How to get the best hospital birth possible

Physiological birth in hospital

Here are some of my tips to inspire and assist you in enjoying your baby’s birth in hospital. If you need that extra helping hand join me at the Trust in Birth – Active Birth workshop on the 23rd of October.

Following the natural rhythms of labour, the vast majority of mothers with normal pregnancies are free to let their bodies’ normal physiological functions birth their babies. Many women birth in hospitals avoiding any medication and medical intervention unless medically necessary. We have used the term physiological birth to steer away from some of the different interpretations of ‘natural’ birth. By physiological birth, we mean a healthy mother with an uncomplicated pregnancy giving birth with no medical interventions. Of course some births will necessitate assistance from your caregivers but we mean to differentiate necessity from hospital procedure or managed birth.

Book with an independent midwife or a midwifery led unit

(domino or community midwives)
Midwives are highly skilled and trained to look at birth as a physiologically normal and magical event in a woman’s life. The rate of women expressing birth as a satisfying experience, and success rates of physiological birth, is often far greater with midwives than with consultant led care (private or semi-private). There are great midwifery led units and independent midwives all over Ireland. Book early; they are popular and normally fill up.

Obstetric training comes from a different approach to midwives. Here skilled doctors look in great detail at the problems relating to pregnancy and birth. In their training they would be exposed to a whole plethora of conditions where their intervention may be crucial for the best outcome of the baby or mother.

Although important in modern maternity care for complications in pregnancy and birth, their general approach may affect these professionals looking upon birth as a potentially dangerous event with some or other disaster waiting to happen. There is a saying that when you’ve got a hammer in your hand, everything looks like a nail. Many obstetricians have lost touch with the possibility of physiological normal birth; sadly they just don’t get exposure to them.

There’s another saying that birth is as safe as life gets. If birth does become dangerous for the baby or, very rarely, for the mother, this is when hospital-based maternity care really shines. If a midwife feels that there is need for intervention, mothers can transfer into hospital or obstetricians are at hand and able to step in where medically necessary

From the onset, midwives are best trained to support pregnancy and birth with the best outcomes as far as fewer interventions and most definitely mothers profess to having a far better birth experience in their care.

Attend independent antenatal education classes

Independent childbirth instructors focus on their clients needs, and will spend time discussing a variety of options in coping with the intensity of labour and birth. Since nearly all encourage physiological birth, they will equip and prepare you to manage your entire labour and delivery, not just try to “keep you comfortable until your epidural”.

They may inform you about both benefits and any associated risks with medical interventions and explain why they are sometimes not necessary but perhaps hospital procedure. They may also educate you on how to question interventions to see if they are medically necessary.

Classes offered at the hospital largely focus on helping “patients” understand what to expect at the hospital, and what the procedures are. They are often bound to teach according to the facilities current policies and procedures. Unfortunately these policies typically do not reflect the current evidence on pregnancy and birth related care, but are more in line with reducing litigation and keeping a steady throughput of women. They tend to focus more on medical pain relief by offer a menu of choices rather than encouraging and empowering women to with coping techniques.

Finding good independent antenatal birth classes and workshops, will really empower your self belief and give you multiple ways of dealing and coping with the rhythms of labour and birth. They will show you how to promote the good hormones that can make labour shorter and help women experience and cope with the intensity without having to resort to drugs.

Book a doula

Having a confident and positive woman with you from early on in labour will your labour to become very well established before you arrive into hospital. Furthermore she will normally have a bag of tricks to help you through any intensity experienced in labour, such as, practical measures, loving support and empathy, jokes, ways to distract anxious partners, effective pain coping techniques. She doesn’t have to be a doula, she could be a friend or relative who believes in natural birth and trusts your own abilities. Negative or fearful helpers should be avoided.

Some Irish hospitals have a strict one person per mother policy. We suggest your doula call herself a friend and have the father (if there is one) wait in the waiting room to be called when the head is emerging.

Even if you decide to not have doula in hospital, it is still worth having one at home and supporting parents there. Fathers may feel like a fish out of water at first births. Women often arrive too early into hospital when fathers feel anxious being at home with a woman displaying unfamiliar and sometimes distressed behaviour. Doula’s on the other hand will keep anxiety levels down and provide comforting support.

Stay at home as long as possible

At your independent antenatal classes, they should help you with recognise the rhythm of labour and when the uterus is pulling the cervix up away from the birth canal. Once this is well established, your labour is progressing nicely. Arriving in hospital whilst the cervix is dilating like this, will assist in your physiological birth.

It’s quite common for things to slow down and stop during the journey to hospital and whilst being admitted and settling in. This is a natural effect of adrenalin that may be produced in anticipation of the new environment. Once you get settled and relaxed, labour should establish itself again and start doing the work needed to birth your baby.

Often women come in very early on in labour, especially with first babies as they are unsure of what stage they are at. Normally midwives would try and send mothers home who are not in an active dilation stage. Sometimes mothers do go home, others may feel too nervous and want to stay.

It is common in hospital to start a clock once some form of dilation is noted, and can lead to time constraints and extra anxiety for women to dilate within a set period of time. If labour does indeed slow down, options for speeding it up again may be offered. These can range from walking, change in position, water, relaxation but can sometimes be medical interventions such as breaking of the waters (ARM) or synthetic oxytocin (syntocin). These may lead to other side effects precipitating more interventions.

So do try and stay at home for as long as possible. Good antenatal preparation, yourself and partner watching realistic birthing films and having a doula or woman experienced in physiological birth at hand will all help you do this.

Visit the facility

It is very important to visit the rooms you may labour or give birth in. This way the familiarity of them will not cause you to be fearful or anxious of what it might be like. You can ask what can be done with the lighting or the arrangement of the room and what you will need to bring in terms of extra pillows, balls mats etc. Find out how you can warm heat packs as hot water bottles are not normally permitted due to burns risks.

Have a short birth plan

Your plan really doesn’t need to be the birthing magna carta! Keep it simple and one page long. Highlight the important points. Have a few copies with you and arrive with it in your hand. Have your partner refer any attendants to your plan whilst politely explaining that you are saving energy for labour and staying focused and would they be so kind to have a quick read of your plan.

You are likely to see several staff during your labour so make sure your partner keeps each of them aware of your plan before they start talking to you.

Make a sign for the door or wear a T-shirt stating

“Natural Birth in progress – please do not offer any pain relief. Mum is fully aware of its availability, and will ask for it if she needs it. There may be some noise (-: Thank you”

During labour it can be common for mothers to be frequently asked, “what are you doing for pain relief”? Probably because so many women are given it as part of the pain relief menu in antenatal classes, or all their exposure to birth is set around an epidural, thereby assuming it is a necessary part of birth, most automatically ask for it without understanding the negative side effects. Many midwives don’t get to practice their wonderful midwifery skills so it’s good to prepare them for your individual birth wishes, they will be delighted. Sometimes caregivers change or other staff may come in, and being asked during the throws of labour about relief only serves to disempower women who are coping.

Sometimes women ask for an epidural but really don’t want one! A midwife and well-educated partner can normally spot this and use something else to help a mother cope; reassurance, changing positions, using hot water and many more techniques really help. Distracting from one centimeter to the next is a great art.

Ask for an attendant who is enthused by natural birth

Asking for a midwife who is experienced in natural birth can really make a difference. Write it at the top of your birth plan. Many new midwives rarely experience a physiological normal birth and many experienced ones may not see them as often as they like. Due to the increased management and medicalisation for birth, the role of the midwife has changed over the last 50 years. Many midwives are unhappy about this new role they find themselves in working more as an obstetric nurse, rather than a midwife.

Any midwife should relish the opportunity to support your physiological birth and bring in her finely tuned observation skills, support techniques and experience. If after communicating your birth plan and being with your caregiver you find they are just not into what you are trying to do, ask for a change of staff. Many midwives will be biting at the bit to assist with a physiological birth. It is a chance for them to put into practice their amazing skills.

Eat well during labour

Keeping up your energy levels at home and in the hospital by staying hydrated and nourished is one of the best ways of keeping your labour progressing and reducing exhaustion. It’s a uterine marathon you are doing after all. You need to keep the fuel coming in to keep your uterus working well.

Some hospitals still restrict food intake as part of a blanket policy. This practice is outdated and is for historical reasons only. It serves NO benefit for the mother. It stems from when many C-sections were performed under a general anaesthetic to reduce the likelihood of food aspiration (inhaling food) during anaesthetic. Aspiration is the result of poor anaesthetic technique, and general anaesthetic during labour is very very rare. Think of all those who end up in A&E – are they only allowed onto an operating table with an empty stomach? Nope. Remember both the WHO and NICE (World Health Organisation, National Institute for Health and Clinical Excellence) recommendations clearly state women should not be deprived of food and drink during labour.

So, forget about an extremely unlikely scenario (c-section, general anaesthetic, aspiration etc) and think about the danger of labouring whilst energy depleted and exhausted. Women eat and drink at homebirths and in birthing centres freely. And so should you. If food and drink are banned in your labour rooms – sneak it in and get it out when they leave the room. Most women I know don’t really fancy a full on meal in labour, its normally snacks they really like an copious amounts of labour aid (a great drink for labour – see below). My rule is to offer something that has high energy but won’t be so bad if it is thrown up – curry is definitely out!

Stay upright for fetal monitoring and request to be monitored intermittently

Your baby’s heart rate is an excellent indication of how they are doing in pregnancy and labour. In your last trimester you are going to become familiar with the hand held device (Doppler) for listening into your babies heartbeat. When you start having contractions your baby’s heartbeat will at some stage start to respond to the increase in uterine pressure during a contraction which will temporarily alter the blood flow in the uterus. Your baby has a great response to this blood flow change by increasing their heart rate to maintain their oxygen levels. Fetal monitoring will pick this response up. It can also check if you are possibly compressing the cord which would be accompanied by a suggestion in a change of position. In rare circumstances if you baby is starting to get tired or is not managing the labour that well, it can pick up a heart beat that is going to fast or slow or perhaps dipping after a contraction. This would then lead to perhaps another suggestion to help the baby.

Monitoring can be done using several devices:

Fetal stethoscope
Pinard (hand held ear trumpet)
Doppler – using ultrasound
CTG – machine with two belts correlating uterine pressure with fetal heart rates
Scalp monitor – a device attached to your babies scalp in utero that picks up their heart rate.

The recommendation for monitoring by WHO and NICE recommends in uncomplicated labours to use only intermittent monitoring with a hand held device.

In Irish hospitals, there is a policy of taking a baseline trace with a CTG for 20-40 minutes upon admission during labour. This trace would then serve as a record to your baby’s response to contractions and the strength and length of contractions. It may provide you with reassurance that all is progressing well.

The best way to take the CTG trace is to stand up whilst the monitor is attached and then stay upright during the trace. This would reduce the likelihood of any cord compression or reduced blood flow to your placenta and baby and give a more accurate trace. There is no medical necessity for you to lie down. If you think about it, your body is in the same position standing as it is lying down – just a different angle.

Lying down risks increasing pressure on your vena cava (blood vessel connected to the placenta) which can reduce oxygen to your baby. Or you may also compress the umbilical cord whilst lying down which can have the same affect. These reductions in oxygen may cause the baby to show fetal distress of some kind which wouldn’t have been present if you were upright in the first place. So, don’t lie down and if you are asked to do so for monitoring just explain it is very uncomfortable and not good for the baby. Some caregivers may be used to having a women lie down for monitoring.

During labour itself if mother and baby are both doing well and there have been no previous indications from monitoring of problems, intermittent monitoring with a hand held device is the recommendation from WHO and NICE. There is no evidence that continuous monitoring for a healthy labour is of any benefit. In fact the evidence states that continuous monitoring may lead to more interventions with just the same healthy outcome as intermittent monitoring.

Bring a birth toolkit with you

If a baby is in a good position in your pelvis and you stay relaxed and focused, most women can get through birth with great support, breathing and encouragement. Sometimes, babies take a while to get into a good position or labour can be very intense. A bag of tricks can really help get you through a difficult birth. Stuff you can bring should act as a comfort aid or assist in dealing with the intensity of labour. Your independent antenatal classes should let you know what to bring, but here is a short list of essentials:

Heat packs and towels to wring out in hot water and act as heat packs
Food and drink (yes you can, see above)
Cold water spray and lip balm
4 extra pillows (hospitals contrary to belief don’t have a ready supply)
Birth ball and mat for protecting knees
Nice smells (oils are good but burners are not allowed in the majority of hospitals -fire hazard)
Bendy straws for partners to hold drinks up to mothers lips
Cosy blanket – hospital ones are over starched and crispy – good for sticking over your head and hiding underneath
Long t-shirts and warm socks – two or three sets in case of any kind of fluids getting on them
Birth plan
Sign for the door
Courage, open mind and sense of humour

Encourage your endorphins and oxytocin

You can’t forget them. They are within you. Great news.

Oxytocin – the hormone of love will help a labour be efficient and shorter. Think of it needing the same environment as you need for a good nights sleep:

Privacy
Safety
Respect
Love
Familiarity with those present
Subdued lighting
Lowered voices
Permission to go deep within
No expectation of rationality – no questions that need thought, no idle chatter
No causing a woman to feel self-conscious or under observation (how easy would it be to sleep with a stranger in a white coat prodding at your nether regions?)

Endorphins – our natural pain relief

Natural or alternative pain relief you might have heard it called? Some people think that just because it is natural means it isn’t as good as drugs. Not true. If you stay relaxed and focused and create the right environment in your body and mind for oxytocin to flow, your natural endorphins will increase as your labour intensifies. Endorphins actually mean – “morphine within”. You produce beta-endorphins in bucket loads during labour. And here it is – endorphins are stronger than morphine! How much stronger? Research points to between 100-200 times stronger.

Facing possible intervention

If mother and baby are both doing well, there is often no need for medical intervention. If there is a problem with mother or baby, the safety net of modern obstetric care is fantastic.
However, in our climate of stressed maternity services running beyond their capacity, the inclination to get a women through labour within 12 hours by actively managing her labour, is unfortunately common practice.

Sometimes of course, medical interventions are necessary, but if it is a case of your baby taking too long to arrive and you are both doing well, you may consider questioning your caregiver’s suggestions.

1.   What is the problem I am trying to prevent or to fix?
2.   What are the benefits of the proposed test, treatment, or procedure?
3.   How is the procedure done?
4.   What are the chances it will work? If it doesn’t, what next?
5.   What are the possible risks and adverse effects (complications and “side effects”)?
6.   What are the possible alternatives? (Repeat questions 2-5 for each alternative.)
7.    Does it need to be done now, or is it possible to wait awhile?
8.     What happens if we do nothing?

Remember, if you feel you are just being pressurised to speed things up you are fully entitled to refuse any intervention. Medical staff are very good at letting you know when there is a true emergency taking place. However, midwives are often under pressure from their superiors to get a woman moving along, when in their hearts they know doing nothing is the best option for the mother. In fact, midwives are often delighted to report that a coping mother has refused an intervention although their superior may continue to put pressure on them to get you to comply. A simple smile and refusal works a treat.

If the pressure to do something gets intense, then I suggest the birth partner steps out of the room, and politely but firmly states that you both consider the intervention unnecessary at this point and would they come back in an hour or two and perhaps discuss again.

Advanced pregnancy teacher training

If you are interested in learning more about teaching Couples Birthing Workshops, our new Advanced Pregnancy Module for these workshops with Lisa Wilkinson, Melissa Curtis & Private Midwives Ireland (Liz Halliday) is a great opportunity to explore and learn.

Advanced Pregnancy Teacher Training starts April 27th, Individual module booking available.