Supporting Plus Size Women – a Must-Read Guide for Midwives

This is a lovely article with some very helpful information for midwives and other carers of pregnant women who are plus size. It’s so important to remember that larger women are not necessarily less healthy than slimmer women- and even if they do have medical conditions related to their weight, they still need and deserve personalised care.

And of course, labour and birth in water offers huge benefits to women of all sizes, and women should not be denied access to water just because they are “plus size”.

Read the full article here…

OASi – The Right Care for Serious Tears?

The OASI Bundle refers to a specified list (the Bundle) of interventions which are being evaluated to see whether they reduce the numbers of very serious tears during birth, known as OASI, which affect the woman’s anal sphincter. The package is outlined by RCOG here. These types of tears can be hard to repair, and can lead to life changing injuries for women. While Aquabirths absolutely supports the concept of trying to reduce the chances of these types of birth injuries, there are some serious concerns about the OASI Bundle and whether it is the best way to achieve this.

OASI stands for “Obstetric Anal Sphincter Injury”. The Bundle contains four components:

  • Communication with women about their chance of OASI (more about this in a moment)
  • Using the “Finnish Grip” as the baby is born
  • Use of episiotomy as per indications in the details of the Bundle
  • Checking the mother by inserting a finger into her rectum and feeling for tears which might not be immediately obvious and which can be present even if her perineum is intact.

We were initially pleasantly surprised to see a list which specifically included the requirement to speak to women about the intervention. While sometimes a guideline will say “do X with consent”, rather than just “do X”, it is very exciting to see a specific component of a Bundle being that women should be making an informed decision to be a part of a trial. However – despite being the first part of the Bundle (after all, nothing can be done without consent) the fact that this component is listed last in RCOG’s detailed guidelines speaks volumes about the consideration of its importance. Even more worryingly, in practice, midwives are reporting that women are arriving at hospital in labour without having been given information about the Bundle by their community midwife and therefore ensuring that ensuring that informed consent is given is much harder. This should itself invalidate the data that is being collected by the trial, according to its own rules, and performing any intervention on women without informed consent is, in law, common assault.

The Finnish Grip is the main intervention in OASI. It involves gripping the perineum with the intention of redirecting pressure towards other vaginal and labial tissues. This video shows it in practice (keep the sound off – the artificial sound effects are somewhat irritating, especially the “push-push-push”!) You will note from the video that the “woman” is on her back, pushing against gravity with her baby’s head therefore pressing down hard against the perineum. The Finnish Grip is designed to push the baby’s head up and away from the perineum – yet encouraging women to be upright or forward facing has the same effect! With an upright, forward facing or even side lying position the baby’s head is lifted by gravity towards the woman’s front, rather than being dropped by gravity heavily onto the perineum. The Finnish Grip also displaces the pressure of the baby’s head towards the clitoral area, and this causes increased numbers of tears in this area, often with serious loss of sexual feeling for women. These tears are considered to be less severe than anal sphincter tears (although partly this is because reduction of female sexual function is often considered to be of less importance than it is to the individual woman) – and again, we would not want for a moment to understate the catastrophic consequences of these – but what if there is another way?

What we know about perineal trauma is that women who birth on their backs, perhaps in lithotomy, are more likely to experience serious tears than women who birth in upright positions. Women who birth in water experience fewer serious tears, and the OASI Bundle cannot be used in water. The evidence around waterbirth reducing the incidences of severe tears has been well known for years, and we welcome hearing HCPs suggesting waterbirth to women who are worried about their personal risk of a severe tear, or who are at higher risk of it.

We also know that some obstetric interventions can increase the risk of OASI. For instance, inductions and epidurals lead to a higher chance of birthing lying down or in lithotomy, which as I’ve already discussed leads to gravity pulling the baby’s head more firmly down onto the perineum. However, the very low rates of severe tears in women who birth without pharmaceutical pain relief (allowing them to follow their instincts more clearly and leaving them with the sensations from their bodies to respond to), especially in low-medicalised environments such as home births or midwife led unit births, lead many to feel that there are other ways to reduce OASI without pinching a woman’s genitals as she is trying to push a baby through them.

Many midwives have noted how women will naturally close their legs together to slow the birth of the head – and yet how many women are encouraged to open their legs to “make space for the baby”? In artificial birth positions such as lithotomy, this is simply not possible, which may explain the higher numbers of tears which the Bundle is trying to reduce.

Margaret Jowitt has introduced an interesting theory that in upright or forward leaning birth, the baby’s head presses against the clitoris (again, as the pressure is spread towards the opposite side to the perineum), and in a spontaneous birth where the woman’s and baby’s bodies are working together the baby’s head could be “cushioned” by the the internal parts of the clitoris, (the bulbs and the crura), triggering it to enlarge and gently support the baby as the head passes through and out of the vagina. Midwife Joy Horner discusses the need for the vaginal and perineal muscles to soften and relax, much like is needed for comfortable love making, and a supportive, loving birth environment with a known and trusted care giver (continuity of carer!) who would not interfere with that oxytocin creation could explain why independent midwives have such low rates of OASI.

It is deeply worrying that we are seeing signs, during this OASI trial, that women are not being given information antenatally to ensure that they can give informed consent during their birth despite the fact that this is a key part of the Bundle. The Finnish Grip appears to be trying to rectify a problem which may well be caused in the main by over-medicalising birth and not supporting women to follow their instincts, and the damage that the Finnish Grip can cause with the associated increase in labial and clitoral tears may cause more women problems than would have suffered with anal sphincter tears. Instead of rolling out yet more intervention, perhaps it’s time to take a step back and look at supporting more women to birth in water, or to have more continuity of carer to ensure that during one of the most intimate periods of their lives, women and their carers can feel the deep and loving bond that even the very best, most caring midwives cannot be expected to develop when they meet for the first time in a hospital setting.

Organising safe and sustainable care in Alongside Midwifery Units: A Review

Oldham Midwifery Unit with Aquabirths birth poolAlongside midwifery units are defined as midwife-led units which are on the same premises as an obstetric unit (OU). They are usually next to the OU and may have come about following restructuring of the OU.

 

A follow on study from Birthplace 2011 investigated the way that alongside midwifery units are organised, staffed and managed, as well as the experiences of the women who use them and the staff who work in them.

 

The researchers looked at 4 different alongside midwifery units. They interviewed midwifery staff and service users, and also those in a management and organisational role. What became clear from the study was the fact that midwives working in alongside midwifery units were able to practice more autonomously, using their own clinical judgement. This is how all midwives, who are all autonomous practitioners, should be able to work, but obstetric units often discourage or reject this aspect of the midwifery role. Midwives also reported how they valued the work environment and culture, although the study did acknowledge that there was a need to ensure that midwives were supported to continue to develop their confidence, which is not a surprise as so many would have been trained in a far more repressive environment.

 

Another challenge for the sustainability of the alongside midwifery units was the fact that of all of the women who were considered to be good candidates to birth there, only a third ended up doing so. This study does not look at why this might be, but we know from feedback from women that very often they are simply not made aware of the midwife led unit in their area, so they did not have the opportunity to consider it for their baby’s birth.

 

Ultimately, Aquabirths would like to see the facilities which are commonplace within a midwife led unit such as birth pools, birth couches, mats and birthing balls, as well as the environment which is designed for calm, and to promote oxytocin, available as standard within all types of units, including obstetric units. There is no reason why these facilities could not be used by far more women, and we strongly believe that if a better birth environment was available to all, that more women would birth their babies with fewer unnecessary interventions. We hope that more research like this will encourage designers of all types of maternity units to create spaces which support both women and midwives to work together for better births.

 

Oldham Birth Centre: Nurturing Families

Oldham Birth Centre – A Place to Want to Labour!

Aquabirths birth poolOldham, in Greater Manchester, UK, has created the most stunning, supportive and effective birth centre which is family-centred and woman friendly. Designed to nurture women and birth, creating a safe, positive and caring space for the whole family – including other children, who can be present at the birth of their sibling.

Designed to support the physiology of birth from the ground up, the Birth Centre rooms do not centre around an obstetric bed. Instead, they feature slings, balls, mats, Softbirth couches, adjustable lighting and the stunning Aquabirths birth pool, with a large family bed available for parents and baby to rest in after their little one is born.

The Oldham Birth Centre’s philosophy of care is key to the success of this midwife-led maternity unit. Midwives are trained in hypnobirthing techniques, aromatherapy, acupuncture and using water to support positive, safe, physiological birth. Minimising adrenaline is key to maximising oxytocin, and maximising oxytocin is key to birth progressing well, so the whole room is designed to be calm and to help everyone to relax. An aromatherapy diffuser by the door greets the birthing family as they arrive, and the scents in the air, the dimmed lights offset by coloured bubble lamps and the Aquabirths birth pool gives a sense of walking into a spa.

Oldham Birth Centre Wall Painting
Oldham Birth Centre Wall Painting

Midwives describe seeing women sitting in a chair and looking around, and visibly relaxing. A kitchen is available for all to use, so birth partners can help themselves to drinks, and they can make their own snacks. Midwives make it quite clear that this space is for them to use, which is an important part of helping everyone to relax and continue to reduce any adrenaline levels.

The Oldham Birth Centre is not an extension of the labour ward, but instead is designed as a birth centre for the families of the city. While there are strict criteria for straightforward access to the unit, if a woman wants to birth there she can attend a Birth Options Clinic where their choice of place of birth is discussed, and the woman will be supported by the midwives.

The unit itself is nothing without its midwives, and the midwives at Oldham are hand picked for their inbuilt nurturing nature – not a trait which can be taught. Diane watches the student midwives who show an interest in physiological birth and support women’s choices. Those who wish to become part of the community/birth centre team are encouraged to apply.

Oldham Birth Centre is not unique, but it is unusual and it is beautiful. The women and families of Greater Manchester are extremely lucky to have this wonderful facility with its fabulous midwives.
The unit has a video on You Tube which showcases the birth pool and other facilities: https://www.youtube.com/watch?v=2wOHqJfLhGg

Choices-in-Childbirth January 2018

#Waterbirth – what can we learn from each other? Free Softbirths Mini Birth Couch, CFM: nothing but damage? A Year in Doula-ing, Women’s Art & News

https://mailchi.mp/ac16926a98f0/b0cx24sjnh-3125301?e=2ded6ce75b

Better Births in Powys – Supporting Women, Improving Care

Powys delivering better births
Ruth Weston of Aquabirths in the new Aquabirths birth pool installed in one of Powys’ birth centres.

Powys: Supporting women and supporting Better Births.

In the heart of Wales, in one of the most rural areas of the United Kingdom, lies the beautiful county of Powys. In this stunning region the recommendations of The Birthplace Study and Better Births are being wholeheartedly implemented. In extraordinary contrast to some areas of the UK, Powys has determined to ensure that Midwife Led Units are recommended as the optimal birth place for healthy women and babies, provided they are happy to birth there – supporting women in their decisions and supporting Better Births.  20% of women give birth in a midwife led unit in this area, compared to 14% for the rest of the UK.

Powys has 6 midwife led units across the county, limiting the distance that women need to travel in labour, increasing safety for women and babies and reducing the stress on families at a time where the birthing woman needs to be able to focus on her job at hand.  In addition, Newtown, one of Powys’ towns with a birth centre, has recently celebrated  the huge achievement of obtaining funding to run sonographer services local to where women are, reducing the travelling distances for women by 3000 miles a year!

Newtown has also used its funding to add in a permanent Aquabirths birth pool, and a double bed so that new parents can snuggle up together with their baby after the birth, rather than being separated at one of the most profound times of their lives.

Well done Powys – you are an inspiration!

Guest blog by Emma Ashworth

Free Mini Birth Couch Kit with Birthing Pool

Birthing Couch Kit for Smaller Birth Rooms

The SoftBirth birthing couch kit has a new little sis!  A shorter version for smaller rooms at a smaller price.  A HoM asked us to design a smaller birth couch kit for smaller rooms, so we did and will even fit in the back of a small hatchback. Anyway, with all our birth couches we offer very large discounts when more than one of the same couch is bought. So, this is £600+VAT but 3 or more would be at £500 each.  As with the larger SoftBirth couch, this is a kit – the stool and kneeler are included.  The mini is also FREE with Aquabirths’ Canberra, Venus and Heart-shaped birth baths.

Mini birth couch kit

Waterbirth : Part of a World Movement

Revisiting WaterbirthBarbara Harper, founder/director of Waterbirth International reviews the second edition of Dianne Garland’s textbook ‘Revisiting Waterbirth: An Attitude to Care’ in the context of waterbirth practice around the world.

It is no secret that water is healing and that the use of water is an effective medium to facilitate changes in actual brain wiring. It is with excitement and great pleasure that I welcome the publication of the second edition of Revisiting Waterbirth: An Attitude to Care. Dianne Garland has continued to provide waterbirth education and training not only throughout the UK, but around the world. Our mutual passion brought us together for conferences, workshops and presentations many times. It has been my privilege to work closely with Dianne as a teaching partner in China, Spain, the Czech Republic, Israel, India and the United States. Her excitement about demystifying waterbirth is contagious, and the reader, whether midwife, doctor or mother, will experience that enthusiasm within the pages of this book.

There has never been a time in our combined history when the message and knowledge within Revisiting Waterbirth: An Attitude to Care has been more necessary. The misinformation surrounding waterbirth that Dianne and I have witnessed in different parts of the world is sometimes distressing and occasionally humorous. This book gives every practitioner an effective, informative guide to start a waterbirth practice and integrate that practice into any clinical setting. It also provides concrete examples and stories from those with whom Dianne and I have worked. The inclusion of detailed stories from practitioners and parents is a wonderful supplement to the new edition of Revisiting Waterbirth.

The use of water for labour and birth has increased exponentially since Dianne and I first started writing letters to one another in 1989. When we finally met in person 26 years ago in Kobe, Japan, at the International Confederation of Midwives conference, we excitedly shared documentation of the efficacy and safety of waterbirth. The demand for accurate, useful information and descriptions of experiences has also increased. When we first started our collaboration, waterbirth was referred to as a fad or a trend that would soon be gone. Women seeking the ease and comfort of water will continue to increase in every part of the world. Waterbirth is part of a world movement that seeks a more humane and gentler approach to childbearing.

The use of warm water immersion has long been seen as an aid for labour, making it easier for the mother to enter into and remain in a state of hormonal bliss. Today, there are well-designed studies that prove the efficacy of water for labour and the safety of water for the birth of the baby. Dianne’s experience as a hands-on midwife attending waterbirths, as well as her design and documentation of research, makes her the perfect person to lay the foundation of education for those who want to incorporate the use of water into maternity care settings. This book is also a guide for those who have already started waterbirth practice to improve their experience.

The message in this book is simple, straightforward and very hopeful. It is hopeful in the sense that more and more women are asking how to make labour less about ‘enduring the pain’ and more about creating a good, healthy and loving experience of birth for the baby. Women understand that creating a new human being is one of the most important jobs on the planet. The providers who serve those women need the encouragement that this book offers to step out of the routine medical care and become open to the possibilities that water can, indeed, change the course of a labour and should be utilized as a valuable tool for almost all women. The attitude with which professionals view a woman’s ability to give birth can either enhance or detract from her experience.

In 2014, the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatricians (AAP) launched a campaign to put doubt about the usefulness of waterbirth into the minds of nurses, doctors, midwives and the public. Some US hospitals paid attention to the published and widely distributed ACOG opinion paper and halted their successful and incident-free waterbirth programs. Dianne and I travelled together to hospitals in Cleveland, Ohio, and Minneapolis, Minnesota, shortly after the article was published, to educate hospital staff and help reinstate waterbirth policies in these facilities. We were welcomed in these places and our efforts were rewarded when the practices were put back into place.

It is my sincere hope and desire that practitioners throughout the world are guided by the message in Revisiting Waterbirth: An Attitude to Care and start implementing protocols in more hospitals. All women should be offered the choice and opportunity to labor in water and birth their babies with the ease, safety and pleasure that water so beautifully provides. I also hope that our tandem careers continue to bring this message to every corner of the globe. As founder and director of Waterbirth International, I have relied on Dianne Garland to provide a multitude of research and documentation from the UK and have used this book in its earlier editions as a teaching tool and recommended reading for nurses, midwives and doctors.

Barbara Harper, RN, CLD, CCCE, CKC, Midwife
Founder/Director of Waterbirth International

Follow Ruth Weston’s BornStroppy Blog

ABOUT RUTH AND ‘BORNSTROPPY’

Ruth Weston, BornstroppyBiog:

Ruth Weston mother, business woman, lactivist. Ruth is the mother of five children, four born at home and in water. She liked her waterbirths so much she took over Aquabirths as a small Yorkshire birth pool hire firm 15 years ago.

Since then she and her husband have grown the business, now, with midwives and doulas, designing pools and soft furniture for the NHS and around the world.

Ruth is passionate about women having good care and a good birth: she set up  ‘Choices in Childbirth’ childbirth group in her home 14 years ago which became a network of similar groups across Yorkshire and beyond with a regular monthly E-newsletter which you can subscribe to.

Ruth helped set up the MSLC in Bradford and Airedale and became its first chair. Ruth is now turning her considerable determination and energy to the delivery of continuity of midwifery carer and the reform of regulation for midwives – structural reforms she believes necessary for the delivery of humane maternity care for women.

For 25 years now I’ve been campaigning along side others to improve women’s experience of childbirth. Part of my work has been to provide the means and equipment for better birthing experiences: that may be knowledge and training or it may birth room equipment.
If you would like to sign up the monthly newsletter ‘Choices in Childbirth’ or ‘Choices in Childbirth for Midwives’, fill in the form below. Or click on the image below.

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Bornstroppy RuthWeston

I’m Group B Strep (GBS) Positive. Can I have a Waterbirth?

GBS testing is not routinely offered to women in the UK.  This is because it is considered that the high rate of carriage compared to the low rate of infection means that the harm done to women and babies in offering antibiotics to every woman who is carrying GBS would outweigh the benefits.

However, some women do end up being tested for one reason or another, and those who find that they are carrying GBS are often then denied access to water during their birth (unless they’re at home, in which case it’s always the woman’s own decision). Aquabirths asks, “Is this a reasonable position for trusts to take?”.

Many trusts are open to women birthing in water and some are not, and within trusts some midwives or obstetricians will deny women access to the trust’s pools, and others will be completely happy to support women who want to use a pool for their birth. What’s going on?

There is limited data on the impact of waterbirth on how many babies born to women who are carrying GBS, but what data there is shows either a reduction in the numbers of babies born underwater who are infected with GBS, or no statistical difference, but with a trend towards a reduction in affected babies who are born underwater. This is despite the fact that the water in a pool birth could have high levels of GBS in it, and therefore the theory is that the water is essentially washing the baby and mother, providing some increased level of protection compared to babies born on dry land. (1)

An article by JS Cohain (2) states that infection with GBS was 1/4432 in babies born underwater v 1/1450 in babies born on land – that’s three times as many babies becoming infected with GBS when they’re born on land than babies born underwater! The article discusses the reasons for this, including considering whether it might be “a massively successful international campaign has covered up the reporting of all deaths and disease from GBS after waterbirths.” There’s nothing like covering all bases!

Even though the evidence on GBS and waterbirth is limited and more studies are needed, if the trend was the other way – that more babies seemed to be infected with GBS when born in water – there would be no doubt that there would be a huge push to try to ban birth in water! Given that the opposite is true, and the best data that we have shows a trend towards fewer babies being infected with GBS when they’re born under water, opening up water birth to women who have found that they’re carrying GBS is something that every birth centre and obstetric unit should support.

Article by Emma Ashworth.

Many thanks to Dianne Garland for her help with this article.

References:

(1) Springer Link, “Water birth: is the water an additional reservoir for group B streptococcus?” 

(2) Pubmed, “Waterbirth and GBS”

Further Reading:

AIMS GBS book, “Group B Strep Explained”

RCOG “Group B Strep and Waterbirth”

Practicing Midwife for the GBSS, “Waterbirth for women with GBS: a pipe dream?”

Dianne Garland’s book, “Revisiting Waterbirth” is due out in April or May 2017