confused: labour ward or MW led birthing unit? Also: hands on / hands off midwifery?

[vezzie]

I'm 39 weeks pg with dc2.
dc1 was born at home, in water, and I had a 3rd degree tear (repaired in hospital, healed perfectly). dd was 9lb 1oz. This baby is scanning smaller (but we don't know when it will come of course)

I was told this time at the very beginning that following the tear I would not be allowed to have a home birth but it was suggested that I go to the MW led birthing unit attached to my hospital. This is what I wanted to do.

Today I had an appointment with a new doctor I hadn't seen before (standing in for the consultant I am supposedly "under" but have seen once for 5 minutes) who said things I had never heard before:

I should not go to the MW led unit because if the MW who attends me is trained to be "hands off" (as opposed to "hands on") I have a 50% chance of a 3rd degree tear again as there will be no doctors to intervene.

They will very likely want to give me an episiotomy (this directly contradicts what the consultant said: he said tears are preferable and heal better. This is the same hospital and he is this registrar's boss: )

this to me sounds like the sort of situation - lying down, feet in stirrups, ready to be managed by doctors - that leads to mothers getting distressed, babies getting stuck, forceps, maybe worse, etc. I really wish I could have a birth like dd's: calm, private, relaxed, one to one care, happy alert completely unscathed baby, agpar scores 10 and 10, feeding within 5 minutes.

It is my decision what I do but I feel that suddenly this very anti-MW led unit view has come out of nowhere and I am so confused. I don't want to tear again, or tear worse, and I think it would be stupid to go against advice on this; but on the other hand, a calm and happy birth, upright in control and with a strong happy serene baby at the end, would be so lovely. I found dd's early weeks a lot easier than some of my friends - no ventouse bruises, easy feeding, good sleeping for her; no weird infections for me.

Every time I go to hospital, people are missing, other people bark irritated questions at me about where people or things are that I can't answer, I never know anyone's name, I am always hungry or freezing or thirsty for hours, people barge in and out of rooms while you are taking your knickers on or off, I am immobile for some reason and completely lost. That is ok if you are just having stitches or something but I am not sure I can bear having a baby under those conditions. I'm afraid I'm going to freak out in some way, I am getting tearful thinking about it.

Now I have to decide fast!

Can anyone say anything that might help me see this more clearly? In particular can anyone tell me more about this "hands on / off" distinction with MWs because this seems to be extremely important to the doctor I saw today and I had never heard of it. She said if I go to the birthing centre I must ask the MW who attends me which she is and ask to go to the labour ward if I don't get a clear answer, or if she says "hands off"?

thank you for any help anyone can give

God sorry that is so appallingly long, I cut bits out along the way but not enough. thanks to anyone who reads it.

I hadnt realised this until today but you CAN have a home birth if thats what you want.
It may be a little late to organise it now, but you CAN insist and its your decision, not theirs..... they cant make you go to hospital or have any intervention that you dont want... if you dont want to lie on a bed in stirrups, dont, refuse, again they cant make you.

I know I can't be made to go to hospital, but I would really like some help to make the right choice.
I feel that everyone I speak to has entrenched personal views and I am struggling with all this - even the people "on the same side" (doctors on the consultants team) contradict each other.
No one admits that this is the case either, they make out that I am stupid and misrepresenting conversations and I know I am not, I always ask a lot of questions, make sure I understand and make notes. (the "official" notes are meaningless)

Mmmmmm, all sounds very odd to me.

Firstly how is a Dr going to save your perinium in the consultant led unit? They won't be tehre for the birth unloess there are problems.

All midwives are trained the same whetehr at the MLU or a consultant unit. Some may practice in a more hands off style, some in a hands on style. But I think most midwives aren't totally one or the other - they will adapt their style at the time if they think it needs it. I tend to be hands off but will frequently do hands on for nothing more than a gut instinct that I need to. I don't notice a difference in perinieal trauma between the 2 methods.

There was some research ages ago called the HOOP trial Copied and pasted conclusion of Hoop from another article here;

Results of the HOOP trial showed that trauma is indeed a very common experience of low-risk childbearing women: 68% had major or minor trauma to the perineum, 61% had vaginal lacerations, and 11% had episiotomies. The trauma profiles of women in the "hands on" versus "hands poised" groups were virtually identical (recall that the techniques were used at expulsion of the baby, and not earlier in the labor). However, marginally fewer women in the "hands on" group reported perineal pain at the 10th postpartum day (31% versus 34% for the "hands poised" group). This represents a 3% absolute difference (95% confidence interval, 0.5% to 5.0%; statistically significant because the confidence interval for the risk difference does not overlap 0). While this difference is small, it is of interest to U.S. midwives because "hands on" for management of the actual delivery is the practice norm in this country.

So trauma about the same but it says that HANDS ON = less pain/discomfort down the line. But there has been some discrediting of these results.

From Sheila Kitzinger website;

"On care of the perineum, they quote Enkin et al in A Guide to Effective Care in Pregnancy and Childbirth: 'Touch may be a disruptive distraction and potentially causes trauma'.

Recommendations include: There is no justification for 'hands-on management during second stage of labour to prevent perineal trauma... (They are critical of the HOOP trial, which revealed that after midwives were 'hands on' at delivery fewer women had pain 10 days after birth, since every woman who participated in the trial was 'managed' and had to assume a semi-recumbent or sitting position for the second stage.)

The recommendations continue: 'Episiotomy is the most common operation in obstetrics and is associated with complications such as increased blood loss, infection, and prolonged sexual problems. The use of routine episiotomy should be abandoned. Specific informed consent should be obtained prior to performing an episiotomy.
They conclude: 'Rather than seeking the perfect technique to save the perineum, perhaps we should make extra efforts to enhance women's natural birthing capabilities.'

"

This is good

clinicalevidence.bmj.com/ceweb/conditions/pac/1401/1401_I3.jsp

thanks Viva - great name!

very interesting - especially the the last sentence of the quote in your first post. I feel like the doctor I saw today is completely perineum obsessed, do you think I am a bit too cavalier about this as I healed so well last time? I admit I feel a bit: so I might tear, but tears heal.... anecdotally better than episiotomies.

What would you do if you were me?

I can't read your bmj link because it wants a subscriber log in.

Right will paste the whole lot. Its the BMJ best clinical evidence

?Hands-poised? versus ?hands-on? method of delivery
In this section:
Summary | Benefits | Harms | Comment

Top Summary
Reducing perineal trauma

?Hands-poised? method of delivery compared with ?hands-on? method of delivery The ?hands-poised? method of delivery may be more effective at reducing the proportion of women with episiotomy, but not at reducing perineal trauma requiring suturing, or the occurence of third- and fourth-degree tears. The ?hands-poised? method may be less effective than the "hands-on? method at reducing the proportion of women with perineal pain at 10 days ( low-quality evidence).

Adverse effects

?Hands-poised? method of delivery compared with ?hands-on? method of delivery The ?hands-poised? method of delivery is less effective at reducing the proportion of women who require manual removal of the placenta ( high-quality evidence).

For GRADE evaluation of interventions for perineal care, see table.

Top Benefits
We found no systematic review. We found one randomised and one quasi-randomised trial comparing the ?hands-poised? versus the ?hands-on? method of delivery. [2] [31] The RCT was a large, robust, multicentre, pragmatic trial carried out in the UK and the results are likely to be generalisable. [2] Both trials found that the ?hands-poised? method of delivery reduced episiotomy rates compared with the ?hands-on? method. The RCT (5471 women) found that the ?hands-poised? method significantly reduced the episiotomy rate compared with the ?hands-on? method (280/2740 [10%] with ?hands-poised? v 351/2731 [13%] with ?hands-on?; RR 0.79, 95% CI 0.65 to 0.96; NNT 38, 95% CI 23 to 106). [2] It found no significant difference between methods in the risk of perineal trauma requiring suturing, or in third- and fourth-degree tears (suturing required: 1636/2740 [60%] with ?hands-poised? v 1605/2731 [59%] with ?hands-on?; RR 1.02, 95% CI 0.97 to 1.06; third- and fourth-degree tears: 40/2740 [1.5%] with ?hands-poised? v 31/2731 [1.2%] with ?hands-on?; RR 1.3, 95% CI 0.81 to 2.05). The second, quasi-randomised trial (1161 women) found that the ?hands-poised? method significantly reduced episiotomy rates and third-degree tears (episiotomy: 51/502 [10%] with ?hands-poised? v 103/574 [18%] with ?hands-on?; RR 0.57, 95% CI 0.41 to 0.78; third-degree tears: 5/502 [1%] with ?hands-poised? v 16/574 [3%] with ?hands-on?; RR 0.36, 95% CI 0.13 to 0.97). [31] The quasi-randomised trial was carried out in the University Hospital of Vienna, and used alternate allocation based on the date of delivery (even days allocated to ?hands-on?, and odd days to ?hands-poised?). Data were missing for 45 women in the ?hands-poised? group, and for 40 in the ?hands-on? group. There was no significant difference in the rate of first- and second-degree perineal trauma (175/502 [35%] with ?hands-poised? v 171/574 [30%] with ?hands-on?; RR 1.17, 95% CI 0.98 to 1.39).

Top Harms
The RCT found that the ?hands-poised? method significantly increased the risk of requiring manual removal of the placenta, and significantly increased perineal pain 10 days after delivery (manual removal: 71/2740 [2.6%] with ?hands-poised? v 42/2731 [1.5%] with ?hands-on?; RR 1.69, 95% CI 1.16 to 2.46; NNH 95, 95% CI 45 to 417; perineal pain: 910/2669 [34%] with ?hands-poised? v 823/2647 [31%] with ?hands-on?; RR 1.10, 95% CI 1.02 to 1.19; NNH 33, 95% CI 18 to 212). [2]

Top Comment
The two RCTs show no difference in benefit between the ?hands-poised? method of delivery compared with the ?hands-on? method regarding risk of perineal trauma.

References
2.McCandlish R, Bowler U, van Asten H, et al. A randomised controlled trial of care of the perineum during second stage of normal labour. Br J Obstet Gynaecol 1998;105:1262?1272. [PubMed]
31.Mayerhofer K, Bodner-Adler B, Bodner K, et al. Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women. J Reprod Med 2002;47:477?482. [PubMed]
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OP I'm guessing that you're in the US, only because you mention stirrups which I've never come across in the UK, only in the US where I had my first two babies.

I also don't know what the definition of a 3rd degree tear is but after my second birth I needed 26 stitches - not sure where that is on the scale but quite high I think (the UK consultant for my third birth expressed surprise anyhow).

I've had six normal delivereies since that second birth although I was strongly advised to go to a high risk unit though for different reasons, not to do with the tear. As far as the tear went, there was nothing different from normal on any subsequent birth and I never needed any more stitches. There was 15 months between the second and third births.

There may be something relevant there.

What would I do? The problem with asking this is that for different people they may have different perceptions of what is an acceptable risk, etc.

Some people in your position would want a section.

Purely on a personal level I'd give birth where I felt most confortable whetehr that was at home, MLU, CLU. Personally I would not want to deliver in the pool even if I laboured in it. I'd want a midwife who would talk me through the pushing stage, ie; tell me when the head's crowning and when to do little pushes/not push. M/w needs to be able to see what's going on in order to do this which is hard impossible in the pool. Doesn't mean you need to be flat on your back, could be kneeling or on your side. I'd maybe do a bit of perineal massage i nthe mean time, may not help but won't do any harm.

Is this relevant? I had an episiotomy with the first birth but (obviously) not on the second and not with any of the other six children either.

We have stirrups in the UK.

Yellowstone - it sounds like you had a second degree tear. 26 stitches doesn't sound that unusual to me at all. A 3RD degree tear involves the anal sphincter and I think you'd know if it had been that bad.

I don't think that not having an epis for the 2nd is relevent. Or that you had an epis for the first. Its unusual to have an epis unless for fetal distress or an instrumental delivery. Its thought that tears heal better. Often its just the perenium is tight and tears, or pushing too fast/hard at crowning or just the position of the baby.

I am in the UK - I say stirrups because I saw them in the labour ward when we did the tour. I don't know when they are used though so I am jumping to conclusions.
VivaleBeaver - can I put that level of detail in a birthing plan (and will it be read) - can I specify that I want to be talked through the pushing stage in just the way that you describe?

Maybe I should be asking for a CS!

AGH

Vezzie - I used the stirrups in the UK for my first DC, I had an epidural and was tired and shaky. I think they also used them with my second DC - but only while stitching my tear, not during the actual birth.

There are two schools of thought.
One to have a managed birth with planned episiotomy or
Two to have a birth which is planned to avoid tearing (e.g. Water birth, side lying pushing or all fours, no coached pushing etc
IME I have supported two women to birth after third degree tears, one had a home water birth, the other was semi induced due to low waters, but contractions started after pessary and she birthed on the MLU with a 'Hands off' midwife, on all fours.
Neither had a tear for this second birth.
Episiotomy will definetely cause perineal damage and some research has shown they are more likely to extend to a big tear.
"women should be advised that there is no evidence to support the role of prophylactic episiotomy in subsequent pregnancies.1" From Australian obstertric website.
Tearing is also associated with active restraint of the fetal head (hands on!)
You should be encouraged to push in your own time without breath holding, chin on chest type cheerleading and to stop pushing as the head is born and pant.
S

Thanks Selina.
I am really starting to get very stressed about all this now. I can't believe I have been expecting a baby since last summer and have had so much new stuff thrown into the mix at 39 weeks. I have dutifully attended all the (delayed) appointments (with random people who don't put their names in my notes) and asked questions and thought about all this and suddenly when I might give birth tomorrow, a new doctor is scaring the crap out of me (crap, ha ha ha, not funny)

I wish I could talk to someone, no chance of that now really - what happens if you just phone up and ask to talk to the consultant?

that 50% figure sounds so made up to me too

Its difficult if you don't have a consultant's opinion that you trust.
The only other thing you can do, is look at research and your got instinct and make a descision about the type of birth you feel will give you the best outcome. (and then stick to your guns and not be swayed by anyone!)
Are you worried about birthing in hospital in comparison to your previous homebirth? HAve you been on a hospital tour?
Its not too late to have a home waterbirth if you want, or an MLU birth or even a planned CS if thats what you felt was best.
Need to chat to your DP and do some soul searching.
Some more thoughts here-
www.birth.com.au/Third-and-fourth-degree-tears/Another-vaginal-birth
www.efn.org/~djz/birth/obmyth/epis.html

vezzie don't get stressed, that's the worst thing to do. I was an ingenue with most of mine (hence not even knowing what a 3rd degree tear was until just now).

But you mentioned pushing. This may be one thing that I can usefully add. My US midwife advised always to be talked through pushing and with my seventh in the UK the midwife said 'just do what feels natural' and left the room. The cord was aroung the baby's neck. I pressed the button on the bed because I didn't feel safe, remembering that first midwife's advice. That's a vital stage, the don't trust to nature approach is very wise.

Good luck. I think choosing whatever feels safest to you even if it's not the birth that you'd wish for is the one you'll be happiest you chose.

No, don't ask for a c,section. You can definetly put that level of detail in your birth plan and it will be read. If you not sure if its been read ask the midwife if she's had chance to look at it yet as you want to discuss it, make sure its ok. They won't mind. Good luck.

I can't bear to read those links - I started them both but I just can't face all this.
I can't face the risks.

Unfortunately there is a baby inside me that has to come out and I am not up to this!

Vezzie, you are up to it! It sounds like you had a lovely birth last time until the tearing. You can definetly have another lovely birth and its unlikely that you'd tear like before. Tearing is much much more common with a first baby and the majority of women then go on to not tear the next time.

Statistics show that you ahve a 96% chance of not having another 3rd degree tear. So while your risk of having another 3rd degree tear is higher than if you hadn't had one the first time I still think that they're good odds.

I don't think that hands on/hands off will make any difference. I do think that being talked through the pushing stage could help, just so you know when to give little pushes.

I'm sorry the links worried you, I thought they were quite positive in explaining why hands on/hands off wouldn't make a difference and that teh Dr you saw who worried you was talking twaddle about that.

Hi VivaleBeaver
Sorry, I was just freaking out because tired I suppose. The links were not scary in themselves, I just didn't want to face the reality of what I am thinking about.

Thanks for all your help.

I suppose what I am struggling with here is the fact that there is no consensus at all among professionals and I am being asked to make a decision and I know I am not a pro. Whatever I decide I will be going against someone's deeply held view and that feels wrong. I am in one way the only one equipped to make the decision - I am the only person who knows exactly what happened last time and have read all the notes and been to all the meetings this time. (no one else has been to more than one or had time to read anything about any of the others.) But this makes me feel very exposed. Shouldn't I have a doctor or similar who knows everything and is prepared to talk to me about it? I feel like I am being left to it, like choosing a holiday off a website.

• not by you though! I knew there would be sensible input from mn.

No firsthand experience to add (I'm expecting my first and have no idea how it will go!) but my impression from your post OP is that the hospital setting and care you've gotten to date has stressed you out a lot and that's not how you want to be feeling when you're giving birth! Also the conflicting information and "statistics" are a worry. But ultimately your biggest concern (aside from the usual stuff like the health of baby, etc.) is having a severe tear, right? So that's what you're looking to clarify and find out about risks and do whatever you can to avoid one.

As the others pointed out, MLU vs consultant-led is not going to reduce tears -- the only thing that will be 100% guaranteed to avoid a tear is a c-section, which comes with its own risks. Episiotomies should only be for fetal distress or emergency situations, according to the research. So I don't see the benefits to you in labouring in the hospital. In fact, I can only see risks based on how you've described your experience so far! Unless there's something else that isn't apparent in your OP that your consultant knows that we don't, I really don't see why you can't labour in the MLU like you planned. Make sure your midwife is on side with your notes and understands your previous experiences and your fears/wishes for this time. Communication is key here.

Your MLU is attached to the hospital, so if you were to need obstetric help during or after the birth, it wouldn't be hard to get you over there.

To me it seems like you need a person you can trust with your care, and who will support you, give you confidence and see you through it. At the moment you don't sound like you have that in the consultants you've dealt with so far! If it were me, I'd be extremely worried that my confidence and faith in myself to birth a baby safely and happily was shaken, and I'd need to have that restored before anything else. Can you make an appt to discuss all this with a MW at the MLU to ease your mind?

My opinion is that all things being equal (i.e., you really have no greater risk of tearing at the MLU than at the hospital) you should go with your gut feeling which comes through loud and clear in your posts and stick with the MLU. I think submitting to a hospital birth as it currently stands with consultants you don't entirely believe in or trust could be a big mistake.

Vezzie, go back for another opinion. I was similarly terrified by a registrar a few weeks ago who, after mentioning c-section 70million times, then said I couldn't labour on MLU anyway - after my first childbirth was medicalised into a nightmare, I just wanted the calm alternative. Saw the consultant last week who agreed with everything I said and sgned me back to the MLU - was reassuring to have someone calm and not hugely into interventions. That said, our MLU is 30 yards from consultant's ward.