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AIBU?

Share your dilemmas and get honest opinions from other Mumsnetters.

To question the "partners only in active labour" current NHS policy?

131 replies

RainMinusBow · 29/03/2020 13:35

Define "active labour." How can this be determined?

OP posts:
aurynne · 31/03/2020 02:31

I am a midwife, and although I work in a different country, the systems are similar. here is my advice if you think it could be useful.

I have facilitated plenty of births with no VEs. Most times, a woman´s behaviour, specific landmarks on the body and where you listen to the baby with the doppler machine can indicate progress, and give you a very good idea of how far labour is at any given time.

However, this works much better in multiparas (women who have birthed at least before), not only because, as a general rule, they birth faster and progress is more regular, but also because they have gone through the process before, know their bodies and what level of pain is normal. Multiparas very rarely call you in labour unless they really are in established labour. A primipara will call an average of 3-4 times, convinced she is in advanced labour, and she will be on average 1-2 cm. As you imagine, very few midwives will happily stay by a woman for 3 days just because she does not want a VE and "thinks" she is in active labour. At some point you will have to: a) accept a VE, or b) let the midwife go home and risk having the baby on your own.

In some cases a VE may mean the difference between safety (as in detecting a problem) and a series of adverse outcomes:

If the baby is posterior, often women will behave as if they were just about to push the baby out when they are just 2-3 cm, because the back of the baby's head puts pressure on the colon and gives them the urge to push. Without a VE, they may rupture their cervix trying to push the baby past it. In a less dramatic scenario, the baby will get increasingly stressed.

Regular VEs are the only way to asess failure to progress, or obstructed labour, where the woman will behave as if she is in advanced labour but the cervix does not dilate, dilates extremely slowly (incressing baby's levels of stress), and/or the baby does not come down the birth canal. There can be several reasons why this happen, which range from mild to severe emergencies with different degrees of interventions needed to guarantee the baby's and mum's safety.

A VE will show a malpresentation/malposition. Sometimes babys are breech and this has not been detected antenatally, or they can turn breech right before or during labour. An abdominal palpation does not always pick up a breech baby, as the baby's head and the bum feel very similarly, especially in bigger mums. the baby may also be in rarer positions, like transverse, oblique; or may have a shoulder, brow, or face presentation. These last 3 will not be detected by palpation or auscultation and will result in an extremely dangerous pushing stage. Some of them will cause en obstructed labour in second stage, which is a massive emergency.

A VE will show you if there is a cord presentation/prolapse (where the cord is caught between the baby's head and the vagina, an emergency in which the baby's life is at enormous risk and you have minutes to act). There is no other way to detect this (except when you have a complete prolapse and you can literally see the cord protruding from the vagina... you really don't want this to happen, believe me).

A VE will show the presence of vasa previa: in some women the umbilical cord's vessels separate before the cord joins the placenta (it's called "velamentous insertion), and one of these vessels is caught under the baby's head. if her membranes rupture, the vessel may break and the baby will bleed to death before they have a chance to be born. Again, massive emergency with minutes to save the baby.

This just out of my head. Are you a first time mum? If so, you absolutely have the right to decline VEs, but need to be aware of how useful they can be whe things don't go to plan, which is something that happens much more frequently in primiparas.

On top of that, the current unprecedented pandemic situation means that every extra person in a ward multiplies the risk of COVID19 transmission, and the longet that person stays, the higher the risks. Most of the World have already given up basic rights (freedom to get out of the house and go wherever you want, for example) in order to protect the whole of the population. Midwives are some of the health professionals at a much higher risk of contracting/passing around the virus, as they have to spend many hours in close contact with labouring women, who do not behave as the stereotypical hospital patient, who just lies on the bed meekly. Labouring women pace, kneel, go on their knees, huff and puff, sweat, vomit, cry, pee, poo and break their waters on or in close proximity to their midwife on a regular basis. A partner in the room is an extra person to potentially get exposed to, trample over, get in the way, faint, vomit, use the toilet, eat, drink, get impatient when things take time, and/or behave irresponsibly. So I am fully behind the rule on "only partners during active labour", which we are already implementing in my country of residence.

Please, don't be that person who makes the health professionals' life infinitely more difficult by making a scene at the hospital because you don't think the rules apply to you. You don't want VE's? then sure, try a home birth. However, you need to know that, if anything goes wrong at home, or if hours and hours go by with no evident progress, the home birth midwives will be strongly recommending a VE too. I am a home birth midwife too, and our threshold to tolerate abnormality when birthing at home is much lower than at the hospital. you don't want a massive emergency to happen at home, so you become much less tolerant of small things that "don't look quite right".

Whatever happens, best of luck for you and your baby!

RainMinusBow · 31/03/2020 03:45

@aurynne That's very useful advice, thank you so much. I understand the added risk of hb with first pregnancies but not specifically, so this has really helped with this. This will be my third birth, sixth pregnancy.

From my own pov, I'm not averse to VE'S per se, but having looked into it, questioning in some cases whether it's just a "done thing" at routine points without being fully necessary. My firstborn was an extremely drawn-out IOL, and I must have been told I was 3cm every half hour or so for literally hours on end! It caused a lot of increased anxiety and stress as I'm sure you cam imagine.

The info you've given on Covid-19 and transmission risk is also really helpful.

I do feel for my hb mw - she said in her last text they were taking their phones from them. Maybe this is why she's been unable to explain to me why hb's have been suspended in our Trust and not in others. I did ask my community mw who is lovely about my other birthing options, but she said said she would only really talk about these at 36 weeks.

The difficulty with that is I obviously need to decide sooner rather than later if I'm going to book an IM or birth in a different Trust to where I live etc. I did this with my first two sons and don't regret that decision.

OP posts:
aurynne · 31/03/2020 03:56

If you have had two vaginal births, and no risk factors and a normal pregnancy this time, you seem to me a perfect candidate for HB. Not only it would keep you and your baby away from hospital (which will reduce the chance of catching COVID19), but you actually have much higher chances of a normal birth by doing that. You could also have whichever birth partner(s) you wanted. If you were here I would definitely volunteer to be your midwife!

Home births of multips are also much more likely to progress fast and regularly and not require VEs. In fact plenty of time the midwife is called and mum births the baby within the hour that the midwife is there. third time mums often know very well how far they are and how close to birth, as their bodies send them strong messages to stay home when time is close and they know what to listen for. You also have much lower chances of having failure to progress, as your cervix progressed to fully dilated twice already, and also lower chances of obstructed labour. Even if you had a posterior labour, being a multip you would most likely birth the baby posterior with no issues.

The other issues I mentioned are rare enough that you would not need to worry. If your HB midwife was worried she would discuss this with you with heaps of time.

RainMinusBow · 31/03/2020 04:06

@aurynne Aw thank you sooooooh much for the reassurance, you've made me feel a lot better. Yes, two vaginal births, no risk factors and a normal pregnancy this time.
So can you be my midwife?!! Grin

I did well with my second son and by the time I got to hospital I was already 7cm. So much quicker than my first! But due to the mw prematurely rupturing my waters (they needed the room I was in, ward was incredibly busy), my calm labour up until that point turned into an emergency situation.

I'm meeting with an IM next week who will go through everything with me.

I hope this doesn't sound like a silly question, but are there differences in the way IM's tend to work compared to NHS midwives generally?

OP posts:
aurynne · 31/03/2020 04:35

I work in New Zealand so unfortunately a bit too far away and too much lockdown to be your midwife!

We also don't have private midwives in here. The community midwives work as self-employed midwives but get paid by the Ministry of Health as public contractors and they have their own caseloads of women. The hospital midwives are there to support the LMC midwives and care for women who need specialist/secondary/tertiary care.

Plenty of my colleagues have moved here from the UK. I believe that the difference between hospital midwives and IM midwives in the UK may be similar to differences between core (hospital) and community midwives in New Zealand. When you work in the hospital for a while you get used to see all the "abnormal", so you tend to get more comfortable with interventions and less comfortable with letting things just progress normally. Community midwives are the ones who try their best to keep the normal normal if there are no complications. Plenty of hospital midwives who have never worked in the community would not feel comfortable facilitating a home birth because it is alien to them not to be surrounded by machines and a button on the wall to call for help. I have worked in both environments and love, love love home births! Nothing compares to the sight of a woman who is in her own home, in control, who tells you what to do instead of expecting you to tell her. in fact, most home births I spent drinking coffee with the woman's family while she and her partner get on with it in privacy, entering only when I need to listen to baby or when she calls me in because she is pushing.

In New Zealand every home birthing woman gets two midwives present for the birth, I believe it is the same in the UK. We are ready to deal with any emergency and organise transport if there are complications requiring transport to hospital. We have our own emergency equipment, including baby and adult masks and oxygen, IV equipment, etc etc. Community midwives in New Zealand are very good at improvising and make use of every available person and house item for whatever eventuality. I once sutured a woman's perineum with her feet resting on two buckets and her buttocks on a piano stool. A colleague of mine used a computer cable (one of the old phones) to help birth a baby whose shoulders got stuck :).

You will be in good hands!

aurynne · 31/03/2020 04:36

*one of the old-style thick cables I meant

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