Bradford’s Birthplace Conference Notes Re-posted

The new draft NICE guidance on birth place has caused a stir and some controversy.  Below I have re-posted the conference notes from the northern launch of the Birthplace survey which was the evidence behind the new draft guidelines.  It is a reminder that these guidelines are based on strong clinical evidence regarding safety, outcome, satisfaction and cost.   This evidence now needs to be implemented, the draft guidelines have to be confirmed and put into practice by CCG commissioning.  To comment on the guidelines you need to do so through a participating organization like http://www.aims.org.uk.

The Birthplace Conference at the Bradford Royal Infirmary was a wake up call for birth and midwifery. It was absolutely clear what women require for a normal natural birth – and it is not an Obstetric Unit! It was also clear that the myths of the higher cost of midwfery led units and safety fears, were all just that –  myths – well not even myths because myths require an element of truth.

I rarely take notes these days but once the conference had ended I wish I had!!!!! So I asked my friend and fellow Airedale Mum, Sally Watson, Student NCT Antenatal Teacher and all round good guy – if I could borrow her notes and publish them on my blog. She kindly consented and so here they are.

BRI 10 February 2012

Mary Stuart; Birth Place Study (see on SDO website, BMJ or NHS choices website)
All research on birth place has its limitations. The focus of this particular study was on outcomes for actual place of birth – rather than planned place of birth, this inevitably skews the data.
This research looked at 4 different places of birth, obstetric unit, freestanding midwifery unit, attached midwifery unit and home birth, comparing 65000 women
Primary aim of the study to compare intrapartum and early neonatal mortality and morbidity – by planned place of birth at the start of care in labour.
A disproportionate number of complications occur in obstetric units – this must be talked about!
Characteristics of those who choose homebirth – white, middle class, affluent, have a partner.
In all places there is a low risk of an adverse outcome (4.3/1000) where the mother is low risk.
Adverse outcomes included; stillbirth (14 in total), early neonatal death (18), neonatal encephalopathy (114), meconium aspiration (75), bronchial plexus injury (20), fractured humorous or clavicle (2)
Statistically significantly higher for first time mums (1 compared with 1.75)
Event rate is higher for homebirth than obstetric unit (3.5 compared with 9.5) the researchers were not able to say why this was, but said that the majority of the adverse outcomes were neonatal encephalopathy and meconium aspiration – there is no way of knowing the long term impact of these outcomes. Much was made of the infamous daily mail headline – the authors stressed that their reporting of the study was simply not true http://www.dailymail.co.uk/health/article-2065928/First-time-mothers-opt-home-birth-face-triple-risk-death-brain-damage-child.html the number of still births/ neonatal deaths were so small that it is of no statistical use to analyse these.
For nulliparous women there was a 45% transfer rate from home to hospital, for multiparous women this reduced to 12%
Birth outcomes;
C/S rate – 11.1% Obstetric Unit, 2.8% HB
Spontaneous vertex – 74% Obst Unit, 93% HB
Normal birth – 58% Obst Unit, 88% HB, 83% FMU, 76% AMU
Definition of normal birth – labour spontaneous, without episiotomy, forceps or ventouse (can include ARM, Syntometrine, pethadine).

Juliet Rayment (research assistant at city university of London, she focused on case studies Juliet.rayment.1@city.ac.uk)
She found that women were limited on where to give birth by the distance. Their choices really came from within the community – women talked about their friends, sisters, family etc. The more information they had, the more choices they had. Women wanted to birth close to home – don’t want to travel distance.
Also found that the leadership of an organisation/ unit set the tone for learning and accountability rather than blame, when things went wrong.
Women felt that their concerns about their health or the health of their babies was not always heard.
The study raised questions – are women receiving optimal care from Obstetric Units? The findings would suggest not – there is a need to find out what’s going on?
Cost according to place of birth (irrespective of outcome)
Obstetric unit – £1631
AMU – £1461
FMU – £1435
Home – £1063 (included with that are the staffing costs – yet home birth is still cheaper)
Look on BMJ website for full report.
Should advise low risk women to give birth outside of an obstetric unit, their outcomes are likely to be more positive, also much better obstetric health for subsequent babies.
One quote from obstetrician in the study “keep women away from us…we meddle”!

Mary Newburn (NCT)
Talked about the birth centre research study, found that physical environment led to psychological safety. For the women in the study it was important for them to see the place/ the atmosphere, once there, they felt compelled to birth there.
Why women chose to give birth in birth centre (some of the reasons they gave); they heard about it, being allowed, all natural, comfortable, calm and appealing, it made sense of how labour works, husband can stay, could ‘see myself there’, midwives get to know you, holistic approach, feel safe/ confident.
The midwives in the birth centre have a different mentality
– a belief in normal birth (not the conveyor belt production that Dennis Walsh talks about)
– Connection with a woman
– Understanding birth physiology
– Inspiring confidence in women
Midwives who worked in a birth centre from an obstetric unit talked about ‘pushing boundaries’, forget instincts and what you feel/sense in the room.
Parents talked about how it was like “going into another world”, the midwives provide continuous care, a firm support.
One of the fathers used the analogy of labour as like going to the gym ‘two more bounces on the birthing ball, then we’ll get you into the shower…then we’ll move somewhere else’
Midwives talked about “walking the line” between competing pressures and demands.
Knowledge and resourcefulness of early labour – a lot more needs to bedone on how to support dads/ birth partners support women in early labour. Mary Nolan has undertaken recent research into dads involvement – in Midwifery journal in past month.
Recommendations from the report; need a consistent welcome in the birth centre, and quiet time (unit was not always quiet), there was a heavy focus on the birth and lots of privacy post birth – but not so much support – couples tended to be left alone, yet there is a need for BF support, there is huge disparities in respect of who accesses the unit – still groups of the community who are not using the birth centres. There followed a general discussion with midwives from birth centres in different areas – all talked of referrals coming from the same midwives – with other community midwives not referring – it was felt that this was because they didn’t believe in natural birth.

Jane Munro (RCM) campaign for normal birth July – August 2010
They had 1000 returned surveys from 24 units (46% response rate which is pretty good)
67% Obstetric Units
1% Home births
32% Midwifery led unit
Found a link between instrumental delivery and semi-recumbent position. Although the majority of women in the study laboured upright, 49% birthed on the bed
RCM produce cards with different birthing positions on for midwives – include 22 images
Home births;
52% reported HB training in their initial training, 71% had experience of a homebirth in the last 12 months, 58% didn’t have any CPD on home births since qualifying
57.6% of the respondents said that their area always offered a home birth service
Confidence in attending a HB – 50.4% said very confident, 37.1 confident (slide went away before I could take the rest down)
There was some discussion about taking beds out of the rooms in birth centres – one midwife said that in her unit the bed flips out of the wall. A woman can use chairs/ sofa and the bed is only pulled out if particularly long labour and she wants to sleep – or afterwards. Other midwives talked about sitting on the bed or raising the bed so women can’t get on!

Chris Warren – Yorkshire storks
Talked about her statistics.
In 48 deliveries since 2005; 25 homebirths, 2 PPH, 6 forceps/Ventouse, 12 CS, 1 Elective CS, the rest hospital births.
They have had no emergency transfers to hospital (blue lights), their transfer rate is 10% (more for primips).
Women do not choose bad options when it comes to place of birth – they are scarred into it.
Look at evidence based guidelines for midwifery led care May 2008 (unsure of reference – might be RCM!)

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The Dangers of Uninterpreted Birth Footage

Dear all,

 

It has always been my main critique of programmes such as One Born Every Minute that they give footage without comment, analysis or context thus rendering the information it provides at best un-useful and at worst downright misleading.  For instance watching a shoulder dystosia without some discussion about its rarity, on the fact that it’s occurrence is more likely in the semi recumbent position, and the various methods of dealing with the situation, renders the footage both distressing and misleading to watchers.

 

I remember years ago a theologian, I respect immensely contended that the Bible should not be read in public without appropriate interpretation to the listeners.  He gave the example of John 21 where after the crucifixion the disciples lock themselves in an upper room ‘for fear of the Jews’.  This passage without appropriate context and interpretation had been the justification for anti semitism and violence against Jewish people over many centuries.  However contextualised, you would realise for instance, that the disciples were Jews and Jesus was a Jew – so how could they lock the door for fear of ‘the Jews’ when this was their identity also?  This phrase is actually believed to come from the context of the writer of the Gospel some decades later, a context where Gentile Christians were being persecuted by the Jewish population in that area.   So the phrase ‘for fear of the Jews’ which has caused so much strife and suffering has little to do with the Gospel story itself and much to do with the context in which the story was written down.  “This,” said my friend Dave Bowen, “Is why the Bible should always be read with appropriate interpretation.”

 

I have come to think this same rule should apply to the sharing of birth stories and especially of the televising of birth.  Editing and comment is everything in these situations: We need to have the analysis and information to really interpret what is happening in its appropriate context.  This would mean discussion from different perspectives, disagreement and comment about the practice presented, enabling viewers and readers to get a real flavour of the variety of opinions and practices that  women can receive in their birth and the opportunities for choice there are.  It would also mean of course that practitioners would have to submit their practice to the discussion and comment of their peers in a public arena – it could be a brave practitioner and a very tactful editor who could accomplish that feat.  And yet without it women are being misled and misinformed by the ‘camera that never lies’.

 

With this in mind I came to this latest birth story to cross my desk.  As I read it, questions were raised in my mind and I thought, this is a lovely birth story but there are some real questions about the practice of the carers and the way policies are implemented and practice explained.  I felt that this birth story should not be published without some pointers and questions for further discussion. 

 

For instance:

  • Where does the 24 hour deadline for induction after waters breaking come from?  Where is the risk/benefit analysis of this policy?
  • Fantastic way to spend your early labour: on the allotment and walking the dog! Not worrying about progress or lack of it.
  • Could the midwife have avoided that devastating moment for the mother by giving her positive information that would encourage her efforts rather than dishearten? How could she have encouraged a woman making slow progress with her birth?  Is giving the information ‘1cm dilated’ as unhelpful as uninterpreted  birth footage? What about effacement? What about not giving a number but simply saying progress is being made but there is a way to go yet? What would a caring midwife say to a woman in this situation?
  • The most glaring question in this story is: if the TENS was not working and the pains were so strong – why did the mother wait so long to get in the pool? – particularly when it clearly gave so much relief?  Was she waiting for permission from the midwife? Why did she need it?

 

With these questions I hand you over to the Mother’s tale:

The arrival of Albert Oliver, 7th March 2012.

My waters broke when I woke up at 8.30am on Tuesday 6th March.  After getting in the shower I decided that they really had gone, and that I wasn’t just suffering from late pregnancy incontinence!  I rang my husband, Tony, who was already at work, and he headed home to be with me.  I also rang the delivery suite who rang the community midwife on call.  San came round at about 9.30am and confirmed my waters had gone.  She told me that I needed to ring them again when my contractions were 5 mins apart, and that should labour not begin within the next 24 hours, I was booked in for induction at 8.30am the next morning.

I spent the day with Tony and another friend, Carol.  Carol had arranged to visit that day anyway and help me rotovate my allotment. Poor Tony got roped in too.  I kept moving (light allotmenting jobs) throughout the day.  At 4pm Carol left, taking our dog with her.  Another friend called in, and we went for a walk, and had an evening meal at about 6ish.

Throughout the day I had been having contractions, and at about 7ish these became stronger and more regular.  I’d put my TENS machine on early in the day, as soon as I started feeling mild contractions. A bit after 8pm I rang the delivery suite again, as we were recording my contractions as coming every 2 to 5 mins.

Cat arrived at about 8.30pm, and after observing me, we decided that I would have an internal examination to see where we were up to.  I was really very nervous about this, as I hadn’t had any internal prodding so far in my pregnancy.  It was absolutely fine however, nowhere near as intrusive as I thought it would be.  However, the examination revealed I was only 1cm dilated at this point, and Cat commented that my contractions weren’t either consistent or long enough for me to be in established labour.

I was understandably devastated at this news (as it REALLY hurt by this point!).  Cat left, saying that I needed to call her when my contractions were every 2 minutes and lasting a full 60 seconds.   The next 2 and a half hours were not fun, and I caved in at 11.30pm and asked Tony to ring delivery suite.  Cat arrived by midnight and examined me again.  At this point I was 9cm dilated, and was incredibly relieved to hear it (as it REALLY REALLY hurt and the TENS machine by this point just didn’t seem to be cutting the mustard).

I finally got into the pool at about 12.30. We’d filled it around 6pm, so Tony needed to boil some kettles to get it back to temperature.  It felt amazing as soon as I got in, and made a massive difference to my pain management (the gas and air was making me too sick so I didn’t bother with it).  The second midwife dealt with further kettles after I got in the pool, as I didn’t want to let go of Tony’s hand.

Albert arrived at 1.39am, so I was only in the pool an hour or so.  I picked him up (with help from the midwife) and cuddled him in the pool, but had to get out to deliver the placenta (as I was bleeding).  Albert was wrapped up and given to his dad to hold, so Tony had loads of time with him immediately while the midwives dealt with my third stage.

I would recommend a pool birth to anyone, whether at home or in hospital, it made a huge difference to my labour experience – as soon as I got in the pool, the pain seemed manageable, and Albert seemed to arrive quite quickly.  We now have a perfect, happy little boy!”

A happy ending to a good birth story.  But as practitioners and as stroppy mothers and midwives, that cannot be enough – we have to ask the questions too.