informed choice - Stockport Birth Services

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

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

What Is The LOA, The OFP, And Other Acronyms.

The presentation of baby in labour is extremely important for how that labour progresses. Most women know, or come to know, through their pregnancy that their baby should be head down in preparation for birth: but even a head-down baby can be in an optimal or suboptimal position depending on where their spine aligns. The baby’s position is important as it affects their ease of rotation and descent as they travel through the birth canal.

The occiput anterior position is the most effective way for the baby to travel down through the pelvis and make its way into the world. The baby is head down, facing the maternal spine which gives space for the chin to be easily tucked in onto their chest allowing the smallest part of their head to fit through the cervix first. The soft bones at the fontanelle fold to make their head smaller still. This position allows the baby to travel through the pelvis as easily as possible. There is less likelihood of a baby in an occiput anterior position needing medical assistance in being born.

The occiput posterior position, while head down, is not so effective at helping the baby on its way through the pelvis. The baby’s spine is aligned with the mother’s such that the baby is facing towards the mother’s naval. As the baby descends they have to rotate all the way around so they’re facing the back, often making the labour longer and more painful, with the pain being felt at the woman’s back caused by the hard surface of the baby’s skull pressing on the mother’s back. It is more difficult for the baby to tuck their chin down, meaning that the diameter of the presenting part of the head is bigger (approximately 11.5cm) than if presenting in an anterior position (approximately 9.5cm).

There needs to be a good connection between the baby’s presenting part and the cervix in labour in order for oxytocin to be released – oxytocin being the stimulus to the uterus contracting. An occiput anterior position allows the best fit of the baby’s head into the cervix, resulting in good contact and hence causing a good flow of oxytocin to be released. When in labour, kneeling positions can encourage this contact by allowing gravity to assist in putting pressure between the baby’s head and cervix. If the baby is in an occiput posterior position, these movements will not be working as effectively for the baby or mother. This can result in a long latent phase of labour for the mother or having a stop-start pattern to contractions.

It was Jean Sutton and Pauline Scott in 1996 who coined the phrase ‘optimal foetal positioning’[1]. Through their work they showed the importance of the mother’s posture and position in pregnancy and labour. They showed that babies who start labour from a left occiput anterior position seem to birth easier. Babies in that position tend to curl the crown of their head into the mother’s pelvis better, allowing a flexed vertex presentation of the skull with a diameter of approximately 9.5cm.

Sutton and Scott noted that the number of left occiput anterior presenting babies are decreasing in recent decades, and attributed this to the change in lifestyle of women. Women are less likely to spend substantial time in active physical housework (often leaning forwards or on all fours) and more likely to spend their time relaxing on laid back sofas. Gravity does the rest in pulling the heaviest part of the baby – its spine – down towards the mother’s spine. By paying particular attention to the encouragement of a left occiput anterior position during the stage of pregnancy where the baby is beginning to start engaging (around 36 weeks for a first time mother and slightly later for biparous or multiparous women) women can help themselves have the most efficient labour possible.

There are ways for women to help position their baby optimally by building in things to their everyday lives. These include: changing their sitting style to ensure their knees are lower than their hips; not crossing their legs; kneel over a birthing ball while watching television; not putting their feet up; sitting on a birth ball not a sofa and swimming using breaststroke or front crawl.

Babies who are right occiput anterior may rotate away from that position as they travel through the pelvis and become posterior during labour. Indeed, Gardberg (1998) states that the majority of occiput posterior babies in labour start off as occiput anterior[2] – likewise the majority of posterior babies will turn in labour too. This, then, would lead to the conclusion that while there is an optimal position to begin labour in, it really isn’t a defining moment for the mother if baby turns away from this position.

[1] Sutton, J. and Scott, P. (1996) Understanding and teaching optimal foetal positioning. 2nd edn. Tauranga, New Zealand: Birth Concepts.

[2] Gardberg, M. (1998) Intrapartum sonography and persistent occiput posterior position: a study of 408 deliveries.

Antenatal Education: Why Is It Important?

The pregnancy and perinatal period is one of immense change for a woman as she gets to grips with becoming a mother, both physically and emotionally. In many regards, particularly for first-time mothers, pregnancy is a threshold which separates the known world from one that will be radically different. In this context, emotional balance is likely to be disturbed readily and substantially. Antenatal classes provide a safe space for women to explore this change and empower themselves with knowledge and confidence, while reflecting in an informed manner on the change that awaits them. As will be elucidated here, this provision of balance is achieved through the careful consideration of and respect for the relevant social, hormonal and bonding factors, as well as each mother’s own belief structures and anxieties.

A big consideration when thinking about a woman’s changing emotional state while pregnant is that of her adaptation to her new role, either as a first-time mother or when changing the family dynamic to include more children. Both parents are understandably nervous about that which they don’t yet know and this can cause extreme challenges within the family unit and for the parent’s mental health. Cowan and Cowan argue that there is a “conspiracy of silence[1]” around the pregnancy and newborn period that can make parents feel that they’re the only ones that are struggling. One only needs to take a quick glance at the multitude of mother forums online to see a glut of ‘am I the only one…’ and ‘is this normal…’ postings by mothers who suffer from a lack of support around them. One of the big reasons that women seek out antenatal classes is to make friends with other like-minded people in a similar situation to them, and a key role for the antenatal teacher is to help facilitate friendships within the groups they teach. Having a support network of people going through similar experiences will help de-mystify their journey and ease many worries of each woman.

Classes where a woman can take some time to focus and centre herself will be beneficial to those who are dealing with pregnancy difficulties bigger than those ‘normal’ feelings and worries. Helping mothers to use techniques to have control of their own labour can help to counteract the negative impacts of health concerns that the mother may have about her own body or that of the baby. Antenatal classes help to empower women to make genuine change over their pregnancy and to benefit from the confidence this gives them. Antenatal teachers help a woman take charge of her body, filling her with self-belief by empowering her with knowledge and therefore control of her pregnancy and birth, the definition of antenatal classes according to Dick-Read who champion antenatal education to remove anxiety and dread, inhibiting fear and replacing it with confidence and increase normal labours and pregnancies[2].

There have been studies which link the level of a mother’s bonding with her child after birth to the amount of engagement with her pregnancy and the thoughts she has around it and what the baby will be like once born[3]. Benoit, Parker and Zeanah[4] linked this to the security of attachment the baby has to its parents in the first year of life. Antenatal classes encourage the mother to focus on her baby, creating a peaceful bond between them and soothing anxieties that they may not develop a strong bond. Antenatal teachers aim to anchor these bonding moments through techniques used in pregnancy which baby will recognise and be soothed by once born. Classes are spaces within which mothers can reflect on their pregnancy and learn to prepare for the future; this has substantial benefits for her emotional balance.

It is not unusual for a pregnant woman to experience feelings of stress, anxiety or depression; often this is from the usual worries and concerns a woman has when embarking on a pregnancy as seen previously, and it is important that we encourage women to let these worries go. Creating balance and harmony in her mind has a knock-on effect on her body; there are a number of studies which show various physical responses to anxiety and stress hormones in the pregnant body including reducing oxygen and calorie intake to the baby, maternal cortisol crossing the placenta and restricting foetal brain growth, growth delays, reduced levels of serotonin, reduced ‘quiet and active alert states’ when born and increased risk of hyperactivity in the long-term[7]. As Gaskin alludes to, when the mind is steadied the body can open for birth[8] and it is our aim to equip each mother with the tools to help balance her mind as well as her body.

[1] Cowan, C.P.P. and Cowan, P.A. (1993) When partners become parents: The big life change for couples. New York: Basic Books.

[2] Grantly, D.-R. (2006) Childbirth without fear the principles and practice of natural childbirth. London: Pollinger in Print, United Kingdom.

[3] http://www.refuge.org.uk/get-help-now/what-is-domestic-violence/domestic-violence-and-pregnancy/

[4] Dex, S and Joshi, H (2005) Children of the 21st Century: From Birth to Nine Months. Bristol: Policy Press

[5] Stern D (1985) The Interpersonal World of the Infant. London: Karnac Books

[6] Benoit D, Parker K and Zeanah C (1997) Mother’s representations of their infants assessed pre-natally: Stability and association with infants’ attachment classifications. Journal of Child Psychology, Psychiatry, and Allied Disciplines

[7]https://www.rc.org.uk/sites/default/files/Emotional%Wellbeng_Guide_WEB.pdf

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