Letter from Danielle; thank you for the pain free labour.

Hello Ann,
My name is Danielle Law, and I gave birth to a 7lb baby boy, Jake, last Friday.
I just wanted to write and thank you for reccomending your book, which I bought a week before I gave birth from Amazon for my Kindle. (no longer available)
Jake is my second child, I have a daughter, Holly, who is 4 in July. Her birth was long, traumatic, painful and left me terrified of going through childbirth again. It ended with me being too exhausted to push, an episiotomy and forceps.
When I fell pregnant with Jake I was so worried of how I would cope again.
I bought your book and read it in a day, it was great to read advice from someone with so much experience, both personal and professional.
I started having contractions at 8am on 5/4/13. I was at home with my daughter all day, with the contractions gradually getting longer and closer together. I used the tecniques I had read in your book, stayed calm, breathing through each contraction. They were so managable that I got all my cleaning done, and kept my daughter entertained all day, and without my daughter knowing that anything was wrong. At 7pm my contractions were 5 mins apart, so called my parents to come and look after my daughter. I tucked my daughter into bed and phoned the labour ward.
On the phone to a midwife at the labour ward, I was told that I had two options:- To wait at home a little longer until I was sure the contractions were 5 mins apart, or to come in and they could monitor me and the baby..I'm pretty sure that the midwife didn't believe I was really in labour or as far as I was because I wasn't screaming down the phone when she was asking me questions. I told the midwife I would like to come in now please!!
I got off the phone and my waters popped, in front of my horrified dad! We got everything together and set off for the hospital. We arrived at 7.40pm. This is when my contractions finally got painful, and I made my way (loudly) to the labour ward, got through the door, told them I needed to push..helped quickly onto a bed and Jake made his very quick entrance into the world, born at 8.20pm.
The whole labour was amazing, so easy to cope, not scary and stressful like my first. We only stayed in hospital for 5 hours, then we were home with our beautiful baby.
I just wanted to say a huge thank you to you for your book, which I have reccomended to all my pregnant friends! Without reading your book there is no way I would have been able to remain so calm. I was very sceptical at first that it was possible but i truly had a pain free labour! It was so amazing to experience a nice labour, something I never thought was possible.

Thank you again, I hope more women manage to have an easy labour like me.

Danielle Law x

Do you belive in a Pain Free Labour?

The study of belief systems is a fascinating one. Some people will believe just about anything. Modern society today believes that labour contractions will cause pain. Why? Who does this belief system benefit? Certainly not the women in labour.
The British philosopher Jonathan Glover compares belief systems to floating boats. It is almost impossible to change them all in one go, as it would be to alter the boat significantly all at once. It has to be done slowly so as not to disrupt the stability of the boat which could cause it to sink.
Our society has known about pain free labours since the 1940s when my hero, Dr Grantley Dick-Read, first published his book Childbirth Without Fear. The hypnobirthers, who have based their teachings on Dick-Read's book, have been preaching against painful labours ever since. Yet we still will not believe. 
Religion is a belief system that is based solely on faith. There is no proof that any so called Gods exist and yet millions of people continue to believe. This is because people want to believe, they want a sense of belonging and a hope that there will be something better when our time here is done. If you believe in a Christian God then you must also believe in Allah and Zeus as there is no more evidence that one exists at the exclusion of the other. We take our comfort where we can.
The bible has been altered and translated over many years. It is unlikely that it bears any resemblance to the original script. And yet we choose to believe. If in a thousand years from now the only books left in existence are the Twilight books then people will believe in vampires, they will be watching out for the 'sparkly ones'. To be honest, I know some people in Manchester who believe firmly in 'sparkly ones' and will be seen as disciples in that distant future. You know who you are.
If women today suddenly started to believe that labour contractions were not designed to cause the sensation of pain during a normal labour then chaos would ensue. The boat would start to sink. Health services would not be prepared for women demanding a pool birth to aid their relaxation. Did you know that Oxford, England has only two birthing pools to offer where as Cambridge England has eleven. Just shows where the really clever people are.
A harmful belief that is not backed by science or logic is really not worth holding onto. If painful labours were scrutinised carefully then it would be found that uterine smooth muscle is perfectly capable of contracting without causing pain. I could not find any research into the workings of smooth muscle that proved it was designed to cause pain whilst contracting. And yet we believe. 
The only people who benefit from keeping labour painful are men. It is the last vestige of control that they have over us. It would take a really good philosopher to understand all the myriad of reasons as to why we have not yet broken free of this often crippling belief.
All it takes is to believe. The truth.

Avoiding PPH?

Just read a very interesting article in Midwifery Matters magazine, the Manchester issue (Winter 2012) Issue 135 P. 21. It is an article on A Novel Way to Prevent Postpartum Haemorrhage? Judy Slome Cohain, the author, puts forward a natural method of delivering the placenta without drugs and without excessive blood loss. Sounds good.
Study days attended have taught me that the 3rd stage (expulsion of the placenta) can be done in two ways:

• Active management where an intramuscular injection of Syntometrine (if you are normotensive) or Syntocinon (if you have high blood pressure) is given into your thigh muscle immediately after the birth. The cord is clamped and cut. The injection causes the uterus to contract strongly and push the placenta away from the uterine wall. After noting signs of detachment, the midwife will then pull the placenta out by pulling on the cord. This usually takes about 10-15 minutes.
• Physiological management where no drugs are given. The cord is left to pulsate and so give baby extra blood needed to perfuse the newly working lungs. Mum, dad and baby are settled onto a bed or other comfortable place and the midwife awaits mum feeling an urge to push the placenta out while watching for excessive blood loss. This can take up to an hour.

Judy's 3 4 5 Protocol, goes back in time to when women did not bleed excessively after giving birth. Judy explores the history of post partum haemorrhage (PPH) and how women in the past avoided it.

• (3) Skin to skin contact is initiated immediately after the birth. The cord is left to pulsate and is not cut before 3 minutes after the birth. The midwife does not touch the cord or the uterus. After 3 minutes the cord can be clamped and cut and the baby kept with mum or given to dad.
• (4) The new mum is asked to do "a good deep squat with her bottom almost touching the floor". This is over a low bowl or other implement to catch any blood loss or the placenta. Mum is then asked to push even if she does not feel a contraction or urge to push. 
• (5) If the placenta has not been expelled by 5 minutes then the midwife is allowed to gently pull on the cord to lengthen it out of the vagina and reassure mum that the placenta is low and to keep pushing.

Mum stays in a low squat while she continues to push. When the placenta has been expelled, mum is made comfortable and given a maternity pad to wear and baby is returned to initiate breast feeding. It is advised to massage the uterus through the abdominal wall to expell any clots, if the pad becomes soaked during the next 5 minutes then an injection of an oxytocic is to be considered. If a woman has a history of PPH then an oxytocic can be offered after the placenta has delivered whether she is having a PPH or not. (Why not just give the injection in the first place anyway and avoid the risk of another PPH right from the start of the 3rd stage if you are going to give it anyway?)

A retained placenta is diagnosed if mum has been pushing for 25 minutes and medical assistance is advised. This method of delivering the placenta is said to avoid a placenta being trapped by the cervix closing after the birth as it should be out after 5 minutes. The baby's lungs are well perfused by the extra blood from not cutting the cord till 3 minutes have elapsed and mum keeps most of her blood by expelling the placenta quickly.

Judy is asking for maternity units to participate in a multicentre study of her protocol and can be reached at judyslome@hotmail.com

Thank you NHS

I spoke to a young lady recently who I was to review her birth plan with. She told me that she wanted an epidural and episiotomy.
I was speechless.
She was low risk with normal deliveries achieved at her last births. I was told that it was normal in her culture to have an epidural and episiotomy as standard. A doctor delivers the baby and obstetric nurses care for you in labour and after the birth. Not a midwife in sight.
OMG
It took a while but I eventually persuaded mum to at least try the birthing pool at her local birth centre before opting for a medicalised birth. I described how the warm water eases away any aches and would keep her relaxed during the labour. Delivering in the pool would help her perineum to stretch naturally and she could maybe avoid any trauma to her lady bits. Baby would be listened to every 15 minutes to ensure they kept nice and happy.
She was certainly very interested in this strange way to labour and birth and eventually decided to at least give it a try.
I have spoken to lots of women who come from a culture of medicalised care in labour and when they decide to try the pool they get back to me with glowing reports. "I didn't know it could be that good, I was in the pool and no way was I getting out. My baby was born in the water and it was simply wonderful".
With the increasing number of Midwifery Led Birthing Centres opening in the UK, I feel we need to say a silent thank you to the good old National Health Service (NHS) and all the dedicated workers who strive to empower women to seek a more natural way to birth their babies.
Thank you.

Evidence based practice to support a pain free labour - Three

It is Sunday afternoon and I have been researching smooth muscle for the past two hours. I now know all about calcium ions and calmodulin proteins which activate an enzyme called myosin light chain kinase which uses ATP to phosphorylate a portion of the myosin head. This means that the myosin head can then bind to actin and contraction can occur. I really did not need to know all this. However, what I did need to know was that SMOOTH MUSCLE IS NOT DESIGNED TO CAUSE PAIN DURING NORMAL USE.
There are three types of muscle in the human body. Cardiac muscle is found only in the heart. Striated muscle is voluntary and attached to our skeleton so that we can skip and dance. Smooth muscle is not voluntary, we have no conscious control over it. It is found in the walls of hollow viscera, airways, blood vessels, the iris and in hair follicles. There is no fourth category of muscle. If uterine smooth muscle was so different from other smooth muscle then it would be in a section of its own. If uterine smooth muscle was designed to cause pain when contracting, as many people believe, then it would be very different from the smooth muscle in your stomach. It is not.
I have read thorough Tortora and Grabowski's Principles of Anatomy and Physiology on muscle tissue and nowhere do they say that uterine smooth muscle is any different to smooth muscle in other parts of the body. In fact, I think they would turn in their penthouses if anyone suggested that their beautiful book had a major flaw, that of not recognising a fourth muscle group.
So, why do so many women today experience uterine smooth muscle contractions as painful when they go into labour?
 See posts:

• Why labour hurts.
• Why labour hurts 2
• Why labour hurts 3
• Why labour hurts 4
• Why labour hurts 5

Once you know the truth, you have the chance to choose.

Evidence based practice to support a pain free labour - Two

It has been recognised for decades that there are adrenergic receptor sites on cervical smooth muscle membranes for catecholamines. There appear to be two main receptor sites, alpha-adrenergic and beta-adrenergic. The alpha-adrenergic sites, when stimulated by adrenalin in a person's blood stream, are responsible for cervical smooth muscle contracting. The evidence to guide our practice with reference to adrenergic receptor sites is freely available on the Internet and:-

Identification of alpha-Adrenergic Receptors in Uterine Smooth

Muscle Membranes by [3H]Dihydroergocryptine Binding*

http://www.jbc.org/content/251/22/6915.full.pdf+html 
 is one such piece of research.

Another is the research conducted to compare different local analgesia given during large loop incision to the uterine cervix by Howells et al (2000). 

http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2000.tb11575.x/full

Lignocaine with adrenalin was found to have more side effects such as shaking but caused less blood loss. These results can be attributed to the adrenalin diffusing into the woman's general circulation and causing her blood vessels to send extra blood and energy to her arms and legs which would cause shaking. If you have ever had to stand up in front of an audience and give a speech you will know all about adrenalin and shaking! The reduced blood loss can be put down to alpha-adrenergic receptors binding with the adrenalin and causing the cervical smooth muscle to contract strongly and so cut off any damaged blood vessels and so reduce blood loss. 

So, what on earth does all that mean to a labouring pregnant woman? It means that telling women about receptor sites on the uterine cervix is evidence based and so should be allowed when offering evidence based care within midwifery services.

Society repeatedly informs women that labour contractions are meant to be painful. When women go into labour they are naturally anxious. This anxiety causes the release of adrenalin by the autonomic nervous system. The adrenalin circulates in the blood and attaches itself to receptor sites on the uterine cervix causing the smooth muscle there to contract and become rigid. The cervix should be relaxed in labour so that the uterine smooth muscle can pull it up over the baby's head. If it is being held rigid by adrenalin then it is more difficult to pull up and a longer labour can be experienced causing more stress and more release of adrenalin.

Various posts within this blog describing relaxation techniques in labour striving to stop women being anxious when going into labour and so stop the release of adrenalin. The relaxation technique I generally teach to pregnant women is called Progressive Muscle Relaxation. A relaxed person does not secrete adrenalin, which is only needed in times of stress to prevent you giving birth when there is a massive tiger at the cave door looking for a quick snack.

Practicing one of the relaxation techniques is vital in pregnancy so that when labour day arrives, you can slip easily into a relaxed frame of mind. Bliss.
  

Evidence based practice to support a pain free labour - One.

Midwives today have improved the care offered to pregnant women by providing Evidence Based Practice. That is, only offering a plan of care that has been proved to be effective by research. The concept of evidence based practice was developed by Dr. Archie Cochrane in order to encourage all health care professionals to use evidence when making care decisions.
The Cochrane Library are a wealth of information when seeking research to guide our practice. They take the findings of similar research projects and amalgamate them to present an overall picture of what the researchers were hoping to discover. Their aim is to present independent high quality evidence for decision making within health care settings.
Lawrence et al (2009) examined 21 such studies which included the experiences of 3706 women. Their subject matter was Maternal Positions and Mobility During First Stage Labour.  Their findings after examining each piece of research by two independent health care specialist were:

• The first stage of labour was one hour shorter in the upright groups.
• There was less use of epidurals in the groups that remained mobile and upright.

They concluded that remaining upright and mobile during the first stage of labour was advantageous to women. They pointed out that lying down in labour should not be encouraged due to the weight of the pregnant uterus putting pressure on the abdominal blood vessels.

This blog supports staying upright during labour. This summer I visited Bonny Scotland and was amazed at how hilly it was. Walking up the hills was hard work, I would arrive at the top of a hill breathless with the muscles in my legs hurting. When women lie down in labour the uterus has to work against gravity and push the baby uphill, no wonder the uterine muscle starts to hurt, just like my legs did in Scotland. However, I had the choice of sitting down and getting my breath back at the top of the hill and so the hurt went away. Labouring women do not have this choice, of stopping the labour to relieve the hurt.

From the research available to guide my practice I can surmise that staying upright in labour will shorten the labour and make it more comfortable. I can therefore be confident that when I advise labouring women to have a little walk or adopt an upright position such as sat on a birthing ball or kneeling on a mat, my practice is evidence based.