Opinion from my friend the doctor!

[ohthegoats]

I have a friend who is a high up anaesthetist. We were just out for lunch with her and a group of others, most of whom have kids already.

The doctor's advice on birth is:

If things go early and seem easy, then all is fine - go for the natural option. If you are overdue and they start talking about induction, then do the following: don't turn it down, they are suggesting it for a reason. Go in for the induction sooner rather than later, have an epidural as soon as they will let you. If things work OK for you at this point, then go for the 'natural' option. The minute they start talking about interventions because something has slowed it down, or you're not progressing etc, refuse the drip to speed you up, refuse forceps or ventouse and just ask straight away for a C-section, before things get too far along. Put your foot down on the issue. The epidural is already in, you're not already massively knackered, and often a calm, non emergency C-section is easier to recover from than a failed induction/ natural birth/ forceps tear/ cut. That's what all doctors would do.

So... what do you reckon to that suggestion? Oddly, as she was telling this story I remembered another friend's birth story - she's in obstetrics somewhere, not sure detail of her job, and that was her exact situation.

Thanks for those figures they are more up to date and in fact less scary then ones I've seen before.

But I would think the absolute risk even at 43 weeks is pretty tiny. I think part of my issue is that being past due date is talked about as if is an actual medical reason even when we know with out best methods of working out due date that it isn't precise.
I'm not suggesting a skewing all medical advice and I don't think obs and gyns are evil beings or what ever but I think we have to be careful not to try to cover potential risk with medical technology when wait and sees might be effective.

theunnecesarean.com/blog/2009/10/3/postdates-separating-fact-from-fiction.html#sthash.8SUfgUc1.dpbs

Dinosnores - if you were referring to my post, this was research back in the 1970s, specifically dealing with what was happening at the John Radcliffe during the time when they were enthusiastically promoting induction.

Whether that is the case now, is something that I hadn't commented on, except to say that some decisions appear to be more driven by protocol rather than the individual's need. This is rather confirmed by Penguin's post above, in that whether you are 'offered' an induction at 10 or 15 days depends on your hospital's policy.

(It was an old Horizon programme - they are celebrating 50 years of the programme and are showing a selection from past years.)

Sorry my use of the correct language is a bit rubbish.The second study you liked to is talking about post term. which is post 42 weeks. That is what I would like to see being used as the time rather then post dates which is 40 weeks. My trust at lest did my booking even though I tried to decline for 40+12 which is not post term but within dates.

midwife thinking has an excellent blog about balancing the risk between going overdue and induction. It's a tough decision to make for any women I don't have any criticism of any women on how they decide to proceed.

I think there is some sense to what your friend is saying. Personally had I been in a situation where they were debating forceps and ventouse and it looked like the baby was slow or stuck and would need some serious intervention then I would probably try and push for a CS. I suppose it's something to do with the more knowable outcome of a CS (I know there are risks but you have a better idea of what injuries you will have) compared to the injuries that might occur with forceps etc.

My biggest fear in childbirth was to have failed forceps and then a CS as I imagined I'd just end up torn and cut everywhere then.

"Anaesthetists will probably have seen plenty of births of all varieties during medical school and foundation training. Far more than the average lay person. And let's not forget they may have had a couple of births themselves."

I'd like to make it a requirement that doctors in training should attend a homebirth if possible, so they can see what an undisturbed birth (or as near undisturbed as possible) looks like. If they've only ever seen birth in hospital they probably aren't getting a representative picture of normal physiological birth. I suspect it's quite possible to go through training without witnessing a physiological third stage for starters....

I think the advice is good for someone induced or augmented. I had a horrendous delivery with dc1, only got the drip after an hour of pushing approx 54 hours after my waters went.
But I was not allowed refuse forceps and elect for a CS when we were going to theatre. I was told I could only consent to trial of forceps and CS afterwards - they got DC out with high forceps after which is had a pph and reaction to the spinal amongst other things. I was left with PTSD and PND.
I had an ELCS for dc2 and am considering a VBAC for DC3 but only because I'm in a different country where I have more faith in being able to refuse instrumentation.

Nicole - In many areas that would make it difficult to qualify though wouldn't it? Homebirth rates can be very low. Plus I would have refused a student doctor at my birth - I think it would utterly change the atmosphere (though would have been very happy to have a student mw).

I do agree though that medical training could have a better understanding of straightforward birth. I have a GP friend who said he didn't think people should have waterbirths because when he's seen them, the babies always looked grey and unresponsive. He was comparing a baby who had been delivered straight onto the mum's chest to rest there and who was calm and chilled to his perception of 'normal' - which was a vigorously rubbed down and screaming baby. Not saying that approach is wrong, but it doesn't mean that the waterbirth was.

"Plus I would have refused a student doctor at my birth - I think it would utterly change the atmosphere (though would have been very happy to have a student mw). "

I'm interested as why there would be a difference between a student midwife and a student doctor as we look pretty similar and how they might "utterly change the atmosphere".

I've been the student doctor at a number of deliveries when I was a student (a wee while ago now!), both at completely uncomplicated vaginal deliveries and at C sections.

Sadly, it would be impossible to make it a requirement for student doctors to see a homebirth, not just because of the low numbers, but because so many people don't let students in for their birth even in hospital. It was particularly hard for my male colleagues to see and assist deliveries.

I've had two live deliveries myself. In the first, a very new student midwife was watching her first home birth and was completely hands off. In the second (induction for complications), a more experienced student midwife delivered my baby, with the registrar who had been called in because my baby's heartbeat was concerning.

I always thought I would say no to a student doctor but found myself agreeing to it for my hospital birth and he was positive and supportive, so I have never regretted it.

For my home birth, the student midwife didn't make it because it happened so quickly.

Dino - Sorry if I wasn't clear, but I meant at a homebirth. To me, part of the point of a homebirth is that I was surrounded by people who were committed to and believed in facilitating homebirth and natural birth (where it was medically a good idea, I'm not obsessive about it!). That isn't necessarily the mentality amongst doctors. I also think it would change things for the midwife, and therefore for me, to have a doctor there. Even if it was a student one.

My birth plan actually said that, at a homebirth, I was happy for a MW student. In hospital I was happy to have students if they were shadowing a registrar/consultant, but not to have a pile of students pour into the room on ward rounds or suddenly appear when something 'interesting' like forceps happened. In theatre I was happy for them to be there. Basically, either come and stay or don't. Don't 'pop in'.

Yes, mine too was on a 'come and stay basis', not a
"pile in when it gets 'interesting' ".

A student MW caught my baby. She was awesome and much more supportive than the qualified MW who said I had to be on my back or I would tear

I think the more students the merrier, although I too would draw the line at a ward-round mid delivery

How can medical students have a better understanding of birth when people are against allowing them in to their births?

When I was doing my obstetrics placements I had already had a baby myself, and always got to know the woman all the way through labour, I can't see why having me there would have been any different to a student midwife!

I've seen a lot of things that have gradually changed my opinions of the birth process, plus my own experience of an elcs with dd (not through choice - she was breech). I don't want to bring up things I've seen as they may be upsetting, but there is a reason why some doctors are at the more cautious end of the spectrum, it is often from bitter experience rather than just medicalising for the sake of it.

I'd like to make it a requirement that doctors in training should attend a homebirth if possible

The practical problem with this, surely, would be that many women opting for a homebirth really really want to avoid being in a room crowded with students and doctors. Added to the fact home births account for a small proportion of births, the logistics might not add up?

I am not opting for a home birth but have asked not to have lots of students coming in (I'm OK with one MW OR ob/gyn student 'staying throughout') because when I had a partial molar they all piled in at what was a very distressing time ("you've lost a baby and might have cancer" essentially) just because I was 'rare' and some of them said/whispered insensitive things.

Nicole I have not seen a home birth but unfortunately I have seen women who have come into hospital after attempts at home birth that have gone tragically wrong. I know people personally that have had successful home births though. That may give me a biased opinion, but perhaps people who are only ever sold positive stories of home births might also have a skewed viewpoint? I am not against home births per se btw.

I have also seen women who have had massive haemorrhages after a "physiological" third stage.

I have seen plenty of "normal" deliveries and obviously they are great and definitely the way I would choose to do things in an ideal world! However I have seen plenty of normal low risk pregnancies that have thrown up unexpected complications (including my own) and in these cases intervention has been entirely appropriate. However as I mentioned I totally agree with the op's friend in that based on what I've experienced I would rather go straight to cs if an unassisted vb wasn't looking possible, as on the balance of risks I think the cs is safer with fewer long term complications.

Stone - Not sure if your comment was to me, but I was against student doctors attending my homebirth, not against them being present anywhere. If someone had told me in hospital (or potentially an MLU, although I didn't use one) that a student doctor was shadowing the MW in the same manner as a student MW would, I wouldn't have an issue with that either.

"That isn't necessarily the mentality amongst doctors. I also think it would change things for the midwife, and therefore for me, to have a doctor there. Even if it was a student one."

And if people don't let student doctors/medical students see normal deliveries, no wonder doctors have the general mentality that they do! For the sake of all future labouring women, please consider having student doctors in so that the only births they've seen aren't the complications/instrumental deliveries/crash sections.

When I was a student doctor, I was there working alongside the midwives, doing the same sort of stuff as the student midwives (at a very early stage commensurate with my experience). I certainly wasn't barging in just to catch the baby!

As for student doctors meaning a "room crowded with students and doctors", all the deliveries I attended, I was the only student there. It was only ever one student midwife or one student doctor.

When the student midwife came to my home birth, she sat quietly in the corner of my living room, so there were three of them there but it never felt crowded. We (DH and I) were just allowed to get on with it.

"a student doctor was shadowing the MW in the same manner as a student MW would"

When we are doing our delivery unit slot, that is exactly how it happens. We are working with the midwives. There are slots when we are shadowing the doctors as well, in clinic, seeing emergencies, on the wards etc, but for the delivery unit shifts, we are shadowing midwives and working with them.

Dino - Well I'm done having babies now . But as I keep saying, I would have been happy with a student doctor attending a normal birth in hospital (provided it wasn't a 'pop in as you start to push' type attending). But I wouldn't have felt comfortable at a homebirth. So often their mentality is that homebirth is risky, even if they say that they are pro homebirth.

Funnily enough the OP is pretty much what my birth plan looked like!

I'm not a doctor. Just clearly spend too much time on MN

But that's because they don't know any better! We need to educate them!

Whenever I mention to doctor friends that I've had a homebirth, most of them are shocked at my irresponsibility! I've been told by a consultant that I was "letting the side down". I share evidence showing the safety of home birth and get told "home delivery is for pizza".

Even after my home birth, the midwife who delivered my baby said, "We didn't want to say before, but we were surprised to read that you were a doctor!"

I've no idea of the opinion of the student midwife who attended my home birth. She just sat there quietly with the other two. I imagine a student doctor would do the same.

Perhaps if student doctors/obs and gynae SHOs and registrars saw homebirths in the flesh alongside the reassuring evidence, then it might change things.

Dino - while I don't disagree with that evidence, it only starts at 39 weeks. I'm part of a vbac clinical trial and the evidence we were given did show that the risk of stillbirth was higher at 36-37 weeks than it was at 38-42. It was the same at 37 weeks as it was at 43.

I also agree that post dates (40+1) is not at all the same as post term (43), and there should be a greater distinction for post due women. I also think that there should be more offering of expectant management rather than instant induction (due to the massive variance in conception dates vs scan dates. Some women have 43 week pregnancies and I'm sure I've read that the average is 41+3). Adding in a third tri and post dates growth scans and umbilical cord dopplers would do a lot to identify placenta function. There is also an argument that if a baby is suffering from a failing placenta, that they should not suffer labour/induction anyway.

Incidentally, my stillbirth was at 39+2 Useless anecdotal evidence.

I agree completely that I would go to a CS before instrument usage. I don't agree with the rest of it though.

I only have three doctors in my circle of friends.

One, paediatric registrar, had two home births. Another, GP, one c-section followed by one home birth. And an oncologist who had one planned c-section.

I do know one neonatal nurse who had a planned home birth turn hospital transfer for normal birth, then planned normal birth in hospital for second.

Three midwives I know - one had two home births, one had two normal vaginal hospital births followed by one home birth, and the other had one hospital birth with epidural then three home births.

So seven medical professionals, six of them planned home births.

I'm another one who refuses students I wouldn't mind if they were silent and just there to observe, but that has never been my experience and it's been traumatic before as a result.

Also, I'm hoping for a hvbac in sept!