These archives contain extracts from discussions held on the UK Midwives and Consumers email list, a discussion group for people interested in midwifery in the UK. Open to midwives, students, mothers, and anyone interested in improving maternity services in UK. Posts in these archives express the views of the individual authors, and not those of the Association of Radical Midwives.
Ok before I start, this is going to sound really stupid so please forgive my inexperience.
How do you learn to be hands off? I've only ever seen hands on births and
this is therefore what I practice although I know I'm quite gentle ie not doing
lots of flexing of the head etc. I'm very scared about doing nothing though
and no-one at my unit practises this way so how is it done. Do you know when
you need to be hands on ie are there any circumstances which would prompt you
to be more interventionalist? What would those be? What is the effect on the
perineum of hands off versus hands on? I've had one woman who birthed her second
baby in a standing position where to be honest I just didn't quite get my hand
there in time and head was out before I realised what was happening but she
sustained a 2nd degree tear and I keep thinking maybe I could have prevented
it. Previous delivery was an instrumental though so she was really really pleased!
Thanks as always.
AR Midwife - Loving the job but still with loads of questions
Have you been with a woman having a water birth? If you are with her, as the baby is being born, just watch. As the baby is born, you can float the baby through her legs (if she is leaning forward) and say to her to pick her baby up.
Next time you are with a woman having a baby not in water, have your hands
poised to take the baby so it does not fall on the floor (if the woman is standing
or kneeling up) and pass the baby to the mother. If the woman is on her back
or semi-prone, just watch the head be born. Women left alone will usually hold
back from really forceful pushing because of the discomfort of the head coming
out into the world, all on their own too! Many women tear and there is not always
very much we can do about that. Just trust the women, they usually know best.
You know when to intervene if someone is pushing very hard and fast, but I must
say, that most women at home do seem to know exactly what to do all on their
own.I had a client a few years ago who had PTSD from her previous birth which
was a CS. The baby's head was coming up, possibly 2 cm for the introitus and
visible and her whole perineum exploded, rectum, posterior vaginal wall, the
lot. The stage she was at was at a point that I would not have considered performing
an episiotomy (even if I was thinking of performing one which I rarely ever
do). THere was nothing I could have done to stop this happening. It was awful
and a very difficult repair. The doc in hospital was soooo kind. Her skin was
sooo friable. It was a strange complication and i hope I do not see many of
those in my life but there is often little one can do. I think bigger and worse
tears occur when we do interfere. Anyway, I don't want to start rambling and
I may do, so keep reflecting, questioning and thinking of what you are doing.
I never stop, isn't it tiring at times?
You may like to look up the 'HOOP' trial - Hands on or poised. They had a training video at the time, which showed a hospital delivery 'hands poised' style.This would be a start - the rest is talking to those of us who 'do it' that way.
There are many criticisms of HOOP - 'training video was a woman in semi-recumbent on bed' etc etc, but it at least looked at the alternative, and as a student at the time, it allowed me to train in more than one method - and I now choose 'hands poised'.The main point, I learnt, was that hands poised is more appropriate than 'hands off'. I do sometimes use my hands - but the most important thing for me, is that hands poised means that the baby is 'talked out' - it is essential to have the woman focusing on what you are directing her to do. Now, I know the whole 'direction' thing is a dirty word, but if we're not using our hands, and not using our mouths - why else are we there as midwives? When I say directing, I mean verbalising how the woman can slow the birth perhaps.Anyway - this is a huge and interesting subject - good luck.
By the way - the HOOP trial was huge and expensive! I recall one of the main published findings as being something daft like 'women experiencing less perineal pain on day 10' - but those of us in the trial also recall another unexpected outcome, which to my knowledge has never been addressed - there were more retained placentas in the hands poised group????I do also recall the funny moment when you were supposed to open the envelope - at crowning - which contained a red or a green card - red/stop - green/go/use hands. More than once we didn't do it in time!!! Used to drive the research midwives crazy.
I think the "exploding perineum" that you mention probably just does happen and there is not much one can do about it. I think it may be associated with a woman who is a bit short of collagen and there is not much one can do about that either. She's maybe got widely separated abd. recti as well.
However I do question your comment "many women tear". Frankly no they don't if one is selectively "hands on" . I am far more hands off now than I ever was, but I am hands on if I think prim's baby is coming fast and without much respect for its Mums perineum. Nature is not too bothered about tears. I flex heads and try and let them extend s l o w l y over the perineum I try and have the Mum BLOW during a contraction when the widest diameter is coming through and ask her to think of her baby s l i d i n g out g e n t l y Hopefully we will have talked about this antenatally and perhaps practiced it together.
I don't get many tears but then I am of a generation that got hell from Sister
if I got a tear that she considered avoidable. As a 1st part pupil I trained
in an establishment where women were not "allowed"(yes the A word)
to "deliver " in the dorsal osition because Gracie my targe of a LW
sister and mentor, considered it predisposed to tears. I was taught either Left
Lateral or almost on the knees and I did see squatting but not encouraged. Interesting
I am saying that I got the tears as a pupil, and that is how I still think of
it its ME that get the tear, not the women, I am obviously sort of subconsiously
still taking the blame for the tear!
I have been to check out the article but could only locate the abstract at
this moment in time. The authors state:-
"In normal labour, the smallest diameter of the fetal skull, the suboccipito-bregmatic,
presents through the woman's vaginal opening. In order to negotiate the 90 degrees
curve in the birth canal, the baby must change from an attitude of flexion to
an attitude of extension during birth... Flexing the fetal head cannot cause
a smaller diameter to present, and the pressure the birth attendant applies
to flex the head serves only to retard the emergence of the baby and unnaturally
force the emerging fetal head down toward the stretched perineum."
By my reckoning if we are flexing the baby's head, then instead of the SOB being
the presenting diameter, the SOF is, thus increasing the diameter from 9.5cm
to 10cms. Does that make sense?
I remember a long time ago reading a small book in a hospital library that
was a study of animal perineums at birth. They almost all had some tearing or
grazing.Unfortunately I have no idea of the title or author and the small unit
no longer exists.
I would never be absolute about anything in midwifery and that applies to
a hands on hands off approach as much as anything else, and I will always ask
women if it is something that they have thought about before labour even begins.
In my experience some women actually like feeling some light support on their
perineum and it gives them a sense of security. However, I do fundementally
believe that the mechanism of birth is designed to occur without someones hands
being there.
Karen Myrfields article, (Myrfield K, Brook C, Creedy D. (1997) Reducing perineal
trauma: implications of flexion and extension of the fetal head during birth.
Midwifery 13. 197-201) really made me sit up and think about what exactly we
are doing when we apply flexion, because in brief what Myrfield and her co-writers
state is that by flexing the head we are actually increasing the presenting
diameter which will surely lead to greater risk of damage to the perineum.
I attended a study day some ten years or so ago just at the time that the HOOP
trial was being carried out and the presenter explained that many of the midwives
who were recruiting for the trial had not seen a hands off birth. So they made
a video to demonstrate how a baby could be born without a midwives hands being
near the perineum. During the video I looked around the auditorium and saw almost
half the audience reaching out with their hands. Old habits die hard!! I won't
get onto the HOOP trial which I consider to have laid a false trail although
sadly one that continues to inform guidelines around the country vis-a-vis this
subject. I will just finish with the words of my friend Sara, which sums it
up for me really. "If babies needed hands to guide them out, wouldn't women
be born with an extra pair attached to their inner thighs? "
In my experience babies certainly usually don't need hands to guide them out
to a safe arrival and survival. However some mothers do need hands to to assist
the baby to be born with as little trauma to mum as possible. Nature is concerned
with the survival of species not the state of an individual woman's perineum.
Nature is fairly ruthless in making sure the fittest survive and tough on the
rest of us! I would be interested to see how assisting the flexion of a fetal
head as it is passing through the introitus increases the diameter. Its a long
time since I learnt mechanisms but I do not think the anatomy of the moulding
fetal skull can
have changed that much. I often have my hands on and I am unaware that my perineal
trauma rate compares unfavourably with that of my peers. I have also helped
occasionally "chin" a baby out over an intact perineum that it has
been bouncing on for the last half hour .
These postings make me want to sob. I have just had my fifth baby, here in France. The others were born in the UK. I ended up with the midwife on thetable (note, not bed) with me, pushing down on my stomach, legs in stirrups and the Ob doing a James Herriot impression, whilst yelling at the mw to extend my leg higher and press harder..............
Hands off (and Ob on Golf course) would have been wonderful.
Why didn't you yell at him to f--- off. and order him out of YOUR room. Just
like here, women will get the care they are prepared to tolerate
I personally don't believe it is women tolerating care. Telling someone to
F@@# off when vulnerable and/or being violated is extremely hard. If we were
to say the same thing to a survivor of rape or other abuses that it was as simple
as telling someone where to go, then a lot of cowardly abusers would I am sure
go scuttling off into the distance. The violations that occur in labour have
been described by many women in the same language that rape survivors use. Many
rape survivors also talk of "freezing" or being unable to talk/shout/move.
During the "birth" of my eldest son, I was physically unable to make
a sound although inside
I was screaming for it to stop... The psychology IMO is not so black and white!
Jumping in: probably, because she didn't know whether anyone better (or perhaps,
anyone else at all) would come if she did,
and by that stage, did not feel confident to give birth alone.
It is *extraordinarily* hard to complain about one's care in labour, constructively enough to have an effect. I felt badly cared for in labour. I was well informed (member of this list for years beforehand), I was at home, I had a supportive partner with me. I thought about telling the midwife to leave my home. I *DIDN'T DARE*, because I was worried about whether that would be worse for my baby. It didn't help that part of the problem was that the midwife had been (IMO) shroudwaving. If I couldn't tell her to go, I can't be surprised that this woman couldn't get rid of the OB. Incidentally, the midwife in question was an IM, ARM member, member of this list.
You just can't blame women for putting up with poor care in labour. Beforehand,
we do what we can to get the best care - as I did, engaging an IM and planning
home birth. Sometimes that isn't enough. During labour, there is usually no
real alternative. And afterwards, what can one usefully do? I wrote a long birthstory
which included part of the explanation of why I'd been unhappy with my care,
and gave it to the midwife. That was hard for me to do and hard for her to take,
but at least it was a constructive attempt to help her improve her practice
in future (and I learned things too which would be important if I were ever
pregnant again, but I'm not planning to be). I can't think of anything else
I could have done, before during or afterwards, that would have got me better
care.
I didn't post the birth story at the time, but if anyone's interested, I will (without naming the midwives concerned).
I would love to read it and I am very sad that a midwife made you feel like that in your own home.....I pride myself in thinking that IM's really do respect women in the true sense because they dont have the establishment breathing down their neck and questioning their every move.....it makes me sad that you still were not respected despite choosing an IM........
Reading through many of the last few days posts on this list I am concerned by what appears to me to be a lack of understanding of what we as midwives are for, and an apparent philosophy of nature knows best, so do not interfere. Well yes but for our professions sake, and the safety of women and babies, remember that there is most definitely a place for helping women to birth their babies as atraumatically as possible. My special interest is breech presenting babies, and yes hands off the breech is the norm BUT one does not sit on one's hands as babies die!, which in some cases the little darlings will unless the normal mechanism is assisted by a competent attendant (whom I think should be a person called a midwife, ) or it is recognised that nature intends to sacrifice this one, and that for that baby's safe delivery a surgical operation is necessary. .
Sorry for the rant but look at the mortality rates of "Nature" and
be glad that we have knowledgeable midwives who know when and how "nature"
needs a good kick.
Thanks for the post I know IT IS terribly difficult to be assertive in labour
but the scenario described of blatant assualt in France
on a woman who had had two normal births does seem pretty drastic and seemed
to call for drastic measures.
Congratulations to you for having the courage to raise your own issues with your midwife which as you probably had some relationship with her must have been really difficult, but it seems had a positive outcome. None of us are perfect, and we can all get it wrong at times, and I hope if I had got it wrong with a client (which I have), they would find a way of raising it with me.
But I do repeat we MUST not accept abusive treatment from anybody, . though
it does seem that I am blaming the victim. If women had not got off their backs
and ordered us not to make routine episiotomies I wonder if we would still be
doing them.
What a difficult situation, being in your own home I can imagine in normal circumstances (ie not in labour) much easier to ask someone to leave. However, being in labour makes it so much harder to assert needs especially when focused and concentrating on the job in hand. I do think your story is not an isolated one wherever a midwife may practice. What is good is that you informed the midwife of your concerns. I think the complaints system within the NHS tends to get buried in layers of beaurocracy which either stops women from complaining or the complaint doesn`t get addressed by the person whom you are complaining about!
If I were your midwife, I would have found it hard to hear the criticism but
would have definitely preferred to know. I send women an evaluation form with
a SAE after I have discharged the family from midwifery care. If I ever get
constructive criticism it surprises
me as it is often something that I really didn't have a clue about!
Thank you. I am no shrinking violet :) and this was my fifth baby. I have worked inthe NHS for nearly twenty years and dealt with my fair share of Godlike Consultants.....
BUT, there you are, desperately going with the flow and following your body and feeling the baby descend and counting the contractions and the minutes till you have the baby there with you - and BOOOOM, the door swings open, the lights go on, one's legs are hoicked up one after the other, the Obs dons gloves and starts yelling instructions at the mw. I was hardly in a position to complain, and with the babe en route and in the deepest throes of labour, hell, it was too late to order anyone out. It was Goya-esque. Really utterly dreadful. Tolerate is not the word I would have used. I was unable to walk properly for nearly a fortnight, and Maude was very bruised and had mild dystocia. However, I do have the yummiest baby daughter who actually came out smiling, like a Leboyer photo, and has been the smiliest baby of the lot, in spite of her battering at birth.
But a Consultant delivery - never, ever again.
And sometimes they just ignore you anyway. You can scream "NO" with
four people in the same room - and have every one act as if you weren't there.
I think I do the "talking the baby out" thing anyway and I have always discussed it with the woman prior to 2nd stage so that she understands what I am likely to say and why. I aim to be encouraging without being cheerleading but equally to slow the descent of the head to allow stretching to occur. With my hand I suppose I am controlling the head so it doesn't pop out like a champagne cork more than anything else rather than doing the true flexion thing.
Yes DP I've been with women having water births - lots in fact, but somehow
that is different in that no-one else touches the head either. What I mean is
that all the midwives practice in the same way and this is something new for
me and something which just isn't done in our unit. I am thinking about maybe
just not telling anyone that's what I'm doing as there is only me there for
birth anyway. Does that sound sort of devious. Not sure. Anyway, thanks to everyone
for your great input. I only have another two
weeks on delivery suite before moving to postnatal ward
LW updated June 4, 2005