When labour needs to start

A different way of approaching the baby’s birth. Useful techniques but also a different way of thinking about how birth begins and making a birth easy.


There are several situations when it is preferable that labour start sooner rather than later. These include-

  • prolonged pregnancy (although the WHO recognises than normal human gestation at term is 38-42 weeks many women, especially older mothers have pressure put on them to accept induction from 40-40+10 days, due to a potential increased risk of stillbirth)
  • Elevated blood pressure (gestational hypertension at term)
  • Women with type 1 or 2 diabetes at term
  • rupture of membranes at term without labour

Although some women are happy to accept induction, others would prefer labour to start naturally or are planning to birth at home so do not want o go into hospital for induction.

I have been offering a ‘Starting labour’ one to one session(in NorthWest and Wales, UK)  for the past few years and have had good results (the majority of women going into labour within 24 hours) although some people have…

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How to Commission a Homebirth Serivce – by a CCG Commissioner

Notes from 2nd July NCT Birthplace conference, Birmingham Medical School

Diane Reeves Accounting Officer for Birmingham South Central CCG:

Commissioning a Homebirth Service

These are a mixture of my notes of the presentation pulling points from the power point slides. I have labelled my comments clearly and where I have lifted slides the extra speaker comments are in italics from my notes. Italics can also denote my interpretation of what was said.

For the full slide presentation and recording go to: http://www.nct.org.uk/professional/events

Personal story –She was present at the birth of her sister in 1965, and 3 years later with her younger sister she ‘giggled’ through the birth of her brother. Diane is a GP by profession and has 4 children. Three were born at home, one against medical advice.

Comment: in her talk this experience and understanding clearly influenced her work as a clinician in this area and she was open about the fact that it had. She said that she convinced her peers with medical evidence, but her personal experience was what kept this as a priority and kept her pushing with her CCG colleagues. It also helped that her Commissioner colleague for maternity services at the CCG was a GP who, along with her siblings, had been born at home. They both felt that peer to peer discussion was what worked in pulling this off.

It was clear from Diane’s presentation, her colleague the commissioner in the audience and the senior Clinician speaker earlier in the day that there had been a number of them convinced of the need, and wanting to set up, a homebirth service in Birmingham, however, the barriers had been too great until now.

Key barriers were:

  • Finance and tariff issues- introduction of more granular tariff
  • Lack of published evidence-Birthplace study endorsed the safety- published 2011 BMJ
  • Interaction of evidence with clinical commissioning – lack of pathway from evidence to implementation. Need for leadership.
  • Increasing population, young city, high birth rates- links to capacity – easier to do more of the same?
  • Under-used home birth service because not dedicated – on call midwives pulled into labour ward leading to patients not satisfied (promised service not happening). Not promoted as a result.

GPs were also wary and unconvinced about having such a service:

What were the GPs concerns about the service?

GP HB survey findings

GP survey circulated in July 2013

42 surveys completed

Main concerns:

  • Medications •Attendance – •Transfers •New baby checks

Comment: Key concern seemed to be that they would be landed with situations beyond their competency: they would be called out to a birth or be involved in night transfers. Thought they would have to do the baby checks – but midwives can do it. Worried be responsible if things went wrong when they had no control over it. Clear that most GPs had little expertise in this area and were unaware of latest research on homebirth and other research findings.

W hat made it succeed:

  1. A cross section of convinced and committed professionals pushing for it over a long period of time. Doctors, midwives, women.
  2. Peer to peer advocacy important.
  3. Building sustainability in terms of finance and numbers is important right from the start – the service had to work on the Maternity tarrif alone – this has been a problem with past projects.

What made it happen? Key success factors

  • Evidence, data, choice and capacity issues creating a mandate – ie the combination of the medical evidence, the choice agenda in public health policy and the hospital capacity issue – too many babies being born for the Obstetric Unit to cope with.
  • Enthusiastic provider team (MWs and OBs), enthusiastic (female) GP commissioners- with a desire to improve choice and reduce interventions for low risk women.
  • Non recurrent spending requirements- initial pump priming . To get the results and the savings long term initial investment has to be made.
  • Work to promote it to GPs- educational events, GP networks Peer to peer education seemed to be key.
  • MSLC support – the MSLC kept raising this issue over years ( I get the impression that they were fed up of raising it by the end) but it kept it on the agenda until all the elements were in place
  • “Big social conversation” engagement events- reaching diverse communities (but BSC patients only at present) Community participation not a top down approach (more of this in another presentation)

I would add strong leadership from CCG Commissioners – who were female, mothers and had personal experience of homebirth. It is a strategic thing.

Commissioning for Quality

  • Intra-partum transfer review and benchmarking – ensuring that transfer rates do not exceed the Birthplace average
  • Continuity of care is important: 3 or fewer midwives through whole package of care. Another presentation by the head of the HB team said that they decided not to do 121 midwifery but team care due to staff lifestyle balance – but the standard is that women meet 3 or fewer midwives during the entire pathway.
  • Breastfeeding rates 75% – high BF rate is expected and delivered
  • Incident reporting and monitoring – this has to be as rigorous as in a unit
  • Diversity of users – not just for hippies

Diane showed a video of an interview with South Asian couple. They could not understand this thing about being given toast after the birth. She said ‘Why am I being given warm bread? Is it some kind of ritual?’ Remembering the cultural aspects of communication and birth!

Sustainability and where they are at: 240 births is the breakeven point for sustainability and in their first year they are on target to meet this point within three years. For equity however the HB team needs to be rolled out across Birmingham. Also, HB team in first year – none of the GP concerns have been realised!!!

Message to everyone out there:

  • Build sustainability into your business plan
  • Strong cross professional leadership needed. Key here was GP leadership.
  • If it fails this time around keep pushing: its time will come.

The Story of Miss Margaret the Granny Midwife

Fifteen year old Tilly Weston has done a work expereince placement with Aquabirths this week.  As part of here work she was asked to choose a DVD watch it and write a review.  Here it is:

Miss Margaret is an inspirational film that is well written following the story of a legendary Granny Midwife from Eutaw, Alabama.

Margaret Charles Smith was born in 1906 and died in 2004 at the age of 98. Margaret was brought up in Alabama by a slave woman; she was the last of 10. She grew up working in the cotton fields until she decided she wasn’t going back to the fields again and she was going to get a different job! She started as a laundry woman, and then continued to do a midwifery course after showing natural skills delivering her husband’s cousin’s wife’s babies.

She became a highly regarded midwife and delivering 3,500 babies at home (in a county population of just 10 000). She never lost a mother and never drove a car – despite travelling all over Alabama and sometimes further. There were times she delivered 4 babies a night, but she said she never gave up on a mother: using prayer and motherwit as her main tools, and patience and kind words as her main techniques.

In her words “They’ll know what they’ve got to do, if you know how to talk to them. Give ‘em love and kind words. That beats it all.”

Then she was pushed into retirement as a law was passed that midwives, like her, were no longer allowed be midwives. So Margaret Smith wrote a book named ‘Listen to me Good’. This along with her phenomenal life story inspired the next generation midwives.

I think this film was beautifully made, inspiring the watcher and emphasing the utter ‘amazingness’ of this woman’s extraordinary life despite the troubles she had being a black woman in America. It also made me think how tough things would have been for women then, how things have improved, and how things should continue to improve for women all over the world to have a comfortable birthing experience. It makes me think what an important vocation midwifery is.

The DVD is called ‘Miss Margaret’ produced by Sage Femme.

You can buy this DVD (and others) at: www.sagefemme.com

You can buy the book ‘Listern to me Good’ by Margaret Smith at http://www.amazon.com/LISTEN-TO-ME-GOOD-PERSPECTIVE/dp/0814207014

And many other online and off line book stores.

Michel Odent in the New Scientist Magazine

Michel Odent – in the New Scientist!!!! Below is a pdf photo of the article in the 4th July issue.  Well done NS!

Odent argues again that the medicalisation of birth is inhibiting normal physiological birth and this could have health consequences for our populations.  And we should really think about what we are doing.  Read that book: Do we need Midwives by Michel Odent

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