NICE GuidelinesBBA Part 2

For those that were following the comment threads on my BBA post.
The NICE Guidelines have been published.

Interesting idea about birthing pools – and if someone can point me to the evidence that they are superb, rather than an infection risk, I'd be grateful.

There is a campaign site for normal birth. Something that I would agree should be everyone's choice.

The only thing that I'm not sure about with this emphasis on 'choice' is that there are a fair numberof people out there who I don't think are really competent to make an informed choice. If people are daft enough or self-deluding enough to get pregnant and not realise it, then can we really say that every mother is clever enough to make an informed choice.

But then this is where the skill of being a midwife comes in. Much as I urge some people that I meet about their healthcare choices.

31 thoughts on “NICE GuidelinesBBA Part 2”

  1. I LOVE antenatal care, it's my favourite part of being a midwife. I think that given the right time and also continuity of midwife antenatally (and this can be done outside of a caseload system) you CAN give women an informed choice, even if they don't have a high level of understanding: you just learn to pitch things at the right level with the right vocabulary. In such a way, I've helped mothers from all backgrounds to achieve a positive-and safe-birth experience.Women do not choose things that are not good for her and her baby, on the whole, unless they don't understand the reasons or risks. If these are explained and the woman accepts the risks and takes that responsibility then that is fine! Nobody can stop her unless she's not mentally competent.Incidentally, we are trained as midwives to deal with emergencies at home and in the community setting and as such, our Uni trained us with 'what to do when there is no doctor to call' scenarios. I am quite confident that if I was in Tesco and a woman gave birth in the freezer aisle and started haemorrhaging that I'd know how to deal with it- because it's what I am trained to deal with if necessary!

  2. If you look at the other figures quoted in the research, e.g.”The duration of the first stage of labor was significantly shorter with a water birth than with a land delivery (380 vs. 468 minutes, P < 0.01). The episiotomy rate in all water births was lower with a water birth than with a delivery in bed or a delivery on the birthing stool (0.38%, 23%, and 8.4%, respectively)."

    the water birth figures are given first, so the 1.22% neonatal infection rate would probably be for water births and the 2.64% rate for land deliveries.

  3. The attitude of the midwives in my area here appears to be “If you don't choose everything as we think best, then you're a bad mother”. Several pregnant friends (qualified, professional people) were rather upset by the way they were lectured and almost bullied in the (rather minimal) prenatal classes.

  4. My mother had a home birth with my brother in the 1950's. It nearly cost her her life. It only needs there to be a haemorrhage and no-one qualified to deal with it to turn it into a disaster. With staffing as stretched as it is, it could be a return to the dark ages.How many of a woman's wishes will they take into account? I'd have been happy to get a decent cup of tea after each of my experiences, let alone a water birth.

  5. Haven't read the NICE report, but in the BBC reporting of it (http://news.bbc.co.uk/1/hi/health/7012295.stm) there seems to be an awful lot about the mother's choice, and next to nothing about the safety of mother or baby. Now, I can see that all else being equal, 'what the mother wants' is an important factor (and taking it to extreme, refusal of treatment is the patient's – legally the mother's – right in this country). But surely NICE should be spending its time thinking about the (highly emotive) argument about outcomes for home/midwife-led/consultant-led births for a wide range of different risk profiles? Otherwise, the mother can't make an informed choice!Or do we no longer care about rigourous analysis – as long as we have choice based on news reporting, scare stories from both sides and anecdote, standards will surely improve…!?

    Scientist

  6. About the infection risk with waterbirth, use of the pool in labour. Haven't got the research to hand, but it is out there, and it reports that there is little to no risk. Certainly, at the 2 units I work out of, there are strict infection control protocols in place and one of the units uses liners in the pool. I have worked in areas where pool use is commonplace for 15 years and I have never heard of any infection occuring as a result of pool use. (I think the baths on wards are far more of an infection risk).

  7. Tom – I hope that this post was written 'tongue in cheek'…A question for you in response to yours about birthing pools – is a bath in a hospital when in labour 'safe' or would it pose the same infection risks??

    I think you're over-generalising somewhat with your comment about whether a mother is 'competent' or 'clever' enough to making informed choices……. Are most of the prospective mothers you see 'stupid', then??

    I had my 2nd son almost 2 years ago – the NICE guidelines then stated that a mother having a subsequent baby didn't need as many appointments as a 1st time mother. How these appointments would pick up high blood pressure or protein in urine when the appts are about 4 weeks apart in the 3rd trimester, I do not know. I wasn't offered any classes this time round and I would probably only describe my care in the community as 'adequate' as I stuck to the NICE schedule. I'm a 'middle-class' “educated” mother – how do you think those not best placed to find out about their care get on?

    I guess all this comes down to whether you feel that mothers to be should be allowed choices – ie where to give birth. I would challenge you by saying that I would question the quality of antenatal care and therefore the ability of women to make an informed choice. You cannot make an informed choice without high quality information.

  8. Oddly enough it is possible for women to get pregnant and not realise it. My 15 year old stepson's mother first knew that he was on the way when she was 7 1/2 months pregnant. She had a long history of chaotic hormones due to polycystic ovaries and had extremely erratic periods. Earlier in the marriage she had been thoroughly investigated in the hope of being able to conceive and had been told that she was infertile. The shock on finding that she was pregnant years later was colossal. It was normal for her to have no period for such a length of time so she had no reason to be suspicious, she hadn't put on any significant weight either. Apparently, once she knew she was pregnant, the weight piled on, psychosomatic reaction or what? She was 42 at the time. I have a theory that women's hormones have a final push before menopause starts. What do others think? She was a very late baby too, her mother was 48. The human body is never without surprises.

  9. That's been the experience of some of my friends who've given birth as well.Then on the other side, you get the well-meaning amateurs – frequently male, or much older females – who make the person feel bad for wanting any pain relief. The idea boils down to, that you're being a bad mother who's selfishly poisoning your child to avoid a little temporary discomfort.

    But I'd love to know how many proponents of “natural” childbirth have “natural” – drug free – dentistry, or are willing to face a “natural” unmedicated death from something painful.

  10. 'But I'd love to know how many proponents of “natural” childbirth have “natural” – drug free – dentistry, or are willing to face a “natural” unmedicated death from something painful'In that one sentance you have encapsulated the whole concept of the medicalisation of childbirth.

    Childbirth is not an illness. It does not need treating. It is a normal process. It is not an infection, it is not the bodily systems slowly failing or an abnormal growth.

    The pain of childbirth has never killed anyone. However, an an epidural does affect the normal course of labour and birth. FACT. It leads to more assisted deliveries and more use of drugs in labour to improve progress.

    This is not to dismiss the fact that sometimes a labour is dysfuntional and therefore will need help which could then necessitate the use of an epidural. Then childbirth has become abnormal.

    Before the widespread use of epidurals the normal birthrate in the UK averaged out at around 70 – 75%. Since the increased use of epidurals it is now around 50%. That whole figure cannot be blamed on the epidural but it plays a large part.

    Has the use of epidurals been of benefit in helping women have painfree births? Yes. Has it improved birth outcomes? No.

    I know which I think is more important.

  11. Just read it – bloody awful and just another sign of the state the NHS is in due to mismanagement by people who haven't the faintest idea what they are doing.

  12. Except….Haven't child birthweights increased over the years due to better motherhood nutrition? Doesn't that lead to more painful childbirth?

    Does increased pain in childbirth lead to a reduction in mother/child bonding? Maybe even an increase in post-natal depression and other mental health issues?

    I honestly don't know the answer to these questions (not being a midwife – or, surprisingly enough, not that interested in something that I'm never going to have to go through).

    Dying is a natural part of life – should that also be done without medication that may speed the ending?

  13. Absolutely.I wholeheartedly agree that there isn't enough science (and I mean *good* science) going into social planning in this country.

    It's a shame that no-one can think of how to turn a homebirth vs. consultant led birth into a profit making study. Then we'd have hundreds of the studies popping up.

    Frankly it scares me as to how easily the media informs government decision making, and how little *real* science informs the media.

    (See Ben Goldacre's excellent blog for further examples).

  14. That's cool, it was a genuine question, but in the abstract is says,“The rate of neonatal infection was also not increased with a water birth (1.22% vs. 2.64%, respectively)”

    Which seems to say that a doubling of the infection rate is 'not an increase'? Not too sure I'd agree with that (and I'm not paying 18 to read the full paper).

    And I'd suggest that the lack of analgesics is due to the sort of women who would want a water birth).

    (Of course, this is just the abstract)

  15. It's not an over generalisation – some people really are stupid, borderline competent.I get to meet lots of them.

    Here is an example I was told yesterday – Woman gives birth at home, realises that she doesn't have anything for the baby, so grasps it by the ankles and walks down to the shops with the umbilical cord still attached between her and the dripping wet baby.

    Someone sees this and (rightly) calls an ambulance.

    This person isn't mentally ill – just daft.

    Trust me – there are lots and lots of very silly people out there, just because you don't meet them doesn't mean that they don't exist.

    Take the woman who smokes during the pregnancy because she *wants* a small birthweight child as it'll be easier to deliver. I met a few of them in my time as a nurse.

    They are mentally competent to make decisions. But are still idiots.

  16. And yes – competent people should be allowed to make a choice – even when it affects their own health.With pregnant women though, it's not just them that 'suffer'.

  17. I'd start off agreeing that baths on wards are almost certainly far more disgusting.(and if you've worked out effective infection control would you mind telling the rest of the hospital please…*grin).

    With infection control being one of the reasons the (for want of a better term) 'home-birthing supporters' being so adamant that home-birthing is safer I was interested to see if the commenters who identify themselves as home-birthers would be as equally supportive of water births even if they do occur in hospital.

    But now I run the risk of sounding snide.

    More seriously, I have *no* experience of water-birth and so am genuinely interested in what research exists.

  18. I was born on a No 23 bus outside Sheffield Rail Station in 1961, no midwife, just a couple of women helping my mum who's labour lasted less than 10 mins (I was her first child and a week early). Taken to hospital by the bus and discharged a few hours later with mum to go home.My brother and sister (twins) were both born at home two years later, again no complications and they arrived just before the midwife.

    My mum was sent to hospital by the midwife as her labour was taking a long time and her history seemed to indicate that this was unusual. Mum had the most horrendous experience of her life being treated like a thing to be sorted out rather than a person. She wasn't allowed to walk around was planted and left in styrups, had any number of people peering up her (as she delicately put it) and felt completely miserable. The baby was whipped away from her immediately and she felt disconnected from the experience. She always said giving birth on the bus was a better experience and less painful.

    Medical intervention isn't for everyone and perhaps mum was lucky in that there were no complications even with twins which she didn't know about btw. This was during the 1960's where the services were different and people didn't rely on health services as much as they do now.

    No scans in those days or complicated tests, it was just accepted as a normal part of life that didn't necessarily warrant a trip to the hospital.

    The majority of her friends had home births and it was unusual for someone to be in the hospital for something as simple and natural as a birth. Midwives were present and local with the time to care for my mum during her pregnancy they just weren't quick enough to make it for the births.

    I guess what I am trying to say is that perhaps life was simpler when we didn't rely on health services for our health but instead took some care of ourselves and some responsibility for our friends and families.

    Cate

  19. If I had ever thought a home birth was a good plan the experience of a close friend last Sunday would have changed my mind. Following a totally normally birth she began haemorrhaging rapidly and potentially catastrophically. Had she not been in a hospital and rapidly transferred to theatre where a consultant obstretrician stopped the bleeding we would not now be celebrating a new baby but planning a funeral. Interestingly in my extremely subjective experience she is the third friend to suffer potentially duisasterous blood loss following childbirth in a year (In different hospitals and indeed different parts of the country.) does this reflect current short staffing in maternity units I wonder or is it simply coincidence. I do know that should I ever get to the point of reproducing it will be hospital for me everytime.

  20. Most home birthers who are also waterbirth advocates woudl advocate waterbirth in hospital in my experience. It is becoming a lot more popular; I've done quite a lot of them, and the home waterbirth I attended last Christmas Eve has to be up there with my top midwifery experiences.

  21. Re the smoking thing- it's all very well people thinking that, but it's usually because nobody has been 100% blunt with them as to WHY smoking causes low birthweight babies. Tell it like it is and people do at least register the facts. Years of being PC about everything have engendered this culture whereby people are terribly misinformed but if those who are meant to be giving them information aren't doing it in a way that is relevant then someone has to take some responsibility. Some things seem dead obvious when you know them, but if you don't, you don't know what you don't know.Although as you say, some people really are just daft but as long as we aren't allowed to put contraceptives in the water supply I think we are stuck with those few…

  22. It's difficult to say without knowing the scenario. Often management of labour means predisposition to postpartum haemorrhage (PPH)- eg speeded up labours, instrumental delivery, caesarean section, long labour (often due to malposition of baby, due to sedentary lifestyle of the woman antenatally) etc. Also mismanagement of the delivery of placenta.So sometimes women will have PPH that they wouldn't have had, if they'd had less medicated or medicalised labour (eg you have an epidural, and end up with forceps, as a result (epidural increases risk of instrumental delivery) and you have a PPH as a result of needing your labour augmented and the inevitable episiotomy…) In which case it MAY have been that in some womens' cases, if they'd been at home they wouldn't have bled in the first place.

    That, and sometimes the perception of things is not as it seems- Women have said to me that they lost a lot of blood, nearly died etc, but it turned out it was 300ml and it just seems like a lot of blood when it isn't if you are used to it! Not disputing your friends' stories but it's not usual for LOTS of women to have a PPH (I've seen 2 in 5 years, both following precipitate labours).

  23. Not sure anyone's still reading this, but here we go anyway…..Particularly to Clarabelle, but also to anyone else with an opinion: Do you think that the issues to do with medicalisation of labour (particularly anxiety leading to non-progression) are an inevitable consequence of being in hospital?

    I'm wondering whether there is a middle ground, where women can go to a 'homely' birth unit to be looked after by an appropriate number of experienced staff of whatever profession is appropriate, but still be within a corridor's jouney of a theatre should that prove necessary. Personally, I would choose to give birth in a hospital – but I work in a hospital, I know what they smell like, I am comfortable in that environment. If you could make hospital comfortable for everyone, with noone feeling their midwife doesn't have time for them, or wondering if they'll get to eat today, or having to look at blood-stained walls, or any of the other horror stories you hear about, would that tip the balance towards hospital for more people? It would cost money to get the staffing up and the rooms nice, sure, but I would have thought it would be cost-effective in the long run if it let more women have normal births.

    Any thoughts?

    Scientist.

  24. There was a unit, just like the one you describe in Devizes, Wiltshire, until this year. It was a midwife lead Unit as part of a 'cottage hosiptal'. I did consider it when pregnant with my first. The only thing that put me off was having to be transfered to Salisbury, Bath or Swindon in the event of an emergency.Alot of women had very positive births there. Sadly, it was deemed to be too expensive to run. Now many women in rural areas in that area have reduced choices and further to travel.

    When I looked at Southampton Hospital's unit, they had a room set up in a more homely fashion where you could give birth. I think some London hospitals operate a 'Domino' system where they have a birth unit attached to a larger hospital and a team of midwives provides care, ensuring that the woman has met her midwife before The Big Day. I hadn't met either of my midwives when I had my children and it didn't bother me. What I will say about the environment in a hospital Delivery Suite is that it is very much a hospital bed in a room.

    To Tom regarding 'Stupid People' – sadly people will always do things other consider to be daft…. are you suggesting that only people who aren't 'stupid' be allowed to have babies??

  25. Childbirth weight has increased due to improved nutrition, but so has the size of the average woman, and I'm not talking BMI here! Unless you are talking 'large' as in over 10lbs for the baby there is little difference in the amount of pain a woman will experience due to the contractions.With regard to the bonding issue it could be argued in both ways. Epidurals reduce the production of the bodies natural painkillers, endorphins, so the woman does not then have the natural 'high' following labour and so in a positive and receptive state. Good for bonding. This arguement could be countered by the fact that the release of adrenalin will also cause endorphin levels to fall and so if a woman is terrified in labour due to pain it would cause her endorphins to reduce.

    Death is natural, but as it is the end of life, where bodily systems are failing and administering drugs is only going to lead to the same conclusion, it should not really be considered in the same argument as the normal physiological process as birth.

  26. Yes- we have a home from home unit and also a lot of our women have met their midwives before labour because we are moving to that sort of system. Normal births and home births increased by a lot, and also need for epidural decreased. Physiologically, any kind of stress response will inhibit labour which is why the contractions usually go off for a while once you get into hospital!To be honest, I think the answer is more small birth units and also home assessment in labour with the option to choose to have baby at home at that point if you want to, or go in to hospital. It means that the onus on women to choose place of birth so early on is taken away- and many women do a lot better in labour than they think they will and then opt to stay at home, but if you don't have that option, you choose the 'safe' one because a lot of women think it's homebirht with no pain relief and if anything goes wrong You and Your Baby Will Die, or Nice Safe Hospital, when actually it's a lot more mundane than that; if you change your mind you can always transfer in!

  27. UCH has a midwife led birthing unit at one end of the floor with the delivery suite. I didn't use it as I had high-risk pregnancies both times but friends have spoken highly of it. The chances of knowing your midwife in advance probably very slim mind. It would have been difficult for me at any rate as I saw a midwife for booking in and then a series of professors/consultants until the births themselves. I didn't have a choice of where to give birth but even if I did it would have been the hospital – I wanted to know that if I wanted heavy duty pain relief it was there and in the event I needed it the theatre was there and not a drive away. A bath full of blood and other fluids – no thank you.In my view it is post-natal care that is a disaster – not having a choice of a water birth or not.

  28. Obviously I wasn't present (I would rather visit the dentist and have all my teeth pulled without anaesthesia than watch) but they were all attempts at normal labour – no epidural, no forceps etc but I assume a four/ three pint transfusion after (varies according to the friend) = fairly huge blood loss but am willing to be corrected. I do have a fairly wide friendship group well gepgraphically spread out. All first (large) babies for women in their 30's I don't know if that has any bearing on it either. Mind you I probably would think 300ml lots of blood a littel spreads a long way. I managed to cut my finger stick it under a fast running tap, it sprayed and turned my kitchen into something out of a horror movie and I suspect it was actually less than a teaspoonful of blood.

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