone has the same feelings, but some "tough it out" and others have an epidural, but I don't think that's right (correct me if I'm wrong!).

Everyone is different - but I am of the opinion that women are able to tolerate the pain if they are well prepared and supported.  However that preparation starts with what happened when you were ill or you fell over and what your mum did for you when you were tiny, or with the stories your mum told you about her births, or with what you have seen or read in the media, or even with your general health. The issue of preparation is multifactorial and it is not my job to judge a woman if she wants an epidural.

What I do know though is that women can cope with the pain, and they do - often.  Their body knew how to make and grow the baby, and it knows how to get it out.  It just has to be trusted.  A relaxed, easy going woman who is open minded about her birth experience generally does better (ie less analgesia and less intervention) than someone who has been very rigid and inflexible about their birth choices. 

 

Offline ratbag

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Re: Ratbag's Reality Check - How to have a good birth
« Reply #34 on: Apr 14, 2010, 12:13:44 PM »
I'm absolutely petrified of not being in control...being preganant you lose all control and you're just a slave to your body and at the mercy of the medical profession.

Absolutely not true - you are still you whether you are pregnant or not.  Your autonomy and independence doesn't vanish with your waistline.  The medical (and midwifery) profession can do nothing to you without your consent - and if you approach them knowing that they can't bully you either....




Not to mention the whole thing about having a parasite inside you, stealing your nutrients, causing you untold discomfort for 9 months culminating in a 2 day long pain-athon.

Its not stealing your nutrients - its taking what it needs, which in comparison to what you need, is actually very little, and which you can compensate for in extra calories (in the last triemester) and extra micronutrients (in the first trimester).  You could have these extra calories as a big bar of chocolate or in a cake or by having a small healthy extra meal a day - the choice is yours....

Very few women have untold discomfort for the whole 9 months - those that do probably have underlying health issues - whether physical or mental.

And a 2 day pain-a-thon - I'll give you that actually.  For most first timers that is indeed what it is.  But there are ways of making that better.




Offline ratbag

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Re: Ratbag's Reality Check - How to have a good birth
« Reply #35 on: Apr 14, 2010, 12:20:53 PM »
I dont think everyone tears but maybe ratbag can correct me on that? you can 'prepare' your perineum pre birth by massaging it daily (basically putting a finger in your vagina and stretching it if i recall and sort of rubbing) but how much of a difference that makes i dont know. again ratbag's the one to know.

No not everyone tears.  You could try perineal massage - there is a good info leaflet here  but remember that everyone's tissue is different - some women have skin that gets stretch marks and some women don't for example.  So some women will tear, and some women won't.  As a rule of thumb each labour will mean less tearing - nature makes the hole bigger so the next baby can get out....

Offline ratbag

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Re: Ratbag's Reality Check - How to have a good birth
« Reply #36 on: Apr 14, 2010, 12:23:46 PM »
My midwife always asks me if I think the heartbeat sounds okay????  ::)  You tell me.

Maybe she asks everyone that?  :)  I make sure women have heard their baby and they are happy that they have heard it - its their baby after all....


Offline ratbag

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Re: Ratbag's Reality Check - How to have a good birth
« Reply #37 on: Apr 14, 2010, 12:24:42 PM »
keeping things normal - we carried on the whole day doing what we always do on a tuesday right up until the contractions got too intense, then we set off for the hospital. I'm not saying cooking dinner and watching tv are any good for pain relief but keeping to a routine makes whats coming a bit less daunting.

Exactly what I tell women to do  ;D

Offline ratbag

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Re: Ratbag's Reality Check - How to have a good birth
« Reply #38 on: Apr 14, 2010, 01:15:01 PM »
It is important to note that until you are in labour ward you will not just have one midwife - I had around five who looked after me at different times. They also don't always tell each other everything so you will probably find you have to repeat things over and over again, even when they are written down.

I don't know about your midwives but I would much rather get a history from the woman, in her own words, than rely on my colleagues who may or may not have got the story straight....It also give me an opportunity to get to know her.   But I get that for some women getting to know another midwife is not something they actually want - for all sorts of different reasons.

As for care in labour - the aim is to have only one midwife looking after you but if labour is long it may take more than one shift to get it out....that means more than one midwife I'm afraid....

Offline labrat

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Re: Ratbag's Reality Check - How to have a good birth
« Reply #39 on: Apr 16, 2010, 02:01:59 PM »
you are still you whether you are pregnant or not.  Your autonomy and independence doesn't vanish with your waistline.  The medical (and midwifery) profession can do nothing to you without your consent - and if you approach them knowing that they can't bully you either....

ratbag - great thread! 

I'm very interested to read the comment above.  After a straightforward (and quick) first homebirth, I am booked to see a consultant for a hospital twin birth in two weeks.  I am really not good at standing up to medics without getting argumentative and I don't think that's constructive.  The hospital twin protocol lists induction at 38 weeks, epidural, continuous monitoring, two paed teams in the room at delivery... everything I want to avoid.  Instead, I trust that I can give birth to these babies if I am in a calm, supportive and not overpopulated environment where I am allowed to move around (water would be good too!).  Ideally, I would like midwife-led, not consultant-led birth.

So, with apologies for high jacking this thread, but hopefully it is a question that is more generally relevant: how can I persuade the consultant to create an environment in which I envisage I can give birth, even if it goes against hospital protocol?  Thanks :)

Offline ratbag

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Re: Ratbag's Reality Check - How to have a good birth
« Reply #40 on: Apr 16, 2010, 05:43:21 PM »
The hospital twin protocol lists induction at 38 weeks, epidural, continuous monitoring, two paed teams in the room at delivery... everything I want to avoid.

You can decline all of these interventions - this is your birth experience, whether you choose to have your babies at home or in hospital.




Instead, I trust that I can give birth to these babies if I am in a calm, supportive and not overpopulated environment where I am allowed to move around (water would be good too!).  Ideally, I would like midwife-led, not consultant-led birth.

I am sure you can - my personal preference would not include birth in water but certainly labouring in water would be beneficial.  And it is certainly possible to have a midwife led rather than doctor led birth.

how can I persuade the consultant to create an environment in which I envisage I can give birth, even if it goes against hospital protocol?

You don't have to persuade him - he cannot do anything to you against your will.  Make sure you are well prepared - if you don't want induction ask him to explain his rationale to you.  Did you go to term or overdue last time?  Did you need induction?   

They will offer an epidural in the belief that they can do a LSCS in super quick time if you need one as an emergency (ie after the first twin is born or if a sudden deterioration in fetal heart condition).  This is true - but in a real dire emergency they could give you a general anaesthetic too - which is your preference?  An epidural limiting mobility for the 80% chance you have of a normal birth, or a GA for the 20% chance of needing an emergency operation - these figures are based on the WHO figure of attaining a 15% CS rate (some babies will always need to be born this way) and the definite but small increased risk in having twins.

As for two paediatric teams in the room - if your babies are born at term the first is very unlikely to require assistance - the second may need a bit more, especially if it is breech.  You can ask these people to wait outside until they are needed. 

Rehearse your speech - "Thank you for your advice.  I have decided to (decline the epidural/ask people to wait outside/wait for spontaneous labour/whatever else you have decided)."

If you are strongly encouraged (bullied) into doing something you are not comfortable with then say this "I have told you what I have decided Dr Bloggs, and I appreciate your advice, but I do not appreciate being harassed on this matter"

If the harassment continues say "I thank you for your advice, but if you continue to harass me I shall have no alternative but to report you to the GMC - perhaps you could give me your registration number?"  This will totally shut them up - you are the patient, you have your faculties intact and they CANNOT bully you.

If possible write to the Supervisors of Midwives, or if there is a consultant midwife, at your hospital and ask for them to attend your appointment too - this should give you some support and will make you feel less alone in your decision making.

There is lots of information out in internetland about birthing twins -many women do it at home, did you consider another home birth?

Best of luck - and good birthing vibes coming your way

Offline labrat

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Re: Ratbag's Reality Check - How to have a good birth
« Reply #41 on: Apr 19, 2010, 07:45:37 AM »
Thanks Ratbag, lots of useful information there. With apologies again for highjacking the thread, some replies to your specific questions:

A home birth would be lovely, but I am concerned about the risks to the second baby, and unless I can relax about them, I don't think I would be able to labour well at home.  Monkey was born as 40+6, and it took 15 hours after my waters broke before labour started, so I think I do need to be prepared that I may go past 38 weeks this time.

I will be learning by rote those sentences to use with consultants!  Thanks :)

Offline little-rogue

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Re: Ratbag's Reality Check - How to have a good birth
« Reply #42 on: Apr 27, 2010, 03:39:05 PM »
Really great thread  :D
Where there is love, there is no darkness

Offline ratbag

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Re: Ratbag's Reality Check - How to have a good birth
« Reply #43 on: May 14, 2010, 08:42:50 AM »
Pain Relief Options in Labour

The pain of labour is not like the pain of a broken arm, it is like the pain of exercise.  This is a key thing to remember about labour.  The pain is not telling us to stop, it is telling us to continue...

Endorphins - the bodies own defence against pain.  Think of when you exercise - how it hurts at first but after 20-30 minutes it actually feels quite nice, those are endorphins at work...  Our body reacts to pain by producing endorphins - sadly their manufacture is not instant.  Pain starts and it takes a while for the body to catch up.  This is a key point to remember in labour - if things get too much try waiting 20 minutes before making a decision on pain relief - you might find you can still do it!


Always keep moving, always keep mobile, always try to relax...

First, when labour starts, paracetamol, hotwater bottle or a wheat bag...really.  Try to stay low tech for as long as possible  ;D

TENS machine - stands for Transcutaneous Electronic Nerve Stimulation.  You have four pads, two either side of your spine just around the top of your pants, and two either side of your spine just below your bra line.  Start off with it on its lowest setting - just enough that you can feel it.  Have it pulsing on an off for around 20-30 minutes, this will start your own endorphins off...Once you have become accustomed to the tingle you can start to use the boost button during tightenings.  And as the tightenings increase you can turn the TENS machine up. 

Mostly TENS works for pain like a radio tuned between stations works for blocking out the sound of a pneumatic drill...tune your radio to the white noise, turn it up loud and see if you can hear anything else...TENS does this with your pain receptors.  Additionally it makes you make endorphins which are a good thing.

Entonox or N2O O2, or Gas and Air is an inhalation analgesia - the Nitrous Oxide (N2O) is laughing gas, and its mixed with oxygen (O2) so you can breathe!  You might use a mask or a mouth piece - either is ok.  The key is to use it effectively.  Lots of women take a breathe, hold the pipe at arms length and say "It isn't working!" - well it won't unless you are actually breathing it, one puff is not enough as most of the stuff is moved back out of your body by your lungs as soon as you breathe out, and there is a definite delayed effect to it.  The trick is to get to know your tightenings - learn about how they feel before they hurt - do you feel your belly go hard?  Is it in your back? A pressure feeling in your fanny?  Whatever the sign that the pain is about to start is, learn to recognise it.  And when it comes start to take puffs of entonox - in and out, in and out, in and out....not so deep straight away that it makes you gag...get used to it first.  If you start taking it before the pain is strong the effects should be fully in place by the time the peak of the contraction hits you...then you can take normal breaths again...

Entonox has a  very minimal effect on the baby, but if you use it deeply for hours you can get quite stoned....You may be asked to come up for normal air to make your brain wake up...

And it makes you very thirsty - keep drinking.

A note about entonox in the second stage - you can't push effectively while doing deep breathing - your midwife may take the entonox away from you if you are too distracted by it....

A community midwife would be able to bring entonox to a home birth

Opiate Analgesia - like pethidine or meptid.  These are heroin's little brother.  They don't take away the pain, they make you not care about it in between.  For some women that is a perfect way to spend a labour - dozing in between and relaxing.  Other women cannot stand the drunken stoned feeling that it brings.  It is a drug that is very useful when women are very tense - the relaxation it brings can speed a labour up in some cases, however, if used too early in labour it can stop it completely....

If given within an hour or so of birth pethidine can dull the respiritory reflex of the newborn - making them reluctant to breathe... we have an antidote and are all fully trained in neonatal resuscitation, and it is quite rare so don't let it stop you having the drug if you think you need it.  Pethidine can also dull the sucking reflex of the baby - this can make it more difficult (but by no means impossible) to establish breastfeeding in the first day or two.  Finally - there are some studies that indicate that babies exposed to opiates in the womb are more likely to become addicted to opiates as adolescents and young adults...

A community midwife might be able to supply opiates at a home birth but may be very reluctant to do so because of the implications for neonatal resuscitation....

Epidural - an injection into your back that leaves a little tube inside through which pain killing medication can be given either as a continuous infusion or as a series of top ups.... Advantages - usually total pain relief, although sometimes it doesn't work equally on both sides or you may have a window of pain or it may not work at all and will need to be resited.  Given by an anaesthetist - some labour wards have them available all the time, others have to share them with ITU for example.  It takes about 20-30 minutes to perform, and you do need to be able to sit still at certain points of the procedure - if you have a pain coming tell them and they will stop what they are doing.  You'll almost certainly need to have a venflon in your arm or hand to give you fluids as epidurals can significantly reduce your blood pressure and we can correct that with a drip. 

Epidurals can slow labour down, especially the pushing stage.  They are more likely to lead to an instrumental delivery (ie forceps or ventouse) because the woman may have reduced sensation to push.  They are not more likely to lead to a caesarean section....

Side effects include headaches and backaches but these are very minor and remedied easily.  More serious, but very rare side effects include paralysis and nerve damage....here is the information card our hospital uses.



Offline Sherpa

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Re: Ratbag's Reality Check - How to have a good birth
« Reply #44 on: May 14, 2010, 11:12:18 AM »
Thanks for this ratbag.

Can I ask you a question about membrane sweeps? My consultant is very worried about me going overdue - with some good reason due to age (i'm 42), ivf and family history. I had a membrane sweep on Weds which revealed that cervix was 2cm dilated and 1cm thick, so looking promising, and i had a show yesterday morning though nothing since. Plan is to have another sweep on Weds if I haven't gone into labour between times: I was thinking of having another on friday if that didn't work, but I was wondering, given your concerns about examinations, might it be better to hold back?