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You can find the current article at its original source at http://www.theguardian.com/society/2016/jan/21/how-to-plan-your-perfect-birth-all-the-options-you-need-to-know
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| Giving birth: everything you need to know before labour day | Giving birth: everything you need to know before labour day |
| (7 months later) | |
| A home birth or a hospital? Birthing pool or bed? Drugs or no drugs? | A home birth or a hospital? Birthing pool or bed? Drugs or no drugs? |
| Membership Event: Guardian Live | How do we pay for NHS we want? | Membership Event: Guardian Live | How do we pay for NHS we want? |
| Having a baby is a challenge enough without all the options in this great age of choice. So what’s best for you? | Having a baby is a challenge enough without all the options in this great age of choice. So what’s best for you? |
| Let’s imagine you are a fit and healthy first-time mother. If you have risk factors, you will still have choices. “We want all women to have a better birth experience,” says Jacque Gerrard, director of the Royal College of Midwives, “not just the women who are low-risk.” | Let’s imagine you are a fit and healthy first-time mother. If you have risk factors, you will still have choices. “We want all women to have a better birth experience,” says Jacque Gerrard, director of the Royal College of Midwives, “not just the women who are low-risk.” |
| But in a way, you have to imagine that you’re low-risk before you can decide what sort of birth you want to push for (ahem). If you accept your risk factor – age, weight, underlying health condition – as your defining feature, you’ll be inclined to defer to authority rather than explore the options. | But in a way, you have to imagine that you’re low-risk before you can decide what sort of birth you want to push for (ahem). If you accept your risk factor – age, weight, underlying health condition – as your defining feature, you’ll be inclined to defer to authority rather than explore the options. |
| Where? | Where? |
| If your only consideration were clinical, it is safer for first-time mothers not to be on a labour ward (aka obstetric unit), due to cross-infection and thromboses (it makes no difference to the baby). Your best option is a midwife-led unit alongside an obstetric unit – known as an AMU birth, “alongside medical unit” – or an FMU birth, “freestanding midwifery unit”. But you can’t get an epidural anywhere other than a labour ward. | If your only consideration were clinical, it is safer for first-time mothers not to be on a labour ward (aka obstetric unit), due to cross-infection and thromboses (it makes no difference to the baby). Your best option is a midwife-led unit alongside an obstetric unit – known as an AMU birth, “alongside medical unit” – or an FMU birth, “freestanding midwifery unit”. But you can’t get an epidural anywhere other than a labour ward. |
| Giving birth at home for a first-timer carries higher risks of stillbirth or neonatal death for the baby, according to figures from the National Perinatal Epidemiology Unit.There is also a high transfer rate into labour wards. According to the NPEU, 45% of planned home births end up in an obstetric unit. | Giving birth at home for a first-timer carries higher risks of stillbirth or neonatal death for the baby, according to figures from the National Perinatal Epidemiology Unit.There is also a high transfer rate into labour wards. According to the NPEU, 45% of planned home births end up in an obstetric unit. |
| You can see certain things immediately: first, if you get too hung up on avoiding a labour ward for clinical reasons, you are likely to be disappointed or think you’ve failed should you end up there. Second, home is actually – amazingly – as safe as anywhere and safer than a labour ward for second and subsequent babies, but for your first time, it’s almost 50:50 that you’ll end up in an ambulance. However, as associate professor Jennifer Hollowell, who conducted the NPEU research, says, it’s subjective: “I don’t think I would want to transfer in labour, but many women feel glad that they did part of the labour at home.” | You can see certain things immediately: first, if you get too hung up on avoiding a labour ward for clinical reasons, you are likely to be disappointed or think you’ve failed should you end up there. Second, home is actually – amazingly – as safe as anywhere and safer than a labour ward for second and subsequent babies, but for your first time, it’s almost 50:50 that you’ll end up in an ambulance. However, as associate professor Jennifer Hollowell, who conducted the NPEU research, says, it’s subjective: “I don’t think I would want to transfer in labour, but many women feel glad that they did part of the labour at home.” |
| Pain relief | Pain relief |
| The next decision is how far to insulate yourself from the pain that is an inevitable part of childbirth. Options include gas and air (a no-brainer) a water-birth (the pain relief is surprisingly effective - with the caveat that no pain relief really works except being unconscious. But it is warm). Pethidine is available in all birth settings, but women are generally advised that its pain relief is limited, and it will make both mother and baby drowsy. | The next decision is how far to insulate yourself from the pain that is an inevitable part of childbirth. Options include gas and air (a no-brainer) a water-birth (the pain relief is surprisingly effective - with the caveat that no pain relief really works except being unconscious. But it is warm). Pethidine is available in all birth settings, but women are generally advised that its pain relief is limited, and it will make both mother and baby drowsy. |
| The Which? birth tool has it about right: it asks you three questions, do you want a water birth? Do you want an epidural? What’s your postcode? And it will give you an answer based on that, plus your risk factors. (Warning: if you try this and are over 40, you will have the rude awakening that women over 40 are inherently high-risk.) | The Which? birth tool has it about right: it asks you three questions, do you want a water birth? Do you want an epidural? What’s your postcode? And it will give you an answer based on that, plus your risk factors. (Warning: if you try this and are over 40, you will have the rude awakening that women over 40 are inherently high-risk.) |
| There are three kinds of values-based decisions: the anti-medicalised or natural or independent mother (sometimes known informally as the Warrior Tigress) – she will be on a spectrum from simply wanting to do it without pain relief to wanting to give birth at home, alone. | There are three kinds of values-based decisions: the anti-medicalised or natural or independent mother (sometimes known informally as the Warrior Tigress) – she will be on a spectrum from simply wanting to do it without pain relief to wanting to give birth at home, alone. |
| Second is the “I want as much pain relief as possible, I’m a human being” value, which essentially means going to a labour ward for an epidural (an injection to the dura mater of the spinal cord, producing loss of sensation below the waist). Professionals will try to discourage this, since their ideal is a vaginal delivery with no interventions. All interventions are more likely once you’re already on a labour ward. Many obstetricians and mothers would argue that pain relief is a personal choice, and even if it increases the risks of other kinds of intervention, that doesn’t of itself make it a bad decision (if the alternative is agony). Susan Bewley, who chaired the group that developed Nice’s guidelines on childbirth, says: “Ah, but the pain that you have will vary according to where you are, how comfortable you are, the kind of labour you’re having. The surroundings and context will affect the subjective experience of pain.” | Second is the “I want as much pain relief as possible, I’m a human being” value, which essentially means going to a labour ward for an epidural (an injection to the dura mater of the spinal cord, producing loss of sensation below the waist). Professionals will try to discourage this, since their ideal is a vaginal delivery with no interventions. All interventions are more likely once you’re already on a labour ward. Many obstetricians and mothers would argue that pain relief is a personal choice, and even if it increases the risks of other kinds of intervention, that doesn’t of itself make it a bad decision (if the alternative is agony). Susan Bewley, who chaired the group that developed Nice’s guidelines on childbirth, says: “Ah, but the pain that you have will vary according to where you are, how comfortable you are, the kind of labour you’re having. The surroundings and context will affect the subjective experience of pain.” |
| Caesarean section | Caesarean section |
| Finally, there is the elective caesarean which, as founder of the Positive Birth Movement, Milli Hill, says, “is another right that a woman has, and it absolutely should be upheld.” Clinically, almost everybody tries to talk a woman out of a C-section because of its heightened risk and longer recovery time: it is also widely felt that only anxious women would choose it, and they should have their anxieties assuaged rather than their demands met. But Hill provides some context. “Often if people have had lots of miscarriages or lost a baby, the levels of anxiety are much higher, they want a certain thing for a certain reason,” she says. | Finally, there is the elective caesarean which, as founder of the Positive Birth Movement, Milli Hill, says, “is another right that a woman has, and it absolutely should be upheld.” Clinically, almost everybody tries to talk a woman out of a C-section because of its heightened risk and longer recovery time: it is also widely felt that only anxious women would choose it, and they should have their anxieties assuaged rather than their demands met. But Hill provides some context. “Often if people have had lots of miscarriages or lost a baby, the levels of anxiety are much higher, they want a certain thing for a certain reason,” she says. |
| “A woman who has lost a breech baby might not want to have an ECV [external cephalic version], which is where they try to turn the baby from the outside. If you look at the research, it would be safer for her to try and have a vaginal birth but if you think about her, you can see why she wants a C-section.” | “A woman who has lost a breech baby might not want to have an ECV [external cephalic version], which is where they try to turn the baby from the outside. If you look at the research, it would be safer for her to try and have a vaginal birth but if you think about her, you can see why she wants a C-section.” |
| Those are the only interventions that anyone would choose. The others are all responses to a given problem: | Those are the only interventions that anyone would choose. The others are all responses to a given problem: |
| If you are overdue | If you are overdue |
| You will be offered (very) regular scans from 42 weeks. Nobody can force you to be induced but you may well want to be. From 10 days overdue, you’ll be offered some variation of the prostaglandin hormone: a “prosto teabag” is fashionable. | You will be offered (very) regular scans from 42 weeks. Nobody can force you to be induced but you may well want to be. From 10 days overdue, you’ll be offered some variation of the prostaglandin hormone: a “prosto teabag” is fashionable. |
| If your baby is breech or transverse | If your baby is breech or transverse |
| “This is around 3-5% of pregnancies,” says Hill. “The amount of choices that you face in that situation is a minefield, and the thing that’s really hard to do is make an evidence-based choice. Even the professionals find that hard.” The two main options are an ECV and a planned caesarean. | “This is around 3-5% of pregnancies,” says Hill. “The amount of choices that you face in that situation is a minefield, and the thing that’s really hard to do is make an evidence-based choice. Even the professionals find that hard.” The two main options are an ECV and a planned caesarean. |
| If you didn’t want a caesarean but it’s the only option | If you didn’t want a caesarean but it’s the only option |
| You may be able to have a “woman-centred” C-section, which is partly defined by having a more reverent atmosphere in the operating theatre so that everybody is more respectful of the fact that a baby is being born and this is a significant moment in several people’s lives (midwives are certainly aware of this, but it won’t be an option in every hospital). “Sometimes people like to have the curtain lowered so they can see the baby coming out. Some people like to have a particular piece of music, or immediate skin to skin contact with the baby, all of those sorts of things that make the woman feel more part of the experience and less objectified,” Hill explains. | You may be able to have a “woman-centred” C-section, which is partly defined by having a more reverent atmosphere in the operating theatre so that everybody is more respectful of the fact that a baby is being born and this is a significant moment in several people’s lives (midwives are certainly aware of this, but it won’t be an option in every hospital). “Sometimes people like to have the curtain lowered so they can see the baby coming out. Some people like to have a particular piece of music, or immediate skin to skin contact with the baby, all of those sorts of things that make the woman feel more part of the experience and less objectified,” Hill explains. |
| Forceps and ventouse delivery | Forceps and ventouse delivery |
| These are extraction methods when the second stage of labour is taking too long (more than two hours) and there are heightened risks for either mother or baby. Use of forceps carries a higher risk of quite a severe tear (a not-insignificant 22%, compared with 15% for ventouse and 3% for spontaneous vaginal delivery). In a small-scale qualitative study, 28% of forceps mothers rated the birth “unbearably” painful as opposed to 17% of ventouse mothers. Ventouse use is associated by one large-scale trial in Pakistan with increased risk to the baby of query 6cephalhaematoma (a lump caused by a pocket of blood underneath the scalp) and retinal haemorrhage. | These are extraction methods when the second stage of labour is taking too long (more than two hours) and there are heightened risks for either mother or baby. Use of forceps carries a higher risk of quite a severe tear (a not-insignificant 22%, compared with 15% for ventouse and 3% for spontaneous vaginal delivery). In a small-scale qualitative study, 28% of forceps mothers rated the birth “unbearably” painful as opposed to 17% of ventouse mothers. Ventouse use is associated by one large-scale trial in Pakistan with increased risk to the baby of query 6cephalhaematoma (a lump caused by a pocket of blood underneath the scalp) and retinal haemorrhage. |
| Episiotomy | Episiotomy |
| This an incision made to the vagina during the final stage of labour, if there is a sign of foetal compromise or the medical team are in the middle of an instrumental delivery. | This an incision made to the vagina during the final stage of labour, if there is a sign of foetal compromise or the medical team are in the middle of an instrumental delivery. |
| Vexingly, nobody will be quite straightforward about what’s a real choice and what’s a pretend one | Vexingly, nobody will be quite straightforward about what’s a real choice and what’s a pretend one |
| Everybody involved in pregnancy who is not pregnant talks incessantly about giving mothers the birth that they want – or rather, enabling mothers to make the best choices. To the actually pregnant person, this often sounds like complicated language designed to obscure the fact that one’s choices are limited, by the professionals and by fate and nature; and yet, vexingly, nobody will be quite straightforward about what’s a real choice and what’s a pretend one. | Everybody involved in pregnancy who is not pregnant talks incessantly about giving mothers the birth that they want – or rather, enabling mothers to make the best choices. To the actually pregnant person, this often sounds like complicated language designed to obscure the fact that one’s choices are limited, by the professionals and by fate and nature; and yet, vexingly, nobody will be quite straightforward about what’s a real choice and what’s a pretend one. |
| My advice: make your plan A based on the kind of pain relief you want; make a plan B for the failure of plan A, which is probably that either your first or second stage didn’t progress; make a plan C for when you end up somewhere other than you wanted to be. This can be as simple as “this isn’t the end of the world; at least it’s not forceps”; make a plan D for forceps, which should be “epidural first”. | My advice: make your plan A based on the kind of pain relief you want; make a plan B for the failure of plan A, which is probably that either your first or second stage didn’t progress; make a plan C for when you end up somewhere other than you wanted to be. This can be as simple as “this isn’t the end of the world; at least it’s not forceps”; make a plan D for forceps, which should be “epidural first”. |