A few final questions....

[madcatsazz]

Hi all - am 39weeks today with 2nd baby. 1st delivery was the usual story of CFM, laying on the bed all day, pethidine, epidural and finally a spinal block with forceps delivery and episiotomy. I wasn't unduly upset by it at the time as i accepted this as standard births. Incidentally it took about 2 weeks to fully establish breast feeding and a whole lot longer to heal!

This time around I have spent a lot more time researching birth and labour techniques as well as reading about the ever debated 'cascade of interventions'. I'm fairly confident that I will be refusing CFM, ARM, induction, syntocin etc and plan to remain open minded about 3rd stage although again determined to delay clamping and injection to see what happens. With all this in mind I am left with a couple of questions that I can't seem to readily find the answers to and I'm concerned they leave me open to coercion from well meaning medical staff on the day! My first question relates to CFM. With 1st baby, they detected a dip in heartbeat with every contraction from the first stage of labour - baby was posterior - so they kept me strapped in the hope they could get a consistant 20 minute readout (which they never got due to my writhing and wriggling). I have read the research that shows CFM does not statistically improve birthing outcomes but in this instance, what else could they have done? Ifthe same were to happen again, what other options are there and what did CFM do anyway? They never did anything other than monitor for the next 12 hours - what were they waiting for?

My second question relates to Resus and cord clamping. All my research is suggesting that babies with initial low apgar and slow to breathe but that still have placenta attached will recover in minutes as the oxygen gets to them. Even as i request no cord clamping until it stops pulsating, surely if baby is slow to breathe they will clamp and resus instead. Obviously I don't want to put the baby in any risk at all but will they delay resus and allow the cord and placenta to do it's final job?

Two emotive questions and I'm looking for medical information, not negative opinions. I just need to gather these thoughts before I proceed and make decisions for me and my baby. Thanks in advance

Hi Madcat. Great to see you're doing loads of research. On your first birth, had any drugs been administered before the detection of dip in heartbeat? As you'll now no doubt be aware, the baby's heartbeat can be affected by the drugs, particularly pethidine which causes it to dip.
I'm am by no means a medical expert, but I think your answer regarding the cord clamping will have to wait until your baby is born. Ideally you will request immediate skin to skin contact with your baby (unless the cord is too short) and then allow the cord to stop pulsating until it is clamped. He/she can be visibly monitored for colour, breathing, temperature and activity. Sometimes babies can take up to a minute to start breathing. They will only resus if the baby is not breathing and other signs are poor. I hope everything goes to plan and have a great birth. x

thanks Doula Kate - with regards to dip in hearbeat, no I had no drugs at that point. I went in early (1st birth nerves) and they were set to send me home again but put me on the monitor first to check the heartbeat and noticed a dip with each contraction. I believe it was due to her position but I don't really know and my memory of the whole thing is hazy at best. I suspect the actual events are somewhat different to my memories although I'm fairly sure of the details at the beginning. The thing with the heartbeat can't have been too worrying though because they never acted on it - i was monitored (excluding 1 hour where I had to leave the room for a walk because I was going mad)for the rest of my labour which was about 11 hours and only after I had been pushing 2 and half hours ineffectivey with epidural was I rushed to theatre for forceps and poss emcs if that had been unsuccesful. It's just so easy to find reasons not to have CFM and I'm very sure I don't want it but it is harder to find the reasons that they do it in the first place - I can appreciate a 'just in case' attitude but the question is 'just in case of what?' and would it be any different to intermittent or hand held monitoring and what exactly do slight decelerations indicate? Again, baby in distress but what are they looking for? One dip or several or increased? Because several and increased would surely be picked up on handheld or intermittent....IYSWIM! Hmmm, can you sense my inpemding birth playing on my mind......

Hi. It's normal for the baby's heart beat to dip slightly during a contraction. What would be worrying is if it didn't recover afterwards. It sounds like you had an awful lot of intervention in your first birth. Maybe the hospital was particularly busy which often means midwives need to rely on machines and drugs to monitor you as they can't be with you continually? If they could be with you all the time, they wouldn't need to monitor you so rigidly. I really hope you get what you want. Trust your instinct. x

thank you for answering - I really hope I get the birth I want to - or a variation of it! I guess watch this space. I feel good being more prepared though as last time I literally had no idea what was happening. I thought the antenatal classes had prepared me but they really hadn't!

If it's any help, you sound well informed and confident of what you want. In which case, you're half way there to having a great birth...you've now got the challenging bit to do. Very excited for you. Do come back and let us know how things are going.

Have you been through the notes from your 1st labour with a senior MW from the hospital? I realise its short notice now, but if you rang up the labour ward and explained the situation they may be able to accomodate you - even if its only a chat over the phone.

I'm not at all qualified, I'm afraid, but intuitively (to me at least) if the baby does need resus you could ask for it to be done before the cord is cut. It might be worth asking before you get too far into labour, but I think I recall seeing a discussion by MWs on this issue and the consensus seemed to be that the baby was taken to the resus unit more through force of habit as necessity. I'm sure there are exceptions where it is necessary - but if you don't ask you don't know...

Re the EFM. I've just been looking in the NICE guidelines for intrapartum care (online version here). One thing they say is that they don't recommend EFM on admission for low risk women/pregnancies.

Fingers crossed things go more smoothly for you this time round

With regard to CFM - pethidine and other opiates do not cause fetal heart rate decelerations, they do however reduce the variability of the heart rate - but this in itself would not be a reason to perform CFM in the absence of other concerns. When interpreting fetal heart rate traces (CTG's) they are subdivided into sections, most units use DR C BRAVADO
DR define risk ie small for dates, IOL, bleeding, meconium stained liquor, audible decelerations. There should be a valid reason for women to be monitored, those would are low risk have intermittent ausculation.
C - contractions, frequency and strength, these should be palpated by the midwife
BR - baseline rate, normal between 110-160bpm
A - accelerations, rises in heart rate often when the baby moves and are very reassuring
V - variablity, how much the heartrate varies around the baseline rate, the more the better.
D - there are various types, some can be physiological ie with head compression that stimulates the vagal nerve during head descent and causes a temporary drop in heartrate with a contratcion which quickly goes back up to normal. Late - which happen after a contraction and can be a sign the placenta isn't coping well with labour Atypical, again without contractions and taking longer to recover to baseline and typical variable, sometimes with contractions, some without but recovering well to baseline rate.
O - overall, the CTG depending on the various features above is then classified as either normal, suspicious - therefore do nothing but keep a close eye for deteriation or pathological which would mean either fetal blood sampling or delivery.

It would appear that you must have had a suspicious CTG that was being observed (as recommended by NICE guidelines), however, CEFM does not mean that you have to be strapped to the bed, standing, on the ball, all fours - whatever you fancy. So don't worry if for some reason you need it again. If the midwife is having difficulty maintaining the trace because you are moving ask for a scalp electrode, that way there is contact with the baby all the time and you can shimmy about regardless. (FSE aren't as bad as you'd imagine!)

Good luck, hope all is sooooo normal CEFM isn't needed!

ps they would cut cord if necessary, but not breathing straight away often happens with waterbirths and physiological third stages, the midwife will assess the babys tone, colour and heartrate, if needed she will cut the cord but most just need a good rub!
As much as the midwife will adhere to your wishes, she would only do so if safe for you both.

Malteser, she can't do anything to the woman which the woman has not consented to.

Hi - thanks for all the responses. It's been really helpful. I didn't set out to be so informed this time round because as I said, I ust presumed last time was 'the norm' and had no expectations for this labour other than hoping it would be a bit quicker and that baby would present in a better position. However, I drifted onto MN after clicking the link of an email and started reading and found myself hooked! I was genuinely surprised to discover the hormone for third stage was exactly the same as the one for induction for instance - because I had been sure for a long time that I was anti induction (although ask me that if I go 2 weeks overdue!!) but had no idea placenta could be delivered any other way (how stupid does that sound?!)

Anyway, your responses have helped put my mind at ease and whilst it probably is a little late to find out about last time, I am more confident that I can question procedures and come to a better informed decision with the midwives if necessary. I was just starting to wobble a bit and worry that under the influence of 'white coat syndrome' I may roll over and play nice. Here's hoping for the birth I want to - I've even considered asking for the pool if available.... that's only due to MN because before reading so much about it I was positive the idea of floating poo was just too hideous....even with the little poo net!! TMI!

Make sure you write down everythig you would like in an ideal world, and school your birth partner, if you are having one in with you, exactly what you would like and why. You might not necessarily get what you want if it's a medical emergency, for example, but having someone able to communicate your wishes in a confident way will hopefully stop you feeling either corced or railroaded when you are at your most vulnerable.

Midwives are obviously v keen that baby is delivered as safely and healthily as possible, but of course they will err on the side of caution in may cases. You may feel like you want to be up and about, or stamp around the room, or get into water, or give a situation another 10 mins to see if it gets worse. All of these things you can specify, but may not be in a position/frame of mind to insist upon. Be prepared and prepare your birth partner too.

Good luck!

An acronym we were given at NCT classes was to remember to use your BRAINS when you're asked to consent to any procedure:

What are the Benefits
What are the Risks
What are the Alternatives
What does your Intuition tell you?
What happens if we do Nothing?
Smile!

I also found these phrases by Mary Cronk very empowering - I think I only ever used one of them once (*), but they reminded me that it was ultimately up to me to decided whether or not to accept their recommendation, howsoever they might choose to phrase it. I also like another of Mary's: "Allow is not a word to use to a mentally competent adult!"

I do suspect that with some MWs how you act will determine how you are treated. I was contrary, asked lots of questions (or got DH to) and insisted on understanding why they wanted to do every last single thing. I never had a problem getting the information I wanted - and even though I wound up agreeing to just about everything they suggested I came out of it feeling that they'd been working with me to achieve the best possible result.

• just as DD2 was crowning the MW rested her arm over my coccyx. She wasn't aware that she'd done it but I definitely was - and told her to "take that arm off my back AT ONCE". It went away extremely fast (poor MW was mortified afterwards).

CUNextTuesday and Tangle, thanks for additional advice - I particularly like Mary Cronks phrases Tangle - I stumbled across them a couple of times in my research and they're also in the book 'Stand and Deliver' which I have just finished reading. All empowering stuff. The Brains acronym is something I may well write down and really pay attention to because that's the point isn't it - i don't want to be difficult and make life hard for the medical staff because afterall, they went into the job wanting to help women give birth but I do want to feel part of the process so it is valuable advice. Watch this space - only 6 days until EDD (DD was 2 days early)....

Littlesilver - be sensible, which mother wouldn't consent to the cord being cut if there were concerns about her child?

Malteser, that was not the point I was making. Your post said:

"As much as the midwife will adhere to your wishes, she would only do so if safe for you both"

That kind of post makes me very uncomfortable as it implies (I do not know if you meant this) that a midwife can override a woman's autonomy over her own body. This is not the case for a competent adult. And as someone who was assaulted by an HCP I feel very uneasy with the implication that consent is optional.