Student midwives say Mumsnet posters on the birth forum just peddle horror stories about birth and midwife bashing WTF?

[Ushy]

This is the link and it made me feel really upset.
They have no idea how traumatic birth can affect people. This forum is one of the few places people can share their experiences without being judged.
www.studentmidwife.net/fob/mumsnet-and-the-promotion-of-medicalised-birth-thoughts.69784/
Not at any point do any of them question whether their apporach is wrong. No - it is all WE need 'empowering' 'educating' 'encouraging' to do things their way.

I did it their way once - big mistake and PTSD. Subsequently went for caesarean and epidural.

What scares me to death is that if I ever had another child, then I could fall into the grips of this lot and I just think that is scary.

Anyone else feel the same?

controlled relaxed first stage. No one knows who will be lucky enough to have a lovely 4 hour manageable waterbirth and who will end up in a chaotic, unpredictable situation with limited care, denied pain relief and demoralised and degraded. Is it any wonder women want a more controlled experience with risks spelled out than chancing their arm with an understaffed, bureaucratic and impersonal NHS service?

Thank you to Lulla and other midwives who've taken the time to come on and post. I'd like to follow up your points about physiological birth, Lulla. I'd be interested to hear what you have to say in response to the argument that evolutionary biology works at the level of species, not individuals. So what matters is that enough of the offspring of a given species survive that it's able to outcompete competitor species for the same ecological niche.

With some species - e.g. leatherback turtles - loads of eggs are laid and only a tiny handful of the hatchlings make it across the beach to the sea. In some species (Pacific salmon) die after spawning. Humans have an evolutionary trade-off between having bigger brains (hence large heads relative to the birth canal) and an upright posture which makes birth statistically more likely to go wrong than in other similar sized mamals. So natural, physiological birth is still a process which can, quite frequently and quite naturally, go wrong.

If you buy this argument, then an important part of a midwive's job is accepting that not all women will achieve a natural childbirth and being able to make the right judgement calls during labour to assess whether women will be able to deliver in a physiologically natural way or will need intervention (and also respect the wishes of women who've had it all go tits up in the past and want to avoid a repeat, even if that repeat is low probability). Incidentally my reading of Sheila Kitzinger is not altogether at odds with this position - facilitate women to have a natural birth, but accept for the cases where it goes wrong, modern medicine is a life saver.

I suspect where we're disagreeeing is on the level of statistical likelihood and risk (which are not the same thing - risk is usually defined as a product of both probability of occurence and severity of consequences). Although educating women can take teh form of giving them the correct statistics,only they themselves can assess risk - two women may be given the same odds of a subsequent birth leading to more pelvic floor damage, and one decide VB is the way to go, while another judges the consequences so life-impairing that she opts for ELCS. And I think the medical profession should respect the individual patient's assessment of her risk - once you've realised this is different from probability of occurrence. (NB, my day job is atmospheric science, so I deal with this sort of combination of social and mathematical issues all the time- statistical predictors overlaid with a huge amount of chaotic noise, plus wildly differing assessments of risk depending on where and when things like major storms/hurricanes happen).

PS,should add that I was lucky in that both midwives and consultant-led care was fantastic throughout my pregnancy, ELCS (for medical reasons - but the complex sort requiring just this sort of statistical judgement call) and aftermath, so I have a very high regard for the midwifery profession.

Pesto I think thats the thing - there is either a feeling to go to one end of the extreme or the other. Either the homebirth or the ELCS route. I completely understand both... there needs to be a whole bunch of ways and approaches to tackling the issue. Because we are all so different.

In terms of best outcomes I'm not convinced that looking at the population as a whole is always helpful. Different groups have different problems and issues. I think that breaking down into groups according to risk and expectations can reveal different patterns.

For example:

CS are generally associated with more problems in terms of bonding and PND.

But then you look at other studies and you look at what the woman PLANNED to have and you start to get a very different picture.
Women who planned a CS come out better in satisfaction of experience than those who planned a VB. Mainly because in the VB group women there were women who didn't have things go their way. But the interesting thing that comes out of that, is actually the problems in terms of bonding and PND for planned CS came out as being as good as planned VBs.

This example also shows up a problem with some methodology:
Far too many studies are badly put together. ELCS and EMCS are consistently lumped together and VBs are used in stats in isolation without taking into consideration that it should be about planned VBs including EMCS resulting from that. The net result is that often VBs come out more favourably than they should be, giving a distorted picture thats difficult to unpick and compare. That's not good for midwives, doctors or patients.

Another example:

You look at outcomes for women who have been diagnosed with fear.
Acta Obstetricia et Gynecologica Scandinavica (AOGS) published a study by Gunilla Sydsjo at the University Hospital in Linköping, Central Sweden in Sept last year. Its well worth a read (and don't read the news articles - read the proper study). Women who presented with higher levels of fear didn't seem to respond to counselling and still came out far worse physically.

I certainly think is all pointing towards outcomes being heavily influenced by what the woman wants, her expectations and level of fear and just how important they really are before you even get to the door of the delivery room.

So where this fear is coming from is really important in understanding how you deal with it. I do get annoyed at this idea that we are influenced primarily by the media and it is a new phenomena. Its really patronising. Research into tocophobia has revealed clear patterns in medical history and mental health. If we were influenced primarily by the media, would this appear? I doubt it.

Then there is the history of fear of childbirth. People suggest its a new thing. I personally think the only new thing is, the ability to have a choice. There is a french book from 1858 where a doctor made the following observation:
?If they are giving birth for the first time, waiting for unknown pain worries them beyond all measure and they are plunged into an indescribable state of anxiety. If they are already mothers, they are terrified by the memory of the past and the prospect of the future; they are privately convinced that they are going to die from the ordeal which awaits them?.
He added that ?this idea becomes absolutely fixed in their heads and triggers a melancholy frame of mind which takes over all their thoughts?
Of course the threat of death was much more real, but the similarities in that description are quite startling.

I have to say I do feel it backs up my feeling that, that whilst we look at stuff on the internet or tv and take it to a degree, its far less important than being aware of the experiences of those who we know in real life. You can read a billion studies and anecdotes but what stays with you most is what happens to women closest to you and that distorts your ability to respond rationally to statistical risk, in a way that the media doesn't.

thunks - exactly. And how can we trust and rely on the opinions of MWs or other HCPs in obstetrics when they are formed, at least partly, on the basis of evaluations of births that do not take into account all the relevant facts?

Why do women then consistently have to fight for what they feel will suit them best against midwives who insist that they are experienced and they know best

?????

Perhaps because generally they do know what it best. Perhaps because they have trained to understand the contraindications, complications and risks to all things.

Seriously...lets say a woman goes to a midwife/OB GYN and say 'I want a CS'..is the midwife/OBGYN expected to say 'ok' no problem'. Never mind the fact that it costs the NHS an extra £2K approx, never mind the fact that it is MAJOR abdominal surgery (and all the increased risks such as infection, PPH, Respiratory distress for the baby and this is a very small number of risks). Midwives and HCP have been educated and trained to know and understand all these risks.

I very strongly disagree that women should be granted a CS because they are scared of childbirth (True tokophobia is a seperate issue).

If you go to your GP and demand a drug that will cost almost double that of your usual drug would they give you it? I doubt it very very much.

pesto I didn't take any offence at your post.

I am expect a baby any day now (was due date yesterday according to my dates, - some time ago according to the midwives).

To quote you yourself:

'I've had 2 normal problem-free homebirths, relatively quick with zero complications. Yet, I am beginning to get into a complete state about the thought of trying to arrange this birth'

I also am stressed out trying to ensure that the midwives understand my birth plan which is based on YEARS or research on the very specific and individual circumstances that are central to ME, balanced with very up to date knowledge of the risks and stats that are relevant to my decision.

I have given up discussing any of it at any midwife appointment because although the midwives (this time, - never happened before) have shown an element of interest in my plans, it is a new one each time and it is exhausting and stressful telling a new one, yet again, that I will be refusing VEs and justifying my reasons, because that midwife is very unlikely to even be there at the birth anyway.

singing, - should they be granted a c/s because they are afraid of the environment, attitude, and lack of support during vbs?

'Perhaps because generally they do know what it best. Perhaps because they have trained to understand the contraindications, complications and risks to all things.'

How can they? If they've never met you?

A successful VB is intrinsically tied up in the pychological and emotional state of the woman. Being frightened is a huge risk factor for a poor outcome.

cardamom, just to pick up on what you said about 'auditing' births - this has been a bee in my bonnet for some time.

Analysis of birth costs purely in money terms always seem to be done in an 'on the day' way for one dept in a hospital. There's nothing holisitic about it, it's just 'vb cost this much, cs cost that much.' I've said before, a birth which requires subsequent surgery or physio for the mother, or baby, or any counselling or therapy, doesn't show up on the 'birth balance sheet' anywhere. It's different staff, different bits of the nhs, different budgets that pick up the pieces when things go wrong after a mother and baby have left hospital.

Even the latest NICE guidance on casearians admits that they have no research which factors in the 'downstream' costs [slightly unfortunate choice of word!] of urinary incontince that occurs years after birth and worsens with age.

I've seen more than one post on this board along the lines of 'I was told I had a text book birth but it was awful and I have PTSD.' For as long as we have such a limited and short sighted way of 'accounting' for births, nonsense like that will continue.

I cannot help feeling too that the insistence on the primacy of the 'physiological' experience of vb contributes to a 'narrow' evaluation of a successful birth. I've said it before, and I'll keep saying it - WOMEN ARE NOT JUST A COLLECTION OF HORMONES. They have mental and emotional needs too and these may not on an individual level be best served by the ideal physiological process.

When a woman has an unassisted vb, where all of her hormonal processes should come into play in a natural way, but where she is mentally traumatised by the experience, that trauma isn't somehow wiped out by all the natural oxytocin she has swooshing around.

Hmm, it strikes me that in terms of saying the risk of death was more real historically, that ties in with the evolutionary argument too. The risk of death has always been real and though it is now so controlled that fear of that risk can be perceived to be "irrational". However, I feel that if you can say that transition in labour etc is a throwback to when a woman might need to take flight from a bear mid-labour, then it stands to reason that our bodies/hormones/minds etc haven't caught up with this decreased level of risk and we are not really programmed to truly believe the reassurances we are given.

It's interesting how the desire to control birth medically is often pitched against giving in to our "animal selves", but actually as Lurcio has pointed out, in the natural world there really is a truth to the idea that giving birth is one of the most vulnerable times of your life in terms of mortality so having some fear is probably inevitable. I guess the idea is that if you can disengage your thinking brain and engage your primitive, "lizard" brain the biological urge to procreate takes over and cancels out any higher order cognitive processes that can flash up points of risk in the process.

However, we are not animals and we do have these higher level brains and different people find it easier or harder to switch this on and off.. and perhaps some people's brain development, early environment, neurotransmitter functioning etc prioritises some hormones over others and there isn't enough happening to really facilitate that transition to the animal brain.

fruity - exactly - financial cost is another point. The bill for investigation and treatment for my birth injuries will be in excess of £30,000 by the time we are done. Yes, this is private, but it would still be a sizeable sum on the NHS. And this figure excludes my GP appointments and prescriptions I've had on the NHS. Much cheaper than an ELCS....

Yes Singingbanana it is important to be made aware of the risks - but the TRUE risks, not some politically engineered, one-sided assessment of risk. And these risks need to be looked at in the context of the INDIVIDUAL WOMAN.

EMCS and ELCS figures are lumped in together all the time, even though they do NOT have the same risks. VB is no safer than ELCS - just a different set of risks (and this is my consultant talking as well as doing my own research).

For example one of the risks of VB is incontinence issues - either urinary or faecal. Because of my previous medical history my own PERSONAL risk is greatly increased, hence I am having an ELCS as for me personally I perceive it as LESS RISKY.

And my first community midwife couldn't even read the 'weight in lbs to weight in kgs' conversion chart correctly, recording my weight incorrectly low which could have meant me being excluded from gestational diabetes testing. The second ignored my concerns about spotting and pelvic pressure, recording 'all fine' in my notes. Midwives are not infallible.

And my understanding was that a CS costs the NHS an extra £600-700, not £2000. No doubt my reconstructive gynae surgery would cost a lot more, as well as loss to the tax payer in terms of my earnings. Should women's health and wellbeing be measured out in terms of financial cost? I don't think so.

Fruity Really good point.

Singing a c/s doesn't cost £2000 extra, including downstream cost of only one bad outcome (incontinence which is higher with VB) the cost dropped to just over £80.00 - that is BEFORE you take into account psychological treatments for traumatic planned VB (i.e. where it goes wrong). (NICE estimates)

Read lurcios post about risk being in the eyes of the beholder. I've copied some of her post here - (hope that is ok lurcio) because it is so so right.

"Although educating women can take the form of giving them the correct statistics,only they themselves can assess risk - two women may be given the same odds of a subsequent birth leading to more pelvic floor damage, and one decide VB is the way to go, while another judges the consequences so life-impairing that she opts for ELCS. And I think the medical profession should respect the individual patient's assessment of her risk - once you've realised this is different from probability of occurrence."

How can they? If they've never met you?
???

Well the same can be said for GP, nurses, consultants. That is a bit of a silly statement you have made there!! So are HCP just meant to give joe public whatever they want because 'you know yourself better'?

Let me give you a scenario

Joe public - Dear mr GP, I am feeling very down. I am really really depressed. I want some anti depressants.
GP - Ok I don't know you so here you go...have a prescription.

Seriously...I am not even sure how else I can respond to your suggestion that midwives should just grant you whatever you want because we don't know you. So how exactly so you suggest we get around this It is not possible for midwives to know you that well unless you have a close member of your family be your midwife.

Starlightmajesty..no they shouldn't. Midwives and woman should be talking and trying to work through these issues. It is about working together surely and trying to find reasons and solutions.

Apologies for the short posts. I usually am way more eloquent but with 4 kids demanding my attention it is a bit difficult.

Ushy..sorry can you please show me where you get those figures. Those are very amusing. A CS women should be in hospital 3 days as opposed to 6 hour-24 hour for an SVD. Not to mention the cost of the cons/reg and 5 other theatre staff and peads for a CS birth.

That only costs an extra £80. WOW. I know NHS staff are poorly paid but :D :D :D

I assumed that was a typo and £800.00 was the figure. I think it came out with the new NICE guidelines.

Lulla,

I?m not sure you can see the logical inconsistencies in your own post. Here?s one example:

?physiologically, it does have the better outcomes. This is not the same for every woman??

The second statement is inconsistent with the first. Can you not see that?

?it cannot be denied that doing (pain relief) without is the most 'desired' outcome in terms of pysiological benefit.?

This obsession with and misunderstanding of physiology is disturbing. Firstly, brains are also a part of our physiology, no more or less so than the reproductive system. Thoughts and emotions are as physiological as these fabled endogenous hormones. Yet women?s opinions and feelings are not what midwives are referring to when they talk about physiological birth, or physiological benefits or whatever. If they were included in the definition, then the physiological benefits to a woman of having her pain relieved would be referred to. The calming hormones produced in her brain by having her assessment of her pain taken seriously by carers and by access to effective pain relief would be considered extremely important. There would be studies quoted by midwives of the effects of high levels of cortisol caused by inadequate access to pain relief or having no control over whether or not it is provided etc.

The truth is that this word ?physiological? isn?t being used in its full sense here and it never will be. It?s just the latest word (I hesitate to say euphemism) to be used instead of ?normal?. Normal was found to be offensive to women who ended up with ?abnormal? births. Before that it was ?natural? until it dawned that that was both offensive to women who had ?unnatural? births and, perhaps, people began to realize that that was far too close to reminding people of the natural fallacy. ?Physiological? as used here, still means the same thing ? normal and natural ? with all the value judgments that go with them. It?s that naturalism which causes midwives to promote one set of physiological processes over others. It?s nothing more than the old mind/body dualism, in this case exalting the body and the ?instincts? over the mind.

Beyond that, you have throughout again demonstrated an inability to read the science without bias. Since you started by quoting Odent I suspect it would be a waste of time to pick apart your claims. All I?ll say is that it should be self-evident to anyone that human bonding is a rather more complicated matter than the operation of one physiological system. Again, if women were treated as more than the sum of their reproductive systems, that would be self evident.

?It is difficult to get a balance- I have a responsibility to individual women's care, yes, but the cultural and political nature of birth also interests me, as it does most midwives?as you say we cannot serve two masters easily.?

That ?yes, but?? is a common one as you say. It?s also completely unethical and it?s long past time the midwifery profession confronted that. Your interests in culture and politics are your business. They should not under any circumstances be influencing how you care for individual women. It's not an issue of balance. Midwifery isn?t a hobby. I didn?t say you can?t serve two masters easily. I said it can?t be done.

Ushy I absolutely agree with the quote from Lurcios. You seem to be holding onto this pelvic damage/incontinence thing. Are you aware that pregnancy alone is the cause of most UI and pelvic floor repairs? I don't have the stats to hand but can post a link once I get it. Vaginal birth is the highest cause of this.

Singing: your example is exactly what happens! GP gives Joe Bloggs antidepressants on the basis of a 10 minute consult. Been there, done that, have the T-shirt.

I've also been in the position where these all-knowing professionals have

• told me that there are no antidepressants should be used in any pregnancy
• waterbirth is too dangerous for someone with an anxiety disorder
• it's perfectly fine for a three year old to have no speech

None of these is accurate.

I am a professional too. We get things wrong. There are definitely expert patients who do know their stuff. No one's training covers everything.

Generally I would say I've met a fair few consultants who know their field inside out and backwards and can quote research at you but it's much more hit and miss with Health Care Professionals who often don't have the same level of rigorous training or critical thinking. Midwives aren't really spectacularly trained any more than any of the rest of us HCPs and there really isn't a sufficiently proven evidence base for some of our assertions.

Singing Might be amusing but the figure is correct. (I am not a nurd - I work in medical litigation so have to look at this stuff daily).

NICE Caesarean Guideline Update Page 219
Table 13.19 Results when urinary incontinence is included as an adverse outcome
£84 (ICER) which is the increase over the cost of vaginal adjusted for maternal health.

You are also right Angelico, £700-800 is the cost but BEFORE adjustment for the additional cost of urinary incontinence repairs.

It is the point other posters have made - vaginal birth results in a lot of costly downstream perineal/psychological damage which can be costly to repair.

The evolutionary arguments are interesting, but for me personally don't resonate really. I can honestly say I have no fear about giving birth itself and never have had, and I do realise that in many people's eyes this makes me lucky. Even first time round in advance friends were amazed I was not scared about it. I was scared about not being listened to and what might be done to me in hospital, as well as being without DH or labouring in front of lots of other people -as it turns out rightly so . By the way, I imagine everyone at the hospital I attended would classify my first birth as successful ('only' a forceps and 2nd degree tear). When asked the day after giving birth for feedback on the epidural I raved about how marvellous it was. In a few weeks/months when I was still suffering the consequences and had had time to reflect on my experiences and look into the reasons given for induction and everything else that happened my perspective changed radically. Ironically, if you look at my first birth plan, it was sufficiently flexible that it could be said what happened was within it.

My fears in relation to my births since have all centred around how I will be cared for, not the actual physiological birth process at all. Sadly, my experiences have shown these fears to be well grounded and equally that after a very distressing and painful out-of-control first labour, I can experience a comfortable and well-controlled birth (twice so far in fact!). It is not true that pain is part of everyone's birth experience. However, I totally accept that for many many women it genuinely is, and their real experiences should be respected just as much as mine.

Apologies if I am taking the discussion away from pure fear of birth to include fears surrounding birthing.

Singingbanana - you example doesn't entirely follow because with a GP, the chances are that you will get to know them over a number of years. Depending where you live you will probably have a choice of GP, so can try to choose one who suits your own approach to health care. I changed from a GP practice which stated quite bluntly on their website 'we don't support home confinements': I knew that wasn't the practice for me.

Come maternity care, unless you go privately, you take pot luck as to who you see. Why can't we have a system where midwives are organised into practices (like Holland?) and you would be able to choose to go with one whose philosophy of birth would be akin to your own?

No HCP (or anyone else) can possibly, without having even talked to me (or anyone else), know what is best for me (or anyone else). My bugbear is these so called expert HCPs who put you in a box before they've even met you without trying to understand.

I was for the most part exceptionally fortunate but when I went into labour the MW who saw me in triage was awful. She didn't seem to take note if anything I said, anything that was written on my notes, anything DH said - it was her way or the high way. 5 minutes trying to get to know or understand me would have shown her that what she was insisting on was, for me in my individual situation, not the best course if action even though I presented as a fairly 'normal' early labour. I hate to think what that would have been like if every MW from the first consultation had taken that attitude.

So when I refer to HCPs knowing what's best it's the default position they take of a 'me professional / you patient' dynamic instead of working in partnership not the genuine application of medical knowledge to the situation.

I spend a lot of time ensuring that the MWs I teach are able to communicate not just the medical imperatives but to create a relationship with the individuals they care for.

Ooops . Type too slow and thread moves on. Sorry folks