Part 5 (1/2)

87.rather anonymous experience of going to a hospital and being delivered by someone you have never met before. It isn't just a question of hospital versus home delivery; women want more choice within the hospital setting. Change is still in its infancy but what choices are available?

There may be more than one maternity unit available. If you are within a reasonable distance of more than one maternity ward, you might like to look around both and decide which feels best or which offers the things that are important to you. The hospital midwives may be able to offer different types of delivery, for example, there may be facilities for a water birth on the labour ward. The service may be able to offer a 'domino'

birth: domiciliary-in-and-out delivery. This involves the midwife joining you at home and a.s.sessing the progress of the labour and then going in to hospital with you for the delivery. Then if all is well, you can return home six or so hours after delivery. In practice, this type of service may not be available to all women due to resourcing problems.This combines some of the aspects of home and hospital deliveries that women want. In an ideal world all women would have had some contact with the midwife who delivers them since research shows that this can decrease the length of labour and the need for intervention. Generally there is a drive within the NHS to reorganise services so that more women are delivered by a midwife whom they have actually met during pregnancy.

Deciding to go to hospital is not a cut-and-dry issue.Towards the end of pregnancy it is something to discuss with your midwife and at any antenatal cla.s.ses you attend.You can also phone the hospital ward once labour has begun and a.s.sess your situation with them. Despite what one might see on TV, women rarely have their babies within minutes of feeling a contraction and with a first baby it is not unusual to be sent home from hospital after a couple of hours because you are not in active labour or because labour often slows down if you arrive at hospital in the early stages.

This may be because it is difficult to keep active when given a room with a bed in it and not much else.

If you choose to have your baby in hospital, you can also opt for 'shared care'and have your ante-natal appointments at your GP's surgery.

Independent midwives Many midwives who want to offer a different sort of experience to that available within the NHS operate as independent midwives either individually or in group practices. They may offer to deliver you at home, in a 88 separate midwifery unit or at your local hospital.Wherever you decide to have the baby, this offers you the support and continuity of seeing one or two midwives throughout. Unfortunately the NHS rarely provides such services and the cost of this type of care means it is only available to a tiny minority.

Home births Deciding to have your baby at home may not be met with a great deal of enthusiasm by your family or the professionals. Only a very small proportion of women have their babies at home and it is not recommended as a standard option for all mothers, especially first-timers. It has been a.s.sumed in recent years that hospital is the safest place to have a baby but is this correct? Increasingly, evidence is growing to show that home birth, in an uncomplicated pregnancy, is at the very least no more risky than hospital delivery which carries with it different sorts of risk.

Many doctors do not encourage first-time mothers to give birth at home. You may have problems convincing those around you too that it is a good idea. Seeking help and advice from the local midwives might be a good starting point. As one of these will be delivering you, it is important to feel rea.s.sured that they are supportive. Other organisations such as the National Childbirth Trust (NCT) may be able to offer advice and information.

The politics of birth Birth is an aspect of women's lives that has been the subject of debate for a number of years now.There are arguments over where is the best place to have a baby, whether medical professionals use too much intervention and why the rate of Caesarean section has increased rapidly in the past 30 years.

In the latter half of the twentieth century it was argued that birth had become over-medicalised and under the control of (usually male) doctors.

This led to the growth of women's movements such as the National Childbirth Trust (formerly the Natural Childbirth Trust) which campaigns to increase women's choices and offers support and information to pregnant women with the aim of avoiding unnecessary intervention. In this country the control of childbirth has been fought over for centuries.The growth of the medical profession in the seventeenth and eighteenth centuries led to control moving into the hands of men and out of those of local women.

Developments such as the invention of forceps in the nineteenth century So what exactly is a domino?

89.and the use of morphine needed the medical pract.i.tioner to administer them. Gradually, therefore, the hospital became the safe place to give birth with the doctor present to oversee. If you go into hospital, medical intervention is available, should complications occur. However, if you are in hospital, intervention is readily accessible and therefore more likely.

More intervention, for example, an epidural, can slow down the progress of labour and lead to the need for further intervention such as forceps. So deciding where and how to have your baby today is not a simple question and might mean quite a bit of information gathering and thought before you can be clear about what is right for you.

Caesarean section Around one-fifth of all births now are by Caesarean section. There has been a rapid rise in the past 30 years or so in the use of Caesarean section and the rate has risen even faster in the past five or so years. It is too early to say whether the trend has peaked or is set to rise even further. Some might argue that Caesarean section (C. section) is performed for medical/clinical reasons and therefore it is not an issue of general concern, however, the rate has risen so sharply over such a short period of time that it has caused debate over why, and whether all these operations are clinically necessary.

There seem to be no definitive explanations for this trend but a number of factors are perhaps involved. Caesarean birth has become safer since the advent of local/ epidural anaesthesia and this may have led to it being seen as a less risky option medically. There may be a trend to intervene early rather than risk later complications that would then require emergency C. section under general anaesthetic. Women also perhaps perceive Caesarean as safer than their mothers would have done and therefore are more willing to opt for it. For example, few breech babies are now born spontaneously: most women are offered and accept a Caesarean delivery.

They will be conscious while their baby is delivered and able to have some contact with him immediately after birth.

So if it is perceived to be less risky, has a situation developed where women are 'demanding it', as has been suggested in the media? A current stereotype is of the'too-posh-to-push' mother. She is the a.s.sertive middle-cla.s.s mother'demanding'a Caesarean partly because a planned Caesarean delivery fits better into her busy life schedule. There is some research to suggest that obstetricians are prepared to offer C. section to women who request it for reasons other than necessary medical ones. If this is the case, then we have to ask, what are women's perceptions of birth currently such that they are beginning to choose surgery over labour with all the 90 possible complications and restrictions (i.e. you can't drive for six weeks after a Caesarean)? Has the common perception of birth become that it is really too painful and risky and that Caesarean is the safe pain-free alternative? The increased C. section rate is a world-wide phenomenon, therefore, some of these cultural explanations could only be part of the picture. There have been reports by doctors suggesting that women need re-educating about the need for Caesarean section but until all the factors in this puzzle are understood, it is not clear who needs re-educating.

Studies, particularly in the USA, show that increasing Caesarean rates are related to fears about malpractice prosecutions: doctors are intervening earlier rather than risk complications and possible litigation.

Individual doctors and different inst.i.tutions have differing rates of C.

section and one American study showed that the rate of C. section corre-lated with the malpractice claims status of the doctor. Clearly there are issues about how clinicians a.s.sess risk.

If we want more women to go through labour, then also the right type of services need to be available. Hospitals currently cannot provide the level of staffing that would allow more women to choose home birth, domino delivery or have continuity of care so that they are delivered by a midwife involved in their ante-natal care. Research shows that the poorer the quality of care, the longer the labour and the greater need for intervention.

If women have less personal and less than adequate care, it seems far more likely that intervention will occur. In these less than perfect clinical situations, the fear of litigation probably makes early intervention more likely too.

There are certain factors that clearly will have led to the increase: having had Caesarean at first birth, then it becomes clinically more likely for a subsequent labour due to concerns about the effect of labour on the scar.

Many women may therefore opt for a planned Caesarean rather than have the dual difficulties of labour and then a Caesarean.We are delaying the age of first pregnancy, and increasing maternal age makes Caesarean much more likely. As yet it is not clear whether an increased C. section rate is necessarily a bad thing: we don't know yet whether maternal and child outcomes are better than with a lower C. rate. After all, what exactly are appropriate clinical reasons? If a woman is terrified of labour, possibly following a previous traumatic delivery, then perhaps a Caesarean is the most appropriate course, since intense fear can cause complications in labour.

Clearly, this debate is complex and we are waiting for better research and advice. So it is within this climate that women have to try to understand and make choices about their birth.

Labour 91.Labour Late in pregnancy it is not unusual for women to become preoccupied with anxieties about labour: will I know when it has started? When should I go to hospital? There can be an increased sense of panic about getting things done before the baby comes or an increasing lethargy, a sense of feeling fed up with the pregnancy and wanting the baby to arrive. Partners may now also be concerned about the role that they will have to play. Some may be worried about what is expected of them or how they will react to seeing their partner in pain or distress. Others may be focused on getting their partner to the hospital quickly.

This sense of uncertainty about labour is understandable.'Full term' is now considered to be anywhere from 37 to 42 weeks.This is a long time to live with the sense of 'any minute now'. Pa.s.sing your due date can also increase a sense of frustration and many women become anxious for something to happen.There may be many early signs of labour ^ a show of blood or stronger Braxton hicks' contractions (Braxton hicks are the painless contractions that some women feel throughout pregnancy) ^ and then these recede. Has it begun? Are you any closer to the birth?

Obviously, yes, but is this labour?

How will I know when it has started?

Despite all we know about pregnancy, it is still not clear what the precise mechanisms that trigger labour are.The beginnings of labour can be very different for different women and you may well think it has begun a number of times before it actually progresses. The technical definition of being 'in labour' is that the cervix has dilated by 2 to 3 centimetres. Some women at this stage may have experienced few indications that they are in labour and may not in fact recognise themselves to be in labour until further down the line. Other women might go into hospital in great agony feeling ready to deliver, only to be told that they are 'not actually in labour yet'as they are not 2^3cms dilated.

Signs of labour beginning The signs of labour commencing are: . a show: loss of blood and/or mucous; . backache/period type pains; . regular and strengthening contractions; 92.. waters breaking; . nausea/vomiting/diarrhoea.

Labour may begin very suddenly with your waters breaking but more likely, especially for a first birth, the signs of labour will begin gradually perhaps over a period of days. Clearly, eventually you will know you are in labour because the symptoms will increase and progress: contractions will become more regular and more painful. Your midwife will help you towards the end of the pregnancy to think about what will happen as labour begins, when to go to hospital and who to contact if you are at home. Here obviously attendance at parenting cla.s.ses can be invaluable in helping you to understand what is happening to you and how to deal with the experience.

What about going overdue?

Your due date may seem like a very important marker during the course of the pregnancy, however, as previously mentioned, there is in fact a five-week window in which your baby's arrival would be deemed normal.

Many women are very concerned about going 'overdue' and possibly having their labour induced.There may be some women who now feel so desperate to have the baby that they are relieved when offered a date for induction.

Once your due date has come and gone, there is no precise time at which intervention might occur: it very much depends on the individual pregnancy and how it is deemed to be progressing, however, pregnancies don't usually go beyond two weeks overdue. A medical induction involves using drugs (hormones) to bring on labour. This can be combined with rupturing the membranes i.e. actually making your 'waters break'. These procedures are often employed once labour has started spontaneously but fails to progress or progresses slowly. Many women are emotionally distressed by the idea of such interventions for a number of reasons. It is perceived by many to be unnatural and more painful than spontaneous labour. It can also make women feel as if they have 'failed' in some way, that therefore they are not having the 'natural' birth that they wanted.

They may also feel that the birth has from the beginning been wrested from their control.This can lead to a sense of powerlessness and therefore the expectation and acceptance of more intervention.

It is crucial in labour to retain, as much as possible, a sense of being in control and involved in what is happening to you. Just because labour is started artificially doesn't necessarily mean that you cannot progress with Labour 93.the rest of the labour as planned (obviously not if you wanted a home birth).The birth partner can be very important here in terms of trying to a.s.sess the mother's mood and trying to help, rea.s.sure and encourage her.

What about raspberry tea?

As discussed, the mechanisms that cause labour to begin are somewhat elusive. Although hormones will definitely bring it on, clearly, other factors also affect the beginning of labour. It seems to be common practice that women who are medically fit with their baby fine and well are given a date to come back to the hospital for induction rather than being taken in immediately. Often being told you are to be induced is closely followed by the beginnings of labour. Perhaps the baby was about to appear anyway but it is interesting to speculate on what psychological mechanisms may be at play. But what can you do if you are sitting at home waiting for that baby to arrive and feeling concerned about the possibility of being induced? Many other factors are thought to help the onset of labour and other women may share with you how their labour started. Some of these are dietary: the drinking of raspberry tea (available from health food shops) or eating spicy foods is suggested to help labour begin. There is no scientific evidence for these and obviously it's not a good idea to do anything that you don't enjoy or anything to excess. s.e.xual stimulation is said to bring on labour in some cases. One could see how this might be possible since s.e.xual activity encourages the release of certain hormones and may also cause some contractions. Increasingly as women are looking to alternative methods of induction there has been some research evidence for the efficacy of acupuncture in inducing labour.

With all of these things, however 'natural' they might seem to be, obviously it is important how each individual approaches the situation. If you have previous experience of acupuncture, and know the acupuncturist, this might be helpful for you. However, drinking lots of raspberry tea, if it makes you feel sick, or approaching an acupuncturist for the first time when you are two weeks overdue may not be the best way of approaching labour. It is important to try to approach labour in as calm and relaxed manner as possible.This will facilitate feeling more in control, more able to make choices, more able to actively partic.i.p.ate in your labour.

Has it really started? Stages of labour So you have woken up in the night with the arrival of a contraction, others follow intermittently but they continue to come.Your labour has begun. In 94 order for your baby to be born your cervix, which is the neck of the womb, needs to soften and open to allow the baby's head to pa.s.s through into the birth ca.n.a.l. This first stage of labour lasts until you are 'fully dilated': this is where the cervix has expanded to about 10 cms. Stage 1 can last a couple of hours or 10^15 hours in a first labour. However, your first stage may appear even longer since you are only said to be 'in labour' when your cervix has reached 2^3 cms dilated. So in fact you may feel as though you are in labour for some time only to be told that it hasn't yet started.

The first stage of labour often ends with an urge to push but there may be a period of transition where the contractions seem to stop, the mother may feel nauseous or actually vomit. Although this might be unpleasant, it does signal the beginning of the much shorter second stage where the mother has to push out the baby with the help of her contractions. Some women feel an overwhelming urge to push. Others need support and encouragement from the midwife to push during a contraction. This stage ends with the delivery of the baby. The third stage of labour is the delivery of the placenta.

What can I do about the pain ?

Many writers do not use the word 'pain' when talking about labour partly because they feel it doesn't describe the experience of labour fully and that it gives mothers negative expectations. These expectations lead to fear and therefore the experience is more likely to be poor.

Clearly the 'pain' of labour is a much broader experience than just the physical sensation, it is emotional too, and it includes many thoughts and fears as well as the contractions. However, you are unlikely to find a woman on a post-natal ward who will say that their labour wasn't painful. Therefore it does seem useful to talk about pain so that one can get information and be prepared for how one might deal with that experience.

What is pain?

Pain at its simplest is a series of messages sent from a site of injury to the brain to alert the individual that some form of action is necessary. It is an adaptive response to our environment: if we are being bitten by a predator we need to fight them off or stem the bleeding. If we have put our hand in a What can I do about the pain?

95.flame, we need to remove it quickly. But people experience pain in different ways and to different degrees. Any pain is made up of both physical and psychological aspects and therefore everyone's experience of pain is different: we talk of people having different pain thresholds. This does not mean that you are'making it up'as some mistakenly believe, but it means that the actual physical reaction of pain is mediated by psychological factors. If you put your hand into a bucket of ice eventually you will remove it because of the pain. If you are watching your favourite film at the same time you will probably not remove your hand so quickly: being distracted has changed your experience of pain. Clearly it is also important to have learnt something about potential dangers and this learning changes our behaviour: we have stored memories of pain. For example we automatically use oven gloves: we remember that the saucepan handle is hot, it will hurt me, therefore, I must use a glove.We have also learnt about how to respond to an injury. As a child, if your mother becomes distressed and terrified every time you fall over, then this will affect how you experience pain. It is likely that you will feel that any injury is something to be feared and that you will experience pain more negatively. (This is not always true: some may learn to disregard the response of their parent, as it does not concur with how they feel.) However, your experience of pain will be mediated by what you have learnt and experienced as a child.