Alice Roberts' article today on evidence based childbirth (HB/MLU/hospital)

[VinegarDrinker]

Not sure if this has been discussed elsewhere?

m.guardian.co.uk/lifeandstyle/2013/mar/10/alice-roberts-on-science-childbirth-risks

Seems a fairly balanced article to me, but I am an evil patriarchal obstetrician.

jcchocchip, don't you think the converse is also true. Midwives should also not be let loose to influence decisions and that midwives might give an overly rosy picture of birth? Just as much as an obstetrician.

The fact is NEITHER should be influencing you either way, and your comment is very biased in exactly the way that needs to be taken out of the equation and assumes that midwives aren't doing what you see obstetricians being guilty of.

There are good obs and bad obs. And there are good midwives and bad midwives.

I find your comment odd, given you say to choose your own risks first.

Oh and they told me my baby might die if I chose a homebirth

That is a very unusual part of the UK then, I think you would find you are probably to only person on MN to have had a booking appointment with an obstetrician. And pelvic x rays to predict CPD went out with the ark. Sounds very bizarre altogether.

Risks to baby, much rarer but potentially devastating. (Oversimplification for sure!)

Yes but in the UK it's not an either/or. If your birth starts outside a CLU but needs help then you can transfer. It's for you to decide whether this is something you are prepared to risk. Alice Roberts chose to put rather a great store by the ACOG. Not only is the record on maternity care in the US nothing to write home about, the midwifery situation is different. Some states don't recognise midwifery, and use 'lay midwives' so the option to transfer isn't there in the same way.

Now it may be that some PCTs have much smoother transfer processes than others, which may account for discrepancies in the stats. I have read comments from independent and community midwives that when they transfer a woman in, the hospital doesn't always take their word for it that the transfer is necessary and wastes valuable time. But the remedy here is to improve the communication.

Accepting the risks of your decisions is part of being a grown up; a good friend of mine had a HB that went badly wrong and caused her child to become very severely disabled indeed.

I wasn't her, my birth history was completely different, but as an adult I did accept that- whilst praying like hell it would never happen.

Vinegar you may think I am bizarre but it was not that long ago - certainly not as long ago as the ark.

And what is wrong with choosing your own risks? I chose hospital for my first after the dead baby comment and I was happy with my ds's birth. I wanted to have a second hospital birth but had moved house and after discussion and seeing delivery suite I wrote to the director of midwifery to raise some concerns. She dealt with these by talking me into a home birth and I'm very glad she did. It was a very positive experience and one I would not have got in hospital with the consultants running delivery suite at the time.

Vinegar - who you book in with seems to depend on where you are in the country. Some surgeries send you straight to the midwife. One surgery in my town hardly seems to know that midwives exist, and says that you must be seen by the nurse first and then the GP. Your first visit used to be solely about which consultant you got referred to, but that might have changed in recent years. I say 'consultant' but in practice you were unlikely to see the consultant.

Peachy -I have had friends whose babies have died in hospital. It doesn't mean that the hospital was bad. As you say, you weigh up the risks, and decide what is acceptable to you.

I didn't say you were bizarre

"Also to say - you have to look at the risks to the woman and the baby separately if at all possible imho"

What about factoring in the risks to a baby of having a mother die or become catastrophically ill during or following emergency surgery? It can happen. It does happen - every year in the UK, although it's rare.

What about the risks to any babies born to mothers in pregnancies following on from a birth which ends in emergency surgery? What about the risks of going through another pregnancy and birth with a scar on the uterus (between 2 and 7 in a 1000 will experience a uterine rupture during pregnancy)? What about the 7 to 8 women in every thousand whose c-section leads to an unplanned hysterectomy? Possibly increased risk of stillbirth in the next pregnancy? These risks are listed in the consent guidance for C/S on the RCOG site.

We really need to take into account the risks and benefits of birth choices beyond that of the immediate baby, and acknowledge that an uncomplicated vaginal birth pays big dividends further down the line in most women's reproductive life, and that a c/s often results in diminishing returns in terms of pregnancy outcomes with each subsequent baby.

It amazes me that Alice Roberts clearly doesn't consider the doubling of the surgery rate for low risk multips giving birth in CLU's (without any improvement in neonatal outcomes) an important enough issue to give any weight at all to in that article.

Yes, funnier enough I've read the guidelines on taking consent for CS, I do it every day...
All obstetricians are very aware of the long term risks of CS hence the (some would say too) pressure to prevent the first CS.

But the risks to the mother also include her baby being permanently damaged or dead. It goes both ways.

*funnily

Btw, you say an "uncomplicated" vaginal birth pays dividends in the future. I'd disagree. Having an instrumental, or epidural, or episiotomy or other "non natural" interventions has no impact physically speaking on future deliveries.

Urgh, typos everywhere. Post two above should say "too much pressure" (to reduce CS)

Vinegar do you count immediate cord clamping as an intervention? Just interested.

Alice Roberts is having her second child. And if she's anything like the average women in the Uk she probably won't be too concerned about her future reproductive life as there is a fair old chance she's planning to stop at two.

It might be worthy of comment in the article - if it actually did what it promised to do - but then she missed so many other things too, that were actually IN the study she was referring to and were of relevance to her. Looking beyond things relevant to her circumstances perhaps really is a big ask, unfortunately.

Any kind of cord clamping is technically an intervention.

LaVolcan - that was exactly my experience, that the hospital did not take the independent midwife's assessment that a transfer was required seriously at all, to the point that my DH had to drive me to hospital as they could not 'find' an ambulance! I still felt the experience overall was much better for having started at home and having been listened to properly throughout (I have no criticism of the hospital staff btw, they were great too, but the NHS seems to find it nearly impossible to be joined up in any way -- they insisted on repeating every single test and check the IM did).

Vinegar - I realise that this discussion has moved on massively, but I've been out all day. Didn't for one second mean to suggest that you were pro closing the Lewisham CLU. What I was clumsily trying to say was that, in Lewisham, the illusion of promoting a MLU is really pushing CLU's because women are too scared of a MLU that doesn't have an on-site CLU.

Episiotomy is interesting. I would think of it as adverse. My mother still has aching from hers over 30 years later. I have some degree of discomfort (for example, when I needed an internal scan in a later pregnancy, the pain on the scar tissue resulted in my bursting into tears). Now I don't know if a tear would feel like that of course. Another area where data would be interesting and helpful...

vinegar you say you are not anti HB. Do you think they have a place in the UK today? Or do you think the risks are too high?

I'm currious what are the risks you would identify?

Hope these come as genuine questions not hostility! I had two hb for both my DC so now wonder if I 'gambled' with my and their lives?

never having another so not a dilemma I'll have again :)

sorry I know I am off topic, but vinegar I am very interested in the timing of cord clamping. Immediate cord clamping is not evidence based. The advantages of a physiological third stage to the baby in terms of establishing respiration are well documented. As such, the cord clamp can be dangerous as it can hinder physiology. My hospital birth had a protocol for third stage that meant that I could not have the cord clamped until it stopped pulsating which took a surprisingly long time. Dd1, born at home had immediate cord clamping which I found upsetting at the time because I wasn't expecting it.

Chunder I would expect women suffering from dv have capacity to choose where and how they give birth and their home situation is one that they can factor into their decision. They have capacity to choose so no one is going to interfere. Unless they post on mn when they would probably be be told to ltb.

When a woman has a medical condition, they can make an informed choice about their care. We can all decide what sort of birth we would like but all know that we can't predict what will happen and have to take advice from doctors and/or midwives to increase the chances of a healthy outcome.

In the case of someone with extra special needs there is a serious question of capacity under the MCA and someone is basically going to have to make decisions in their best interests. Recent case law is interesting on this point and I think that capacity to consent to si could well have been lacking.

Hellobear - I'd like to point out that according to the POB study it's not 'out of hospital' birth that categorically appears to be associated with poorer outcomes for the babies of first time mums: it's home birth. In the study first time mothers who chose free standing midwifery led unit as their setting for birth had outcomes which were no worse than women who had chosen CLU's, even when you factor in a high transfer rate. Actually I say 'no worse' but in fact I mean that the neonatal outcomes were no different. The maternal outcomes were very much better for women in FMU's.

Vinegar is resolutely ignoring this point as far as I can see.

IMO this suggests that the increased risk of homebirth for first timers might be linked to issues surrounding the practices of home birth midwives. This wouldn't surprise me at all. IMO there is a huge difference in the quality of homebirth midwifery when the midwife in question is part of a busy and experienced case loading homebirth team, or when she's just snaffled off community to do the odd homebirth in an area with a low HB rate. The study didn't look at these issues. I'd very much like to know if case loading is associated with better outcomes. My common sense tells me it would be, and there is other research suggesting that this is so.

Funnily enough, the medical community don't seem to be interested in this - they - like vinegar, have pounced on the POB findings of higher neonatal deaths for first time home birth mums and have accepted this as clear evidence that this group should opt for a hospital birth as the safest option, resolutely ignoring the evidence on FMU'S.

shag I am not ignoring anything. I have mentioned and acknowledged reduced risks of intervention for women having HBs several times. I just said that for me personally, when deciding about my own deliveries, that was outweighed by the risks to the baby of being at home - hence choosing an MLU (which indeed I am lucky to be able to).

jchoc Please do start another thread on cord clamping. There is definitely a big lag in the evidence for delayed cord clamping being out there and known about and it being routinely practised.

HelloBear they certainly do have a place. If a woman wants one I totally support her. My job is to provide information. I
have several friends and colleagues who have had them. Personally I wouldn't have one for my first baby, and possibly not even then due to those pesky very rare but unpredictable situations mentioned above, but that's just me. I certainly wouldn't be feeling guilty for anything in your position!

I'd love to know how you think you are in any way qualified to tell me what I am interested in, shag Would you be so rude to my face, or indeed if I hadn't been upfront about my job?

How can you presume to say that I think first time mums should have a CLU birth - I haven't ever said anything like that, anywhere here or IRL.

It's a shame what has been an interesting thread is being constantly falsely polarised by yourself. Use of terms like "the medical community" to make generalisations about is misleading and false. Do you realise just how dull it is to have a conversation with someone determined that you think a certain thing even when you state clearly that you don't?