Adapting My Birth Plan after Consulting with Mrs A the Midwife

Mrs A is truly amazing. Her name actually begins with ‘M’ but I’ll call her Mrs. A so you can remember how amazing she is.

(Mrs. EQ would have done equally as well as she’s very high in the EQ department).

She was due to do a home visit with me at 2pm and I overslept, waking up at 1.55pm. So when the doorbell rang  I answered it with my hair all over the place- as I’d been hoping to quickly moisturize it and comb it before she got to my house. Wishful thinking! I have a mass of curly, bouncy hair that I’ve been growing out, so no wonder she looked astonished!

Anyway, what I thought might have been a 20 minute visit took just over an hour. Clinic visits usually take 10 minutes but there’s something informal about a home visit with Mrs. A.

Like my dear obstetrician back in Trinidad, she makes you feel you have all the time in the world, so you do remember to ask all your questions.

In the end we concluded that so far I do continue to have a green light for a home birth. (Yaay!)

I was too hurried to show her the draft birth plan but I did resolve the uncertain issues through the discussion.

(You may remember when I posted the draft I reminded everyone that your own draft should be done in consultation with your health care provider!)

Issue #1: The option of a vaginal delivery for a breech presentation (which at the moment I don’t have as baby is head down and unlikely to flip over at 35 weeks) is definitely wide open but hospital policy will require intermittent monitoring at the very least and this on the labour ward. I will be free to labour as I like unless this interferes with effective monitoring.

Why not ease the labour and delivery with a water birth?

Mamatoto is a birthing centre in Trinidad

Mamatoto is a birthing centre in Trinidad

Well, Mrs A explained, because labour and delivery of a baby in a breech presentation is a bit more difficult than the usual head-down (cepahlic) presentation, the labouring mum needs to listen carefully to her body and immersing in water blunts the signals that the body wishes to give her. Remember the discomforts of labour are often a clue to use a more comfortable position to facilitate baby’s descent and the work of the uterus.

What about the long list of complications more likely with the breech vaginal delivery? (This is not to say that many a breech vaginal delivery has not be perfectly uncomplicated and beautiful!) Mrs. A said the most common problem is that the baby may need a bit of resuscitation. Welllll, even though this is often just simple “bagging” which can be done at home (stimulating the lungs by inflating them using a mask and bag of air that the midwife squeezes), I agree I’d want to be at hospital in this case – in the event it turns out to be a little more serious than that.

(now remember all this is theoretical and exploratory: I am almost certainly not going to have my baby flip over into a breeched position at this point!).

But what of the undiagnosed breech? The one that is discovered during the home delivery when the midwife notices a bum or a foot as the presenting part when mum and her uterus are pushing baby out?

Ah, the old phrase I remember from medical school days: “Hands off the breech!” Allow the mother to birth the baby and be ready with your bag and mask in case you need them. The mother and baby will not be served at this point by attempting a transfer to hospital. It’s simply too late.

How often does this happen? Very, very rarely. Yes, I know that’s not a statistic. LOL.

But this is what I’m rejoicing about: I actually have a choice. I was not told that delivering a breeched baby is routinely considered too risky by the vaginal route and I have no choice but to do a Caesarean. Now I accept that if there were other factors, diabetes of pregnancy (gestational diabetes as it’s called) and a baby who was Large for Dates for example, Mrs. A might have said, ‘Because of these factors a Caesarean birth will be safer for you,’ but the message was that taken by itself, a breech presentation does not always require a Caesarean birth.

I’m sure some obstetricians will not agree!

Issues #2 and #3

Should we work with a delayed clamping of the umbilical cord and a physiological birth of the placenta?

(These concerns were raised in my very last post). While I felt I wanted to research this matter in detail it was interesting that Mrs. A was very confident  that delayed cord clamping and physiological birth of the placenta (‘physiological’ meaning without the routine syntometrine injection given in hospital) appears to be routine practice for home births under her supervision!

She says at homebirths she and her team have been routinely delaying cord clamping until the cord stops pulsating and allowing the placenta to birth naturally

Well look at that!

I seem to remember that natural expulsion of the placenta often takes an average of half an hour but I forgot to ask her if this is likely to be reduced with a home birth of a third baby.

Would the transfer of additional placental blood to the baby by the pulsing cord lead to more physiological jaundice?

She says she has not seen any evidence that more babies have more physiological jaundice (self resolving and not disease related), as a result. She is interested though in another observation: that it seems as if the lochia (ie the post partum blood flow) is much reduced in mothers who use this method.

So that’s enough now. I’m sold. Mrs. A is confident and happy with delayed cord clamping and a natural expulsion of the placenta so I am too.

After all, which of us is experienced with home births?

Now I owe  you further explanations, I know. Now you might be more curious about the aforementioned risks of a vaginal breech birth and what the medical recommendations for cord clamping and expulsion of the placenta happen to be, since they are not in agreement with some of the opinions emerging from professional community midwives.

So, hopefully, between continuing to prepare the house for our new arrival and other routine business, I just might be able to share a few posts on the subject.

But I’m getting wiser now. *Sigh*.So no promises! I’ve broken enough since I started blogging and serving my facebook page!




Consideration Number One: Deliver the “afterbirth” naturally or with the usual “oxytocin” injection?

Forgive me for this awkward introduction but the “afterbirth” is also known as the “placenta” and is typically referred to as the placenta in medical literature.

When we were in medical school, the standard hospital practice taught to us was to help the mother expel the placenta by giving a synthetic “oxytocin” * injection during the birth of the baby’s shoulders. Typically this resulted in the expulsion of the placenta within five minutes of baby’s birth.

Some advocates of home birth, often doulas and community or private midwives, encourage the consideration of allowing a physiological birth of the placenta. That means “no injection, allow natural expulsion.”

This delays the birth of the placenta which may take 30 minutes rather than 5 minutes to be expelled.

I never considered this option till chatting with my doula a few weeks ago. I knew my iron stores were low from the last ferritin blood test done at 28 weeks gestation. (28 out of the proverbial 40 weeks of the pregnancy). I thought that taking the routine injection would therefore be better, as I should not risk the extra blood loss which we were taught in medical school is more likely with a natural birth of the placenta.

So having written my draft birth plan (see previous post), I decided to see what the research had to say!

Disappointingly, there was no clear conclusion. Midwifery journals included studies that suggested that physiological (natural) birth of the placenta was associated with less bleeding in low risk women. Medical guidelines for obstetricians maintained that active management (use of the injection), reduces the risk of post partum haemorrhage and they used the convincing argument that systemic reviews and the objective Cochrane reviews supported this position.

I used the Medscape website’s link to Medline to find these research conclusions.

Of interest, midwives have counter argued that the definitions and conditions used by research conducted by medical doctors differs from the definitions and conditions used by midwifery lead research. This point is phrased thus, “A psychophysiological third stage is quite different from what has been defined as ‘physiological management’ in the medically designed randomised trials comparing active versus physiological care.”

The trouble is that this line of decision making is not an isolated one:

The World Health Organization is currently recommending delayed rather than immediate cord clamping for full term newborns. Does it make sense, I ask myself, to delay the clamping of the cord if the injection to facilitate the separation of the placenta has already been given?

In my planned scenario, I am holding my baby after birth. Does the skin-to-skin contact and likely nursing or attempts at nursing that follow in this scenario facilitate a natural spike in oxytocin which is quite sufficient for a natural birth of the placenta with minimal bleeding?

Does giving artificial oxytocin hamper the release of natural oxytocin or will the effects be just synergistic?

Does it really matter? I’ve birthed two babies in the past, used active management (quick expulsion of the placenta), and been able to nurse both babies (though they did not get the hang of nursing nor have the inclination within the classic Golden Hour where it’s all supposed to magically happen after a natural birth!)

Well whether it matters or not it’s certainly interesting and before I finalise my birth plan I certainly want to read more, perhaps downloading some of the full research papers to come to a more solid conclusion.

Am I leaning in any particular direction? Well, you guessed it! My perfectly biased self is leaning towards the natural approach.

Ben Goldacre, in Bad Science, warns against the dangers of intuition but thus far I say stubbornly,  my intuition in previous birthing scenarios has not lead me astray!

Will keep you posted!

EDIT (June 5th 2013) : I’m really glad I used the inverted commas for the word “oxytocin”. It’s been more than 10 years since I’ve been on a labour ward and I confess I erred a little in this post. Artificial oxytocin (syntocinon) is often used during induced labour but rarely for expulsion of the afterbirth. It’s a combination of oxytocin and ergometrine (known as syntometrine) which is typically used in the “active management” of the placental expulsion.