Category: birth

Sweeps: How They Might Help (And Hinder) Your Birth

I’ve been talking a lot this week about cervical sweeps with different people and for different reasons.

I’ve been struggling with writing this post and how to angle it as I’m aware it could come across quite negatively yet many women will tell you they’ve had a brilliant experience with sweeps. And yet the evidence around them is insubstantial at best.

Let me tell you about some of the conversations I’ve had recently.

A woman in her first pregnancy had 15 attempted sweeps. That’s not a typo. Understandably she’s traumatised from the experience.

Another woman begging for a sweep from 35 weeks. She got one at 39 weeks. She was left crying, frustrated and defeated because it didn’t work and she’d pinned her hopes on it bringing her baby earthside.

A group of women joking about finding the midwife with the biggest hands to poke their babies out because they’re done with this pregnancy and babies are born before 40 weeks who are fine so why does it matter if theirs comes without waiting for spontaneous labour?

My first baby. Accepted a sweep even though I didn’t want one because I was told it would turn the niggles of early labour into something ‘proper’. The soreness and relinquish of control over what I really wanted set the tone for the rest of my labour and I was left traumatised.

My third baby. Accepted a sweep and on the face of it, it did what it was supposed to do and my baby was born not long after. But I was 42w5 and had been having contractions for weeks – she was coming soon. I accepted as a concession to the SOM who had to pick up the pieces of a registrar telling me my baby would die if she didn’t come out NOW in front of my 2 young children.

( I’ll digress slightly on that note. My baby was transferred from home to nicu shortly after birth to be treated for meningitis and sepsis. The amount of guilt I feel over potentially dismissing the warning signs at monitoring earlier that day will probably stay with me forever. Had the doctor actually listened to me and engaged in a meaningful, transparent conversation with me things may be different. I’ll never know because she didn’t. She will never know the impact she had but I’ll live with it forever.)

Back to sweeps. When did they become so prevalent and synonymous with birth? Why are women being offered – if you’re lucky, the ‘while I’m down here I’ll just give you a sweep’ mentality still exists – without being told they’re the first stage of the induction and intervention process? Why do we not encourage and practice patience when it comes to birthing babies?

They have their place, as all interventions do. But whenever we start interrupting the body’s physiological processes we start introducing risks.

So, let’s talk research.

They can reduce your chance of your pregnancy going over 42 weeks. For some women this is important because that’s the cut off that they’d accept induction of labour. For others who wouldn’t accept induction just for being post term then this isn’t important.

For women between 40-41 weeks of pregnancy there’s a 24% chance of your baby being born within 48 hours of the sweep being done.

They can shorten pregnancy by 1-4 days. Again, these few days might be really important for some women, whereas for others in the scheme of things it doesn’t seem worth it.

70% of women find them painful.

They can cause irritation to the cervix, bleeding and uncertain contractions.

There’s a 9% chance that your waters will break as a result of the sweep. If this happens you’re on infection watch and will be offered further interventions if your body doesn’t spontaneously go into labour within a certain timeframe.

As I said earlier, sweeps have their place. But why are they so commonplace? Why are we encouraging people as a matter of course not to trust their bodies to work as they’ve been designed to, but telling them that they need help? Why are we starting women’s pregnancies, sometimes at booking in appointments, by telling them that they need a medical procedure to go into spontaneous labour? Why is this for the many and not the few whose individual circumstances suggest it might be a good idea?

Image of cervical dilation because I didn’t think you’d want to see a picture of a sweep being carried out 

Stockport antenatal education

Vaginal Examinations: What You Need To Consider

During your pregnancy it’s a fair bet to say that a stranger will, at some point, request to examine your vagina. What fun! A vaginal examination is a relatively quick procedure where your midwife or other caregiver will insert their fingers into your vagina to feel your cervix. As with all things birth, whether you have them or not is entirely your choice. And as with most things there’s some real pros and cons either way.

Let’s have a look at the facts.

Number one on the con list is that someone is having a thorough rummage in your vagina. It’s a physically invasive procedure, sometimes painful, often disruptive to the flow of labour and can put you into a vulnerable state. Now, hopefully you’ll have some rapport built up with your caregiver by this point in the proceedings, but they’ll still be a relative stranger in the scheme of things and what’s more likely to send your adrenaline rising and oxytocin plummeting than being put in that situation? And as we know, you need a good supply of oxytocin – the love hormone – in labour to keep your uterus contracting nice and efficiently; when something happens that makes us uncomfortable, stressed or fearful, the amygdala part of your brain triggers your fight or flight response which releases a burst of adrenalin, inhibiting both oxytocin and the endorphins which are acting as your body’s natural painkillers.

Vaginal examinations are physical, and so present an infection risk. Perhaps not a huge risk in the western world where caregivers have access to plenty of soap, water and gloves, but a risk all the same. Bacteria can be pushed up the vagina, pass through the cervix and enter the uterus. The risk increases if the amniotic sack has displaced already, and some infections can be quite serious for babies in utero. Shockingly, in one study it was found that women who have had a vaginal examination in labour have 80% greater number of different bacteria in the cervix than those who hadn’t.

When a vaginal examination is carried out they can be useful storytellers to your caregiver, telling them important information, more on that below. However, they can also give you and your caregiver misleading tales. There are few rules in labour, no definitive timings, no guarantees that they will progress in exactly the way you have planned. So what happens if you’ve been in latent labour for hours and hours and get told you’re ‘only’ at 3 centimetres dilated? What if you’ve been in active labour for half an hour and you’re told you’re at 8 centimetres dilated? Do either of these things mean that your baby will be here at a specified time? Nope…in both situations baby could still be hours away from making their arrival, or they could be here within the hour. And yet your care pathway may very well be altered to fit the story that your caregiver believes your cervix is telling them. Not only that, but your own expectations can become hinged on the number you’re told and if the story doesn’t go the way you’re expecting then your flow of labour can be interrupted and throw you off kilter. If things happen more quickly or more slowly than you anticipated you could experience panic and fear, and fear leads to pain. And don’t forget distance measuring with only fingers for guides is subjective – if more than one person carries out the examination you could be in the position where measurements are miscalculated!

So what, then, are the pros from having a vaginal examination? Well they can give your caregiver information that they can use to build a picture of what’s happening in your labour. How far dilated you are alongside other factors can give an indication (but not a guarantee!) of how close to baby’s arrival you are.

Vaginal examinations can also tell your caregiver what position your cervix is in. As the cervix dilates it moves from a backwards facing position which protects baby, to a forward-facing position allowing an easy descent down the birth canal for baby.

The examination will also assist in ensuring you know your baby’s position. Again, this isn’t unique to vaginal examinations but in certain conditions such as malpresentation it’s important to have a clear picture of the situation so appropriate care can be given.

Vaginal examinations can be really useful if things aren’t progressing quite how you’d be expecting them to be. If they seem to be taking a wee while longer than expected to make their arrival an internal examination by a midwife can check their descent and position. This will tell them if baby’s position means they might need help to come along (such as asynclitic, breech or occiput posterior). It can also tell them if an intervention such as rupturing of the membranes would be appropriate to carry out. So where does this leave you and your choices? Vaginal examinations can be an important part of your care but should be used alongside other practices from your caregiver as a diagnostic tool. How judiciously they’re used is entirely up to you and your comfort level with them.

How To Release The Fear Of Labour Before Birth

I wrote this blog post for The Daisy Foundation all about how releasing your fear in labour can help ease your pain. Fear, tension and pain are in a self-fulfilling cycle, find out how to break it.

So you’re pregnant – congratulations! Now you’ve started to share the good news, we’re willing to bet that you’ve started getting the horror stories – the failed inductions, the 3rd degree tears, the days long labour…right? In the words of Chandler Bing could that BE less helpful?

Think about your reaction when you got the last round of grim labour stories. You winced, you grimaced, you clenched your pelvic floor and tensed your knees together? Oh yes, that’s the good old fear factor – fight or flight – setting in. Fear makes your nervous system produce adrenaline, which increases your heart rate, makes your breathing shallower, blood diverts from your non-essential organs and your muscles tense. Perfectly understandable…but now think about where your baby’s going to come from. Uh huh. Your body being tense from your belly button to your knees isn’t going to help your baby on their way, is it? Your fear leads to tension, and tension leads to pain.

When adrenaline is produced in a labouring person, it inhibits the production of two other hormones; oxytocin and endorphins. It’s these two hormones that are responsible for stimulating the contractions of the uterus, and for blocking the feelings of pain. Without these present in sufficient quantities labour will be longer, more stressful, and more painful than if we allow our bodies to limit the production of adrenaline.

So what if you were told that you can help reduce the pain of labour? Hell YEAH. Let’s start by looking at the fear aspect of the cycle. Fear of the unknown is a well-established phenomenon and it holds true in labour too. Just as each birthing person and each pregnancy is different, so too is each birth experience. For a first-time mum with no point of reference, the thought of pushing a baby out of a hole that small can be pretty terrifying. Reduce the unknown, however, and you can reduce the fear. And that’s where antenatal education comes in. A knowledgeable, informed woman is one who no longer fears the unknown. Now – no woman can plan their birth experience entirely, otherwise we’d all be having two-hour labours with no tearing or pooing (am I right?) but by becoming knowledgeable about the birth process, about the options available to you and about how you can influence the birth to be the best possible outcome on the day by playing the hand that’s dealt, then you can make it all a lot less scary. What’s more, by being so well prepared, this knowledge becomes innate and you won’t have to rouse yourself too much from your birth bubble to give consideration to anything that might need a decision from you. Coming out of that internally focussed zone allows adrenaline to creep up – not good for your oxytocin levels.

We’ve looked at how you can reduce your fear by preparing your cortex (your ‘thinking brain’, responsible for knowledge and decision making) ahead of the big day, but you can also prepare your limbic system (or ‘emotional brain’) to release fear. Now your limbic system is responsible for many things, one of which is your fight or flight reflex…yep, that again. And where knowledge and information can affect your cortex, we need a different language to speak to the emotional brain. Something that will help you exercise the part of the brain which switches on – and off – that adrenaline switch. This is where relaxations and visualisations come in. Using guided visualisations such as seeing each contraction as a wave building up in intensity, peaking and gently rippling away while in a state of pain-free relaxation can encourage your body to return to that state when anchoring itself to those visualisations in labour. Your breathing becomes easier and floods the body with oxygen, your muscles are relaxed and free of tension which makes each contraction more effective, you’re disassociated from feelings of pain which keeps oxytocin and endorphin levels high. Pretty impressive, right?

There’s another way to keep adrenaline, fear and tension out of the birthing room with you, and that’s the room itself. Imagine a stark white, brightly lit room that smells slightly of Dettol that hums with the electric lights. Now picture a dimly lit, warm room filled with your favourite scent and music. It’s unlikely you’re going to be feeling very comfortable in room number one. And if you’re not comfortable, if you don’t feel safe and secure, then your adrenaline will rise and your labour might stall. So really think about preparing your birth space to be a place where you can feel comfortable in. Many hospitals and birth centres are really accommodating at letting you take in goodies from home.

Now, I’m not saying that birth can or should be pain free. But we do know that working with our emotional and physical selves, really understanding the physiology of how our bodies work, can reduce the experience of pain. And that’s a bloody good start to giving birth isn’t it?

Three Ways Of The Third Stage

Once baby has been born the placenta is no longer needed either by the maternal body or the baby. It is this process of being expelled that is called the third stage of labour. There are three ways in which this can be delivered: the physiological, the active or the expectant management.

A physiological – or natural – third stage means waiting for the body to resume a pattern of contractions by itself, causing the placenta to detach from the uterine wall and be delivered by the woman. This can take anywhere from around 10 to 60 minutes. The cord is left intact during this time, allowing all the blood from the placenta to transfer to the baby, and is only cut when the placenta has been delivered – the term delayed cord clamping is used to refer to this. Optimal cord clamping – to mean that the cord is cut only when it stops pulsating – is the WHO recommended practice to best supply the baby with iron supplies until around 6 months of age although any delay does pose an increased risk of jaundice needing treatment in the baby.

A physiological approach to the third stage occurs mostly in midwife-led units and home births, where continuity of care to women can be practised[1]. This is probably due to the birth being seen as a normal life event rather than a medical ‘problem’ that needs to be fixed; an attitude often seen in consultant-led units.

In comparison, an active third stage involves giving a prophylactic uterotonic, i.e. a drug that stimulates contractions of the uterus, cord clamping and controlled cord traction. The drug syntocinon or syntometrine will be injected as the baby is born or immediately after and the cord will be clamped and cut in order for the drug not to transfer to the baby. The midwife will keep a hand on the woman’s fundus to check that the placenta has detached and will either encourage the mother to push the placenta out or will carry out controlled cord traction to help it on its way out.

By cutting the cord of the baby at this stage the baby could be deprived of up to a third of its blood as it has not had chance to transfer from the placenta. On the other hand, there is evidence to suggest that active management decreases the risk of heavy blood loss immediately after the delivery of the placenta. For this reason, it is generally advised that women who have had interventions have an active managed third stage as these increase the risk of heavy blood loss[2].

For some mothers there will be a health risk associated with a decision to pursue a physiological third stage and these women will be offered active management as an alternative. However, if this is declined then ‘watching’ or expectant management may be suggested, which aims to start with a physiological delivery and switch to active management if needed. The main concern is for women for whom a large blood loss would be extremely detrimental, or where there is already an increased risk of heavy blood loss. This is because the drug used in active management reduces blood loss immediately after the delivery of the placenta[3]. However, this method also reduces the baby’s birthweight due to the non-transfer of blood from the placenta and further has been shown to increase the mother’s blood pressure, heighten the intensity of afterpains and cause vomiting and the readmission of the mother to hospital for the treatment of prolonged bleeding (Beglet 2015).

If the mother chooses a physiological third stage there are means of encouraging the placenta to detach in a timely manner and avoid the risk of having to resort to active management. Michel Odent[4] teaches that it is important to keep oxytocin levels up while the placenta is being delivered, to contract the uterus and push the placenta out and there are a number of ways this can be achieved. Keeping the birth environment calm, quiet, warm and dimly lit will inhibit the production of adrenaline and keep oxytocin flooding the body. Skin-to-skin contact[5] and breastfeeding the baby in the ‘golden hour’ post-birth will also help the woman’s body release oxytocin and shorten the length of the third stage. If a woman has received artificial oxytocin during the augmentation of labour it may be more difficult for her body to produce it naturally, making these actions really important for her to have a physiological third stage. If not enough oxytocin is naturally produced, then the injection would likely be necessary.

Being in an upright position may assist the expedition of the delivery of the placenta and without the need for intervention as gravity does its job of easing it out of the woman’s body. It is shortening the length of the third stage that may be the key to reducing the risk of severe post birth bleeding[6].

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[1]Blackburn S. (2008) Physiological third stage of labour and birth at home: In: Edwins J. (Ed.). Community midwifery practice. Blackwell: Oxford.

[2] https://www.nct.org.uk/birth/third-stage-labour

[3] Begley, CM, et al (2015) Delivering the placenta with active, expectant or mixed management in the third stage of labour Cochrane Database of Systematic Review

[4] Odent M, (2001) New reasons and new ways to study birth physiology. Int J Gynaecol Obstet

[5] Marin GMA, LLana MI, Lopez EA, et al. (2010) Randomizd controlled trial of early skin-to-skin contact: effects on the mother and the newborn. Acta Paediatrica

[6] Magann EF, Evans S, Chauhan SP et al. (2005). The length of the third stage of labor and the risk of postpartum hemorrhage. Obstetrics and Gynecology

Birth Positions Which Can Help You Give Birth More Easily

Many women enter pregnancy having only seen labour occur on television, where women are laid on a bed, knees up, chin to chest, ‘purple pushing’ interspersed with screaming. Understandably, this can lead to some nervousness on the pregnant woman’s part!

The weight of research[1] shows that upright labouring positions can provide advantages to a birthing mother. In an upright position, gravity can assist the baby within the uterus by bringing it down and out, as well as helping keep it in the optimal foetal position when coupled with leaning forward. Being upright can also reduce the risk of aorto-caval compression which could result in a reduced blood supply to the baby. Upright positioning uses gravity to bring a stronger connection between the baby’s head and the cervix, releasing oxytocin and giving more efficient uterine contractions. In traditional squat and kneeling positions the pelvic dimensions become wider, allowing the baby to pass through with more ease. As well as increasing the comfort of the mother and improving the overall birth experience, the positive impact of these positions on the pace and efficiency of labour tend to make interventions less necessary and therefore less common.

The benefits of upright positioning don’t stop there either. Studies have shown that an upright position during the first stage can both reduce pain in the labouring woman[2] and shorten that stage, reducing the need for pain relief and preventing exhaustion in the woman. Interestingly the physical position a woman is in to give birth can also have a psychological impact: being able to find a comfortable position and knowing that the woman’s own movements are helping the baby be born more easily can give feelings of control and stem any fear and anxiety arising from the situation. By reducing stress and discomfort, these psychological responses to a good birthing position can make the whole experience more positive.

Despite the considerable evidence for the benefits of upright birthing positions, the actual positions that women give birth in do not reflect the evidence or national evidence based practice guidelines and nearly half of deliveries are made in a semi-recumbent position[3]. In developed countries where pregnancy and labour has become medicalized, interventions such as foetal monitoring and different types of analgesia can limit the options for position of a birthing woman[4]. A Cochrane review theorises that women are encouraged to push in supine or semi-recumbent positions simply because it is more convenient for the healthcare professional to gain access to the woman rather than being beneficial to the woman. Women ‘choose’ these positions on the basis that they think it is expected of them when presented with a bed in a hospital setting, coupled with the cultural expectation ingrained in them as seen previously, through the medium of television[5]. It is important that the woman knows what positions will help her and to have the confidence to try these positions without being led by the healthcare practitioner in attendance.

A Cochrane review[6] compared the risk of interventions and birth outcomes for upright birthing positions in comparison to non-upright birthing positions and concluded that upright positions can be associated with a shorter length of first stage of labour; a reduction in the use of epidural analgesia; almost a quarter less likely to have an assisted delivery; 20% less likely to have an episiotomy but 35% more likely to have a second-degree tear; 50% of births are less likely to have an abnormal foetal heartrate and 65% are more likely to have a blood loss of more than 500mL. The review found that there was no difference in birthing positions on the length of the second stage of labour; emergency caesarean rates; third or fourth-degree tears; blood transfusion rates; neonatal admissions or perinatal deaths. As there is only a negative impact on second-degree tear rates and blood loss by being in an upright birthing position, it seems clear that upright birthing positions really are the most beneficial, especially as tears can heal more quickly and neatly than episiotomies and there is no knock-on effect on blood transfusions needed.

The birth position chosen by the labouring woman may have a specific purpose. Different positions can bring relief to different complications. For example, if shoulder dystocia presents then the Gaskin Manoeuvre[7] of turning onto all fours and being on hands and knees will cause changes to the pelvic shape which will allow the shoulder to release and the baby to be born.  All fours positioning will be useful for women whose baby is or has turned occiput posterior in labour. Gravity and rotations can help the baby rotate to anterior position[8] although Balaskas points out that when the baby begins to crown each woman should become as vertical as possible to help it out. The use of these positions and a mother’s existing familiarity with them will help to reduce the need for interventions.

There is not just a physiological impact from birth positions on a woman, but psychological too, and these can prefigure the birth itself. Knowing that she can speed up her labour or slow it down if she feels overwhelmed puts her in a position of power. A woman who feels like she is in control of her birth, who feels as though she has a variety of tools at her fingertips to assist a range of experiences she may encounter, will be more empowered to deal with how her labour goes. In contrast, being in a supine position promotes a vulnerability in a healthcare setting that the woman must shed in order to birth most effectively; being upright will automatically help with that.

Ultimately a woman must birth in the position in which she is most comfortable, and the care providers around her must work with her to help her accomplish that goal.

[1] MIDIRS (2008) Positions in labour and delivery. Informed choice for professionals leaflet Bristol: MIDIRS. See also: Gupta, J et al (2012) Position in the second stage of labour for women without epidural anaesthesiaCochrane Database of Systematic Review

[2] Miquelutti, MA, Cecatti, JG (2009) The vertical position during labour: pain and satisfaction Revista Brasileira de Saude Materno Infantil

[3] Royal College Of Midwives (RCM) 2010 The Royal College of Midwives’ Survey of positions used in labour and birth London : RCM

[4] 2016, W.H.O. (2015) Position in the second stage of labour for women without epidural anaesthesia. Available at: http://apps.who.int/rhl/pregnancy_childbirth/childbirth/2nd_stage/tlacom/en/

[5] The Royal College of Midwives (2012) Evidence Based Guidelines for Midwifery Led Care in Labour: Positions for Labour and Birth

[6] Gupta, J et al (2012) Position in the second stage of labour for women without epidural anaesthesia Cochrane Database of Systematic Review

[7] Gaskin, I.M. (2003) Ina May’s guide to childbirth. New York: Random House Publishing Group.

[8] Balaskas, J (1989) New Active Birth: A Concise Guide to Childbirth,London: HarperCollins