I want a home birth... in hospital!

[LaraOnline]

IG''s interesting thread on kids in the birth room made me think about my fav birth topic:
the pros and cons of home vs hospital birth.

How can I (we) get the benefits of home, in a medical centre?
Hmmm, I packed inspirational CDs... never thought to use them.

Pros of Home birth-
- a single midwife, that you know before the day. She stays with you from beginning to end.
Big pro. She''s probably a lot more active in bossing you around than the hospital midwives too. They just tend to follow your lead and leave you alone a lot of the time...problem if you''re lazy like me...

Hmm, that''s the biggest one for me.

Will have to cultivate a better relationship with the hospital midwives this time, by going to their regular clinics towards the end of the pregnancy. That way I get to meet them all...

I certainly will NOT be having birth without my DH to help me! He''s so big and handy to lean (sag) against. I''d just hold it in if he weren''t with me!

 

[Miranda]

I saw your post in IG''s thread about loving giving birth. It made me do this

Wow, you are some kind of woman. I can''t help but be curious. Is it the entire powerful experience you love? Or bringing a new life into the world? Or seeing your child for the first time? Or something different entirely? Please know I am not being critical. I''m just truly interested. I''ve had three kids and while I was in labor I wanted to be left alone completely and medicated when the pain was great. Labor was a means to an end for me. I went through labor to get the kid out. Not because I liked it, lol!

Back on topic, have you looked for a birthing center near your hospital?

 

[Jas12]

Lara--i just responded to your post in the other thread, and i mentioned a birthing center. Is there one in your area? They are typically midwife lead in a family-centered more relaxed environment (i.e. they often less sterile looking than a hospital, have birthing tubs and outdoor areas to walk around etc.). Most centers are aiming for a natural birth but have the means to intervene medically if necessary and are often very close to a hospital if a c-section is required.
You might be interested in reading about the american midwife Ina May--she has delivered 1000''s of babies with her team of midwives (i believe she is in CA) her rate of intervention is around 2 % !!! She will really boost your confidence in birthing centers/homebirths.

 

[LaraOnline]

Hi gurls!

I live in a regional area, so we don''t actually have birthing centres here. That said, our midwives are a pretty pro-active bunch, and the local hospitals do work hard to provide the right birthing environment.

For example, there is a lovely tub for use (but only one for the birthing mums to share), and all manner of fitballs, soft floor coverings and other paraphernalia, like cushions etc.

My second birth was in the private system. I found their brand new birthing suite to be not as comfortable!

No soft floor coverings, no equipment and no tea/coffee making facilities in the room. No ability to curtain off other family members, and no fold-out couch for overnight stays.

This restricted my ability to birth actively. Luckily, because I had experience from the first time, I was able to improvise!

Also, the midwives were very low key...it seemed slightly old fashioned...there was no weekly clinic as there is in the public system, this is a fantastic system to meet the midwives, that way they''re a friendly face when they come to help!

Hmm, I''m thinking I''ll use the public system this time around. It''s right next door to the private hospital, and they share all their back-of-house facilities!

 

[LaraOnline]

Date: 7/14/2008 10:07:00 PM
Author: Jas12
You might be interested in reading about the american midwife Ina May--she has delivered 1000''s of babies with her team of midwives (i believe she is in CA) her rate of intervention is around 2 % !!! She will really boost your confidence in birthing centers/homebirths.

I totally agree that ''active birth'' requires an active midwife! The first time, I''m afraid I didn''t really see the value of this, I was cramping like anything and didn''t want to get active. My labour dragged on literally for days. By the end it was kind of uncool.

So, yeah, bootcamp midwives!! lol

Miranda
We all have different experiences of birth, don''t we... even from one birth to the next.
I''d be lying if I said birth wasn''t a slightly ... challenging... experience. Hmm, the first time, I did start to wonder if I *could* die...I was glad my mum was there...
The second pregnancy I did worry about the labour more, it''s like I was more aware of what could happen...but midwives are confident for a reason, it really, really helps the mum!

Regarding pain control, I found that not making a sound was the best way for me to ''focus'' and keep on top of the cramping sensation. Counting was good, following the breath...You go to the edge and then the sensation ebbs away...
You know, I was better at coping the first time, because my contractions were not as strong!

In my second labour I did take happy gas for a little while, and was starting to wonder if I could cope... but by then the labour was all but finished! It snuck up on me!
I started out thinking drug free (and at home)was the only way to go...but I''ve done a 180! Our state has now passed a law (or is considering a law?) making it illegal for women to have a caesarian unless it is medically indicated. I think that it is wrong.

Anyway Miranda, when I saw a documentary where this French woman was having an epidural pregnancy, I was shocked. She looked so relaxed! I felt a little angry about my own experience! But I also feel proud to have experienced au natural. I can''t have drugs anyway, I don''t think...maybe for this third one I could...but I''m scared my contractions would be too weak.

Sorry for this long post!

 

[Dreamer_D]

I share your desire! Luckily, I live in Ontario where midwives and registered and certified independent primary caregivers, so my midwives have hospital privaleges like doctors (with some restriction where they need to have a doctor consult and "take over" care, though even then they remain with the woman). When I give birth in the hospital I will only be attended by my two midwives, unless they think that extra help is required, so I am hoping this situation will be a "home birth" in the hospital!

Good luck with your search! Let us know what you find out/decide!

 

[LaraOnline]

That sounds interesting, having two midwives that are kind of 'registered' to you for the length of your labour, that would be fantastic.
A really great help, actually.

Are you getting to know them before the 'Big Day'? It would help if you could have a few in-depth conversations about how you envisage the day going...helps you get a feel for their character, as well...

As for doctors, what I really want to know is: what's your sewing like?

ETA: sorry, I couldn't resist.
so far so good. lol
although I would be interested to know what medical techniques and assistance your midwives can provide to you. Do they have oxygen? Can they undertake forceps delivery?

 

[Dreamer_D]

Date: 7/15/2008 12:10:27 PM
Author: LaraOnline
That sounds interesting, having two midwives that are kind of ''registered'' to you for the length of your labour, that would be fantastic.
A really great help, actually.

Are you getting to know them before the ''Big Day''? It would help if you could have a few in-depth conversations about how you envisage the day going...helps you get a feel for their character, as well...

As for doctors, what I really want to know is: what''s your sewing like?

ETA: sorry, I couldn''t resist.
so far so good. lol
although I would be interested to know what medical techniques and assistance your midwives can provide to you. Do they have oxygen? Can they undertake forceps delivery?

In Ontario (Canada), midwives complete a 4 year post-graduate university degree programme and do 2 years of residency at a midwifery practice. So they are considered a fully qualified replacement for a family doctor or OB as a primary caregiver for a pregnant woman, and they also perform postnatal care for 6 weeks. They are paid for by our government health insurance, and are considered a licensed and certified health care providor with their own college governing the credentialling process and the training and education.

They are licensed to perform many routine medical aspects of pre-care and labour and delivery care (like monitoring blood pressure etc etc, doing an episiotomy or sewing up a tear etc), they can order all the same tests as a doctor, and they are also trained in emergency procedures. When they do a home birth they bring a car full of mateirals including oxygen and meds to stop hemmoraging etc. I imagine they have forceps too. In the hospital I don''t know if they bring their own equipment or whether they use the hospital''s equipment. My guess is the latter, since midwife-attended hospital births occurr in the hospital''s regular birthing suits. In the event of a true emergency, nurses and doctors are outside the door and on call, so the response would be immediate. If need be, the midwives can arrange epidurals, pitocin or any other required medical interventions.

One of the core philosophies of midwives here is continuity of care. So I will not be seeing a doctor throughout my pregnancy (unless a referral is required for certain medical conditions), and all my visits will be with my primary midwife. I will see her at the usual times and the visits are 30 minutes each. I will also meet at least 2 other midwives, one of whom will be the secondary midwife or will take over as primary in the event that my primary cannot be there. The idea is for you to form a strong personal bond with your birthing team before the labour/delivery. My plan is to put my trust in my midwife and go with the flow, because as many mothers here have said, anything can happen! But I''m sure we will talk about my hopes and expectations, even if things turn out totally different than planned!

One fun thing, my midwife also delivered our close friends'' two children, so that is another fun "continuity of care" aspect to the whole process.

It sounds like midwifery is different in the US... will you be able to find the type of birthing care you want?

 

[Jas12]

Dreamer--you are lucky to get a midwife. I called the day after i found out i was preggo and was on the waiting list the whole pregnancy, with no luck. They are in incredibly high demand right now. However, i am in northern ontario and it is hard enough to retain OBs (never mind midwives) no one wants to live here so we are in desperate need of young professionals.
I don''t know how difficult it is to get a MW in the states?

 

[LaraOnline]

Date: 7/15/2008 10:16:44 PM
Author: dreamer_dachsie
My plan is to put my trust in my midwife and go with the flow, because as many mothers here have said, anything can happen! But I'm sure we will talk about my hopes and expectations, even if things turn out totally different than planned!

ETA: I think it is very important to talk about expectations, it makes a big difference to how the professionals will react to you, and to events during your birth.
I wrote a birth plan for my first birth, and I think that was very important reason why overall the birth went fairly much along with my plans (ie they didn't cut it short at 24 hours and offer a caesar!)
So yeah, BIRTH PLAN, v good idea. I didn't do it the second time, bit too relaxed - and then my doctor couldn't come and someone else came, and because I didn't have a birth plan, I felt that things moved a little out of my control. But, it was in the private system that time as well, and it didn't seem so up to date with 'active birth'.

It is very interesting that midwives are allowed to provide an assistance delivery (forceps / suction) AFAIK that is off limits to midwives over here, at least in a hospital, they called the doctor for me.

The doctor also was required to sign off on all drugs (although I think they get a pre arranged signature for certain pain relief drugs, for practicality reasons? or maybe they just call the all night intern?)

I think you need a doctor to provide an epidural (never had one so don't know for sure). Pretty sure that most meds would have to be prescribed by a doctor here. Also, drugs to stop bleeding (couple of shots of that), drugs to stop vomiting (didn't work) and induction by drip before that (tried to help it along at one stage) and eventually forceps, local anaesthetic and clean up, all of which was provided by a doctor.

So I can see why midwives would be interested in obtaining the rights to provide these drugs...
sorry for long post, and sorry for graphics (if anyone is reading it like that) I really needed info before my first birth, and all I got was vague stuff...

 

[Delster]

Lara your description of how things work in the US is pretty much the same as how it is here in Ireland.

Home birth is a hugely sensitive topic over here. Notes on home birth in Ireland:
- Domiciliary midwives aren't even supposed to advise their patients on pain relief like taking paracetamol for post-partum pain (hugely controversial on the homebirth chatrooms!)
- The nursing unions have made moves to rescind all professional negligence insurance for domiciliary midwives (meaning they have to organise insurance themselves, which is expensive and difficult) (this one made headline news in the national media)
- Every woman planning a homebirth has to be affiliated to a hospital for scans and in case of emergency, which is obviously sensible, but some of the hospitals have been known to send out letters at circa 38 weeks telling the women that their babies are in danger if they go ahead with a homebirth, and that they can't guarantee them a bed if an emergency arises, but if they agree now to forego the homebirth all will be fine (again, and obviously enough, hugely controversial among homebirth advocates)

Midwives here are highly educated (they have a 4 year nursing degree plus a 2 year postgraduate midwifery degree) and yet they cannot order tests or prescribe medication. They cannot perform instrumental deliveries. Epidurals can only be administered by an anaesthetist here.

We have a 'domino' scheme of midwife-centred care available in two hospitals in the whole country but there are a whole host of criteria like you must live within three miles of the hospital (they are both city centre hospitals) and you can't live in a multi-story building. With the domino scheme, a midwife stays with the mother at home for early labour, and then they transfer to a birthing suite in a hospital. The same midwife will be with the mother throughout, and the mother may even go home the same day. The eligibility criteria are very restrictive though, and the scheme is not widely available.

Oh, and in Ireland you are only allowed bring one person with you into the hospital. So if you want a doula, your partner / Mam / sister / best friend will have to stay outside. That's a particular sore point with advocates of active labour, as oftentimes a woman will be left to labour pretty much alone and it is said to be difficult to sustain active labour without a doula / midwife to help you along.

Anyway that's all a bit rambling but it's just the thoughts that struck me as I read this thread. I think the most important thing is that women should be able to decide the type of care they wish to receive, and to choose according to what feels best for them, whether that's hospital; birthing centre; at home, or whatever. The arrangement dreamer_dachsie describes as operating in Canada sounds wonderful because it provides women with a real choice, which is something that isn't available over here

PS - Did you know active management of labour and the episiotomy were both invented in Ireland? Wee bit of trivia for you there!

 

[LaraOnline]

Sorry Del, I''m actually in Australia. I haven''t had a homebirth, although originally I was planning to for my first birth. Now I''m planning my third. (hey, I''m probably not even pregnant yet, but we are ''trying''

)

A lot of political stuff behind the scenes re midwives vs doctors. I''m very sure birthing women get caught somewhat in the cross fire.

Midwives are happy to assume more responsibility... but then, they probably should organise their own insurance, like doctors, if that is the case? I can see that it''s a lot more complicated than just getting doctors out of the way...if you want to be a doctor, why not go to doctor school?

 

[Delster]

Sorry Lara, I thought you were in the States!

Also I hope I didn't give the impression that I think doctors should be gotten 'out of the way', as that wasn't my intention at all! I believe in having healthcare choices

Over here, professional negligence insurance is most often purchased from a company recommended by the professional body / union, who have negotiated preferable rates with the insurer. The premium may be paid directly by the professional (I know it is this way for lawyers), or it may be included in the annual dues paid to the union.

Here's an article on the insurance issue re midwives in Ireland.

ETA - yes, I agree much of it is probably political, and it's very sad that women's choices end up being limited as a result

 

[LaraOnline]

Date: 7/16/2008 6:52:48 AM
Author: Delster
With the domino scheme, a midwife stays with the mother at home for early labour, and then they transfer to a birthing suite in a hospital. The same midwife will be with the mother throughout, and the mother may even go home the same day. The eligibility criteria are very restrictive though, and the scheme is not widely available.

Oh, and in Ireland you are only allowed bring one person with you into the hospital. So if you want a doula, your partner / Mam / sister / best friend will have to stay outside. That''s a particular sore point with advocates of active labour, as oftentimes a woman will be left to labour pretty much alone and it is said to be difficult to sustain active labour without a doula / midwife to help you along.

PS - Did you know active management of labour and the episiotomy were both invented in Ireland? Wee bit of trivia for you there!

These were such interesting comments! The domino system sounds fantastic - just perfect really - perhaps in high population centres, like cities, it is a little unwieldy? That is a dream arrangement, though!

It''s alarming that you can only have one SO with you! Luckily for me personally, my husband is a *gift* and will labour along with me night and day until it is all over, he is my strength, and as I said in an earlier post, I would simply refuse to give birth if my man wasn''t there to help me!

I agree wholeheartedly that active labour requires a FIRM midwife. That''s probably the most important thing, it''s hard to get marching when you are cramped from head to toe!!

Active labour and episiotomy - completely opposite ends of the spectrum, no?

 

[Delster]

Well you can have your labour partners kind of tag-team if you want

But just one other person in the room with you at any given time.

The domino system is only available in Dublin, and even then, only within 3 miles of the city centre. So if you don''t live in the city centre, or you live anywhere else in Ireland, it''s unavailable. The hospital all the way, or a domiciliary midwife (if you can secure one), are your only options. They did have a domino pilot scheme in Galway but so far as I know it''s been discontinued, which is a shame.

Oh and active management of labour isn''t the same thing as active labour, although there are many excellent care providers who manage to blend both within the hospital environment.

 

[LaraOnline]

''active management of labour''... does that mean drug free, no machines at all, walking, squatting, stretching, all fours, birth balls etc
cause that''s what I mean by ''active labour''

 

[Delster]

Active management is pretty much the opposite of what you just described Lara! It''s primary principle is that that labour should never last longer than 12 hours (believed to be safer, and less tiring on the mother) and that labour should be monitored throughout. As I said though, the 12 hour guideline can be more or less flexible, depending on the philosophy of your care team.

 

[LitigatorChick]

I had a my son in a hospital with a doctor/nurses, but I had a doula present. She made all the difference for me. In the end, I spent time in the shower, on a birth ball, in a variety of "active" positions, etc. I had absolutely no interventions, not even an IV.

If I knew what I know now, I would have had a midwife and just done it at home.

 

[DIAMOND*QUEST]

Hey ladies, I just wanted to share some of my experiences with you as I have been in the healthcare business for years in labor and delivery and high risk ob. Retired nurse as of this february. I personally feel the best place to have a baby is in a reputable hospital with a level 3 nursery. I have known some wonderful Nurse Midwives over the years who have given their patients the best birth experience ever. They were at the patient''s bedside continuously providing support and guidance. I have witnessed many joyful and moving deliveries over the years. I have worked in 4 different hospitals in two states and I have never known a single ob doc, nurse, or nurse midwife have their baby at home with a lay midwife. Both my children were born in hospitals and I never considered having a home birth because there are risks no matter how "normal" the pregnancy. On the flip side of things, I have had patients over the years who actually presented with a 4-5 page birthplan that would just make my head spin. I would often wonder why these people even came to the hospital and more over how their doctors/midwives didn''t review these prior to their arrival to the l/d unit. It made me crazy and more often than none, these women had to have an intervention to assist the labor and delivery process. And these types of interventions were performed after hours of labor and not just on a whim of the attending physician/midwife. Most of the time these types of patients just totally wore themselves out during the process of labor. At times, it was hard to watch. These women and their partners would show up with the most negative attitude and were extremely defensive towards hospital care. They couldn''t have cared less that we followed standards of care of AWHONN. Things got better as we incoporated the hospital expectations in our hospital childbirth classes. I also think well educated, practiced Doulas are wonderful people. I think you need to choose one wisely. I don''t have time to go into my doula experiences but I will say I''ve had the best and worst. If you want the details just ask. Wow, I really didn''t mean to write all this, I just really wanted to give my opinion to those who are about to go through the labor process with my number one being DELIVER IN A HOSPITAL. I think you can have a home like experience with the safety net just in case. And, I have a alot of information based on my experiences on how to labor and what NOT to do that you have probably read to be helpful. So, if your interested, I will be happy to share.

 

[LaraOnline]

Hey Diamond Quest,
thanks for responding to the thread!

So I guess you''re saying the biggest thing is to get a doula (off duty midwife) in there to be with you throughout the labour?
I would love that this time...but I think I''ll have to ''train'' my man, and go for broke this time.

 

[Gemma12]

Hi Lara,

Since you are in Oz I can answer a couple of your questions. Epidurals are provided by doctors only (anaesthetists in private and public or anaesthetists in training in public). They are not available in birth centres. Most BCs also do not do CTG monitoring, any augmentation of labour or assisted delivery. For those things you need to be in a hospital (which the BC may be attached to).

You can get doulas who have not trained in midwifery but have a lot of experience in managing labour. Many of them are excellent. It''s best to get a recommendation from a friend if you have a specific need in mind (as opposed to wanting a support partner) ie avoiding episiotomy or hypnobirthing.

I would offer a word of caution on BCs. I''ve worked in three hospitals that have had BCs attached. I would recommed that you ask three questions before choosing to labour there:

1. How do you decide when transfer to hospital is necessary and how long does it take?

2. What is your incidence of third and fourth degree tears?

3. How does your neonatal mortality rate compare with the nearest hospital''s?

If they are defensive or evasive do not deliver there.

My opinion to follow.....

I personally would not deliver in any of the birthing centres I have had contact with. That is not to say that there are not good midwives out there but there are some that in my opinion sail far too close to the wind with both mum and bubs in the interests of a ''natural'' delivery. I have considered a doula however and that may be a solution for you if you want someone who you know encouraging you through labour.

Hope that''s of interest to you-as I say, the above is only my opinion. I do agree with DQ that ALL the drs I know and most of the midwives would not deliver in a birthing centre, let alone at home. However, again, there are people out there who are happy to-particularly overseas where the set up is very different. I hope the above gives you the option of finding out as much information as possible before you make your decision.

 

[LaraOnline]

Date: 7/20/2008 4:54:47 AM
Author: Gemma12

2. What is your incidence of third and fourth degree tears?

Can elaborate more on this point? I feel I''ve already had enough *cough* sewing to last me a life time!!

How can tearing be avoided?

 

[DIAMOND*QUEST]

Date: 7/20/2008 7:05:46 AM
Author: LaraOnline

Date: 7/20/2008 4:54:47 AM
Author: Gemma12

2. What is your incidence of third and fourth degree tears?

Can elaborate more on this point? I feel I''ve already had enough *cough* sewing to last me a life time!!

How can tearing be avoided?

Lara,

I don''t think using a Doula is the best thing. It depends on your comfort level, the experience of the doula, and how you feel about delivering with one or without. In my neck of the woods, Doula''s can be very defensive and unwilling to work with the nurse, physician, or MW as I think their purpose is to uphold the birth plan to the very last detail. A good example that I have is this:
I had a patient having her first baby and she was about 6cm dilated when she came into the hospital. The physician and I met her, her partner, and the doula. The patient was examined by the physician and the last words out of the physician''s mouth was, "Let her do anything she wants". Well, I was all for it of course, but I do have policies to follow as far as monitoring goes and as a long time labor and delivery nurse, I was going to advise and encourage the patient as she went through this process. The doula on the other hand turned into a fire breathing dragon and as far as she was concerned she was in charge of the birthplan, the patient, and how everything was going to be handled. She was someone I had never met before and things were going so rapidly that we really didn''t have time to "bond". I was also busy getting the lovely paperwork in order and prepping the room for delivery. The patient and doula were doing their thing and they were doing it well. The patient began to feel the urge to push and so I checked the patient and she was fully dilated and the baby was very low. I explained that I wanted to see her push a couple of times because I knew it wasn''t going to take much pushing. The doula freaked out and said no, she is going to use the squat bar for delivery. I said no, and gave my explanation again. She wasn''t going to have it. The squat bar went up and the patient listened to her doula and I was really just a "nobody" in the room. All this while the video camera was rolling. The doula kept saying "the doctor said she can do what she wants!". I knew this physician very well and as a matter of fact, the doctor specifically asked me to take care of this patient. This doctor is very traditional, she dislikes the squat bar and only likes to deliver "old school" style with use of stirrups, in bed ect. So, long story short, the patient pushes once using the bar and the baby''s head appears and the doula looks at me in shock! She screams OMG! I''m pushing emergency buttons while the patient is frozen in a squatting position and well after a very dramatic delivery, the baby was fine, but mom had a 4th degree tear because she did what the doula told her to do and ignored my urgings and directions. So, this is really an example of a not so good doula and it also brings me to the point of answering your question on how to avoid 3rd and 4th degree tears. DO NOT SQUAT! The physics and mechanics of this position puts so much pressure and force on the back side of your bottom that it increases tearing. And, you will see in many books that this is a great way to deliver and push. WRONG!!!! I am a firm believer the best way to deliver is in bed, almost flat,with a wedge under one of your hips and your chin on your chest as you are pushing. Your knees are bent and as far back as you can get them comfortably, no one should physically force your legs back beyond what is comfortable. Because of hormones, you are much more pliable at the end of pregnancy than you ever thought you could be. This position opens the pelvis and allows the pressure and force of the contraction while pushing to be all around the outlet instead of the force going out your backside if you get my drift. Also using an agent to decrease friction at delivery may help you from tearing. And, if you have the ability to control your pushing effort as you are being delivered and directed by the birth attendant, this may also prevent tearing. And, if you are having a big baby, anything you do may not prevent a larger tear. I personally in that case would prefer an episiotomy over tearing. Now, the only exception to using a squat bar in my opinion is when the mom is going to be pushing for a long time. Most women don''t use it for very long as it can be exhausting.

Hope this is helpful to you!

 

[Blenheim]

First, the fact that there are some doulas who are not good doesn't mean that you should avoid all doulas. Just do your research, same as you would while chosing a midwife or OB, etc.

Date: 7/21/2008 11:31:07 AM
Author: DIAMOND*QUEST

Date: 7/20/2008 7:05:46 AM
Author: LaraOnline

Date: 7/20/2008 4:54:47 AM
Author: Gemma12

2. What is your incidence of third and fourth degree tears?

Can elaborate more on this point? I feel I've already had enough *cough* sewing to last me a life time!!

How can tearing be avoided?

Per Henci Goer's Thinking Woman's Guide to a Better Birth pages 157-159, research shows that the following help to protect your perineum:

Choose a caregiver with a low episiotomy rate and refuse routine episiotomy.
Do pelvic floor contactions.
Engage in regular exercise.
Do prenatal perineal massage.
Avoid epidurals.
If the baby's posterior, try to rotate it to anterior.
Push with natural urges, breathing as your body directs you.
Think in terms of breathing rather than just pushing the baby out.
Don't allow injection of local anesthetic into the perineum on a "just in case" basis.
Refuse a forceps or vacuum extraction delivery recommended only because some arbitrary time limit has passed.
If you must have an instrumental delivery, choose vacuum extraction over forceps and don't have an episiotomy.
"Give birth upright, or at least avoid giving birth in a position that stretches the legs wide apart. If your perineum is already under tension, it has nowhere to go. Upright positions reduce the incidence of tears and the need for episiotomy and instrumental delivery."

There's information in the book and in her sources that supports each of these recommendations.

Also, in the US, homebirth midwives carry oxygen, things to stop the bleeding, things they would need to rescucitate, etc. It's interesting what the difference is between countries.

Edited to add: Some hb midwives can be really laid back as well. I think you really just need to interview them as to what their approach is and find someone who meshes with you. Also, some midwives are happy to be more hands on or hands off, depending entirely on what the laboring mom wants. Be sure that you make your expectations clear ahead of time that you want firm direction during labor.

 

[LaraOnline]

Okay, this is interesting, both times I have had forceps (due to extended labour time, and then second one due to concern about the baby)

The second doctor was a stand-in, not the doctor of my choice, he gave me an episiotomy, and it was dreadfully slow and painful to heal. In fact, it was over a year before I sensed a sense of 'normality' returning to my nether regions. My first delivery, with a natural tear, healed within three months to a sense of normality. So I hope I have the courage to refuse an epiosiotomy this time.
(That or get the doctor I choose!)

I have never had the choice of vacuum vs forceps. Perhaps it comes down to doctor preferences? I've heard some pretty crazy stories about vacuum extraction.

Every time in both my previous deliveries, I have got to the point where everybody can see the head, it's about 7cm away the outside world... and then it seems my muscles don't work anymore! I push and push and the baby doesn't move any further.

The first time, I had a more 'active' type birthing arrangement, we tried various positions before the doctor eventually got me on the bed and got the forceps out.

The second labour was in the private system and I was directed to the labour bed (with stirrups) for the final phase of labour. Both times, the head didn't move that last few centimetres.

Is it just the way my body is built? I would really like to fully deliver my babies from here on, it's hard recovering from tearing, and the pain of the epiosotomy really upset me, really shocked me, I felt somehow 'violated', which is something I wasn't really expecting. I got over my natural tear pretty easily.

So What am I doing wrong in the final phase?


ETA: sorry about this thread suddenly going 'a bit graphic'. Of course, I could ask my local doctor, but he is always very busy, and the information is not specific enough to be helpful!
Also, what sort of lotion should I use with pireneal massage?

 

[Blenheim]

I think that any birth threads have a tendency to get graphic, so it doesn''t bother me at all.

Vacuum vs. forceps could be the kind of thing that you could discuss with a doctor ahead of time and put in a birth plan. If you didn''t express a preference, the doctor may have just chosen whatever they prefer. Studies show less incidences of deep tears with vacuum extraction, which is why she recommends that.

I''m really not sure why the head didn''t move down the last bit.

I know that labor often doesn''t progress in a linear manner, and instead naturally starts and stops a bit. Is it possible that you hit one of those stopping points and it didn''t have enough time to start back up again before the forceps delivery? The lithotomy position isn''t good if labor is stalling, from what I understand. But it sounds like the first time, you tried a bunch of positions.

Perineal massage - "Once a day for five to ten minutes, they or their partner should massage vegetable oil such as olive oil into the perineum and lower vaginal wall. Then they are their partner should massage using a U or ''sling'' movement, stretching just enough to produce a slight burning sensation. (The massager should have impeccably clean hands and short nails.)" (Henci Goer''s Thinking Woman''s Guide to a Better Birth, p. 157)

 

[Gemma12]

Lara, sorry not to get back to you sooner. I don''t have long but will just address a couple of things.

1. Epidurals do not prevent tearing but they DO NOT make it worse. In fact, in my experience a mother who has had some rest during first stage because of good analgesia has much more control over 2nd stage (delivery) which is when tearing occurs-as long as the epidural is well managed for second stage, and if the mother does not mind perineal sensation. Some women prefer to have complete analgesia, which may result in abdominal muscle weakness, which of course affects pushing.

2. A very important factor appears to be allowing the perineum to stretch s-l-o-w-l-y on its own. Whether massage (pre or during) labour or using EPI-NO or allowing the head to sit on the perineum for a few contractions, this reduces the chances of tearing. It is very hard to study this reliably but every obstetrician I have spoken to says this is a huge factor.

3. I agree with DQ-positioning (particularly if you have had a previous tear) is key. Squatting has been shown to increase the risk of higher degree tears.

4. Most OBs in Australia do not perform routine episiotomy. Judicial epis may prevent a higher degree tear (although tearing may still occur). Many epis are performed by midwives also in Oz.

5. Posterior positioning or a high hand may increase the degree of a tear. Again, hard to study.

6. Most OBs in Australia do not do forceps or vacuum on time limits alone but this depends on a lot of other factors-such as how the baby has tolerated the labour to that point. Lara, I would recommend based on your story that you have an indepth chat with your OB to discuss that in more detail.

Personally (ie my opinion) is that I will be happy to have whatever is safest in that specialist''s hands. Vacuum vs forceps depends on a number of factors including the postion of the baby in the birth canal and the direction the baby is facing.

Doulas in Australia are not regulated so you have to be cautious of that. As I say, get some recommendations and ask pertinent questions.

You can massage with olive oil (or wheatgerm oil if you wanna get fancy!), that is fine. There is a product called EPI-No which is available in pharmacies in Oz.

I hope this helps! There is a lot of information out there and it can be confusing, especially when things are backed up by bad science or outdated science. OBs have a tendency to change practice if a good study comes out so things like routine episiotomy and midline episiotomy are not big issues anymore in Oz. Also, much of this is difficult to study reliably. As I say, I would recommend a chat with your OB. Not sure where you are in Oz but if you are in a major centre, there are usually a few OBs around who are proponents of active labour and you can usually find someone who has similar philosophies to yourself.

Good luck!

ETA: I meant to ask-are you expecting #3??

 

[DIAMOND*QUEST]

Date: 7/21/2008 6:35:06 PM
Author: Blenheim
First, the fact that there are some doulas who are not good doesn''t mean that you should avoid all doulas. Just do your research, same as you would while chosing a midwife or OB, etc.

Date: 7/21/2008 11:31:07 AM
Author: DIAMOND*QUEST

Date: 7/20/2008 7:05:46 AM
Author: LaraOnline

Date: 7/20/2008 4:54:47 AM
Author: Gemma12

2. What is your incidence of third and fourth degree tears?

Can elaborate more on this point? I feel I''ve already had enough *cough* sewing to last me a life time!!

How can tearing be avoided?

Per Henci Goer''s Thinking Woman''s Guide to a Better Birth pages 157-159, research shows that the following help to protect your perineum:

Choose a caregiver with a low episiotomy rate and refuse routine episiotomy.
Do pelvic floor contactions.
Engage in regular exercise.
Do prenatal perineal massage.
Avoid epidurals.
If the baby''s posterior, try to rotate it to anterior.
Push with natural urges, breathing as your body directs you.
Think in terms of breathing rather than just pushing the baby out.
Don''t allow injection of local anesthetic into the perineum on a ''just in case'' basis.
Refuse a forceps or vacuum extraction delivery recommended only because some arbitrary time limit has passed.
If you must have an instrumental delivery, choose vacuum extraction over forceps and don''t have an episiotomy.
''Give birth upright, or at least avoid giving birth in a position that stretches the legs wide apart. If your perineum is already under tension, it has nowhere to go. Upright positions reduce the incidence of tears and the need for episiotomy and instrumental delivery.''

There''s information in the book and in her sources that supports each of these recommendations.

Also, in the US, homebirth midwives carry oxygen, things to stop the bleeding, things they would need to rescucitate, etc. It''s interesting what the difference is between countries.

Edited to add: Some hb midwives can be really laid back as well. I think you really just need to interview them as to what their approach is and find someone who meshes with you. Also, some midwives are happy to be more hands on or hands off, depending entirely on what the laboring mom wants. Be sure that you make your expectations clear ahead of time that you want firm direction during labor.

I definitely agree with you Bleinheim about researching a doula, but I think that Lara was thinking she was not going to use one for her next birth. And that''s ok too, she is a pro!. I would like to address some of your blurbs up there. There are alot of claims in books sighting research who do have "sources" but its alot of crapola. And, Bleinheim please don''t take this personally. I''ve read alot of these books myself.

Kegel exercises are great for after delivery not necessarily for delivery. Really more for urinary incontinence issues. If you want to practice for delivery, practice having a large BM because that''s the type of effort it takes. I guess I''m being a smart ass. Don''t practice this especially if you are at risk for pre-term delivery or pre-term labor.

Regular exercise is great especially if you were active prior to pregnancy.

Do not perform perineal ironing or stretching. It does nothing for you. The baby does the work for you on the way out and stretching the perineum can be done at the time of delivery. This is of no benefit and indeed it may induce early contractions.

Avoid epidurals? Ok, epidurals are wonderful things for those who desire them. They can be administered safely and can actually enhance a labor. When patient''s have them in truly active labor and the baby is engaged in the pelvis, it oftens helps the woman relax and fully dilate. On a personal note, I had no epidural with my first child and suffered 3 hours of pushing with forceps and a 4th degree. I wish I would have been encouraged to have one prior to the hell I went through.

"If the baby is posterior, try and rotate it." Ok, who is going to rotate it? The mom? There are strategies in getting a baby to turn from an OP position to an OA position. The most effective is for mom to get into a knee chest position in hopes to get the pressure off the baby''s head and encourage it to turn. I highly recommend this. If the baby is not acynclitic or wedged this position works well. And, by the way, the knee chest position is the optimum position for maternal cardiac output. Standing is least optimal.

Yep, pushing without contractions is a total waste of time unless something emergent is happening such as fetal bradycardia and you could be instructed to push to assist delivery.

Breathing is crucial with pushing.

I''ve never seen anyone get local just in case.

The only reason forceps are used is when maternal exhaustion is apparent and the baby is deliverable by this means or there is an ominous situation and the baby is deliverable with this instrumentation.

Most physicians are using vacuum extraction over forceps and I believe its because of the training. Older physicians were extensively trained in use of forceps. I personally would rather have a well trained doc perform forceps on my baby than a new doc with a vacuum. And, please I''ll take the episiotomy.

And the number one.... drumroll please.......... Deliver a baby without opening your legs widely. OMG that''s absolutely ridiculous. And furthermore, I don''t encourage sitting up-straight indian style in a chair or bed while laboring as you will swell your cervix and delay delivery. I encourage a side lying position where you are all the way on your side with a pillow between your legs and NOTHING propped up behind your back. Your shoulders and abdomen should be totally relaxed in this side lying position. Place a hand towel rolled up between your abdomen and the bed to raise the fetus up. This allows for more effective contractions and will assist you to become fully dilated when in active labor. It works hands down better than walking, better than nipple stim, or any other position. And, walking is fine in short stints, but your uterus is running a marathon, the key is relaxing all your other muscles. Conserve your energy for pushing and after delivery.

I''ll have to research the other stuff about the lay-midwives use of oxygen, but I rather doubt it. Technically 02 is a drug.

 

[Blenheim]

Diamond Quest, if you give me citations for what you said, I''d be happy to read them and form my own opinion.

 

[LaraOnline]

Thanks for responding ladies!! *heart* I really appreciate it!

I think I'm just pregnant, I haven't bothered to get a test or go to a doctor yet...

It's interesting lying on the side... if I have my first doctor (doctor of choice), he is a proponent of natural birth, he allowed me to go for ages the first time, and did not give me an episiotomy with the forceps. Fine by me.

I wanted him the second time too, but he was on holidays, go figure. The second guy was older, I think the episiotomy was 'judicial'.

Neither of my previous labours have involved drugs, because I'm worried about this apparent inability to push that last 5-7cm, I think I'll go drug free once more.

I think I'll try lying on my side of the last stage?

Do you think the reason I tear is simply because I can't get the baby's head to that last few cms? If I had a full unassisted birth, perhaps it wouldn't be a problem for me.

I mean obviously the forceps create pressure, but I'd like to get the baby out by myself this time.
The problem is the failure to get this last few cms.

I feel reasonably physically fit and flexible, etc. I recovered physically quite quickly from labour, I have reasonable tone, no weight gain or anything. The second labour moved quite well until that last few cms as well!