Examining the Contract

I have been asked to write about the thought processes behind some of my birth choices. I’d love to detail every decision and all of the research behind each, however, I am a busy mum of two and do not have weeks to draft, fact check and reference such a post! What I can do is highlight a few key aspects and talk about them in general terms.

No VEs. Vaginal examinations are often thought of as an essential part of labour, few women seem to question their use and a great deal of emphasis is placed on “knowing” how dilated a woman is, both by health care providers and by many mums. The fact is that the use of routine VEs is not evidence based. Experts in normal birth agree that women do not dilate in a linear fashion and that time limits placed upon birth are unrealistic and have no place in normal birth. How dilated you are at any given examination tells you nothing about how quickly your labour will progress and some, notably Ina May Gaskin, speculate that the vagina behaves as other sphincters in the body and can actually close up upon intrusion.

For women planning a hospital birth or a water birth in or out of hospital, they will be led to expect VEs in order to assess whether they are in “established” labour or not and whether they are “allowed” to get into the pool. The whole idea of latent and established labour is undermining. It implies that women in the early stages of labour do not need or are not entitled to support and for women experiencing a long latent phase, repeated examinations with little to no progress can be extremely demoralising. As for getting into the pool, it is thought that getting in too soon can slow down labour. Well so what? If that does happen then surely she can just get back out of the pool. Besides which, what is the rush, exactly? Women birthing at home with a pool should feel free to use that resource as and when they feel the need for it. They do not need permission to use it.

An experienced midwife should be able to assess the progress of labour without these intrusive examinations, the woman’s behaviour, the noises she is making, the dark line that extends up from the anus and up the back and even the smell in the room are all signs that midwives can look for to give them an idea of how the birth is unfolding.

I have to emphasis at this point that about six or seven hours into my second labour, all the signs pointed towards a very imminent birth. I laboured in much the same state for another twelve hours before consenting to a caesarean. So these signs are not always reliable, but I would argue that they are no less reliable than VEs and in a normally progressing birth they are probably more reliable.

On a personal note, I felt that VEs were the cause of my first caesarean. I had intended to decline them, knowing how pointless they generally are, however when I was in labour I was told that I “had to” have them every four hours and I wasn’t in a state to refuse. Had I had a doula who could have reminded me that I didn’t want them and that I was entitled to refuse then perhaps that birth would have been different. I was having a long and intense latent phase, it took me twelve hours to reach 4cm. Each examination was painful and intrusive, disrupting my labour and crushing my confidence. This was reason enough for me to decline them second time around.

I did, however, ask for them when I was in labour because I knew that something was not right and I knew that some useful information might be gathered from one, such as the baby’s position, which can be found by the feel of the skull plates. I had to work quite hard to persuade my midwife that I really did want to be examined. She knew how strong my feelings on the matter were and she, quite rightly, wanted to make absolutely sure that I wanted one. I asked her not to tell me how dilated I was, I knew this information was irrelevant, but I needed to know if there was a reason why I had been pushing for hours already and felt no closer to birthing my baby.

No induction or augmentation. As a woman with a previous caesarean under my belt, the risk of uterine rupture was a hot topic. The real risk is tiny, 0.2%, but the use of drugs to induce or accelerate labour dramatically increase that risk. Even without a uterine scar, there are risks associated with this intervention, chiefly foetal distress. There are very few good reasons to induce labour, in my opinion. As long as the pregnancy is straightforward, and even some complicating factors warrant only a watch-and-wait approach, then there is no reason to interfere. I certainly wouldn’t accept induction for going “overdue”. You can see what I think about the length of pregnancy here.

As far as I am concerned, there was no good reason to augment my labour. Either birth will unfold in its own time, or urgent assistance is needed. My first labour was augmented. I was persuaded that my body wasn’t up to the task and I needed help to “coordinate” my contractions in order for my cervix to dilate. I begged for time, I really did not want to open myself up to all of the risks associated with the use of syntocinon, but I was bullied into it, told that my body had had plenty of time already and was clearly failing.

I can see how the use of synto has become so common, it is very normal for women to not labour well in hospital, the conditions are so far removed from those needed for birth to unfold naturally. In some situations augmentation may help to undo the damage caused by transferring into hospital, but for me, planning a home birth, this was irrelevant. I was only going to be going into hospital if me or my baby were in danger and needed immediate assistance.

Leaving the cord alone. I planned and had a lotus birth. I recognise that this is an extreme most people will not be interested in, however, the principle of leaving the cord in tact at least until it stops pulsating, is one that is gaining popularity. Research now shows that babies whose cords are cut prematurely are deprived of up to half of their blood volume and are more likely to be anaemic, suffer brain damage or develop autism. In a straightforward birth there is no reason whatsoever to interfere with this process and doing so is potentially very harmful. Where my view is considered a little more radical is in the belief that even in a complicated birth, leaving the cord alone is possible and even advisable. If a baby is compromised at birth then it needs all of the blood and oxygen that it can get, cutting the cord deprives them of both. Many people seem to be under the impression that a nuchal cord, that is, when the umbilical cord is wrapped around the baby’s neck, is an emergency situation and that cutting the cord is necessary in cases when it is tightly wrapped. This simply isn’t true and this article explains why.

I’ll leave it there for now, but if there are any other aspects of my Birth Contract that you would like to know more about, please comment and I will do my best to explain my reasoning. Thanks for reading.

The All Powerful Birth Contract

My lotus caesarean was possible because I gave the possibility serious thought and planned for it, just in case. I discussed each aspect in depth with my independent midwife and prior to my labour she even floated the vague idea past the Consultant Midwife at the hospital, as a hypothetical situation, for her to discuss with her colleagues. When we arrived at the hospital we produced the following document, which details all of the conditions on which I would accept obstetric help. It is firmly worded, leaving no room for anyone to override my consent. I am so glad I had it and I am reproducing it here in the hope that others will be able to use elements of it, or the document in its entirety, to enable them to get the care and the birth that they are entitled to. It is written with the fact that I had independent midwives and a doula and was planning a home birth, however, it can be edited for those with NHS care providers and those planning a hospital birth. Please feel free to take what you can from it and share it with anyone you may feel would benefit from it.

Birth Contract

Baby expected: Early 2012

Planned place of birth: Home

Independent Midwives (IMs): ****

Birth Partners: ****

Onset of labour

If delivery prior to spontaneous onset of labour is medically indicated, I will only consider induction of any kind or caesarean section after very careful discussion with my independent midwife (IM) and husband.

Labour/Admission to Ward pre-section

I wish for my husband, IM and doula to have access to me to continue providing support, though I understand if this is only possible by rotating persons present in the delivery room.

My birth supporters have been given direct permission to advocate for me if I am unable to do so for myself.

I do not consent to vaginal examinations.

I do not consent to CFM without careful consultation with my IM about the possible risks vs benefits.

The birth space will be respected; anyone wishing to enter the room must knock and await invitation to enter, quiet voices will be used, lights will be dimmed.

I do not consent to the use of prostaglandins.

I do not consent to augmentation of labour with ARM or syntocinon. If there is a genuine reason to accelerate the birth of my child I will agree to caesarean section after discussion and agreement with my IM and husband.

I do not consent to administration of pethidine or any other opiate pain relief.

I will only consider epidural anaesthesia after careful consultation with my IM.

Birth & immediate post-natal period

I do not wish to be coached to push.

I will be using whatever position is most comfortable for me.

I do not consent to episiotomy unless an emergency situation develops.

I do not consent to ventouse or forceps delivery without consultation with my IM.

My baby will be handed directly to me for immediate skin to skin.

I do not consent to prophylactic administration of syntometrine.

I do not consent to premature cord clamping.

If my baby is in need of medical attention, it will be provided with baby in my arms or on a firm surface right beside me. There is NO NEED TO CUT THE CORD FOR THIS. I am planning a lotus birth, the placenta will remain attached to my baby, even in the event of a caesarean section.

My baby will be treated gently and respectfully; no vigorous cleaning, no routine suctioning of the airways.

I do not consent to routine administration of vitamin k. If the birth has been traumatic then I will consider oral vitamin k only and only after discussion with my IM and husband.

My family and I will not be separated. Provision will be made for my husband to remain with me and our baby at all times.

Caesarean Section

I will only consent to a caesarean section upon careful discussion with my IM and husband.

My IM is to accompany myself and my husband to theatre.

I do not consent to routine prophylactic antibiotics during surgery.

Anaesthesia should be in the form of spinal block, rather than epidural. General anaesthetic should only be administered with the direct consent of myself or my husband, upon the advice of our IM.

Voices will be kept low, as will lighting for the birth.

Forceps are only to be used to extract my baby after thorough efforts by hand have been exhausted. My IM will be watching.

My husband and I wish to discover the sex of our baby ourselves, no one else is to announce it.

The baby will be handed directly to me, uncleaned and with the cord intact and un-clamped.

Administration of syntometrine will be delayed until the cord has stopped pulsating. If this takes an unusually long time we can negotiate.

My placenta is to be kept attached to the baby and removed from me only after the umbilical cord has stopped pulsating. I understand the risks of my abdomen remaining open for this period.

If my baby requires immediate medical attention, it will be provided with baby in my arms or on a firm surface right beside me/between my legs. There is NO NEED TO CUT THE CORD FOR THIS. I am planning a lotus birth, the placenta will remain attached to my baby unless there is a clear medical need to separate them, not including resuscitation, as this can be done on a firm surface beside me. I do not consent to my baby’s primary source of oxygen (through blood flow from the placenta) to be cut off.

If I am unable to hold my baby immediately following birth then my husband is to be the primary contact.

If my baby does need to be taken from myself and my husband then my IM will remain with him/her at all times.

My baby will be treated gently and respectfully; no vigorous cleaning, no routine suctioning of the airways.

In the event of caesarean section, I will only consent to oral vitamin k if for some reason the cord has been clamped prematurely.

If the surgery takes place at night, provision will be made for my husband to remain with me and our baby.

Provision will be made for my baby to remain close to me at all times, including use of a co-sleeper bed/crib.

In the Event of Transfer for Retained/Adherent Placenta

My baby is to accompany me into theatre, as are my IM and husband.

My husband is to remain with me and our baby at all times, if admission is at night then provision will be made for him to remain with us.

Provision will be made for my baby to remain close to me at all times, including use of a co-sleeper bed/crib.

Feeding

I am planning to breastfeed and do not consent to my baby being given formula under any circumstances. If I am under GA then my husband and IM have permission to put the baby to the breast for me and express my milk to be given by cup or syringe. My milk or donor milk is to be given if I am incapacitated or unable to feed my baby myself for any reason.

I do not consent to the use of bottles under any circumstances.

Admission to Special Care

If my baby needs admission to the special care unit, my husband and I will be given unlimited access to our baby and we will be using Kangaroo Mother Care.

Please see feeding instructions above. If tube feeding is required for any reason, the milk MUST be breastmilk.

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