Birth

The issues with “active management” of the third stage

I have a few issues with this phrase and the way it is presented to women both in pregnancy and in the moments after birth. Language is incredibly important when it comes to pregnancy and birth, and for too long the negative impacts of the language used in maternity care has been ignored. I believe that “chemically induced third stage” is a more accurate term for what is currently known as an “actively managed third stage”.

The phrase “Active Management” and what it implies

Firstly, the phrase “active management” comes with some serious implications. It suggests that this is the safe, controlled way of birthing your placenta and that waiting for your body to do what it is designed to do is “unmanaged” and therefore dangerous. I went to a birth recently where the midwife described the cervix as a “vice” and told the woman that “sometimes nature just doesn’t do enough to get it out” – this kind of attitude towards women’s bodies is a huge problem in my eyes.

The importance that is put on the length of time passed since the baby was born is immense, but with very little evidence. By calling it a “chemically induced third stage” it is making it clear that this is an intervention that involves medication and is the act of forcing the placenta to be born before the body is ready to do so on its own. It seems appropriate given that it is essentially the same as chemically inducing labour – injecting a woman with an artificial “hormone” to force the uterus to contract.

 

What the body needs for a smooth birth of the placenta

The birth of the placenta needs the same basic things as the birth of the baby. A woman in labour needs to feel safe, unobserved and undisturbed – the same applies to the birth of the placenta given that it uses the same hormones.

If you ever witness an undisturbed birth, and the environment stays the same after the baby is born, you will see a smooth birth of the placenta too. It may not happen fast, but it will happen. If you witness a birth with midwives present, or people around who are looking for danger, on high alert and full of adrenaline, you will see the environment change entirely. The voices that were soft (or better still, silent) for the many hours prior are suddenly at a normal volume, asking questions and stating observations, the lights might even come on and suddenly the birth space is no longer the safe cacoon that it was before.

If midwives are present, the clock is started – they are counting down the seconds until the placenta is born, perhaps not once considering that by asking the woman questions and observing her so closely they are hindering the process. The fear is contagious, even if it is not justified. Despite there being no known “normal” length of time for the placenta to come, the 60-minute limit is applied and so the pressure begins, even though there is no evidence (nor common sense reason) that a woman’s cervix would close itself naturally before birthing the placenta. It does however make sense that this might happen if the woman has induced artificial uterine stimulation due to the use of Syntometrin.



The risk and varying definitions of post-partum haemorrhage

The common British definition of a haemorrhage is 500mls, whereas in Holland the definition is 1000mls. Whenever there is a big difference (in this instance a HUGE difference) in policies and guidance, it makes me question where they are getting their numbers from. What are they basing these thresholds on if they are so vastly different?

We know that when a woman is pregnant her blood volume increases dramatically, so whether this extra blood comes out immediately after birth, or in the weeks or months following, it is likely the same amount in total. The measurement of blood loss also doesn’t tell us much – one woman could lose a lot of blood and feel perfectly fine, another could lose a small amount and feel awful – surely the way the woman feels should determine whether medical attention is needed, not an estimated measurement.

The supposed benefits are based on very low-quality data, all of the studies were undertaken in hospital settings and according to the Cochrane Review;Although the data appeared to show that active management reduced the risk of severe primary PPH greater than 1000 mL at the time of birth, we are uncertain of this finding because of the very low-quality evidence. Active management may reduce the incidence of maternal anaemia (Hb less than 9 g/dL) following birth, but harms such as postnatal hypertension, pain and return to hospital due to bleeding were identified.”.

We know that the risk of having a PPH is significantly lower for women who plan a home birth, even if they transfer into hospital for the birth itself. So why is the same low-quality data that only applies to hospital births being implemented into standard practice at home births too?

Also, as a side note, the maternity system can’t be massively concerned about preventing PPH when they are inducing women at alarming rates, which also increases the risk of having a PPH.



The risk and definition of “retained placenta”

re·tained pla·cen·ta

incomplete separation of the placenta and its failure to be expelled at the usual time after delivery of the child.

So what is the “usual time”? The National Institute for Health and Care Excellence (NICE) recommends that; “the third stage is diagnosed as delayed if it takes longer than 30 minutes to deliver the placenta with active management or 60 minutes if allowed to deliver the placenta physiologically with maternal effort.” 

* Notice the use of the word “allowed” – this is what I’m talking about with the use of language *

However, this doesn’t even begin to encompass the wide range of normal. From listening to women’s stories who birthed with no medical staff present, their third stages lasted varying amounts of time with no ill effects. In one freebirth study published in a midwifery journal, they varied from 30 minutes to 5 hours, and some women anecdotally report going to sleep for several hours before birthing their placenta.

According to an article in ‘Best Practice & Research Clinical Obstetrics & Gynaecology’, in less developed countries, retained placenta affects about 0.1% of deliveries, whereas, in more developed countries, it happens in around 3% of vaginal deliveries. Considering the intervention rates are higher in developed countries, this leaves a lot of questions about what is causing the increase in cases of retained placenta, how they are defining “retained placenta” and whether these stats are referring to women who do not have the injection or include those who do.

There are very clear symptoms of a retained placenta that is causing an issue, but in the standard practice of midwives, they do not wait for any of these symptoms. Instead, like many of the standard practices in maternity care, they simply assume that the body is incapable of performing its natural functions and intervene too soon. 

These are the symptoms of a retained placenta;

  • Constant pain
  • Fever/high temperature
  • Passing large pieces of placental tissue
  • Heavier than expected bleeding
  • Foul-smelling vaginal discharge

* Note that having an extended period of rest between the birth of your baby and your placenta isn’t listed as a symptom, so decisions to intervene should not be based on that without any actual indications of a problem.

 

The risks of Syntometrin

Syntometrin is the injection given for an induced third stage. It is made up of oxytocin and ergometrine maleate. Women are quite often told all of the risks of doing nothing, and only the so-called benefits of having the injection and getting it “all over and done with”. From my experience, the only reason women have accepted the injection (even when they had previously declined), is due to fear and/or to stop the constant pestering. The coercion that I have witnessed during that golden time between the birth of the baby and the placenta is truly awful and eventually takes its toll.

We know that with the injection the placenta tends to come fairly quickly, but at the cost of added discomfort due to fundal pressure and cord traction (having a midwife push on your bump and pull on the cord). But there is rarely any mention of the risks and side-effects of having the injection.

In reading the information provided on Syntometrin, here is what I found on the risks:

  • Ergometrine is known to cross the placenta and its clearance from the foetus is slow. Concentrations of ergometrine achieved in foetus are not known.
  • Ergometrine derivatives are excreted in breast milk but in unknown amounts. It can also suppress lactation.
  • Ergometrine can cause vasoconstriction
  • Caution is required in patients with mild or moderate hypertension, cardiac disorder, or hepatic or renal impairment
  • Oxytocin should be considered as potentially arrhythmogenic
  • Patients should be warned of the possibility of dizziness and hypotension

Some of the reported adverse drug reactions:

  • Anaphylactic/anaphylactoid reactions associated with dyspnoea, hypotension, collapse or shock
  • Headaches
  • Dizziness
  • Myocardial infarction (heart attack)
  • Chest pain
  • Vomiting
  • Nausea
  • Abdominal pain
  • Hypertension

 

“It might just be sitting there”… So what?!

We often hear this from midwives; “It’s likely that your placenta has detached from the uterine wall and is just sitting there on your cervix”. Okay, that makes sense… so what? What is the issue?

In our work as doulas, we trust in birth, we trust in women and their intuitive wisdom. We trust that if a woman feels well, she is well, and if something isn’t right she will know what to do. Women who have had undisturbed births describe feeling contractions and then a sudden urge to move positions due to feeling uncomfortable sitting or lying down, and with this movement, they birth their placenta. These women weren’t timing their third stage or being told when and how to move – just as in their labour, they were listening to the most up-to-date information their body was giving them and acting or waiting, accordingly.

So is a placenta truly retained if it just hasn’t had enough time to come out yet? If it isn’t causing any of the obvious physical symptoms of a genuine issue, does it just need time and patience? Does the presence of someone who is timing this pause have a negative impact on the process? Why are we treating every woman as if a PPH is incredibly likely when that isn’t the case? In the same way that the “failure to progress” label is put on women whose labours aren’t following an arbitrary timeline, intervening can lead to a whole host of other issues, not least that woman feeling like her body failed when the reality is that the maternity system failed to wait.

 

 

Resources:

https://sarahbuckley.com/leaving-well-alone-a-natural-approach-to-the-third-stage-of-labour/

https://www.medicines.org.uk/emc/product/865/smpc

https://www.evidentlycochrane.net/third-stage-of-labour/

https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-12-130

https://www.bellybelly.com.au/birth/how-inductions-increase-the-risk-of-haemorrhage/

https://www.sciencedirect.com/science/article/abs/pii/S1521693408000965

Birth, Human Rights

10 Things We Wish All Women Knew

1. Freebirth is LEGAL

This one is pretty simple so I’ll keep it short. You have the right to birth your baby wherever you like, with whomever you like. You have the right to decline maternity care altogether if it isn’t serving you. You have the right to give birth without a midwife present. It is not illegal. We often hear from women; “I was told it was illegal and that my partner could be arrested!” – this is complete rubbish. It’s a scare tactic to make us think that we HAVE to engage with maternity services and that we HAVE to have a midwife present. Can you imagine the ruckus it would cause if women realised that they didn’t need to put up with being told what to do, how to move (or not move), when to push, or being poked and prodded whilst they’re trying to listen to their body? … it might just topple the system.

 

2. Birth is a normal bodily function that needs very basic things to go smoothly

Birth is made out to be this really mysterious thing that, if you’ve never done it before you couldn’t possibly know how to do it without being told. But that’s just not the case. If we treated all bodily functions in that way, intervening before giving the person enough space and time to follow their own body, it would cause all sorts of issues. If we decided that it was too risky to poo on your own because you might brew a poo that’s too big to come out, so it’s much safer to cut you open and get the poo out that way instead… we’d be in a pretty big mess. And you would probably question it because… we’ve been pooing by ourselves for millions of years. But surely birth is different… oh wait. No, it isn’t. Human women have been giving birth without being told how since the beginning of humans, and before humans, the rest of the females of all species did it too. You might hear the argument “yeah but… loads of women and babies used to die from childbirth!”, and that’s not incorrect, but the technology didn’t fix that problem. We are much healthier as a species nowadays and we learnt that washing our hands can help to prevent infections, that’s all. If anything, technology has made birth more dangerous – just take a quick look at America, a very technologically advanced country – while the global maternity mortality rate has dropped by 44% worldwide between 1990 and 2015, and by 48% in developed countries, the US is one of only 13 nations who has seen its maternal death rate rise. Birth is safest when the birthing woman feels safe, supported, unobserved and undisturbed. The maternity system is based on being risk-focused and avoiding being sued. These two things do not work together.

 

3. You can still opt-out of things, even if they’re seen as “the norm”

It might seem obvious, given what I’ve already said in the previous points, but it’s never presented as an option. You can decline any part of what is considered the “normal” path through the maternity system. That includes booking in. The only thing you legally have to do is register your baby within 42 days of the birth with the Registrar of Births and Deaths in the area in which your baby was born. Women give birth at a wide range of gestations too, and the scope of “normal” gestation (between 37 – 42 weeks) would be a lot wider if the medical model didn’t feel the need to rush the process for no good reason. There are plenty of women who ignore their due date altogether, and they are the women who have a peaceful pregnancy because they know that their EDD is just a number, that is only 4% accurate, and will likely result in the pressure being piled on by professionals, friends and family. There’s another thing you can decline or reject.



4. Pregnancy doesn’t change the fact that you are the only person

who gets to make decisions about your body

When you conceive a child, there is suddenly a whole load of things you are expected to do, whether you like it or not. There are lists upon lists of things you can’t do or eat when you’re pregnant, things you should definitely do because you’re pregnant, things you need to buy for your baby and appointments you have to attend. But is there any other time in life where you would just accept all of these things that people are telling you, even if they didn’t sit right with you? Is there any other time in life where you would be expected to let someone touch, measure, press on your belly even if it was uncomfortable? Or let them put their fingers inside you without asking or sometimes without even warning you? No. What do we want our daughters to know? That it’s okay to say no. That our bodies are our own and nobody gets to touch it without our consent. Right? But for some reason, when we’re pregnant we’re expected to just grit our teeth and get through it because it’s “standard procedure”. That’s not okay.



5. Your human rights don’t go away just because you’re growing another human

In the UK, unborn children do not have separate legal recognition from their mothers. This means that nobody can override your human rights for the sake of your baby, unlike in some other countries. This means that there is no limit to which you are the sole decision-maker when it comes to your care, or opting out of it altogether. This actually makes things a lot simpler than in countries where the unborn baby has rights too. You and your baby are one. What you decide is right for you, is right for your baby by extension. You absolutely matter.



6. You get to decide whether or not you want to go for a scan or appointment

Although scans and appointments are considered the norm nowadays, with women booking in around 12 weeks and having a few scans along the way, this is always a choice. These appointments and scans are not without risk. The information discovered during these appointments is something that can be used to coerce you, no matter how inaccurate the information is. The language used in these appointments plants the seed of doubt, giving the message that at some point your body will fail and you’ll need help. It very rarely gives the impression that birth is normal, and something that when uninterrupted is very unlikely to end up in an emergency. The maternity service is not designed to be woman-centred, it’s designed to manage birth, which just isn’t something that you can do with a bodily function. Treating women like a big, mysterious ticking time-bomb creates fear and will ultimately create emergencies in the process.



7. Birth is not inherently dangerous, but the way women are treated in labour is

As stated in the previous point, birth is not inherently dangerous. It becomes dangerous when we interfere with it. When a woman comes to the end of her pregnancy, there is a whole dance that her body is doing that involves a delicate balance of hormones. Labour begins when the baby is ready, and it will take as long as it takes. Sometimes it starts and then stops again. Sometimes it slows down for a long while then picks back up. Sometimes there are no signs at all and then comes on hard and fast. Labour, even though it can stop and start in different places, is actually very predictable when it is left alone. When people talk about birth being unpredictable, what they have seen or heard of is birth that is interrupted and disturbed by interventions. The evidence is out there – Marjorie Tew who set out to prove that hospitals had made birth safer ended up proving the complete opposite. Michael Odent explains that there are maybe 5 types of true emergency in birth and they are very rare. The intervention and caesarean rates do not reflect that number, which means that we are making birth dangerous by treating it as an emergency and interfering with a bodily function.



8. You don’t have to compromise, in fact, you don’t HAVE TO do anything

As stated in nearly all of the other points, there is no point at which you HAVE TO do anything. This phrase, however, is used in almost every conversation I hear about birth. Women are told by friends, family, strangers and midwives that they “have to” book in by a certain date and that they “have to” go for that growth scan because “it’s for the best” (despite the fact that they’re notoriously inaccurate), without knowing the risks associated with engaging in maternity services. This language is powerful, but you don’t have to listen to it. Anyone who tells you that you “have to” do something (e.g. wait to get in the pool or push now or be monitored in some way) or they use the phrase “we just need to do this” (e.g. a vaginal examination or listening in), should be kept far away from your pregnancy and birth.



9. Nobody gets to tell you what you are or are not “allowed”, or what is safe,

and you don’t need anyone’s permission

If you drive to a doctors appointment and the doctor says; “You didn’t drive here did you?! You’ll have to walk home because driving is too dangerous!” you would probably be outraged because you are a grown-ass woman who has weighed up the risks and benefits of getting in your car today and someone is deciding for you that it is too dangerous. So why is it that, during pregnancy, when we hear the words ‘risky’ and ‘safe’ used, we accept it? Because of the emotive language used around it – this is a tactic that is used frequently and is very effective. But population-level advice and statistics are not the only things that factor in risk and safety. You are a whole woman who has emotional, physical, practical, spiritual and mammalian needs, and nobody else will have the same priorities as you. Your risks and benefits would look very different from someone else’s, so it’s impossible for someone else to judge what is safe for you. In terms of being told what you “have to” do and what you’re “not allowed” to do… you are an individual with capacity and rights, which means that you get to decide where you have your baby, who you invite into your birth space, whether or not you want to engage with maternity services and to what extent. You get to decide when to get in and out of the pool, and if and when you cut your baby’s cord, and who gets to touch your baby. Nobody has the right to allow or not allow when it comes to your body, your baby and your birth.



10. Your intuition can be trusted – it won’t lead you wrong

We often hear women saying “but what if something is wrong and I don’t know about it”. The monitors that we’ve invented are trying to mimic what our body already does, so that it can be plotted on a chart, but those machines can never replicate the instinctual responses that our bodies have. You will be the first to know if something is wrong because nobody else can feel what you’re feeling or even attempt to interpret it from the outside. We all know that when a pregnant woman is stressed, her baby will feel it because of the increased cortisol in the body, and the same is true the other way around. If you are able to listen to your intuition and follow what your body needs, it will not lead you wrong. We hear women saying “I knew that I needed to push but they kept telling me not to”, or the other way around “I knew that I didn’t need to push yet but they kept telling me to” and it’s those women who come away from birth feeling traumatised, it’s those moments where the people around her were speaking louder than her intuition that she feels out of control and it’s in those moments where birth becomes dangerous. Our intuition is what has kept the human race alive and thriving for such a long time, so don’t doubt it.

 

Related Links:

https://www.facebook.com/groups/freebirthnorthwest/

https://www.facebook.com/groups/manchesterbirthsupport

https://www.bellybelly.com.au/birth/fetal-ejection-reflex-what-is-it-and-how-does-it-happen/

Birth, Uncategorized

Sweeps ARE induction (…and there is nothing natural about them)

There is an abundance of misinformation given to women about the infamous ‘stretch and sweep’. This misinformation leads women to believe that a sweep is completely harmless, and in some cases necessary! The feeling that comes from these kinds of ideas is that labour needs help to start and that it would be dangerous to do nothing, undermining the fact that labour is a perfect system that involves lots of hormonal changes before any obvious signs of labour can be detected.

 

Misinformation Exhibit A:

A poster that was displayed in the waiting room of a maternity clinic

Where do I begin? 
Maybe from the top and work our way down.

 

1.Let’s start with due dates. Due dates are calculated on the assumption that all women have the same length menstrual cycle. This is simply not the case, they can differ hugely from woman to woman, month to month. The “normal” range of being full term is between 37 – 42 weeks, so that is already a wide window but it doesn’t take into account how many women are induced due to the fear of going “overdue” (like a library book). So in reality, if we were all left to our own devices this window of normality would probably stretch much further. Whilst we’re on the topic of being left to our own devices – have you ever heard of a woman being pregnant forever? I haven’t. I have heard so many times “I’ve never gone into labour before so I don’t even know if I can” or “I wasn’t going into labour so I had to be induced”. There is no reason to think that your body wouldn’t go into labour naturally given enough time and patience, it is the healthcare system’s incessant need to interfere that undermines women’s confidence in this.

 

2. The next point of focus on this awful poster is the second line; “want to start labour naturally?” … WHAT?! The only natural way for labour to start is to leave well alone because anything that you try to bring labour on before it naturally would, isn’t labour ‘starting naturally’. The other important thing to ask here is why would we want to start labour early? The only reason women feel pressure to “kick things off” is because of the information they are being given about due dates and going past them. That pressure is coming from the maternity service, so they are offering a “solution”. Sweeps are often offered as a way to “avoid induction” but a sweep IS part of induction.

 

3. So you’ve so far been told that approaching your due date means that you must want to get labour going, and that having someone put their fingers inside you to “sweep” around your cervix is a “natural way to induce labour”, and that you should talk to your community midwife about it. I’m not sure about you but the information they’ve given so far isn’t exactly filling me with confidence that talking to them about it would benefit anybody. It is easy to tell from this poster that birth is not seen as a normal bodily function because there is a continuous want to DO something or measure something or fix it. Midwives have to follow the policies of their hospital, and clearly, this hospital (like many others) see birth as something to be managed, which includes inducing labour at all costs. Offering a more “natural method” of a sweep (rather than a chemical method) seems like a compromise, and women are expected to take this compromise to avoid being pressured into further induction techniques. The idea that you can only avoid a formal induction by having a sweep suggests that saying no isn’t enough and won’t be respected. But here’s the thing… you don’t have to compromise. If you don’t want an induction, you don’t have to have one. You can tell your midwife that you will not have an induction and therefore don’t want to discuss it any further, and if they do bring it up against your wishes then you can tell them that they are harassing you. There are many, many ways to avoid the pressure to be induced, but having a sweep isn’t one of them because it is a form of induction, and once you have said yes to one form of induction, it becomes much harder to say no to the rest.

 

4. ‘Available at your local clinic from 40 weeks pregnant’ despite the fact that most women who are 40 weeks pregnant have already been offered multiple sweeps. The main purpose of a sweep is to avoid going post-term (two weeks past your only 5% accurate due date), and the reason for that is based on the increased still-birth rate associated with post-term pregnancy. The research for this is varied, but there are 10 years worth of CEMACH, CMACE and MBRRACE reports that actually show a lower percentage of stillbirths in women who gestate for 42+ weeks, compared to women who gestate for between 37 – 41 weeks.

 

5. ‘Successful for 8 out of 10 women’… I’m not sure where they have found this stat or what they consider to be “successful”. The most recent Cochrane review on the topic, done in February 2020, states “Membrane sweeping appears to be effective in promoting labour but current evidence suggests this did not, overall, follow on to unassisted vaginal births.” So it might be the case that a sweep can trick the body into contracting, but is that really a success if it just leads to a longer, more exhausting labour with more interventions? 

A stretch and sweep can only be performed if the cervix is “favourable”, meaning your body is already preparing for labour (so it’s probably imminent anyway), which means that for women who do go into labour following a sweep it might be that their body was already ready to go into labour and would have done so regardless of whether they had the intervention or not. There is no way to know this, but if you ask around I’m sure the majority of women who went into labour after a sweep has had more than one sweep previous to that one and did not go into labour, so it could have just been a coincidence.

The review also found that women who had a sweep were “less likely to have a formal induction”, but this only perpetuates the notion that a formal induction is inevitable and non-negotiable. What actually makes any form of induction less likely is giving women all of the information and breaking the cycle of thinking that women’s bodies are incapable of going into labour on their own. 

 

6. ‘No known side effects’ … this is a blatant and dangerous lie.

Stretch and sweeps can cause;

  • Pain during and after the procedure
  • Vaginal bleeding
  • Painful contractions for the following 24 hours without leading to labour
  • Longer labours
  • An increased risk of infection
  • An increased risk of rupturing the membranes

And for what purpose?

The Cochrane review found that it did not generally lead to labour within 24 hours, and it did not reduce the incidences of further intervention such as the use of synthetic oxytocin and instrumental births. The very fact that a sweep can cause contractions that aren’t effective will lengthen labour, and there is often a lot of pressure put of women who have been contracting for 24 hours, makes you wonder whether there are actually any known benefits.

 

7. ‘Unlike curry!!’ 

This is clearly meant to mock the more “natural methods” of induction, but as I said at the beginning, anything that you do to try to bring on labour is a form of induction, whether it is chemical or otherwise so they fall under the same umbrella, except eating a curry doesn’t involve someone putting their fingers inside your vagina. The theory behind the curry method is the irritation spicy food can cause to your bowel, which could potentially trick the body into contracting. But, unlike sweeps, eating curry (if you like curry) has many benefits and not just to pregnant women! These include;

  • Satisfying hunger
  • Spicy foods tend to release endorphins which can give you a bit of a buzz
  • Cooking curry can be really fun
  • It tastes great
  • If you don’t like it or it is causing you discomfort/pain, you can stop eating it instantly without having to tell anyone (unlike having a sweep where, if you wanted it to stop, you would have to rely on the midwife performing the procedure to listen to and respect your decision, which isn’t always the case)

 

In conclusion, this poster is a load of shit and is a perfect representation of how frequently women are misinformed in pregnancy and how flippantly this is done. It shows how easily things become routine without really being based on any solid evidence. It also says a lot about the systemic mistrust in women’s bodies and the belief that they need help to perform the most natural of bodily functions.

If you find yourself being offered or pressured into a “quick sweep to get things started” or any other kind of induction, take whatever time you need to go through the BRAIN acronym and consider the benefits, risks and alternatives to what is being offered, check in with your intuition and ask yourself (and your midwife if you want) what happens next if you accept the intervention and what happens if you decide to do nothing. All of this information will help you to make the decision that is right for you.

If you want to chat about any of these decisions or navigating the maternity system, feel free to get in touch with us and book a ‘holding space’ session by emailing hello@greatermanchesterdoulas.com

 

Related Sources:

https://billieharrigan.com/blog/2019/5/6/birth-hijacked-the-ritual-membrane-sweep

https://www.aims.org.uk/journal/item/induction-at-term

https://www.sarawickham.com/articles-2/unpacking-sweeping-policies/

https://www.aims.org.uk/journal/item/ten-things

https://www.cochrane.org/CD000451/PREG_membrane-sweeping-induction-labour

https://www.crd.york.ac.uk/crdweb/ShowRecord.asp?LinkFrom=OAI&ID=12011000682&LinkFrom=OAI&ID=12011000682

Uncategorized

Bodily autonomy and the information we are not given

This post is sparked by my personal experience (it’s Amy here, in case my hilarious t-shirt below didn’t give that away) and also from listening to women talk about their journeys with contraception.
 
Grab yourself a brew (and maybe some biscuits) because this is a long, winding road to a very broad but important point – bare with me.
 
 
Let’s talk about contraception (and information and consent and bodily autonomy… because it’s all part of the same point)
 
Being doulas, you might think that the topic of contraception is a little out of our remit but (as I have so succinctly concluded in the subtitle) that is not the case.
 
As doulas and feminists, we respect every woman’s right to choose what is right for her body, so naturally, the topic of being informed and choices being respected is at the very core of what we believe in. Also, being full-spectrum doulas we support women before they are pregnant and long after they give birth so it does come up a fair bit.
 
 
Let’s start with sex education
Way back in school (Elle would like to point out that it wasn’t that long ago for me), we were only ever told about two or three methods of contraception. We learnt a bit about the pill, maybe a bit on the injection and of course, everyone remembers the demonstration of how to put a condom on a cucumber or banana or any other object that doesn’t look like a real penis so that the teacher doesn’t get embarrassed. I’m guessing it wasn’t all that different for you? But this isn’t enough. If you’re going to teach young people about sex and contraception, you have to tell them all of their options and what each one entails. For example, I don’t remember anyone telling us in school that the longer you are on the pill, the longer it could take to get pregnant once you stop taking it. This might seem like a very way-in-the-future conversation to have with children, but who else is going to tell us that? Especially considering lots of women go on the pill from a very young age. “Wouldn’t that be the healthcare professionals job?” I hear you ask… the answer is yes, it definitely is, but that doesn’t mean that they will fulfil that expectation. The other HUGE gap (or if talked about at all, misrepresentation) in sex education is birth, but that’s a whole other rant.
 
My personal experience with contraception
Over a period of about four years, I tried two different types of the pill and the injection before deciding to have a detox because the hormones were having a very negative effect on my mental health. The side-effects are different for everyone but the general consensus of women I have spoken to is that there is at least one pretty rough down-side to every hormonal contraception option.
 
Condoms were the only other option (that I knew of) – our readily available, non-hormonal, trusty, 98% effective friend. However, it took one of these trusty little guys to split for me to end up seeking emergency contraception. For me (and many women have a much worse time of it), that meant I had to wait about 4 hours at a walk-in clinic (feeling alone and nervous), complete an incredibly personal face-to-face questionnaire and brush off several judgemental ‘I don’t believe you’ looks, for someone to finally tell me about the copper coil! I listened intently as they told me how it was hormone-free, had very few side-effects, could stay in for 5 years (some stay in for 10!) but can be removed any time I want, it doesn’t stall fertility after removal, and it is more than 99% effective…
 
 
…SHUT THE FRIDGE!!
 
Why in the hell had nobody taught me about this option before?! I had suffered through years of hormones messing with my brain, my skin, my personality. I got it fitted that day and four years later have not regretted it once. Now, it sounds like I’m just trying to sell you all on the copper coil, that is not my intention. It works for me and I love that, but the point of my rant is…
 
Why did it take so long for someone to tell me all of my options? Who decides which methods of contraception are offered to us first? If we are born into a religion that believes abstinence is the only way – where do we get the information to decide for ourselves? If our parents decide that sex is too difficult a topic and tick the opt-out box on the sex education form, where do we learn about our body and the changes we are going to go through? Why should other people get to decide what information we get about puberty, sex and contraception? It’s the first step towards bodily autonomy and nobody wants to talk about it! Maybe because bodily autonomy isn’t something that society wants us to have. Working as a doula has taught me that.
 
This power play continues throughout our lives, with anything to do with women’s bodies from contraception, boundaries, birth and beyond.
 
(Sorry, it took me a while to get to the point! Have another biscuit…)
 
From a friends experience
A few years ago, before I was no longer shocked by the controls put on women and their bodies, my friend was seeking the morning after pill at a pharmacy. She had gone to the only pharmacy open that Sunday morning, she steeled herself, walked up to the desk in the not-so-private supermarket aisle where the pharmacy is located and told the pharmacist what she wanted to purchase. There was no medical reason for her to be unable to access the morning-after pill, but the pharmacist said no. He said that he could not dispense the pill because of his personal beliefs.
 
 
I couldn’t believe this was legal, especially with something as time-sensitive as the morning-after pill. I furiously googled it and found that yep, apparently, pharmacists have an opt-out clause which gives them the power to inflict their personal views onto others, potentially causing an unwanted pregnancy. Technically, if a pharmacist exercises this ridiculous clause, they are supposed to offer an alternative, but what good is that on a Sunday when nowhere nearby is open and the customer can’t drive? That’s a pretty risky clause to have, don’t you think?
 
So I have a few questions; would a doctor who is a Jehovah’s witness have a clause to opt-out of giving a life-saving blood transfusion because of her/his personal beliefs? Does a doctor who is Jewish have an opt-in clause to enforce circumcision on all babies because of his/her own beliefs? Is the opt-out clause used for anything other than emergency contraception, or is it a clause solely to deny women the right to decide whether or not to have a baby?
 
Now I am wiser I know that actually, professionals impose their personal opinions on women all the time, it’s just usually less obvious. For example, during pregnancy when something is offered to you (because it is just an offer, even if it doesn’t come across that way), that midwife or doctor should be giving you ALL of the information, the risks, benefits and alternatives, for you to make an informed decision about your care. This very rarely happens, and what we can assume from this is that the person giving you the partial information is deciding, based on their personal views, which information is more important for you to know, and what can be left out. This does NOT equal informed consent. 
 
The patriarchal society that we live in has assumed that women’s bodies, and the decisions women make about those bodies, are to be monitored and controlled. Constant protesting of abortion, the hoops we have to jump through to access all types of contraception, the scare-tactics used in pregnancy and the birth room – it is all about controlling women. Strong, independent women who are able to make informed decisions and stand their ground are a threat to that control. Information is power, and withholding information (or more directly, actual medical care such as the morning-after pill), is to take away a woman’s power.
If we take away a woman’s control of her own body, we are telling her that she is not important and that her body is not hers to be in control of.
 
What does this teach young girls and women about consent? What does it teach us about boundaries? What does it teach us about our power?
 
(and yours too, if you want us to!)
 
 
 
 
 
Resources related to this post:
 
– The most recent changes I found on the opt-out clause (2017):
 
– The Lloyd’s Pharmacy article:
 
– Some fascinating for and against comments from pharmacists about the opt-out clause:
 
– The NHS contraception guide:
 
– Info on the copper coil (IUD):
naomi's positive vbac
Birth, Birth Story, Doulas, Uncategorized

Naomi’s positive VBAC story

Naomi contacted us recently about sharing the birth of her second baby Amelie. Her son Dylan was born by caesarean but second time around she planned for a different experience. With the support of Amy, she had the positive birth she had wished for and we hope that Naomi and her story inspires you as much as she does us.

For the previous two weeks I had been getting lots of braxton hicks and had lost my complete mucous plug, but was determined not to get my hopes up about going into early labour as I went a week overdue with Dylan and I found it so hard waiting. I tried to keep in my head that I would go overdue this time too so that I wasn’t disappointed. I went to bed on the Tuesday evening and had absolutely no signs of labour except from my bump had dropped quite low throughout the day (I was 39+2). I slept so well and got a full 8 hours sleep.

naomi in the pool with gas and airMy alarm went off at 7.45am to get Dylan up and ready for nursery, so I snoozed and got him up at 8 and Ben got in the shower. I shouted through to Ben in the bathroom because I got such a big pain in my stomach but wasn’t sure what it was as I didn’t think I could get such a painful contraction with no build up. He carried on showering and I found myself bent double over our bed breathing through 4 contractions in 10 minutes with poor Dylan watching me wondering what was going on! So I shouted Ben again and he got out of the shower and got dressed and took Dylan downstairs.

I called maternity triage who could hear how regular my contractions were and how much pain I was in and they said to go straight to the birth centre there and then. So Ben called Dylan’s nursery to warn them we were on our way with him and that he’d not had time for any breakfast.  I called my doula Amy to let her know we were on our way to the birth centre, she said she would leave and meet us there. I also called my mum as she was supposed to be having Dylan while I was in labour but I asked her to come and see her granddaughter being born instead as luckily it had fallen on a nursery day!

We all got in the car for the most uncomfortable journey and we were so lucky that it was half term so there was hardly any traffic bearing in mind we were driving towards Manchester city centre in rush hour! When we got near to nursery I was in so much pain I said to Ben don’t take Dylan to his room, just drop him in the office and get back to the car quickly, I felt like the baby was coming soon.

naomi giving birthSo 10 minutes later we arrived at the birth centre and Amy my doula had just arrived before us. The midwives took us into the most gorgeous room with twinkle lights, soft waterfall sound effects and a big projector on the wall with waterfall videos, it was so relaxing. They got me on the futon to examine me and she said that I was 4cm dilated, fully effaced and my waters were bulging. She said I could get straight in the birthing pool and have the gas and air which I did. I forgot how amazing the gas and air is… the hallucinations! And the warm water was so soothing on my back.

I remember at one point feeling a bit panicky about my scar rupturing and asking the midwife if I was showing any signs of scar rupture. And then I panicked that the baby would get stuck like last time and asked her if the baby was back to back like last time. She answered no to both questions and reminded me that this was a different birth and to trust my body.

Amy made me 3 cups of tea which I downed in the pool, and we all had a laugh that I was alternating between gas and air and cups of tea (fab combination by the way!) Like Dylan’s birth, Ben was the official gas and air holder and my friendly face for when I was in crazy amounts of pain. Then as things were ramping up my mum arrived which I was so glad about. She was holding a cool flannel on my head and it was just generally soothing to have my mum there. I felt so safe surrounded by the people I chose to be at my birth and it was so completely different to my poor experience from Dylan’s birth.

Naomi, her partner and her newborn babySoon after my mum arrived my body started to push involuntarily. I didn’t need to be examined, I just knew that I must be fully dilated and my body knew what to do. I looked down between my legs as I thought I had pushed the baby’s head out but it was actually part of the sack full of waters that hadn’t burst yet, so surreal to see!

At this point the midwife used the Doppler and couldn’t find baby’s heart rate so very quickly her and the second midwife said I needed to get out of the pool immediately. I was so worried as it was like history repeating itself, they had to get me out of the pool as an emergency when I gave birth to Dylan.

As I got out of the pool I could feel her head crowning and the midwife could obviously see it too as she put her hand between my legs in case the baby came out! As soon as I was out of the water the pain was so intense as the gas and air had worn off and I had no other kind of pain relief in my system. I laid on the futon and begged for the gas and air but everyone was more focussed on the baby coming out so I didn’t get my gas and air back!

The next contraction came and I pushed so hard and her head was born, then one more push and she was in my arms crying! The sense of achievement straight away was just incredible and  I still can’t believe that I achieved a vaginal birth after so many professionals told me I couldn’t do it.

I also specified in my birth plan that I wanted a physiological third stage which I’m glad about as the placenta came naturally around 10 minutes later. We waited until the cord had stopped pulsating completely and Ben got to cut the cord this time which we were so happy about.

amelie

My doula Amy managed to get some amazing photos of the labour and birth which I’m so happy about as we only got one photo of when Dylan was born. I honestly feel like I would do it all over again, I’m so thrilled I got the birth I wished for all along. 

A perfect example of how listening to your intuition alongside the support of a trusted team who believe in you and your body can lead to a birth on your terms, despite the doubt of professionals. You are amazing Naomi! 

man and women with newborn baby in the bath
Birth, Birth Story, Doulas, Uncategorized

A healing second birth – Part 1

Our recent Wonder Woman was the lovely Jess, wild mother to Luca and Eden. We are lucky enough to be able to share her journey, from a traumatic first birth to the beautiful, healing home birth she had with her littlest one Eden.

Eden’s birth story Part 1:

During Eden’s pregnancy I knew I needed to work through many fears and unanswered questions from my first birth experience if I was going to birth in a way that felt positive and empowering this time round.

Woman with her toddler and a scan pictureI’d wanted a water birth with minimal intervention with my first born, but in the end he was pulled from me with no time for any pain relief. I lay on my back, pain like I’d never known, under bright lights with lots of people watching, I felt helpless and powerless. I tore awfully and had to leave my tiny newborn and go straight to theatre for 3 hours afterwards. Yes I know others have traumatic births and yes I did have a healthy baby, but I’m not ashamed to say it broke me. I felt horrendous. Cheated. Angry. Grief stricken. Violated. Unheard. Except I wasn’t supposed to feel this way. I was supposed to feel lucky, relieved and ecstatic that my baby was safely here and grateful to the doctors that had helped me. People told me how fortunate it was that I hadn’t had the home birth I’d been thinking about having. “Imagine if the doctors weren’t there to help”, they would say. At the time I kind of agreed with them, but I also had this niggling feeling that things could have been different somehow if someone had truly believed in me and if I had truly believed in myself, but I didn’t quite understand what that meant. My body felt like it’d been run over by a train. My mind raced with thoughts of inadequacy; I’d needed medical intervention to get pregnant (IVF) and now medical help to birth my own baby! How the hell was I now expected to trust myself to know how to mother?!

I know that some people reading this may feel triggered by what I’m saying. You may feel annoyed towards me for feeling this way because you had it worse or you wish you had the privilege of birthing a child or you feel differently – maybe you did feel completely supported by your doctors or that you’d never dream of birthing outside of hospital because you see it as a risk. Know that I respect you and I would never judge a woman by her decisions or feelings. I understand these are my own personal feelings and everyone is different. I would say that if any of my birth story does bring up a strong emotional reaction for you, that it might be worthwhile talking it through with someone. Feel free to PM me. Although I’m not trained I can signpost you in the right direction for support.

Anyway it was a long road of acceptance after Luca’s birth. Talking about it with people who understood helped so much. Also breastfeeding, being able to do something with my body to nurture him helped so much.

toddler holding a babyWhen I fell pregnant again, naturally this time, I knew I could never birth like that again. I thought about an elective c-section but it didn’t fit right. So I talked some more, I rehashed Luca’s birth again. I re-examined every part of it, including the lead up to it. More uncomfortably I looked at the responsibility I held in the events that took place. I studied undisturbed birth and accepted some truths about birth in it’s essence. I sat with lots of fears and what ifs. It took a long while to weed out what I truly needed to birth in power. In the end I came to accept my highest need was to be surrounded by those that knew me and trusted me and trusted birth as a process. I’m not sure if I ever fully voiced it out loud but I came to realise that in my current circumstances I felt most in alignment and empowered when I thought about birthing on my own,
and as it turns out that’s exactly what ended up happening!

To be continued…

Stay tuned for the next part of Jess’ amazing birth story! In the meantime you can find her on Instagram @these_adventures_of_ours.