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Yearly Archives: 2015

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Articles, Pregnancy after miscarriage, Third baby

Loss and Rainbows

Posted on April 11, 2015 at 6:55 pm by / 0
It’s 6 years since the day we found out we had lost our first baby. I was 12 weeks pregnant and, after experiencing the teeniest amount of spotting, I had an appointment in the Early Pregnancy Unit for a scan. There was a serious baby boom back then and ‘booking’ appointments were happening incredibly late – mine was at 21 weeks –  so this EPU appointment felt like a chance to get a sneak peek at our baby.  In our innocence, we were giggly and excited, and didn’t for a moment imagine there was anything wrong as we headed into an early morning appointment. We were back on the street a half hour later, our future changed forever after an instant of horrible stillness. Our much-loved baby had become ‘retained products’.  It was 8.30am. Where to now?

Missed miscarriage wasn’t something I knew much about – but now I had to decide what to do about it. This was my pre-GentleBirth life. I wasn’t informed about hospitals or maternity services or options. I consulted Google, found a very mainstream pregnancy forum and asked advice from some wonderfully supportive and sympathetic strangers, who had had similar experiences. Everyone said the same thing: have the surgery (ERPC – Evacuation of Retained Products of Conception. Bad enough having it, and the name adds insult to injury).  I rang friends – lots of sympathy, but it didn’t help me decide. My gut told me that waiting it out was right for me and my baby – even though my baby had been gone already for around 4 weeks, I instinctively felt my body would be able to take care of business. But then, fear – I had a cramp and completely freaked out at the thought of miscarrying at home. I rang the hospital and booked in for two days time, to have the ERPC.

That left a day in between and for some reason we decided that morning to go to Mount Usher Gardens in Wicklow. It’s a beautiful place and I felt as I had to be sad, I might as well be sad somewhere lovely. I think the trip may have been prompted by good weather, but I have little recollection of the day other than breaking down in the car on the way home and crying about my lost little baby for the first time. I wailed in a way that felt like it would break my body, as though I could literally break my heart.

I think the experience in the hospital is for another post – suffice to say, I was not cared for emotionally in a way befitting of the emotional pain I was going through. The weeks that followed were tough. Why is the devastation of miscarriage not spoken about, when it is so common it is almost a rite of passage as a woman? It changed me in a way I wouldn’t have thought possible and marks me still. The grief went to a place inside me I hadn’t known existed, but I know now that place is motherhood.  I wanted to conceive again as soon as possible and although I don’t think my desperation was very attractive, we somehow managed to do so very quickly and, just 7 weeks after that awful day, I was pregnant again.

I have no idea why I chose Mount Usher on that day, but it has become a very important place to us. We had no remains returned to us after my surgery. There is no grave, no other place to associate physically with our baby. The following year, we went to Mount Usher on the anniversary of the miscarriage, to honour our lost one. It was joyous to be there with our 6 week old, having wondered the year before if we would ever have children. Each year, we go to the gardens in April, to celebrate the short life of our first baby. It’s become a very special way in which to remember, mark time, and take stock. Going there is simultaneously returning to a moment in time, where I can meet my baby by remembering that sadness, and celebrating how far we’ve traveled each year as a family.

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2010 – With our 6 week old
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2011 – Now 13 months and flying around the place!
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2012 – 2 years old and non too impressed….
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….and 39 weeks pregnant!
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2013 – 11 month old’s first visit.
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2013 – Proved impossible to get a decent family photo!

Picture2014 – Now aged 4 and 2

Since the miscarriage, I have carried two healthy babies to term. Both pregnancies were emotionally challenging in the early weeks, for different reasons but physically easy,  and wonderful once we got to the 20 week mark. I’ve had beautiful births, thanks to the GentleBirth programme.  There is so much to be  grateful for.  But this year I could have been at Mount Usher again with a full term bump, or a slightly smaller one.  I lost a baby last year who would have been with us within the next few weeks, and another a short while later who would have arrived this summer. They were very early losses,  with no physical trauma and I was thankful that the pregnancies hadn’t struggled on, only to fail at a later stage. There being two consecutive losses was worrying – and Google didn’t help matters as it told me fertility drops off a cliff at 39 and only 1 in 4 of my eggs are likely to be of much use.  The last few months have been difficult at times – being in the ‘baby business’ , I am in contact with pregnant women constantly although, strangely enough, bumps that I meet professionally don’t induce any jealousy. I have naturally enough felt pangs at seeing what sometimes seems like everyone I know becoming pregnant  over the past few months. But it’s been entirely bearable – not the running-my-guts-through-a-mincer feeling that was so overwhelming after my first loss.

The day we spent in Mount Usher this year was our most memorable yet. My 5 year old, who has been extremely challenging lately, was an angel for the day. The sun came out as we arrived and, as the weather had been unpromising, it seemed we had the place to ourselves. We had a fabulous picnic, followed by a gorgeous meander that magically took us to spots we’d never been before. And the highlight…I got to see the sheer excitement on my first rainbow baby’s face as we told her, in our special place, that we will be welcoming another into our family this autumn.  In time for Hallowe’en.  We all agreed – this was the best day ever.  Until next year….

If you are trying to conceive, recovering from pregnancy loss, or pregnant and experiencing nervousness, you can download free GentleBirth sample tracks to support you on the Free Downloads page. The tracks have helped me hugely over the past number of months.  Wishing you well on your journey.

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Articles, Birth preferences, First baby, GentleBirth workshop, Placenta, Third stage of labour

Why the third stage of labour should be more than an afterthought

Posted on January 27, 2015 at 6:55 pm by / 0

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How many of us spend time considering birth preferences for the third stage of labour ? Very few, and yet what happens between the birth of baby and the expulsion of the placenta can have a significant impact on our birth experience.  During the third stage of labour, the placenta separates from the uterine wall and the uterus contracts to expel it. As the placenta separates, there is some bleeding from the area of the uterus where it was sited. The amount of bleeding varies from woman to woman – blood loss greater than 500ml is considered a post partum haemhorrage.

Currently, the policy in all Irish maternity units is to carry out a managed third stage of labour. This involves giving an intramuscular injection, of either syntocinon or syntometrine, into the thigh.  Many women will not even know they’ve had this – they are so engrossed in their newborn that it doesn’t even register. Once the injection has been given, a strong surge usually follows and the placenta is often expelled quickly. Your midwife will feel the uterus to see if the placenta is separating from the wall of the uterus and may use what is called controlled cord traction (pulling the placenta out) to hurry the process along, or may encourage you to push it out.  If you have a managed third stage, your risk of  a post partum haemhorrage (PPH)  is reduced.

The alternative is to have a physiological third stage.  The placenta is left to separate itself, without drugs to speed up the process. It should be expelled using maternal effort, rather than being pulled out. Although a managed third stage is recommended based on current research which shows it lowers the risk of PPH, a study comparing physiological third stages in settings that do not fully support that mode of birth and settings that do is not available. It has been observed by midwives that women who have a physiological third stage may bleed more immediately after birth but then bleed less post partum than those who have a managed third stage, but this is anecdotal rather than backed by evidence.

The vast majority of women will have a managed third  stage, as part of the standard package of hospital based maternity care. In a home birth setting, most women will have a physiological third stage and have no problems with blood loss. In the midwifery led units (MLUs), physiological third stages are far from unusual. But how can you decide what is right for you?

Dr. Sarah J. Buckley believes that we should resist intervening in the third stage of labour, if all has been well up to that point.  The birth process is driven by hormone interactions which, when disturbed by some routine hospital procedures, can have negative consequences for mothers and babies. The drug given in the third stage of labour is an oxytocic drug – it is a synthetic version of the naturally occurring oxytocin in our bodies, which is at its highest level just after the birth of our babies.  Oxytocin is released as we gaze at and touch our wondrous newborn, and yet more is released if baby makes her way to the breast and nuzzles and latches on. The levels peak around the time that the placenta is expelled. So if our body already has everything it needs to do the job, why do we need an injection to help?

Midwife Rachel Reed, author of the Midwife Thinking blog, explains here why the hospital environment is not always conducive to a physiological third stage of birth.  Many women arrive at the third stage after having interventions along the way – birth has not been physiological up to that point. Furthermore, the third stage of labour is a time when mother and baby should be left undisturbed, to get to know each other. Uninterrupted skin-to-skin should be facilitated, to allow oxytocin levels to reach their natural peak – no weighing or other checks that separate mother and baby should be carried out. There can also sometimes be fear in the room if staff are not used to facilitating a physiological third stage – this stress, and the time pressure (sometimes hospitals will put a limit of 1 hour on a physiological third stage) can cause adrenaline release in the mother, which can suppress oxytocin release. My own experience, as a doula in Irish hospitals, is that some staff can become nervous as the hour approaches and the mother begins to feel pressure to perform and produce the placenta – not the ideal environment.

So if a managed third stage means less chance of a post-partum haemhorrage, why would you consider a physiological third stage?  Well, a recent study suggests that breastfeeding duration may be affected by administration of drugs for the third stage of labour.  Women who had had oxytocic drugs for the third stage of labour were significantly less likely to be breastfeeding at 2 and 6 weeks and were more likely to have stopped due to pain or difficulty breastfeeding.  More research is needed to examine why this might be the case.

Another risk is that after the administration of the drug, the uterus may clamp down and start to close, trapping the separated placenta inside. This is why controlled cord traction is used, to help the placenta be expelled quickly. If the placenta is trapped inside, it will need to be removed manually in theatre.

Some women can feel sick, dizzy and too unwell to hold their babies after administration of the third stage drug. This is generally due to syntometrine rather than syntocinon being used. Syntometrine is a combination of syntocinon and another drug called ergometrine, and while effective at preventing haemhorrages, it somes with a list of unpleasant side effects. For this reason, Irish Obstetric Guidelines for preventing PPH recommend that syntocinon be used routinely, where the woman is not at increased risk of PPH. It is worth noting that the manufacturer instructions for syntometrine state that it can “inhibit prolactin secretion and in turn suppress lactation”.  If you are attending a maternity unit where syntometrine is used routinely (Waterford and National Maternity Hospital being two), then you may want to have a birth preference that requests syntocinon, should you be planning a managed third stage or in case it becomes necessary.


If you have had a physiological or minimal intervention birth up to the third stage, then you may feel it makes sense to try for a physiological third stage.  GentleBirth women often have confidence that their body, which has grown their baby from two cells and then launched it into the world with no conscious effort on their part, can finish the job on its own.  The injection can be drawn up and ready to go, in the event that you begin to experience significant blood loss. This lovely article describes facilitating a relaxed third stage of labour. Midwives in Irish hospitals are thankfully now becoming more familiar with physiological third stage, as more women are deciding that this is the best option for them and their baby.  As suggested in the article, maintain the ‘mood’ in the room, whether you birth at home or hospital. Leave phonecalls and texts until after the birth of the placenta. Stay together with your birth partner and supporters and marvel at the new being who has just come into your life. Examine your baby’s face, those teeny fingers and toes. Let baby crawl to your breast and familiarise herself with the new territory. Forget the clock – as long as there is no significant blood loss, the third stage of labour should not be time-limited.  If there is a delay, getting into an upright position such as on the toilet can encourage the placenta to plop out. Most women will deliver their placenta within the first hour after birth, that magical period when you are getting to know the new and wonderful person you have brought safely into the world.

As with all birth preferences, there is no right or wrong answer. Being informed and having decision-making tools will mean that you can make the best possible choice for you on the day.

Further reading
Dr Sarah J Buckley on third stage physiology: http://www.birthspirit.co.nz/leaving-well-alone-third-stage-labour/
Midwife Rachel Reed discusses why a managed third stage may be the best option: http://midwifethinking.com/2012/05/05/an-actively-managed-placental-birth-might-be-the-best-option-for-most-women/
Gloria LeMay on the 30 minute third stage: http://www.glorialemay.com/blog/?p=161
How the placenta grows, functions and is birthed: http://42weeks.ie/2013/08/28/the-mysterious-placenta-and-the-third-stage-of-labour/

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Articles, Birth preferences, First baby, GentleBirth workshop, Holles Street, Induction

7 things you should know about having your waters broken

Posted on January 9, 2015 at 6:55 pm by / 0
You hear it all the time – ‘I had to have my waters broken’; ‘My midwife said it was the bulging bag of waters that was holding me back’; ‘The midwife thought I’d have the baby really fast if she just broke my waters’.  Sounds entirely benign, doesn’t it?  Sometimes fully informed consent isn’t sought for the artificial rupture of the membranes (ARM); you may hear ‘I’ll just give your waters a nick’ as a vaginal examination is being performed.  So it couldn’t be a big deal, right?

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Here are 7 things you should know about ARM. If you prefer not to have it, include birth preferences refusing it as a routine procedure.

1. It doesn’t always do what it says on the tin
It’s sold to you as making labour quicker: “We’ll just nick the waters there and you’ll have your baby soon”.  Yes, sometimes ARM speeds up labour but sometimes it does nothing or even slows the process down.  A review of the evidence says that ARM hasn’t been shown to speed labour up – it’s not evidence based. Why would it slow it down? Well, sometimes when the waters underneath the baby’s head gush out, the baby’s head can come down in a less then ideal position, meaning direct pressure is no longer being put on the cervix to cause it to dilate. You then have to work to get baby to move into a better position and with the waters gone, this is made more difficult.  Sometimes your dilation can even go backwards  after ARM – if it was the bulging bag of waters that was pushing the cervix open.

2. It may increase your chances of a Caesarean delivery
Were you told this when staff offered to release your waters artificially? Evidence shows that having ARM goes hand in hand with increased likelihood of a Caesarean. The water bag is protective and cushions the cord – once that cushioning is gone, there can be times when the cord becomes compressed and this can cause a drop in the baby’s heartrate, ultimately leading to a diagnosis of foetal distress and a Caesarean birth.

3. We don’t know if it’s safe
The amniotic sac, placenta and umbilical cord are something of a mystery. There can be variations in how the umbilical cord inserts into the placenta. One of these variations is known as velamentous cord insertion (VCI). Normally, the blood vessels connecting baby to the placenta are wrapped in a substance called Wharton’s jelly and protected by this and an enclosing membrane. With a VCI, the blood vessels are not protected at the placental end and are inserting separately into the placental membranes rather than the placenta itself. They are often entwined in the foetal membranes ie. the water bag. The major risk is that one of the blood vessels could be near the cervix (this is known as vasa praevia), and therefore could be ruptured if an ARM is performed. VCI is not very common, approximately 1 in 100 pregnancies, but it’s usually undiagnosed – I didn’t find out that I had a VCI until after my daughter was born. My waters had released themselves at 10cm – clever body!

4. It can speed labour up and make it unmanageable
Yes, I said earlier that it doesn’t always speed up labour, but sometimes it does, and your labour takes off like a rocket.  It can be very tempting if you are plateauing at 4cm dilation for a couple of hours to consent to an ARM in order to get things going. However, you might find yourself going suddenly from coping well with your surges to not coping, as sometimes ARM can accelerate labour and make surges longer, stronger and closer together very, very quickly. This means that you have not had the opportunity to build up endorphins in your system to deal with the sensations of the surges, nor have you gotten into the labour groove with coping mechanisms. Many women opt for an epidural after an ARM because they feel they cannot manage the intensity of labour – the epidural may then have the effect of slowing labour down! Cue the syntocinon drip to speed it up again…a classic cascade of intervention.

5. Meconium in the waters can change the course of your labour
Some babies poo before they are born – this is known as meconium. It is more common with babies who are over 40 weeks gestation and is indicative of a mature gut rather than distress, if baby’s heart rate is normal and all is well otherwise.

When meconium is found in your waters, it is generally hospital policy to use continuous monitoring, or cardiotocography (ctg), to check your baby’s heart rate from then on. However, ctg has a notoriously high rate of false positive for foetal distress, and so your chances of a Caesarean increase by around 30% once it goes on. Your movement is also somewhat limited, although you can work around this if necessary (it is not necessary to be on your back in bed if you are on ctg – you can be on your knees on the bed or floor or sitting on a birth ball, for example).

You will also be on a clock, as staff will not want a delay in delivering baby with meconium present – the time limit for labour may now be reduced.

This fascinating article looks at  what happens if meconium is found in your waters, if you would like to know more.

Bottom line – if there is meconium in your waters, it is safer for baby and more desirable for your labour experience that your waters remain intact for as long as possible.

6. The water bag protects baby from infection
You may or may not have heard of Group B Strep (GBS). This is a bacteria which up to one in four of all women carry in the vagina.  It doesn’t require any treatment and, for the non pregnant population, isn’t a problem. For most pregnant women, it still won’t be a problem, but in some cases, baby can become very sick if infected.  Policy in some maternity units for managing labouring women with GBS is that there should be no ARM routinely – so if you don’t know your GBS status, it makes sense to leave the waters intact.  You can find out more about GBS at this very informative website.

7. We just don’t know what’s going to happen next
We can’t predict what will happen after an ARM – maybe labour will fly and we’ll be holding our baby 2 hours later.  Or maybe our baby will be born by c section, after going into distress following the ARM. All interventions carry risk – and ARM can lead to a number of obstetric emergencies.  Our best chance at a vaginal birth is always to avoid any unnecessary intervention.

 

Labour is unpredictable and sometimes we depart from our birth preferences.  On the day, you may feel, all things considered, that ARM is worth a throw of the dice. As long as we make informed choices and are in the driving seat, birth can be a positive experience, whatever path it takes. Guidelines from the Royal College of Midwives state that ARM should not be routine and should only be carried out after a discussion with the woman – and that this discussion should not take place just before or during a vaginal examination. When making choices, always take the time to ask any questions you have and, if you feel you need to, you can ask staff to step outside the room while you discuss your options with your birth partner. It is difficult to get into the headspace to make an informed decision when someone has their fingers inside your cervix!

For further reading, check out:

http://midwifethinking.com/2010/08/20/in-defence-of-the-amniotic-sac/
https://www.rcm.org.uk/sites/default/files/Rupturing%20Membranes.pdf
http://42weeks.ie/2013/10/02/may-i-break-your-waters-information-on-artificial-rupture-of-membranes/

Day 2 of the Your Birth GentleBirth workshop looks at standard hospital policies and procedures and birth preferences.  Find out more about our workshops here.   

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