2 very interesting articles in Guardian today

[pupuce]

Found this !

Strapped to a machine, deprived of control ... the miracle of birth for British women. Survey shows that mothers' dreams of holistic experience end in hospital shock

and How to cope

Why the hell would being at home guarantee a quick birth? That's to do with what your body's doing, not where it's doing it. If your baby decides to take god knows how long revving its way down your birth canal, the location is not going to affect it. Nor is it going to affect the way the baby finally emerges. And certainly from my experiences, stitches performed lying on your sofa with an anglepoise up your fanny are just as likely to get infected as stitches performed in a more orthodox medical setting.

I know quite a few people who had home births. Most enjoyed it, but one of my friends opted to have her second child in hospital because she found her homebirth so unbelievably painful and frightening. It can go both ways. Most people find second labours and births easier, quicker and less painful regardless of where they have their child.

MI the location might affect your birth in terms of how relaxed you are, how able you are to move around, freely adopt positions etc.

OK, take your point. And I did find even visiting the hospital second time made me tense up.

(Although believe me, by the time they got that damn needle in first time, I'd been on my feet for quite a time. And in fact I spent my entire second labour sitting on the sofa with a hot water bottle wedged into my back.)

Anyone who turns down a whiff of gas and air is making a BIG mistake, though.

"other generations accepted the pain and got on with it"

I really disagree with this statement and organisations like the NCT who spout this kind of message. It makes me especially angry that the NCT is generally run by women - it's very 'unsisterly' !!

• Today, less than 1 of every 100 children is stillborn, compared to 1 of 3 in the early 1800s and 1 of 10 in the early 1900s.

• In 1915, the rate of women dying during childbirth was 60.8 per every 1,000 women (it is now less than 1 which is largely thanks to "medicalised birth").

Previous generations of women were likely to know nothing about giving birth, and many gave birth and died in terror. Let's not romanticise it.

In this day and age, I still find it amazing that women aren't supported in their birth choices whatever they may be. As a gender we are our own worst enemies. I personally was stunned at the opposition to my informed birth choice (CS). We are all individuals, and as a result, we will each make individual choices when it comes to giving birth. I found that I had to do a lot of self-examination in making my birth choice. What would I do if I had a 2nd/3rd degree tear? How would I react to a long labour? How would I feel about giving birth in an operating theatre? What if my wound became infected? My choice was right for me, but I wish I had received more support from other women.

With respect to the article, it's been said before, and we need to shout this from the rooftops - the UK needs to increase the number of midwives 5 fold to support women for safe hospital births! We need to ensure midwives are trained in breech deliveries AND are fully trained to give breast feeding support.

Oops, just fallen off my soapbox {wink]

I think people are taking the subject very personally. All would agree that hospital is the best place for people with mid or low risk. But for those that are in the low risk category and want to make informed choices I dod a serach on the medical library of my university.
In case people are actually interested in scientific evidence. I am pasting the abstarct of a few papers on the effect of epidurals on babies , and on comparisons of home birth and hospital birth incidences of complications.
The last one is particularly long, but I found it particularly interesting.

Child Dev. 1981 Mar;52(1):71-82.

Effects of epidural anesthesia on newborns and their mothers.

Murray AD, Dolby RM, Nation RL, Thomas DB.

The effects of epidural anesthesia on newborns were studied using a sample of babies from mothers having (a) little or no medication during childbirth (N = 15), (b) epidurals with bupivacaine (N = 20), and (c) epidurals in combination with oxytocin to stimulate labor (N = 20). Outcome measures included assessments of neonatal behavior (Brazelton Scale), mother-baby interaction during feeding, and mothers' perceptions of their babies' behavior during the first month after delivery. Effects of drugs on the neonatal behavior were strongest on the first day. By the fifth day, there was evidence of behavioral recovery, but the medicated babies continued to exhibit poor state organization. At 1 month, examiners observed few differences between groups, but unmedicated mothers reported their babies to be more sociable, rewarding, and easy to care for, and these mothers were more responsive to their babies' cries. The importance of the first encounters with a disorganized baby in shaping maternal expectations and interactive styles was discussed.

Epidural versus general anaesthesia for elective caesarean section. Effect on Apgar score and acid-base status of the newborn.

Evans CM, Murphy JF, Gray OP, Rosen M.

Department of Child Health, University of Wales College of Medicine, Cardiff.

Elective Caesarean section deliveries over a 5-year period were studied to compare the effect of epidural block with general anaesthesia on the condition of the infant at birth. The Apgar score and umbilical arterial acid-base status were used as determinants of the latter. Epidural block was used in 139 (22.8%) mothers while 471 (77.2%) were performed under general anaesthesia. No babies in the epidural group were severely depressed (Apgar less than 4), compared with 6.2% in the general anaesthesia group. Only 4.3% of the epidural sections were moderately depressed (Apgar 4-6), compared with 15.4% of the others. These differences remained highly significant when infants of less than 2500 g were excluded, and when matched groups were compared. Mean umbilical arterial pH was similar within the two groups (pH 7.28), and was not consistent with asphyxia in almost 90% of the depressed infants. The findings suggest that general anaesthesia, rather than asphyxia or aortocaval compression, is responsible for most of the depressed infants born by elective Caesarean section. This may involve over 20% of babies delivered in this manner, so greater use of epidural block for elective Caesarean section is recommended. Further investigations are required to improve results with general anaesthesia.

Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study.

Murphy PA, Fullerton J.

Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA. [email protected]

OBJECTIVE: To describe the outcomes of intended home birth in the practices of certified nurse-midwives. METHODS: Twenty-nine US nurse-midwifery practices were recruited for the study in 1994. Women presenting for intended home birth in these practices were enrolled in the study from late 1994 to late 1995. Outcomes for all enrolled women were ascertained. Validity and reliability of submitted data were established. RESULTS: Of 1404 enrolled women intending home births, 6% miscarried, terminated the pregnancy or changed plans. Another 7.4% became ineligible for home birth prior to the onset of labor at term due to the development of perinatal problems and were referred for planned hospital birth. Of those women beginning labor with the intention of delivering at home, 102 (8.3%) were transferred to the hospital during labor. Ten mothers (0.8%) were transferred to the hospital after delivery, and 14 infants (1.1%) were transferred after birth. Overall intrapartal fetal and neonatal mortality for women beginning labor with the intention of delivering at home was 2.5 per 1000. For women actually delivering at home, intrapartal fetal and neonatal mortality was 1.8 per 1000. CONCLUSION: Home birth can be accomplished with good outcomes under the care of qualified practitioners and within a system that facilitates transfer to hospital care when necessary. Intrapartal mortality during intended home birth is concentrated in postdates pregnancies with evidence of meconium passage.

Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands
T A Wiegers, research fellow,a M J N C Keirse, professor,b J van der Zee, director,a G A H Berghs, research fellow a
a NIVEL (Netherlands Institute of Primary Health Care), PO Box 1568, 3500 BN Utrecht, Netherlands, b Department of Obstetrics and Gynaecology, Flinders University of South Australia, Flinders Medical Centre, GPO Box 2100, Adelaide, SA 5001, Australia
Correspondence to: Mrs Wiegers.
Abstract

Objective: To investigate the relation between the intended place of birth (home or hospital) and perinatal outcome in women with low risk pregnancies after controlling for parity and social, medical, and obstetric background.
Design: Analysis of prospective data from midwives and their clients.
Setting: 54 midwifery practices in the province of Gelderland, Netherlands.
Subjects: 97 midwives and 1836 women with low risk pregnancies who had planned to give birth at home or in hospital.
Main outcome measure: Perinatal outcome index based on "maximal result with minimal intervention" and incorporating 22 items on childbirth, 9 on the condition of the newborn, and 5 on the mother after the birth.
Results: There was no relation between the planned place of birth and perinatal outcome in primiparous women when controlling for a favourable or less favourable background. In multiparous women, perinatal outcome was significantly better for planned home births than for planned hospital births, with or without control for background variables.
Conclusions: The outcome of planned home births is at least as good as that of planned hospital births in women at low risk receiving midwifery care in the Netherlands.
Introduction
In the Dutch maternity care system midwives are qualified to provide independent care for women with uncomplicated pregnancies.1 2 They also identify and select the women who, because of existing or anticipated problems, require care from an obstetrician.1 3 Twenty five years ago, women receiving primary care all gave birth at home, but since the 1970s they have been able to choose between home birth and hospital birth under the care of a midwife or general practitioner. This has led to a substantial reduction in home births (from 69% of all births in 1965 to 31% in 1991)4 and an increase in the proportion of births attended by midwives (from 35% in 1965 to 46% in 1992). About half of births attended by midwives now occur in hospital, with women and their babies generally being discharged within a few hours after birth.
There is growing concern among primary care givers that these short-stay hospital births (termed "poliklinische bevallingen") enhance the risk of medicalisation and may ultimately eliminate the home birth option. Indeed, referral to an obstetrician occurs more frequently for women with a planned hospital birth than for those choosing home birth.5 The reasons for this difference are unclear. Self selection may be an important confounder, with the healthiest and most affluent women choosing home birth. Also the choice of home or hospital may influence referral to specialist care, as resources are more likely to be used if they are closer at hand.
We prospectively studied results of planned home births and planned hospital births in women with low risk pregnancies receiving care from midwives. We wished to assess whether the planned place of birth would lead to differences in perinatal outcome after the confounding effects of obstetric, medical, and social background were controlled for.
Patients and methods
STUDY DESIGN
The study was conducted prospectively in two periods between 1990 and 1993 among women with low risk pregnancies receiving midwifery care in the province of Gelderland. A total of 97 midwives in 54 practices enlisted 2301 women, who signed an informed consent form and received a questionnaire about their social background and their preference for birth at home or in hospital. The midwives also received questionnaires about their clients, one to complete before delivery and one afterwards. A copy of the birth notification form (a voluntary registration system used by most midwives and obstetricians) with data on medical and obstetric background, labour, and delivery was added to the completed questionnaires.
For 294 women (13.8%) the birth notifications indicated obstetric referral before the onset of labour, which was an exclusion criterion, and for another 171 (8.0%) information from the midwives could not be checked against birth notifications because they were not available. The study population thus consisted of 1836 women, 840 primiparae and 996 multiparae, of whom 1140 had chosen home birth and 696 hospital birth. For 116 (6.3%) women, information was confined to what had been received from their midwife and the birth notification form; these women were excluded only from the subanalyses relating social background to outcome.
DATA ANALYSIS
Data variables were divided into background and outcome variables according to whether the variable was or could be known before the onset of labour. A value of 1 or 0 was awarded to each, based on the optimality concept originally developed by Prechtl6 and Touwen et al,7 in which optimality indicates "the best possible"; it avoids judgments on what is normal or abnormal when defining, for example, "no episiotomy" as optimal. The items were then summed into separate indexes for perinatal background and perinatal outcome,8 reflecting the number of optimal items in each index.
The perinatal background index,8 consisting of 31 items, considers as "best possible" the absence of any social, medical, or obstetrical problem before and during pregnancy. Because of its expected skewness in a low risk population and the poor internal consistency expected with many unrelated items (verified by Cronbach's (alpha) = 0.29),9 the index was used in a simplified, dichotomous manner. Women at or above the median were considered to have a relatively favourable background, the others as having a less favourable background.
The perinatal outcome index consists of 36 items, of which 22 relate to childbirth, nine to the condition of the newborn, and five to the condition of the mother afterwards.8 Optimal values were based on the principle that a maximally healthy mother and baby with minimal intervention for both of them constitutes the best possible birth.8 10 The perinatal outcome index therefore considers not only the result, but also the means by which it is achieved.
Primiparous women and multiparous women were considered separately because of well known differences in outcome. All analyses were based on the planned rather than the actual place of birth because referral to hospital during labour is usually indicative of anticipated or existing problems. Including these women among hospital births would bias the results of planned hospital births negatively and home births positively.
Power analysis, based on detecting a significant difference in the combined frequency of non-optimal factors during and after childbirth, led us to aim for a sample size of 1600 women, with approximately half being multiparous and preferably half choosing hospital birth. Because women in Gelderland more often choose home than hospital birth, only women choosing hospital birth were recruited in the final four months of the study.
Differences in individual background and outcome items were assessed by the 2 test and differences in the composite indexes by Student's t test.
Results
Table 1 shows the various perinatal outcomes in relation to the planned place of birth. Interventionsincluding referral, medication, and episiotomywere more common in primiparous than parous women, confirming the need to consider these women separately.

Table 1Non-optimal characteristics in perinatal outcome index among planned home and planned hospital births inprimiparous and multiparous women--------------------------- % (No) of primiparous women (n = 840) % (No) of multiparous women (n = 996)--------------------------- Home births Hospital births Home births Hospital birthsNon-optimal outcome (n = 471) (n = 369) (n = 669) (n = 327)-----------------------------Labour and deliveryMedication in first stage labour 21.2 (100) 23.6 (87) 6.1 (41) 8.9 (29)Ruptured membranes for >12 hours 13.4 (63) 19.0 (70) 6.4 (43) 7.3 (24)Amniotic fluid not clear 14.2 (67) 16.5 (61) 12.7 (85) 14.1 (46)Duration first stage >10 hours 24.6 (116) 22.8 (84) 3.7 (25) 6.4 (21)Duration second stage >60 minutes 28.9 (136) 28.7 (106) 1.3 (9) 1.8 (6)Non-cephalic presentation at birth 3.2 (15) 5.1 (19) 1.9 (13) 1.8 (6)Assisted delivery 29.5 (139) 29.8 (110) 4.3 (29) 6.1 (20)Perineal laceration 78.3 (369) 74.8 (276) 52.0 (348) 63.0 (206)Episiotomy 52.4 (247) 52.8 (195) 15.8 (106) 25.1 (82)*Referral to specialist care in labour 36.7 (173) 40.7 (150) 8.7 (58) 12.8 (42)Insufficient cervical dilatation 8.9 (42) 9.2 (34) 0.9 (6) 2.8 (9)Inadequate progress in second stage 12.1 (57) 9.5 (35) 0.4 (3) 1.2 (4)Fetal distress 4.5 (21) 4.9 (18) 0.6 (4) 0.9 (3)Induction or augmentation of labour 3.6 (17) 5.1 (19) 1.9 (13) 2.1 (7)Instrumental vaginal delivery 13.8 (65) 15.7 (58) 1.2 (8) 1.2 (4)Caesarean section 3.0 (14) 4.1 (15) 0.1 (1) 0.6 (2)Suturing third degree perineal tear 1.5 (7) 1.4 (5) 0.6 (4) 0.6 (2)Medication in third stage labour 60.5 (285) 65.9 (243) 37.2 (259) 59.3 (194)Placental retention 0.4 (2) 0.8 (3) 0.7 (5) 2.8 (9)Blood loss >/=1000 ml 1.9 (9) 4.1 (15) 0.6 (4) 3.7 (12)Blood transfusion 0.8 (4) 1.1 (4) 0 1.8 (16)Other problems (including need for sedation) 10.4 (49) 19.0 (70) 5.2 (35) 9.8 (32)Neonatal conditionNon-optimal birth weight 17.4 (82) 17.3 (64) 16.6 (111) 19.0 (62) 90th centile 12.5 (59) 8.4 (31) 10.5 (70) 13.8 (45)Apgar score

BTW if anyone would like a copy of the whole paper, let me know.

I think I must've been very lucky. I wanted a hospital birth with as little intervention as possible but ended up with an induction and emergency c-section. It was still a very positive experience. I was consulted before every step and if I said I wanted to wait a bit longer (such as before being put on the petocin drip) they let me wait a bit longer. Of course, I went in for the induction (at 10 days overdue) with the knowledge that once I started down that road there would be no turning back so I didn't feel angry or upset at the medical establishment as things progressed.

If I didn't want for them to examine me because I was in pain I would just say no, but I knew that they would have to examine me sometimes so sometimes I said yes. I felt like it was a team effort.

The C-section was fine and DS came out screaming, was latching on within the hour and never lost weight from day one. At his one week exam he had already gained 6oz, so luckily none of the problems associated with sections that I've read here.

I guess the point is that experiences vary and we should all be able to make the choice that's best for ourselves and our babies, whatever it may be. And not be judged for that choice.

My dd was born by emergency c and I had every bloody drug on offer (except pethidine). I was finally knocked out with a general as she had gone into foetal distress. And none of these things happened to her. Although, I'm not really sure how one determines if a new born is depressed. I mean she couldn't say "oh mummy, I feel so sad. That big shiny knife scared me."

In fact, I had so many drugs in me that by the time I woke up in recovery they gave me a shot of morphine to calm the shivering. I thought I was just cold, but apparently it was withdrawl from epidural, stronger epidural, block, general...

DD got a high apgar score, brething was fine, she pink and lovely, and not a single health problem (apart from the terrible attitude she has now developed )

My gosh.... what a debate !
Hoxtonchick... well I would have gone for an induction in your situation. First of all you are in a situation where you have a medical condition which often makes induction easiers (body wants to get rid of baby to get better).... A 2nd induction is MUCH easier than a first and I (amazingly!) agree with your OB... IMO he is right!
The other option is a section which would leave you in a different place postnatally.... if your OB and I are right you could be out and about very quickly... 2nd easier births often mean women are really fine very quickly!

Generally I see that hospitals do generate emergencies which can often be deabted afterwards (was the intervention really necessary?)... that has often been demonstrated ! So whilst yes we have less stillbirths and dead mothers we have too many women scared by their memories and babies whacked out for no reason...
If I take 2004.... out of my 18 clients (I am including birth and postnatal clients)
I had 1 woman transfered from birthing centre to hospital for a section, she delivered in ambulance
I had a home birth who was told by MWs in hospital this would have ended by ventouse... baby's heartbeat wasn't good (pushing for 30 mins) and he was stuck in birth canal.... as we were at home, MW was force to be ingenious... she was... baby came out without instrument (ambulance was downstairs).
I have had a mom who wanted a VBAC... she chose to refuse the induction suggested by MWs (waters had bveen broken for 24h), she had a total drug free birth

That's 3 births that could have been far more managed....

Uwila - from what I have read.... you seem quite keen to have a section (which based on your experience I can understand) but there is every reason to believe you could have an easy VBAC!
The fact that your child came out so well.... does make you wonder about the problem they picked up in the first place!

A depressed newborn is a newborn that needs to be resucitated because he isn't breathing !

thanks pupuce. actually, my OB is a (fantastic) woman, maybe that's why you agree with her . although my story does sound grim when i write it down, i recovered really quickly after the birth. and i don't necessarily think that would be the case with a section. reassuring to hear about second inductions too.