A question for midwives (and/or anybody who knows) re. meconium and episiotomies.

[arabella2]

Hello
I am 30 weeks pregnant and starting to think about the birth.
Last time with ds I had a very quick labour and when my waters finally broke (not long before the second stage started) there was meconium in them. I don't know if this was ds's reaction to everything going so quickly. Anyway, because of the meconium the midwife who delivered ds said I had to give birth reclining (kind of on my coccyx with my back lifted up by the bed). This is not what I had wanted at all and I am sure it is partly what made the second stage so long (about 1 hour and 20 minutes) and also may have caused the fact that in the end I had a horrible episiotomy.
In my mind there has always been the thought that maybe she was wrong? She was saying that in any other position there would be the danger that ds would swallow the meconium, and in fact a paediatrician aspirated his breathing tubes as soon as he was born.
Is this what you would have done with someone with meconium?
Another question I have is, if you have had meconium once, does it make you more likely to have it next time?
Also, regarding the episiotomy, my midwife made several cuts which afterwards people said was weird... Any comments?
It was an okay birth because it was so quick but though my midwife was kind and capable I think, there are things about it that I don't like thinking about and I am anxious to avoid them this time. Things like the light being really brightly lit, the paediatrician just standing there in full view of all my bits rather than to one side, little things like that which would make the experience less kind of "embarrassing". It wasn't embarrassing at the time but in retrospect it was.
I am really wondering this time whether I should go for a home birth as I am booked in at Queen Charlotte's in London. This is so I can use their birth centre, but I am terrified I am going to end up on the labour ward instead... on my back again... I know you can't always control this and the baby comes first so I am not being irresponsible...
Thank you for any thoughts.

What a shame that you had this experience and are worrying about it recurring again.

It might be useful to know a bit about meconium. Babies often pass meconium when you are past your date and does not mean that the baby is distressed. The only way to know whether the baby is having difficulty is to continuously monitor you. Some babies who are distressed do not pass meconium so the 2 things do not go hand in hand. However, if a baby's heartrate is causing concern, and there is meconium, then certain precautions are taken at delivery. There are also different types of meconium. In our area we grade it. Grade 1 means that there is only a trace in the waters when they break and is of no real consequence. No need for continuous monitoring. No precautions are needed at delivery.
Grade 2 means that there is a fair amount of meconium but lots of water around the baby as well. Continuous monitoring is recommended and precautions at delivery. Grade 3 meconium is much more worrying and is when there is virtually no water round the baby but just meconium. Continuous monitoring is recommened and precautions at delivery. The mother is also crossmatched blood incase the baby shows signs of distress that would indicate the need for a C/S if the mother was not fully dilated. In that case a forceps/ventouse delivery might be needed to hasten delivery if it is not imminent. If the haed was coming on it's own, an episiotomy would be recommended unless the baby was delivering very quickly. The need to deliver the baby more quickly is to reduce the time that the baby is being stressed during delivery. A distressed baby may mean that it is suffering from a lack of oxygen during labour.
A stressed baby is more likely to gasp at delivery and inhale meconium into the lungs. If the meconium is thick, this can be disastrous. Babies 'breathe' when they are in the womb anyway and often that is when the meconium can get into the lungs.
The precautions at delivery are that the airway is gently cleared with suction when the baby's head is delivered. Once the baby is delivered, the cord should be clamped very quickly (not a good time for dads to do it) and the baby transferred onto the resuscitaire (equipment used to place baby on under heater with light, suction and oxygen).
The paediatrician will be present in the room and hopefully the baby will be transferred before he/she has gasped or cried. The paediatrician will look down the baby's throat to see if there is any meconium present. If there is he will pass a tube down to the baby's windpipe and suck the meconium out with a small suction tube. Once it is clear the baby will be rubbed dry and encouraged to cry. In most cases that is all that is needed. If they baby cries lustily immediately at delivery there is unlikely to be a problem with meconium in the lungs!
If mecinium has gone into the lungs, the baby will need transferred to the special care baby unit and started on antibiotics to prevent infection which can develop. Some babies actually need to be put on a ventilator (very few but can happen)and I have known of babies having to be transferred to a specialist unit for treatment where the blood is oxygenated outside the body via a machine to allow the lungs to recover (rare).
In your situation Arabella, there may have been real concern regarding the baby and the midwife needed access quickly. Alternative positions are great for delivery, but sometimes they can be awkward when you need to get access to the baby. However, delivering on your side or on all fours can be just as good as on your back.
The question about the episiotomy itself- several cuts is that the midwife perhaps had to extend it because it wasn't big enough. Ideally it should be done with one cut, but sometimes there can be a thick band of muscle that holds the baby back. It sometimes takes more that one cut to get enough space to deliver the head quickly. An episiotomy is not needed for meconium on it's own - it is if the baby is showing signs of distress with a slow heartbeat.
The fact you had meconium then does not mean you would have it again.

There is no reason why you should not go for a homebirth if that is what you want. Should your waters break at home and meconium present, you would be advised to transfer to hospital. When the waters do not break till the very end of labour, just prior to delivery, the baby is less likely to be distressed because they are cushioned by the water around them. A baby with thick meconium and no water would probably show heartrate irregularities during labourt which would be another reason for transfer into hospital.
I hope you have been able to follow this mammoth post. Let me know if you need me to explain anything that is not clear. Good luck with whatever you decide

Can I add, on another aspect of your post, Arabella2, that there were aspects of my first labour which distressed me a lot, and which I was very afraid might happen again. The hospital where I was booked in provided a Liaison Midwife, so I had a long meeting with her, at which we went through the file on the labour in great detail. I literally talked myself out - voiced my anger and distress, and got the experience out of my head. She was incredibly helpful, explained why things had been done or happened, and helped me prepare myself for the forthcoming labour. She reassured me that, jsut because certain things had happened previously, they wouldn not necessarily happen again. Also, and very importantly, she bolstered my confidence to say 'No' to things or people that I didn't want (and I did it!). That reassurance and 'permission' made an enormous difference to my approach to the labour. I had talked about the first labour and aftermath several times with family and friends, but even though more than two years had passed I didn't realise how angry and frightened I still was until the prospect of my second labour loomed close. Talking with someone whose job was to listen and helped me deal with it was more therapeutic than all the going over and over and over with friends had been. What I'm trying to say in my long-winded way, is that I think you too might benefit from a de-brief with a sympathetic midwife.

You are absolutely right prettycandles. We do not have a liaison midwife as such but the senior midwife of the labour suite has often been asked to go through previous deliveries with women. Arabella2 - you can ask your midwife to arrange a discussion about your last experience.

Thank you very much for your answers Mears and Prettycandles and sorry that I haven't got back to you before but I've kind of been mulling things over in my head.
I have no idea if my midwife graded the meconium - she may well have done. So are you saying Mears that the reason she asked me to be reclining is so that ds could easily be aspirated as soon as his head came out? I don't know how concerned she was at having quick access - she may have been, but it's annoying to think I could have been on all fours because I'm sure that it would have been easier to push him out and I might have avoided the episiotomy... must continue this later as ds is trying to get on my chair and I can't concentrate...

Arabella - I had my dd, 3 months ago, in the labour ward at Queen Charlottes (trial of scar so couldn't use birth centre) and I just wanted to reassure you that, even on the labour ward, the staff were very good at encouraging me to use different positions. They were very skilled, and by moving my position managed to encourage my baby to move her head and get into a deliverable position.
(Although I wouldn't discourage you from a home birth if that's what you want).

Thanks Bluebear, that's reassuring to know. Part of my concern stems from the fact that when I went on a tour of the birth centre at Queen Charlotte's months and months ago, the midwife there made a comment about the labour ward being all "monitor round your waist and lie on your back". That phrase has really stuck in my mind but obviously this is not true.
Do you mind me asking if there were lots of people in the delivery room when you were giving birth? This is my other concern - the one good thing about giving birth last time is that only the one midwife and the paediatrician were present...
I am still considering what a homebirth would be like but maybe a doula brought to hospital with me as well as dh would help me feel more at ease about what was going to happen and whether or not people were going to listen to what I would be finding difficult to express at that time anyway.
I'm glad you found the staff at Queen Charlotte's so helpful Bluebear.
Mears, going back to my episiotomy, I'm sure the midwife made cuts in different places and dh thinks so too (though obviously we must both (especially me!) have been in a bit of a state and maybe we don't remember correctly). It wasn't sewn back very well either... sorry to be using you as my sounding board! Thanks again for all the information you gave me.

Arabella - Queen Charlotte has a birth centre AND a labour ward - not the same.... Bluebear and Pie had their baby in the labour ward (more hands on generally but very handsoff with Pie). If you do a search I know you will find mumsnetters who went to the birth centre.

BTW - I was Pie's doula at Queen Charlotte's

Hi arabella2 - there is only one area that the episiotomy should be made. It should be along a line like a clock hand at 7 o'clock on the clock face. (It can be done straight down but not usually in the UK) Sometimes though you can tear as well in other directions.

This might help here

I think it would be helpful to discuss it all with your midwife, even if you are going to have your baby in a different hospital or possibly at home. It would be better to get your last experience discussed more fully so that you do not dread your next delivery. Happy to help where I can but face to face with your midwife is probably better. HTH.

I do think that birth tends to be embarrassing, though, Arabella. I had a home birth but I still had to be checked out under a bright light (an anglepoise in my case!) for tears, and then stitched.

Motherinferior, yes but I guess if you had one or two female midwives only (I'm guessing this is what you had) then it is not as bad as being worried about who might walk in and out of the room with no warning as in hospital. I don't know why screens are used for everything except childbirth it seems, almost as if you are so far gone anyway that all normal modesty is ignored. Was giving birth at home a good experience? What worries me a little is the thought of any complications (especially in the baby's case but also mine) for which you then have to be rushed to hospital, and not even the hospital of your choice but the nearest one.
I know about the birth centre and the labour ward at Queen Charlotte's Pupuce, in fact I chose it for this reason because I am really hoping to use the birth centre. What was your experience of the way birth was managed on the labour ward? I'd be really interested to know.
Mears, I will see if I can speak to someone at the hospital but the thing about that is that it won't necessarily be the midwife who delivers the baby so you wonder if it's pointless. I haven't read your link about episiotomies yet but I will.

Arabella - (and Pie please correct me as it was YOUR labour )
I found it hands off once Pie made it clear she wanted it hands off (i.e. when she came and had a vaginal examination they offered to brake her waters - she was 4 cm - she refused)...they then let her get on with it. I -personnaly- was impressed that they let Pie, her DH and me alone in birth pool room when IMO Pie was in transition and clearly very close to having her baby. They looked at me (Pie was in her world) and said "call us if you need help"... I thought "Cool"

ANyway they came back for teh crunch and they did in my experience a TEXT BOOK water birth .... no one touched Pie or her baby. She was then encourage to have a physiological 3rd stage. Which she did.

I was very pleased..... but I do think... it was helped by Pie's initial assertiveness,

arabella2, just wanted to give you a few positive vibes
i gave birth in hospital and i dreaded all the people walking in and out and all the embarrassment that went with it. I requested female staff (where possible). They had to break my waters as they were worried about baby and they discovered meconium and tryed forceps as they wanted her out! That bit was awful and i made them stop. I then pushed her out by myself,(they never told me how to lie but i was in the same position as you anyway).
The midwife explained that a male Paediatrician had to come in for dd and of curse i was fine as what mattered was dd. He stood in the corner and really didn't look until the baby was out and then cleared her airways.
I don't really know why i'm telling you all this, i just wanted you to know that, if you do have to go into hospital, you might have a completely different experience
I wish you all the best of luck++++++++++++++++++++++

BTW Mears, your post was fascinating, i thought i knew a bit about meconium until i read you post
Thanks, it was an interesting read

i meant "of course" not "of curse"
Froidien (sp) slip!!

Freudean if I may correct your spelling

thankyou
LOL i even looked it up on google!!! Must be another Froid

Hi arabella, as pupuce says I had DD2 in the Labour Ward of QCCH, and they pretty much left me alone. Gave me an inital examination when I go there, was 4cm wanted to break water I said no, 1.30hrs later babe was born (in the birth pool on the Labour Ward) with no further examinations or anything. It was just like 'oh yeah baby cool' for them. I had a male m/w btw. They were so laid back it was so refreshing. BUT I was quite assertive from the very beginning. I said no breaking my waters and that sort of set the tone and they let me lead the way. I didn't have to assert myself again as they just realised that I wanted to have an active labour not have labour happen to me iykwim. I wouldn't assume that the Labour Ward is as hands on as the tour lady said. I never got a chance to take the tour though, probably would have scared me silly if someone said that!

HTH, are you a west londoner too then?

Yes it does help thank you. Of course you don't know who you are going to get on the day but the fact that that's what it was like for you must mean that there is a general culture of that kind, or at least NOT a general culture of the "monitor on, on your back" kind.
I live in Willesden - where do you live?

Notting Hill/Ladbroke Grove way. My Aunt lived by Gladstone Park for years!

Oh glad I was able to provide some sort of reassurance.

As pupuce said though being a bit assertive helps

arabella, I have no experience of Queen C's, but when I arrived at UCH, where I was hoping to have a water birht, the birthing centre was full, so I was put into the 'high-tech' labour ward. My midwife, however, treated me just as if I was in the birthing centre: low-key, no intervention or monitoring, no staff coming in and out, and so on.

I think Pie's got the right idea - it helps to set the tone at once, so that the midwives know that you have strong feelings about what you want to happen, and also that you are doing that from an informed position.

BTW Arabella, I'm also in Willesden.

Sorry I couldn't get back to you sooner.. here's a brief description of most of my labour - in the 'high risk' side of the labour ward QCCH (there are two sides, one for normal non-birth centre births ie. can use birth pool, and one for high-risk births)
Room was large and had bed, but also rocking chair and floor mat - I spent most of the time rocking on my birthing ball (took it with me but they do have their own available)I was on a monitor the entire time but this was because I was trial of scar - other labours just have the usual monitoring every now and then.
There was a 'modesty' curtain across the room so even with the door wide open no one could see me labouring, staff were careful to pull it across when they went through it.
My labour was very long but for most of it I had one midwife sitting very unobtrusively in the corner of the room (once again.. only there because I was trial of scar). They made sure I was comfortable re: room temperature, and dimmed the lights. They offered me food at regular intervals.
When I decided I needed an epidural, it was mobile. Because I was on the 'high risk' side I had to walk across the corridor when I needed the loo, but I think the rooms on the non-high risk side have en-suite (These are the labour ward rooms you get shown during the tour - there's also a picture of one on their website, all beanbags and coloured 'relaxing' lights)
As I said before, my labour was very long and there were complications... the complications were identical to those I had during my first labour (at a different hospital) which had resulted in a c-section, and some horrific memories.... from the same set of complications the very caring, and skillful midwife and registrar encouraged me to keep going when I was shouting for a c-section, and managed to move the baby into a delivery position (something that wasn't even attempted in my first labour), and finally delivered it.
Because of more complications (large baby, small pelvis), I was finally delivered in the operating theatre using a ventouse, I needed an emergency procedure so there were many people in the room but everyone introduced themselves to me by their name and job title, (and dd wouldn't be here, snoring in my bed, without them!)
SO, in short, even in the high-risk area of the labour ward, the staff helped me to the most 'natural' birth that could be managed in the circumstances.. I did mention my wishes in my birth plan and every midwife who dealt with me read it. Hope this helps... BB

Thank you very much for your message bluebear. Can I just say that I am really touched by how much helpful feedback I have had, I do feel different now and I've also realised that I have somehow been expecting the experience to be the same as with ds1 but of course it needn't be... I don't know why I am expecting to be totally not listened to when obviously so many people have had good experiences.
Pupuce, how much roughly does a birth doula cost? And can you meet as many as you like before committing yourself? I may go down this avenue but it takes a long time for me to make my mind up about anything so I am still thinking.
I'd just like to thank everybody again who has taken the time to write long messages full of helpful information containing details sometimes personal as well.

Arabella - birth doulas in London charge roughly £350 (some more some less). In London they get booked MONTHS in advance so your choice gets very limited if you wait too long. Yes you can meet as many as you like and the one you choose will meet you at least twice (at length) face to face + phone calls/e-mails during pregnancy. She will come to you as soon as you want her there (so that maybe hours before you go to hospital).

If you need more info, feel free to contact me