Midwife Advice

Wendy Turner-Webster: After nine months of waiting in anticipation for the birth of a child, the big day finally arrives. Midwife Claire Wood is in the studio to answer questions about the best ways of ensuring that the actual birth is as pain and anxiety free as possible, be it at home or in hospital. Hello Claire! Claire Wood: Hello! Wendy Turner-Webster: Alright. Let’s start from the top. I have been pregnant for nine months, how will I know I am in labor? Claire Wood: Well, that is a 64-million-dollar question, and it can be something that even very experienced healthcare professionals can find difficult to answer, because when a woman actually goes into labor, it’s quite a subtle process, and it doesn’t tend to be sort of bang, sudden you are in advanced labor. There are various signs that a woman is in labor. The most obvious one really is regular painful contractions, and by that we mean contractions that come three in a ten minute period, three times in a ten minute period, and last about a minute, and are sufficiently painful that the woman has to stop what she is doing, can’t speak, can’t focus on anything else. That really is a sort of hallmark of established labor. But that’s not going to be probably the first thing that happens. Wendy Turner-Webster: And how would you describe a contraction, like a quick sort of stomach pain? Claire Wood: Like probably the most painful period pain you have ever had all your life, but something that comes on gradually, and builds up to a peak, and then dies off, but is an intense feeling of pain in the lower abdomen. Wendy Turner-Webster: Would waters have already broken at this point or not? Claire Wood: They may have and they may not have, either is normal. Sometimes waters will break quite a long time in advance of labor. Sometimes they will break very later on in labor. So either situation is normal, and neither is cause for alarm. So if women begin to have contractions and their waters haven’t broken, that’s not a problem. Wendy Turner-Webster: And just to go into a bit of graphic detail, waters breaking, what does it actually mean and entail? Claire Wood: Well, the waters are essentially the amniotic fluid in which the baby is floating in the uterus. They are in a bag of membranes, and when the membranes break, the water comes out. Now, sometimes a lot of water comes, and that tends to be from in front of the baby’s head. That’s called the forewaters. But occasionally, there will just be a trickle of water, and quite often that’s from somewhere behind the baby, where it’s called hind-water leak, and that’s not all of the water coming. That tends to be just a little of the water. And quite often that can happen quite a long way in advance of labor, and then there’s no further loss of water. So it can be different for different women. It's not always the enormous gush all over the floor that people imagine it will be. Wendy Turner-Webster: And presumably, it’s rather like suddenly wetting yourself, I am assuming? Claire Wood: Yes, probably a little bit, and in fact, women sometimes aren’t sure whether their waters have broken, or maybe they have had a little leak from the bladder. And in fact, amniotic fluid when its clear looks quite similar to urine, so it can be quite difficult. And sometimes the only way to confirm it is to have a midwife or a doctor do speculum examination which will then be able to determine whether the waters are pooling up in the top of the vagina. Wendy Turner-Webster: I am sure it’s a classic fear of somebody who has reached their due date. They pop out to the shops on their own, like what if my waters break. Have you got any practical advice there? Claire Wood: Well, I think first of all, don’t panic. That might be embarrassing, at worst, but it’s not a cause for alarm. It may be inconvenient, but 99% of the time when the waters break, it's fine. It’s a normal event. And if it happens before labor, it may well be a sign that things are starting to happen, and that labor is not too far away. So I would say -- Wendy Turner-Webster: If you are going to pop out on your own, you should carry a hand towel or something, as well as your mobile phone. Claire Wood: Oh yes, we will get to you quickly. But on the whole, there is no need to rush to hospital or call an ambulance or panic in any way when the waters break, unless the waters aren’t clear, and by that what we mean is, if they are stained, if they are green or brown in appearance, that may be a sign that the baby has opened its bowels inside. Wendy Turner-Webster: Is that dangerous? Claire Wood: It can be. It may be a sign that the baby is in some sort of distress, or has had some sort of stressful event that has made it open its bowels. The principal danger from meconium, which is the name we give to the baby’s bowel movement, is if the baby breathes in, if you like, any of the meconium, and that can be a problem for babies. But it’s very unusual for that to happen on the whole, that generally doesn’t happen. And the less meconium there is, the less of a problem that would tend to be, or less likely it would be. If there’s blood in the waters, and by that I mean not dark, old blood, but fresh, frank blood, like you would get from a cut, more that let's say a tape of spinning quantity, then that I think you would want to go to hospital. Wendy Turner-Webster: And what could that mean? Claire Wood: Several things. There may be some bleeding coming from various points, possibly the placenta is one of the most likely places that there may be a little abruption behind the placenta; very, very rarely possibly from the umbilical cord, but that’s quite rare. It would be more likely to be from behind the placenta. It could be from the cervix, in which case it may not be such a problem, but it would be good to have that investigated, I think. But if the waters are clear, which 99% of the time they will be for most women, there is no course for alarm, there is no need to go charging into a hospital. It’s probably a good idea to see a midwife within the next 24 hours, just to have the baby monitored for short period, to make sure that everything is okay. Wendy Turner-Webster: So when do you start preparing to go into hospital? If you are having either contractions or your waters have broken, when is that decision made to go into hospital? Claire Wood: I think if you want to go into hospital to have your baby, you want to give birth in hospital, then the presence of regular rhythmic painful contractions is really the sign that it's time to into hospital. Wendy Turner-Webster: Should there be a sort of certain amount of minutes in between, do you have to start timing them? Claire Wood: Yes. People get very meticulous about time of their contraction. They write them all down on a piece of paper, and how far apart they were and how long they lasted. Without getting too preoccupied with that, it’s quite a good idea to keep a note of how often the contractions are coming. What we are really interested in is how many contractions a woman is having inside a ten minute period. So not so much how far apart they are, but in ten minutes, how many contractions occur, and how long do they last, each of them. And really we would be looking for three contractions in a ten minute period, each lasting at least a minute, and so painful that the woman has to stop what she is doing. She can’t speak. She can’t concentrate on anything else. She can’t move. All she can concentrate on is breathing through the contraction. And really if the contractions are not fitting that profile, then probably it’s still early labor. Wendy Turner-Webster: So it has to be pain to the point that -- you would think that a woman would almost know herself. Do people’s instincts kick in almost? Claire Wood: I think that certainly in a normal labor, where there has been no intervention, and where there is no pharmacological pain relief, where the woman is feeling all her contractions, yes, I think she would certainly notice that the contractions have changed, in comparison to maybe how they were at the onset. I mean, certainly yes, in frequency they will be coming more often. It will be lasting longer, and the pain will certainly shift up a few gears. Wendy Turner-Webster: So you get to hospital, walk in the doors, what happens? What’s the procedure? Claire Wood: Well, if you are having a hospital birth, there are of course different approaches to having a baby in hospital. If you are lucky enough to have a hospital that has a birth center, whether that’s a standalone birth center or attached to the hospital, which would be giving midwifery-led care, then the midwives will admit you into the birth center, and will do an assessment of whether you are in labor, or if you are in labor, how advanced they think your labor is, and there are various ways to do that. We do that by assessing the woman, by looking at her we can tell quite a lot from how she is coping with the contractions, how she looks, whether she seems very distressed or not so distressed. Already that starts to tell us something. Her obstetric history, she has had more than one -- if she has had a baby in the past or more than one baby, we will look at her slightly differently, to a woman who is having her first baby. Second and subsequent labors tend to go a little faster, we will get going more quickly. I guess the most definitive test of how far on in her labor a woman is, is a vaginal examination, where we feel the dilatation of the cervix, and that will tell you really, very accurately, where in the labor the woman is. But it won’t tell you how much longer she has got to go in terms of time or hours, just how far she has come already. Wendy Turner-Webster: That really is a piece of string, isn’t it? Claire Wood: Yes. Yes. Things may suddenly go very quickly or they may go on and on and on, and there is no really easy way to predict that. But based on all of those findings and listening to the baby, that’s a very important thing that should happen. Somebody should listen to the baby’s heartbeat and ask the woman questions about how the baby has been moving and how she has been feeling. Midwives will make an assessment of where in the labor the woman is, if she is indeed in labor. Wendy Turner-Webster: So how quickly could somebody get pain relief? If they felt they wanted it, what’s the general procedure for giving pain relief, and what different forms are there? Claire Wood: Well, it depends on what sort of pain relief we are talking about. There are different forms of pain relief, yes. Wendy Turner-Webster: Will these options have been gone through with the mother prior to getting into hospital? Will you have already discussed this with them perhaps? Claire Wood: Well, certainly I would encourage all women to discuss options for pain relief with a midwife, or if they are considering having epidural anesthesia with an anesthetist, who is probably the best person to talk about that type of pain relief. But there are different kinds of pain relief that women can access, some of which they can use from when they are at home, such as TENS machine. They can get those on at home, and the earlier they get them on, the more effective they tend to be. Wendy Turner-Webster: What are those exactly, I have heard of them, but I am not quite clear in my mind what they actually do? Claire Wood: Well, a TENS machine has some little sort of pads that you put on in certain places around the spine. Four pads that are stuck to the woman’s skin, and with a little kind of control pack that she has, that’s about a size of an iPod or so. She can boost the electrical impulses that come from those pads. And how it seems to work is it interferes with the pain messages that are being sent from the nerves at the base of the spine, that are attached to the uterus, to the brain. So it’s sort of interrupting the message or sort of knocking it off its course. Wendy Turner-Webster: Is it clinically proven? Claire Wood: I don’t know what the evidence is for the use of TENS. I think anecdotally, my observation is, it seems that the TENS machine do seem to work very well for some women, not for all, but some women, particularly if they get the morning early labor. It’s unlikely that the TENS machine would take you all the way through your labor. Probably most women will find that they will reach a point where the TENS becomes no longer effective, and then it might be time to look at some other options, such as moving on to using gas and air, or Entonox as it’s called, or getting into a birthing pool, if a woman is thinking of having a water birth or using water for labor. Or if she is thinking of having an epidural, then that might be the time to have the epidural. Generally with epidural, I think, is the longer you wait to get into established labor the better. Wendy Turner-Webster: Why is that? Claire Wood: Just to let your labor get established, because epidurals can sometimes slow labor down, but again, it’s better to talk to an anesthetist about that, to get all the information. Wendy Turner-Webster: Now talking about epidural, is this true or false, as it were, doesn’t epidural mean that you can’t push as effectively? Claire Wood: It can do. I think that effect is noticed much less in women who are having their second or subsequent baby, but that association, if you like, does seem to be there for women particularly having their first baby. There is quite a bit of controversy around that, and I wouldn’t presume to give you the definitive answer on that. But there is some evidence that epidurals may interfere with a woman’s ability to push, if she has become so numb that she can’t feel the muscles in her pelvic floors sufficiently well to push with them. Wendy Turner-Webster: Okay. Just finally, do you have a key piece of advice for a woman who is about to have a baby, what she will go through, a bit of advice? Claire Wood: It’s not a very practical piece of advice, but I think I would encourage all women to believe in themselves and their body’s ability to birth their baby, because I think lot of women approach labor fearing the worst and doubting their own ability to have a baby normally, and almost expecting that something will go wrong, or that they won’t be able to do this, or they won’t be able to cope, or some more gloomy scenario. And I think I would strongly encourage all women to really, really believe that they can do it. Wendy Turner-Webster: Very well said. Thank you very much for talking to us. Claire Wood: Thank you.