Free Birthing

I have been reading up about freebirthing, also known as unassisted childbirth, recently. It is the practise of a woman choosing to give birth without professional assistance, and it is reported to be gaining in popularity in the UK recently, with the recent uncertainty about the future of independent midwifery. However, that problem is now solved, and there is a future for independent midwives in the UK.

In the UK, it is illegal for anyone other than a midwife or doctor to deliver a baby, except in an emergency situation. Doulas should not be present at a freebirth. It is not, however, illegal for women to choose to freebirth.

I have been reading several articles online about freebirthing, and in many have found misused quotes or statistics from sources. Not surprisingly, many of these articles have been written by women who have previously freebirthed.

Whilst these freebirths often happen without a problem, there are a number of risks associated with childbirth which need dealing with almost immediately otherwise there is a risk to the life of mother or baby. A risk during labour is that of cord prolapse. There are a number of factors which cause this to be a risk, and these are anything which prevents the presenting part of the fetus (hopefully the head) descending in to the pelvis before the waters break. These may include an ill-fitting presenting part, such as small fetus, a malpresentation (such as a shoulder presentation instead of a head presentation) or polyhydramnios (too much fluid). If a cord prolapse happens, there are a number of techniques the midwife is able to use to keep the fetus's head off the cord to stop it cutting off it's own oxygen supply. The midwife must maintain the technique until the woman is in theatre and the baby is being delivered by caesarean section. A woman freebirthing wouldn't be able to use these techniques.

Another risk is that of shoulder dystocia during delivery. From the time the head is delivered, there is only 8 minutes to deliver the fetus. If the shoulders are stuck, and the baby isn't delivered within 8 minutes, the baby is likely to have a poor outcome due to there not being enough oxygen getting to the brain. Again, midwives have the knowledge to deal with this, but women freebirthing will not be able to use some of the techniques.

A risk to the mother is that of postpartum haemorrhage (PPH). Some blood at delivery is normal, but until the placenta is out, there is a risk of bleeding. There is a risk after this, too, but whilst the placenta is in, the risk is greatest as the uterus is unable to fully contract. Breastfeeding can help to cause uterine contractions which may speed up the delivery of the placenta. If the woman starts to haemorrhage, large volumes of blood can be lost in a very short space of time. Midwives have drugs which can reduce the bleeding, and are skilled in the techniques used to cope with haemorrhaging. There are a number of risk factors which can increase the likelihood of a PPH, and these include an overly stretched uterus (such as having a multiple pregnancy (twins or more) or polyhydramnios), a fast labour (less than 3 hours) or a slow labour. Women who are 'grand-multips' (having baby number 5 or greater) are also at increased risk.

A number of the articles I looked at seem to confuse freebirthing with home birth. For instance, this articles by the Daily Mail discusses the safety of freebirthing by looking at the statistics and findings of the Birthplace Study. Yes, giving birth at home is safe, and in most cases is safer than giving birth in a consultant led labour ward. But, this study looks at women who are low risk and who give birth at home (or in a midwife led unit or a consultant unit) with midwives. Even if there are no adverse outcomes, these women and their fetus are still monitored and many of the women would still have opted for an active third stage (an injection to deliver the placenta). Using this study to advocate the safety of freebirthing is wrong.

This article by the Guardian discusses a woman stating that she knew she could do it because she had seen a cat give birth. Humans have very different anatomies to cats (the cat's anatomy is shown to the left, with a straight birth canal) - to most other animals, even. The human pelvis has had to adapt to our ability stand upright. This means that, unlike almost every other animal (and I said almost every other animal as I am not an animal specialist - I assume it is in fact every single animal except us humans), humans do not have a straight birth canal. We have a feature called the curve of carus - this is caused by the S shape of our spine, and the lower part of our spine (the sacrum) intruding in to our pelvic cavity. This means that the fetus has to navigate a bit of a bend, between the sacral verterbraes and the rest of the pelvis in order to be delivered safely. This diagram shows a fetus passing through the curve of carus as it descends through the birth canal. The dimensions are already a snug fit, and a fetus who's head doesn't go in the normal way may not be able to pass through this structure very easily. This may cause a longer labour, increasing the risk of a PPH, or causing fetal distress, causing the fetus to pass meconium (stick poo), and this may be aspirated (breathed in to the lungs) and cause breathing problems in the newborn.

Birth Plans - What to Consider

Labour is unpredictable. Women who have never had a vaginal delivery before may not to know what to expect. Women who have had previously had a vaginal delivery might expect a replica of their previous labour. The truth is; labour is unpredictable. Each woman experiences labour differently and each baby's birth is unique.

That being said, women are often quite keen to come up with a birth plan. In my NHS Trust, there is a space in the handheld records for women to write their thoughts on their labour. It is quite vague, but prompts women to consider some of the things that they will have some control over. Here is a look at some of the things in labour which women might like to think about beforehand.

Who will be there?
Women will no doubt have planned whom they will have as a birth partner. Quite often, this will be their partner who is generally the baby's father. But some times, this will not be the case, whether for cultural/religious reasons, or because there is no father or for any other list of reasons. It is important that the woman choose someone who is going to be there to support her, not just someone who wants to be there so they are the first to see the new baby.  Women should also consider who will go with her if she were to go to theatre. It will only normally be one of her birthing partners.

In addition to the birth partner, women may also wish to consider if they will have a student present. This will usually be a student midwife, but could be a student nurse or a medical student. And although I have never seen it, I presume it could also be a paramedic student, as paramedics sometimes end up delivering babies. Some women I have spoken to are under the impression that if they give consent for students to be present, there will be a long line of them at the end of the bed, just staring. This is not the case. There will only be one student present (although a medical student did come in for the actual delivery of one of the deliveries I did; she met the woman beforehand, and she was happy for this). Quite often, the student will only have one woman in labour, whereas the midwife may have more than one. This means that the woman will receive constant emotional support from the student whilst the midwife may have to pop in and out to look after more than one woman. The student may or may not be hands on with the delivery. A brand new student may just be there to observe and will do very little else other than chat to the woman and her birth partners, whereas a more senior student may provide most of the care, under supervision of the midwife. Regardless, though, the midwife and the student will seek consent before each procedure, such as vaginal examinations. Even if the woman consents to a student being present, she can decline for the student to also examine her.

Where will the birth take place?
There is no reason why a first time mother cannot give birth at home. A recent study (called the Birth Place Study) has found that low risk women who have babies at home are at a lower risk of a negative outcome, with the exception of first time mums, who have a slightly increased risk, although this is not statistically significant.

At home, women often feel more relaxed and as a consequence, there is better release of the hormone oxycontin - this is the hormone that causes the contractions. There is less risk of interventions and the woman can guarantee that the midwife will only have one woman to look after. There will also be a second midwife called for the actual delivery.

Women planning a home birth or a delivery in a birthing unit or midwife led unit, however, must be aware that there are certain times when transfer to hospital will be advised. Women should be prepared for this outcome, and should listen to t he advice of the midwife.

Will the baby be placed skin to skin?
Skin to skin, where the baby is placed, unwrapped, next to the woman's skin is great for bonding. It helps initiate breastfeeding for those women who are planning to do so, and helps the new born baby control their breathing, oxygen levels, temperature and heart rate. It is recommended that the mum and baby should be left like this, undisturbed, for up to an hour. However, some women do not like the idea of this, as the baby may be covered in some blood, vernix and liquor, and prefer for the baby to be dried down and wrapped up before being given to the woman.

How will the placenta be delivered?
Women can either chose to have an active or a physiological third stage of labour. The third stage of labour is the delivery of the placenta and control of any bleeding. There are two options; firstly, the woman may have an injection of syntometrine or syntocinon. This causes a large contraction and the placenta detaches from the uterus and is delivered with the help of the midwife. The other option is to allow it to happen naturally. The cord is left, attached to the baby an dis not touched by anyone. The woman's body will cause contractions to deliver the placenta. This may take as little as five minutes or as long as an hour. The midwife will observe for any bleeding, and may recommend the injection if there are signs of bleeding.

Will the baby have Vitamin K?
Vitamin K is essential for clotting. Research has shown that some new born babies are deficient in Vitamin K, putting them at risk of bleeding. This is known as Vitamin K Deficiency Bleeding, or Haemorrhagic Disease of the Newborn. Consequently, all parents are asked if they would like their baby to have Vitamin K. This can either be given as an injection shortly after delivery, or by mouth. The injection is given once. The medication by mouth has to be repeated on day 5 and, for breastfed babies, on day 28 also.

The research, however, is old, and was done with women having poor access to Vitamin K rich food. There are no recent research studies in to new borns and Vitamin K.

What Actually Happens in Labour?

After my long stint on labour ward for my placement, I have decided to write about what really happens in labour. The media shows unnatural labours. Soaps and movies have women believe labour will entail her waters popping and going everywhere, a pain, a push and a baby. Shows such as One Born Every Minute obviously want to show the most exciting births. But normally, labour is not like that.

Check out the article I have written about what really happens in labour. Let me know what you think!