Independent Midwifery Under Threat

As of October 2013, it will become illegal for midwives to practice without insurance, due to an EU directive. Because there are too few Independent Midwives – around 200 – and just one claim could stretch into the millions, the premiums on offer would be prohibitively expensive. Currently IMs work without insurance and their clients sign a form in acceptance of this. IMs argue that insurance is a profit-making industry, and that it is good standards of practice that make midwifery safe, not insurance policies. They also point out that by making insurance a compulsory prerequisite of registration, there are implications for the freedom of all midwives, not just independent ones. Potentially, the legislation could further erode birth freedom for women too, with insurance companies gaining a say in where and how they might be happy for births to take place.

There is a petition asking for government help in securing workable and affordable commercial insurance to find a way forward.

The Telegraph 25 March 2013

Jacob's Birth

by Emma Ashworth

Jacob's birth was planned as a homebirth.  There are many reasons for this; the main one being that I have a wish to be left alone in labour, not to be following a schedule or conveyor belt system, but just to allow my body to labour as and when it wants to.  I know that to be distracted by being talked to, having someone there, I don't know, even bright lights all affect labour and I didn't want that.  My birth plan specified no vaginal examinations because I feel that they have no value in most cases, labour will progress as it does, cervix opening is not linear and the single most painful part of my first baby's birth was vaginal examinations.

I chose to have an independent midwife with Jacob because I wanted to know who I was having as my midwife, and I wanted Philip (my husband) and I to make our own informed decisions rather than follow NHS guidelines which may not be suitable for us as individuals, and in our own personal circumstances.

For three weeks before Jacob's birth I experienced prodromal labour.  This is when labour starts and stops and can be very frustrating.  It was generally going on between about 3am and 7am so I was getting very tired and needed to sleep some afternoons.  I felt very nesty and was doing a lot of housework which is not like me at all!  I had a pool from Birthworks which was heated and filtered, ready to go, so every evening I would get into it and float in front of the TV, which took all the pressure off my pelvis, which was very achy.  That was lovely.

Sometimes the prodromal labour was quite strong and I had to breathe through the contractions.  They were exciting though, and quite bearable really.  Once I thought that we were good to go and called our midwife to say so, but it all stopped again which was a bit frustrating.  We were hoping to have a friend of mine as a birth companion but she lives in Oxford so trying to judge when to call her was also challenging!  I spent as much time as I could listening to my hypnobirthing CD, every day where possible in the last 6 weeks, and trying to enjoy what would be my last pregnancy.

One afternoon I'd taken a nap on the sofa and was just about to get up to go to school to collect my oldest son when my waters broke.  I scooted into the loo and checked that they were clear - they were.  I went to tell my husband (who works from home) that he'd need to go to school, and could he take our toddler, too.  Labour started up pretty quickly and by the time that my husband got home about 45 minutes later I had to really focus on the now intense contractions, breathing through each one and focusing on not tensing up, leaning over my ball.  My husband called the midwife and our friend in Oxford, Philippa, and then he helped me upstairs.  I found a position on the bed which was comfortable enough and felt right, which was on all fours leaning over duvets and pillows, bum in the air in a way that I could move my hips if I needed to.  I needed the light off (that was bliss and I found out later it really helps the hormones to flow), and I listened to the hypnobirthing CD that I knew so well and it helped a great deal.  I also had my TENS machine on and the boost button was great. 

I didn’t try to time contractions but I counted through one (it took a count of 20) and then for each one I counted to 20 knowing that when I got to 20 it would pass.  That was a great focus and helped me to remember that each one was transient.  I did cheat a bit as they got longer and more intense and didn't start counting for the first few moments!

I think I was there for about an hour and my husband was watching me on the baby monitor we have (with video).  I could hear my boys playing downstairs and that was nice.  Suddenly I felt things were really strong and I didn't want to be alone and somehow my husband was there (he told me later I'd been totally still, then I moved and he came to me).  I was sick, which we were prepared for as I'm always sick in labour and I remember thinking it was probably transition.  Then my husband was gone and my midwife, Debs, was there.  I felt she was behind me sitting on the floor (those of you who know Michel Odent will know what I mean when I say she was doing “virtual knitting”!).  After a contraction or two I said, "Debs" and she said "yes".  I told her that this baby was coming and I needed to get downstairs as I really wanted a waterbirth. I was feeling slightly different about the contractions and while I was not yet pushing I knew that the sensations were changing. 

I'm not sure how, but I knew my husband was taking the boys to a neighbour.  Then he was back and I remember summoning all my strength to get downstairs between contractions and we made it and I shouted at them to get my clothes off!  Hub pulled my trousers and knickers off and couldn't get them past my feet because I wouldn't pick them up.  I remember wondering why he was wanting me to pick my feet up!  The lights were down low and that felt so right.

Up to this point I’d been very quiet with each contraction.  I found that my own birthing sounds distracted me, and I lost concentration.  I preferred to breathe through them quietly.  With Toby this had been the same all the way through but at this point with Jacob I started to feel the pushing sensation take over and I got very grunty.  I was worried that my husband would feel that the pain was too much as I’d been silent all through with Toby, so I told him it sounded worse than it was (which it did).  I felt very calm and comfortable; while it did hurt it's a totally different thing to pain when injured and it was ‘Just OK’. 

I remember leaping into the pool as someone very athletic might leap over a 5 bar gate (although apparently my husband’s recollection of it is less elegant!).  I had maybe two contractions in the pool and then I felt his head crowning.  I think I naturally breathed his head out and I remember saying, "baby's head's out" and then his body followed immediately, not in the next contraction which was a surprise!  I reached down and grabbed him, brought him to the surface and just said, "hello baby" a lot! 

After a few minutes I suggested to my husband that we checked out the variety so we took a look - another boy.  I know my midwife was watching carefully for blood loss and it crossed my mind a bit as I'd had a postpartum haemorrhage with Toby, and it was my only fear about this birth, but I trusted Debs and put it out of my mind. 

I felt no pressure, I know I take ages to deliver the placenta so I just relaxed.  The cord was a bit short to comfortably hold him above water so my husband bailed out enough to make it easier to hold him and over the next hour or so he latched on to me and I just relaxed in the pool. 

I was getting some contractions but not many (as is my norm) and after an hour I was getting very uncomfortable holding him out of the water and I felt it was ok to cut the cord which was now very small, thin and white and had clearly passed his blood across.  We called our older son from the neighbour over to cut the cord, which he did, and that was lovely.  I passed Jacob to his daddy and was able to really focus on what were now painful contractions which took some deep concentration and use of the hypno CD. 

In the end it took 1 hour 50 minutes for the placenta to arrive, just 10 minutes less than it took for Jacob to be born after my waters broke.  That was all fine, there was no pressure as there would have been in hospital and I know my midwife was watching me like a hawk so I could relax.  I know I'm very sensitive to oxytocin release stopping after birth which messed up the placenta delivery for my older two, and this time it worked like a dream, just slowly.

The placenta was intact and lovely and I enjoyed watching Debs check it over and she showed me all the different parts, and we took some photos.  Some time later I wanted to get out of the pool, so I did.  Philip phoned Philippa to say that there was no hurry anymore as she’d missed the main event – she had only got as far as Watford!

I didn't dress Jacob for ages, not even in a nappy, I don't think I did until we went to bed that night.  I just laid on the sofa holding him against my breast allowing him to feed when he wanted and just stroking him and smelling him.  He'd not been dried off or cleaned and he had a lot of vernix and I felt that it was important to allow him to keep that smell that he knew and not to bath or rub him down.  He was very calm and lovely and happy.

I had some food and we all just chatted - it was so lovely. Philippa arrived armed with champagne, cakes and some lovely baby vests and got her first cuddle.  Debs cleaned up although there was really no mess at all - and Philip got our children from the neighbour.  Debs cut Jacob’s cord short and sealed it with a tiny Sterifeed cord ring rather than the huge and uncomfortable plastic clips.  Eventually we went up to bed and my family was snuggled up together at about midnight, so utterly different to in hospital where my husband had to leave me, bereft, and go home alone.  I’d hated the post natal ward and to be together with my family was just amazing.

Jacob's birth was an extraordinary experience and I would do it every day. I desperately want to do it again.  I envy anyone who may be able to ;)  However it was seven years in the making and it took two less than perfect births to get there.  I took everything I'd learnt from Peter and Toby's births and added into it seven years of research and, more than anything, a wonderful midwife.

To summarise, things which were most important to me are:

• my independent midwife, Deborah Rhodes
• low lighting
• not being talked to
• no vaginal examinations
• being able to move how I want, when I want
• counting through contractions
• water - with Toby's labour it was amazing.  Jacob's was too fast for it to help the birth but it REALLY helped with the placenta
• TENS
• hynobirthing
• delayed cord clamping and Sterifeed cord ring
• respecting my body's messages to me
• holding my baby.  He wasn't weighed until he was 3 or 4 hours old and he wasn't wiped off, dried or dressed.  No one held him other than me for the first hour which from Jacob’s point of view must have been calming and reassuring.  Wonderful.

Owain's Birth Story

by Jennie Evans

I was reaching the end of my third pregnancy, planning my second home birth. My due date came and went, but this was to be expected as I was 'late' with both my older boys too. I had a couple of niggly evenings towards the end of the week but nothing significant.

I arranged to go out for a curry with a couple of friends on the following Friday, if nothing had happened by then. At my 41-week midwife appointment on Tuesday I accepted a sweep, which must have done something as I had some definite tightenings that evening. It all stopped once I went to bed though. I carried on as normal, taking Alasdair (my two-year-old) to groups, getting rather tired of the 'so you're still here then!' comments!

On the Thursday evening (41+3) I had more tightenings, which started getting quite regular, though not massively uncomfortable. I went for a walk to try and get things going, and by the time I got back they were coming about every five minutes. We called my parents in case we needed them to look after the older boys, then called the delivery unit (DU), who called the midwife, who called me. She gave me her number and said to call back when we thought we needed her, which we duly did an hour or so later.

She came round and sat with us for a while, observing and timing the contractions, until I asked for a vaginal examination (VE) to see if I was progressing at all as it didn't feel as if the contractions were getting any stronger. She checked and I was only a couple of centimetres dilated, so we agreed that she'd go home, we'd go to bed to get some rest while we could, and would call her again if things progressed overnight. I fell asleep straight away, so they couldn't have been that bad!

I woke around 2:30 with more contractions, so I went downstairs and got the wood burner going again as it had died down. I paced around the living room for a bit, resting on the sofa every now and then, with clary sage oil on my oil burner. I eventually decided that it wasn't going to happen then either, so went back to bed about 5:30 and again went straight to sleep.

The alarm went at 7 as normal, and at 7:30 my mum called to see how things were going, as she hadn't heard from us overnight and wanted to know if we needed any help. I said that I was still getting quite regular contractions so she said she'd come over straight away to take Jamie to school so Tom didn't have to leave me on my own. She then stayed and entertained Alasdair for a couple of hours, by which time we'd decided that it was happening after all, and called the DU again (the midwife we'd seen the night before went off shift at 8am, so we had to go through the whole process again).

At about 11am Mum took Alasdair back to their house, and we agreed that she'd come back at 3pm to pick Jamie up from school and collect an overnight bag for the boys at the same time (I know, we should have had this packed as well as my hospital bag, but we had assumed I'd labour overnight as I had done with Alasdair and they'd sleep through it – not this time!). The midwife arrived shortly after Mum and Alasdair left, and I texted Kate to say that I didn't think I'd be going for a curry after all!

The midwife read through my birth plan, sat and timed my contractions and made some notes. I was still using the contraction timer app on my phone, but as the contractions got stronger I decided I'd get more benefit from pressing the button on my TENS machine than pressing a button on my phone, so I got it out and the midwife put it on for me.

After a bit I asked for another VE to see if things had moved along, as the contractions were quite a bit stronger. She said I was about 5-6cm, so I was getting somewhere! My waters were 'bulging' but I knew from my previous labours that they wouldn't go until much later on. Unfortunately midwives aren't allowed to break waters at a home birth unless it's medically necessary, so I just had to stick it out. I distinctly remember telling them later on that it was necessary, because my dad was coming in an hour to pick up the boys' bag, but this wasn't deemed a good enough reason!

At some point the first midwife called the second one to come over as she thought we might need her soon, but I have to admit I don't really remember this happening. I kept moving around the room, doing all the things we'd practised in my yoga classes to help me through the contractions; the midwife commented that I was moving really nicely, circling my hips to help the baby down. I wasn't doing this consciously, I have to admit, it was entirely programmed into me through the yoga classes – thank you Sally! Tom kept feeding me flapjack and made sure I was drinking enough – the fridge was stocked with water and Powerade.

The midwives decided we should get things ready for baby, so Tom brought the fire guard through to lay the baby clothes out on to warm, and we got the change mat and towels down. I felt like I wanted to rest a bit as I'd been standing all day, so we also spread an old duvet on the floor and I lay down. With hindsight, this should have been an indicator that we'd be meeting our baby fairly soon, as I felt the same with Alasdair, but of course that didn't occur to me at the time!

According to the midwives, I actually fell asleep for about 15 minutes – I wasn't aware of having slept, but apparently I did... I woke up with some very strong, 'pushy' contractions, a definite feeling of wanting to bear down. My waters still hadn't gone, and I think the midwives were getting a bit concerned that I was getting tired, as I recall them saying that they'd give me until 4, at which point they might want to think about some sort of intervention.

One of them asked me to turn onto my back so she could do another VE; this was really not what I wanted at this point, as I was happy on all fours, but I reluctantly agreed to a quick check in between contractions. As one contraction eased, I moved most of the way onto my back, so she could do the VE, and as she did so, the next contraction started and my waters went – right in her lap!

I got straight back onto all fours and could immediately feel the baby well on his way. He crowned with the next contraction. I remember saying out loud 'please don't slip back' as I knew we were nearly there; two more contractions and he was out! I sat back onto my heels as he arrived, so the midwife didn't actually need to do anything, he slipped down onto the duvet between my knees. Tom picked him up while I took my nightshirt off, then handed him to me for skin-to-skin.

The midwives wrapped the two of us in my dressing gown and a towel and got a hat on him while I stood holding him. It was at this point that one of the midwives noticed he had a full knot in his cord – thankfully the cord was so thick that the knot hadn't caused any problems during labour, they had no idea it was there until he'd arrived!

They asked if I wanted to sit on the sofa; I tried to sit down but it was too uncomfortable so I stood up again. 'How about sitting on your birth ball?' was the next suggestion; I tried that but again just couldn't sit down. We soon realised why this was, as just as they were confirming that I definitely wanted a physiological third stage, as per my birth plan, I felt the placenta coming. We waited for the cord to stop pulsing, then it was clamped and cut, and I finally flopped down on the (dust-sheet-covered) sofa and baby Owain had his first feed, quickly followed by his second – he had both sides within 30 minutes of birth!

The grandparents were called, the birth announcement posted on Facebook, then Tom and one of the midwives cleaned Owain up and dressed him, while the other one helped me up the stairs to the shower. I showered, changed, and went back downstairs for more cuddles!

Unfortunately it did not all end there. The midwife realised I was still bleeding, even though she had previously thought that my uterus had contracted back down. She helped me to the toilet, as apparently going for a wee can help, but it didn't. I was still losing blood, and getting some pretty strong after-pains with it. She gave me a shot of syntocinon, but it didn't stop. She then called the DU as she was getting concerned about how much I'd lost; the senior midwife there said to give me another syntocinon injection and if that didn't stop it then I should transfer in.

By this time I was getting a bit wobbly, so I lay down, but every time I moved, I bled again. The midwife decided that I needed to go into the hospital, so she called an ambulance. The First Response car turned up, the paramedic took one look at me and agreed that I needed to go in, so he put a cannula in my hand for IV fluids in the ambulance if necessary. The ambulance got there soon after, the paramedics somehow got the trolley round our stairs and into the living room, then back out again with me on it and into the ambulance.

Tom put Owain in his car seat; I said I wanted them with me rather than following in our car – I couldn't imagine anything worse than leaving them at that point – so we all piled into the ambulance. I was taken straight up to DU and hooked up to IV fluids and syntocinon. A doctor arrived pretty swiftly, and removed a 'dinner plate sized' clot which had been stuck in my uterus. I was also given misoprostil to help stop the bleeding, and the midwives warned me that this may give some nasty after-pains, so to ask for pain relief as soon as I needed it. However the pains I got from the medication were far milder than the ones I'd had when the bleeding started at home, so I was fine! 

Thankfully, as we were on the DU not the postnatal ward, we had our own room and Tom was allowed to stay – they found him a mattress to put on the floor. Another junior doctor took a blood sample, to see if I was anaemic, and they left us to rest.

The following morning, the blood test results were back and my iron levels were fine, my uterus was back as it should have been and I was allowed some tea and toast. One of the new shift of midwives did Owain's newborn checks and we were told that we could go home! Of course our car was at our house, and the bigger boys were at my parents' house, so Dad and my sister came to the hospital to pick us up, while Mum sorted the boys out. We called her when we were nearly home, and she brought the boys over – this gave us a chance to sort the house out, as neither of us were entirely sure what state the living room had been left in! As it turned out it wasn't too bad, so we were all settled by the time Mum arrived; the boys were very excited to meet their new baby brother. There were lots of cuddles all round and some lovely pictures taken, before Mum and Dad left with my sister and let us start properly settling down to life as a family of five.

Anna's Birth Story

by Megan Stephenson

Having had a false alarm early in the morning of 11 January, my parents had come to stay until the birth. 

At about 12.30 am on 15 January I woke up needing the loo and felt a crampy sort of feeling, but since nothing else happened, and having had a false alarm already, I went back to sleep. Woke again sometime between 3.00 am and 3.30 am, having what definitely felt like a real contraction. After a couple more I decided to time them, and between 3.30 am and 4.15 am I found they were coming regularly at about 7 minute intervals. 

I decided that I'd get up at 4.15 am, and make up a birthing space (plastic sheeting and old towels) in the lounge. Then I made myself some porridge and drank a glass of apple juice, to keep my blood sugar up.

I watched some programme about ancient civilisations on the tele, and then, at 5am decided to call for a midwife. First I phoned my named midwife, but she was off duty and her mobile was switched off. Then I called the pager service, where they told me I should instead call the delivery suite at the maternity hospital. I called them, and after lengthy questioning they said they'd get the duty midwife to me. Meanwhile, my contractions were fairly strong, but bearable, and now coming about 5 minutes apart.

Shortly afterwards the delivery suite called back to ask if my named midwife had asked to be called out (she is keen to attend her named patients herself), but I said that I thought she'd appreciate being allowed to sleep longer, and we'd call her out at a more civilised hour. Then the duty midwife called to ask for directions, which I gave her. 

I decided to have a shower, using my clary sage (aromatherapists believe that this encourages strong, productive contractions) shower gel. Then I watched some morning news reports until about 6.10 am when the duty midwife arrived. 

The duty midwife rang the doorbell, after which the rest of the household started to emerge, although Lucy stayed asleep. She unloaded some of her birthing kit out of the car, and we talked through what was happening. After having the shower my contractions had slowed down again, and I had to tell her when I had a contraction. She checked my blood pressure, listened for the baby's heart beat, and checked a urine sample. The urine sample had trace amounts of protein and lucozytes (I think that's what she said) in it, which can be evidence of an infection, so later on I did another, which was fine. 

Mum, Dad and Paul all gradually got up, had cups of tea (as did the midwife) and breakfast. At around 7 am we called the student midwife, who I had agreed could observe the birth. At 7.30 am we called my named midwife at home, but we had to leave a message on her answer phone. Lucy woke up at around this time, she came downstairs, had a look at Mummy, and then went to get dressed and have her breakfast (thanks to Nan). Shortly afterwards (7.45?) we called my named midwife on her mobile, and she got the message just as she was arriving at the maternity hospital for a course, so she turned round and came back out of Cambridge. 

By this time I was moaning through contractions, which were coming more frequently and stronger. My mum, Paul and the duty midwife took turns rubbing my back, and I leant over the birth ball, kneeling, for each contraction. The midwife wanted to check the baby's heartbeat again, and got me to lean back so she could do this, which was very uncomfortable, and had to be abandoned whenever a contraction came. Lucy came in to the room at about this time, and Nan held her and talked her through what was happening. The midwife got the gas and air ready - but it didn't seem to help, so I abandoned it after a few goes. Contractions were now coming thick and fast - transition I think - and I remember moaning “No, no, no” through them. 

My named midwife arrived at around 8.20 am, I think, although by now I was in no state to look at the clock. Very shortly after she arrived I felt a strong pushing urge, and said “push, push, push” although I remember being concerned that it was far too early to be second stage already. I pushed only when my body wouldn't let me do otherwise, and was relieved to feel the head against my perineum, and then my waters breaking and pouring down my legs. My named midwife wanted to check the baby's heart rate again, but didn't try to make me move, the second time she did this though I pushed the sonicaid away, as I couldn't bear the slight pressure of it. 

Another irresistible pushing and I felt the head almost out. In three pushes the head was out, and I felt my named midwife fiddling around, untangling the cord from round the baby's neck I guessed. Another two pushes and the body was out too, it was about 8.36 am. Baby was passed between my legs, and I sat back to admire my new baby girl. 

I felt rather shaky now, and sat down leaning against the sofa. I offered my breast to Anna, and Lucy had some Mum Milk on the other side. This triggered more contractions - to expel the placenta - but nothing was produced. Anna latched on after about 10 minutes, and had a little feed. The trainee midwife arrived about now and the duty midwife left at around this time since baby was fine. The placenta was still not coming after about 45 minutes, and I was getting fed up, I tried squatting over a bucket, but this was just uncomfortable. My named midwife said she could see that the placenta was just sat there, and offered to put her hand on my pelvis to give me something to push against, but this didn't seem to help. Eventually she was able to just gently manipulate it out, which was a relief, and she cut the cord. 

I went and had a lukewarm bath (the hot water had almost run out) to clean up, and then we weighed and dressed Anna (she'd been wrapped in a towel having cuddles). She weighed 4kg exactly. The midwife did various checks (does she have both eyeballs, do her reflexes work, etc), and then went downstairs while we had some family cuddles. Anna settled in for a good long feed, and Lucy had a bit too. 

I was having very strong after pains, which felt just like contractions. Eventually I needed to wee, and went to the loo, where I passed what appeared to be clot the size of my fist. I caught it, having felt it come out, and called to my midwife, as this seemed unusual. She examined it and concluded that it was a piece of placenta, despite the placenta having appeared to be whole. Once this piece had been passed the pains were much less.

Having had a good long feed, Anna slept most of the rest of the day.

Home births are cheaper than hospital for the NHS: research

Home births are around £300 cheaper to provide than hospital deliveries for women at low risk of complications, it was found. For women who'd had previous children, planned birth in an obstetric unit was the most expensive option at £1,142 per woman, with planned birth at home the cheapest at £780 per woman. But for first time mothers, even those assessed as at low risk of complications, there were more problems for the baby if they gave birth at home compared with a delivery in an hospital with obstetricians, a study published in the British Medical Journal found. They were up to three times more likely to suffer a stillbirth, birth injury to the child including broken bones, brain damage and respiratory problems associated with stress during birth.

The Telegraph 20/4/12