Monthly Archives: August 2014

Poo … haemorrhoids & sitz baths … you may never think the same again

A new baby in the house doesn’t always give the new mama the opportunity to dedicate some time to help her to heal and rest.  So many different but important elements that you have to remember with 101 other things that are all “important” … remember to drink plenty of fluids, eat a balanced, nutritious diet and sleep when the baby sleeps … yes I know everyone says this to you  … but it’s true sleep … you need to heal & rest … that pile of dirty dishes or laundry or the dust you spot can wait!   

Why not ask for postnatal gifts and may be your visitors would sign up for doing the dishwasher, putting the washing on, running the hoover around, give the duster a quick run around … these kind visiting souls may just do it for you understanding that you aren’t there to entertain them when they visit.  Actually it’s lovely that they want to meet your baby but it would be lovely if they could just do a little to help around the house.  We are far to “British” and make out that we are coping … when in fact we could do with a helping hand, someone to offer to make a cup of tea … it may be 4 o’clock in the afternoon and you just don’t know where the time has gone plus you are still in your PJ’s … and that may be the first cuppa of the day …

Anyway back to the nurturing of the postnatal body … I’ve had the honour to take part in some Sacred Postpartum pampering and learn all about the herbs that can be used to help heal our bodies.  After giving birth to our second baby I developed haemorrhoids and then having a gastric band in 2010 had a further impact in that I couldn’t always manage my liquid intake I also reduced significantly certain foods in my diet because I just couldn’t process them and so found that my stools were more compacted.  I am reminded every so often that I would much rather give birth to a baby than have compacted faeces.

Going to the toilet post-birth can be quite a shock for the new mother and even those that may have not experienced this the first time round … it can be shocking … your told take lactulose to soften your faeces … it will make it easier … still it can be scary when you aren’t on top of the 101 things plus the essentials of hydrating, nutrition & sleep!  This impacts the body.  I don’t think I need to go into the nitty gritty as I am sure you have at some time been there, done that and got the T-shirt, carrier bag and all the other junk that comes along.  Just to say that there is something that can really help the mother post-birth or the woman who has haemorrhoids or a prostrate condition … Sitz baths.

“A what?” I hear you ask?    A sitz bath … what is this?  You sit yourself in a steeped concoction of herbs.  The herbal blend is made up of a base herb, a supporting herb and an aromatic herb.  The healing herbs contained in the blend promotes the healing of hemorrhoids and the perineal area after birth … wow what a fabulous treat … sit yourself in a bath and immerse your entire bottom in a shallow filled bath, or if you can get down sit in a trug bucket – yes like the ones you do the weeding in … obviously a new one will be required … or sit with a bowl over the toilet seat and gently wash your perineum by pouring it over.  MY preferred method is the bath or the bucket as you are able to sit there relaxed for 15-20 minutes and let the blend take effect … I had heard great things and until today I hadn’t actually tried one myself … however after todays “birthing” … I was so in need of some tender loving care and so delved into the magic of the herbs I had purchased for the Sacred Postpartum.

Ohh boy … the relief … it was amazing … the area had felt very tender (I know TMI but then if you have been to class you know I took about vaginas like they are going out of fashion!)  so tune out … but for those of you who are interested and want to find a solution … I have one … and yes I will happily share & make it up for you so that you can get the instant relief … just to say I was out cycling after the “birth” and I feel so much better.

I mentioned above that the herbal blend is made up of a base herb, a supporting herb and an aromatic herb.  The one I made had witch hazel leaf, calendular and lavender.  I steeped it in hot water in a jar for 15-20 minutes then strained the liquid into the bucket with some tepid water.  I found a nice fluffily soft towel for later on and gently lowered away … 20 minutes later … I was in a state of bliss.  Will I continue my TLC … most definitely …

If you are interested in obtaining this wonderful blend please let me know … it’s not just beneficial for the postpartum mum, it’s for anyone that has haemorrhoids, or even suffers with prostrate conditions … this study showed that Warm water sitz bath treatment reduced postoperative complications such as urethral stricture. These results suggest that large-scale prospective studies are needed to establish an ideal method and optimal duration of sitz baths.”   link

If you have read this and can empathise … lets share a virtual hug … if you know someone who is suffering … don’t let them continue silently … do you know someone who has given birth vaginally … why not treat them to this wonderful blend and ease them into motherhood with a little TLC.

Please feel free to share and comment.

 

The Assessment of Progress – Midwife thinking Rachel Reed

Link

From the webpage … 

The idea that birth should be efficient originated in the 17th century when men used science to re-define birth [1].    The body was conceptualised as a machine and birth became a process with stages, measurements, timelines, and mechanisms. This belief continues to underpin our approach to childbirth today. In current midwifery texts labour is divided into three distinct stages, and further divided into phases within those stages. The first stage of labour involves regular and coordinated uterine contractions accompanied by cervical dilatation. This stage includes three phases: latent, active and transitional. The second stage of labour begins when the cervix is fully dilated and ends when the ‘fetus is fully expelled from the birth canal’ [2].  Again, the second stage is further broken down into three phases: latent, active and perineal. ‘The third stage of labour is the period from the birth of the baby through to delivery of the placenta and membranes and ends with the control of bleeding’ [2]. This categorisation allows practitioners to measure progress through the stages and create limits and boundaries around what is considered ‘normal’.

The tool used to measure labour in hospital settings is the partogram, which is largely based on a study carried out in the 1950s by Friedman [3] where he plotted the cervical dilatation of 100 women having their first baby in an American hospital. He found that the average rate of cervical dilation was 1.2cm per hour, but that this rate was not linear. In other words, most women gave birth within twelve hours of the commencement of labour, but there was variation in their individual dilation patterns. In the 1970s Phillpott and Castle modified Friedman’s graph to provide guidance for practitioners working in a remote area of Rhodesia. Their intention was to reduce the incidence of poor outcomes associated with obstructed labour in this particular setting [4]. They added an alert line, a transfer (to hospital) line and an action (augmentation) line to Friedman’s graph. The resulting partogram is now a practice tool used in hospitals worldwide to monitor the progress of normal labour. A cervical dilatation rate of less than 1cm per hour is considered ‘abnormal’ according to most hospital policies. However, some hospitals are more generous and will consider a rate of 0.5cm per hour normal for women having their first baby.

Since use of the partogram became widespred, researchers have found that Friedman’s graph does not represent normal labour progress. In contrast, research has found that cervical dilation patterns vary widely between individual women, and the average length of labour is much longer than in Friedman’s findings [5,6,7,8,9]. A recent Cochrane review into partogram use in labour concluded that: ‘On the basis of the findings of this review, we cannot recommend routine use of the partogram as part of standard labour management and care’ [10]. This evidence- based recommendation is yet to be reflected in maternity care. Instead, women have their labours managed in order to follow a partogram with limits and boundaries. Fewer than 50% of women having their first baby will manage to meet the narrow criteria of ‘normal progress’ and avoid augmentation of their labour [7].    The World Health Organisation estimates that the rate of obstructed labour is between 3 and 6% worldwide [11] and so a significant number of women are experiencing unnecessary intervention during their labour.

Methods used to augment labour carry risks and alter the physiology of birth. Amniotomy(artificial rupture of membranes) does not reduce the length of labour, and may increase the chance of having a caesarean section [12]. Intravenous syntocinon can increase contractions and shorten labour, but requires careful monitoring of mother and baby because of the potentially dangerous side effects [13]. When augmentation fails to improve the progress of cervical dilatation, a caesarean section will be performed for ‘failure to progress’. Time limits on the second stage of labour result in midwives implementing directed pushing to get the baby out before they must notify an obstetrician. Directed pushing (Valsalva manoeuvre, sometimes called purple pushing because a woman is encouraged to hold her breath and push hard) does not significantly reduce the length of the second stage [14]. However, it does increase the risk of damage to the pelvic floor and perineum, and is associated with fetal hypoxia, in no small part due to oxygen starvation when mum holds her breath. If directed pushing does not improve progress, or the baby shows signs of stress due to hypoxia, the birth will be assisted using forceps or a ventouse. Most hospitals have policies regarding the length of time between the birth of the baby and the birth of the placenta. These vary from hospital to hospital, but failing to meet the deadline will often result in the placenta being manually removed.

The concept of managing women’s labours to follow a partogram relies on the premise that it is even possible to assess the progress of labour. I challenge the notion that it is possible to identify where stages of labour start or end, or to accurately predict the future progress of a labour. Physical changes in the cervix and uterus occur during pregnancy and the onset of labour is a gradual happening [15]. Therefore, identifying an exact time of labour onset is not possible. The definition of ‘established labour’ includes regular rhythmic contractions occurring at least three every 10 minutes, lasting for 45 seconds and accompanied by progressive dilatation of the cervix [16,2]. However, women’s contraction patterns are as unique as their bodies. At home births I have observed women have infrequent, irregular contractions throughout their entire labour and give birth spontaneously. Therefore, contraction pattern is not necessarily a good indication of how a cervix is dilating.

Assessing the progression of the ‘first stage of labour’ also relies on knowing what the cervix is doing. Some hospitals no longer have a policy of routine vaginal examinations in labour, perhaps reflecting concerns about the practice [17]. Even when vaginal examination remains an element of routine management, the timing of assessments is usually four-hourly. A vaginal examination only reveals what the cervix is doing at the time of the examination. It cannot provide information about what the cervix was doing before, or what it will do in the future. For example, a woman’s cervix may be only 3cm dilated but she could birth her baby within an hour of this assessment. Another woman’s cervix may be 9cm dilated but her baby may not be born for another 6 hours. Using a vaginal examination to determine the start of the second stage is also inaccurate. If a midwife examines a woman at 3pm and finds that her cervix is fully dilated, does that mean her second stage started at 3pm? What if her cervix had been fully dilated at 2pm but the midwife didn’t know? There is only one accurate time recording that can be made during labour – the end of the second stage because the baby is born. Although a time can be recorded for the birth of the placenta, the third stage ends with ‘control of bleeding’, which is open to interpretation.

Despite the inability to accurately measure the stages of labour, maternity documentation requires this information to be recorded. Partograms, birth summaries and perinatal data forms require midwives to record the hours and minutes a woman spends in each stage of labour. The result is creative documentation and some interesting conversations between midwives. Such as: ‘What time would you say second stage started?’ ‘Umm not sure – she was making grunty noises around 5.30pm…’ ‘OK, I’ll put 6pm.’ And between midwives and women: ‘What time would you say your labour established?’ ‘I don’t know the contractions were really hurting by 7am then I came into hospital.’ ‘Hmmm well you had your baby at 9am, so you must have been doing something before 7am… I’ll put 6am.’ Midwives also manipulate the paperwork to fit policies, protect women, and avoid getting into trouble. For example, recording the cervix as being 9cm dilated rather than fully dilated to buy more time for the woman. Or ignoring an hour’s worth of spontaneous pushing before recording the start of the second stage. These strategies allow midwives to complete the required paperwork whilst protecting the woman from unnecessary interventions.

However, these strategies also support and maintain the structures that impose time limits. These fabricated times are recorded in standard maternity documentation and then sent to organisations that collect and analyse the data to provide information about labour and birth. By manipulating records midwives are helping maintain the myth that labour has distinct stages which can be measured accurately. Perhaps more importantly, though, they are re-defining women’s birth experiences, often in contrast to the woman’s own experience. For example, recording the length of a labour only from the onset of ‘established labour’ disregards the hours or days that a woman may have experienced contractions before being considered to be in established labour. Abandoning the concept of stages and the notion of accurate assessment may improve outcomes and reflect women’s experience of birth more honestly. However, individual midwives may find it difficult to practice against the cultural norm. Midwives who practice openly and autonomously within a medicalised system often experience ridicule and bullying [18,19]. Therefore it is not surprising that most midwives continue to bend the rules rather than break them.

There appears to be no simple solution to this situation. The concept of stages of labour, and assessment of progress is deeply embedded in our birth culture and practice. Perhaps change could begin with an open dialogue between women, midwives, obstetricians and policy makers regarding a move to a more evidence based approach to childbirth.
Individual midwives can also make a difference, and should support each other to do so. The content of parent education sessions can be changed to focus on what Downe and McCourt refer to as ‘unique normality’ [20] rather than descriptions of the stages of labour. Midwives can share the evidence with each other and midwifery students, and highlight the failures of the current situation rather than sustaining acceptance.
If enough midwives write ‘not applicable’ on paperwork rather than making up a time, there will be evidence that the documentation needs to change. Experience of observing non-augmented labours will assist midwives to develop their understanding of normal birth, and their ability to identify a truly obstructed labour. These changes may be challenging but the result could be a better approach that respects women’s uniqueness and embraces the unpredictable nature of birth.

Research update

Since the publication of this article another Cochrane Review on the use of partograms in normal labour was published (2013), concluding that: ‘On the basis of the findings of this review, we cannot recommend routine use of the partogram as part of standard labour management and care.’ However, it goes on to state that: “Given the fact that the partogram is currently in widespread use and generally accepted, it appears reasonable, until stronger evidence is available, that partogram use should be locally determined.” So once again, an intervention implemented without evidence requires ‘strong’ evidence before it is removed.

References

1. Donnison, J 1988, Midwives and medical men: a history of the struggle for the control of childbirth, 2nd ed, Historical Publications, London.

2. Stables, D & Rankin, J (eds) 2010 Physiology in Childbearing: with anatomy and related biosciences, 3rd ed, Bailliére Tindall: Elsevier, London.

3. Friedman EA 1955, Primigravid labor: a graphicostatistical analysis, Obstetrics and Gynecology, vol. 6, no. 6, pp.567-89.

4. Philpott RH & Castle WM 1972, ‘Cervicographs in the management of labour in primigravidae. II. The action line and treatment of abnormal labour’, Journal of Obstetrics and Gynaecology of the British Commonwealth, vol. 79, pp. 592-8

5. Albers, LL 1999, ‘The duration of labor in healthy women’, Journal of Perinatology, vol. 19, no. 2, pp.114-9.

6. Cesario, SK 2004, ‘Reevaluation of Friedman’s labor curve: a pilot study’, JOGNN, vol. 33, pp. 713-22.

7. Lavender T, Alfirevic Z & Walkinshaw S 2006, ‘Effect of different partogram action lines on birth outcomes: a randomized controlled trial’, Obstetrics & Gynecology, vol. 108, no. 2, pp. 295-302.

8. Neal JL, Lowe NK, Ahijevych KL, Patrick TE, Cabbage LA & Corwin EJ 2010 ‘”Active labour” duration and dilation rates amongst low-risk http:\\/\\/rippleeffectyoga.co.ukiparous women with spontaneous labor onset: a systematic review’, Journal of Midwifery and Womens Health, vol. 55, no. 4, pp. 308-318.

9. Zhang J,Troendle, JF &Yancey, MK 2002,‘Reassessing the labor curve in http:\\/\\/rippleeffectyoga.co.ukiparous women’, American Journal of Obstetrics and Gynecology, vol. 187, no. 4, pp. 824-8.

10. Lavender T, Hart, A & Smyth, RMD 2008, ‘Effect of partogram use: outcomes for women in spontaneous labour at term (review)’, Cochrane Database of Systematic Reviews, Issue 4, Art No. CD005461. DOI: 10.1002/14651858.CD005461.pub2.

11. Dorlea, C & AbouZahr, C 2003, Global burden of obstructed labour in the year 2000, Evidence and Information for Policy, World Health Organisation, Geneva

12. Smyth RMD, Alldred SK, & Markham C 2007, ‘Amniotomy for shortening spontaneous labour’, Cochrane Database of Systematic Reviews, Issue 4. Ar t. No.: CD006167. DOI: 10.1002/14651858.CD006167.pub2.

13. NICE 2008, Induction of Labour, National Institute of Clinical Excellence, London.

14.Martin C 2009,‘Effects ofValsalva manoeuvre on maternal and fetal wellbeing’, British Journal of Midwifery, vol. 17, no. 5, pp. 279-85.

15. Coad, J & Dunstall, D 2005, Anatomy and physiology for midwives, Mosby, London.

16. Fraser DM, Cooper, MA 2008, Survival Guide to Midwifery, Churchill Livingstone, London

17. NICE 2007, Intrapartum Care: care of healthy women and their babies during childbirth. National Institute of Clinical Excellence, London.

18. Bluff, R & Holloway, I 2008, ‘The efficacy of midwifery role models’, Midwifery, vol. 24, pp. 301-9.

19. Stewart, M 2001, ‘Whose evidence counts? An exploration of health professionals’ perceptions of evidence-based practice, focusing on the maternity services’, Midwifery, vol. 17, pp. 279-88.

20. Downe, S & McCourt, C 2008, ‘From being to becoming: reconstructing childbirth knowledge’, in S Downe (ed), Normal Childbirth: evidence and debate, 2nd ed, Churchill Livingston, London