Childbirth: Risks and reality
I have no doubt some mums-to-be will be unnerved by research which suggests that giving birth out of office hours is more risky than during the day. According to a study of more than a million Scottish births, babies born at night or at the weekend have a small additional risk of dying.
The deaths happened among otherwise healthy babies who were starved of oxygen because of some major complication during labour or delivery. It's worth stressing such deaths are unusual - about four in every 10,000 births. Across the UK as a whole, the additional level of risk would be equivalent to about 50-100 infant deaths per year.
The researchers did not have information on the exact care being provided so had to speculate as to why it's safer to give birth Monday to Friday between 9am-5pm. There will inevitably be more specialist staff on duty during weekdays. The researchers suggest that improved access to operating theatres, senior clinicians and higher levels of staffing round the clock could save lives.
It's worth setting such risks in context. The past 30 years has seen a steady decline in mortality rates both at birth and in the first year of life. For example, between 1980 and 2008, neonatal mortality in England and Wales fell by 58%.
There should be no room for complacency. A study earlier this year in the Lancet suggested that although maternal mortality in the UK remains low - 8.2 deaths per 100,000 live births - it is significantly higher than countries like Italy, Australia and Sweden.
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I can testify to this being the case. It is very deeply perturbing in a developed country.
My own first-hand experience being; my sister was told to come into hospital because she was 13 days overdue. Subsequently, she was admitted to hospital on the Friday afternoon, monitored etc, drugs were administered to "induce" the birth.
Contractions started, but as other expecting mothers had also been admitted, they were "prioritised" as they were "natural births" and went into labour without help.
The remainder of the treatments were not administered, and after spending the weekend in hospital was told that the induction had failed.
It couldn't have failed as it was not carried out fully.
On the Monday she was presented with a fáit accompli, and told that she would have to have a C-section.
In my opinion the "duty-of-care" principle was completely ignored, and instead of getting more staff in to deal with the situation or sending my sister home without instigating a treatment, knowing that they actually did not have the staff to carry out the procedure, she was put through unnecessary pain and distress only then to be given no choice as to how to give birth.
This is a digusting way to treat patients and must stop, it doesn't surprise though that this sort of thing is now coming out.
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In 2007, I nearly lost my daughter at birth to hypoxia during an after-hours (8:00 pm) induced birth. I credit the quick thinking of the medical staff with saving Lily's life. This includes the midwife who raised the alarm, and the specialist team who arrives mere seconds later.
After reading this report, I wonder whether, if I hadn't given birth at one of the best maternity hospitals in the country, the outcome might have been much more tragic.
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Refer to post #01 - this sound terribly familiar? AND appreciate your trauma.
Our sister had an horrendous labour from 7am on Thursday and only delivered after emergency medical intervention (due to fetal distress and declining heartbeat) at 9pm on the Friday because she was afraid of spinal anaesthestic that was 'pushed' in the 1980s. She watched 17 women on her ward come and go for all that time - not a doctor in sight, or on site.
It seems clear that maternity services in UK have not improved since the 1980s and still rely on midwives during labour and delivery?
In a so-called developed country - it is unacceptable that during gestation women are monitored and examined by doctors/consultants with a battery of tests etc., - yet at an equally, if not more dangerous time for the mother and baby - doctors are: not present, not available and simply not there!!!
Obstetricians must be brought into the whole scheme of delivery wards immediately, and be on-call too. Midwifery, I'm sorry, is NOT up the job of safe delivery of babies and care of mothers during that process?
I would suggest that the NHS have a deep-rooted disregard of the dangers of childbirth and the unborn child AND use 'unsupported midwives' as a 'cost-effective' alternative to 'expensive medical care' to the most vulnerable?
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Referring to Corum-populo above, it strikes me that this comment is based on ignorance rather than evidence, and sweeping statements are made that undermine not only childbirth in general, but midwifery also.
Midwives are trained to be the lead practitioners for women requiring low risk maternity care, and the outcomes for women are better when they are cared for by midwives providing childbirth is following its normal course. Childbirth is normal, and natural. That is not to say that medicine does not have its place, and that doctors are not essential in high risk maternity services. Maternity services are over stretched whoever the lead practitioner is, be that a doctor or midwife. However, the statement "I'm sorry, [midwifery] is NOT up the job of safe delivery of babies and care of mothers during that process?" is absolutely absurd, and maybe this reader should appreciate the differences between low and high risk maternity care, and also that midwives play a crucial role in the care of women requiring high risk care. A good midwife knows when to call for a doctor, and a good doctor will leave a trained midwife to do her job if she or he is not needed for any medical problems. A core component of training to be a midwife is knowing if something is abnormal. If it is - refer to another agency. If it isn't - midwives are autonomous and are capable of carrying out full antenatal, labour and postnatal care. Sounds like the reader is stuck in a medicalised birth mindset, and needs to read the evidence.
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Appreciate your response 'bluesky303' regarding my post. I am not a midwife, but am a medical professional who has relayed an experience of a relative left too long by midwives. Re-read, especially last para?
Furthermore, childbirth may be natural and normal, but is never 'low risk' - and it is 'unhealthy' for any midwife, as a professional, to assume, or regard themselves as autonomous. Teamwork is the key between ALL professionals caring for a woman during pregnancy, and that duty of care should CONTINUE in equal measure during labour and delivery?
You say "a good midwife knows when to call a doctor". On that, one can only hope that we have enough 'good' midwives to call an obstetrician - or that the Midwifery Council demand their presence or on-call availability? This does not undermine the ability of midwives, but simply acknowledges the teamwork required as already stated.
Kind regards.
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While regrettable, I don't necessarily find the information presented in this blog post to be unsurprising. Studies have repeatedly shown that the number of medical interventions performed during night time/weekend hours increases--particularly in the late afternoon and evening hours. The implication: get babies delivered so birth attendants can be home in time for dinner. The issue the general public doesn't seem to understand (which I write about frequently on my own blog) is that the interventions associated with speeding up a baby's birth also present increased risk--such as the 40% increased chance of ending up delivering via c-section following medical induction of labor. (Why? Because many women being induced aren't ready to go into labor--therefore the body does not respond to the medical attempts to force labor and after trying various methods to push her body along--including breaking the protective bag of waters--there becomes no choice BUT to perform a cesarean.)
Impatience is rarely a good thing--especially when it comes to labor and delivery. And, quite frankly in most cases, midwives tend to be much more patient during the labor and birth process--allowing a normal birth to progress as it will in its own time.
(And, yes, midwives ARE trained to refer out when trouble arises or, better yet, route high risk or questionable-risk pregnant women to obstetricians WELL BEFORE she even comes close to full term. This is the essence of both team work and preventative medicine.)
~ Kimmelin Hull, PA, LCCE
Pregnancy to Parenthood, LLC
Belmont, CA, USA
http://kimmelin.wordpress.com
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Happy to hear from an American on this issue. Our sister was not induced, did have her 'waters broken' as described to her with the infamous 'hook' that accelerated her pain, her contractions for a further 7 hours, also exposing the baby to infection - yet no C-section offered, or even suggested. Reiterate - no obs doctors on site - this delivery was in Cambridge.
It was discovered later that her baby's head and shoulders were too large for her birth canal. For that reason alone ALL professionals, especially midwives, must liase to ensure the mother's physical anatomy and the fetal size is taken into consideration during the third trimester?
My sister believes that her records were either not available, not read or even considered by the midwives - over several shifts - even when she had a high ketone levels and was refused pain relief and IV glucose to maintain her ability to aid delivery of her oxygen deprived infant?
I would refer ALL professionals in the UK involved in pregnancy and childbirth to look again at the Royal College of Obstetricians and Gyna - RCOG in the UK and insist that the Midwifery Council be amalgamated - it's just not good enough right now - any 'normal gestation' infant death on delivery in the UK is totally unacceptable AND avoidable?
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Re Corum-populo's post above, it's very important to examine the problem and evidence before recommending knee-jerk 'solutions' (e.g. more doctors as primary birth attendants) which may not have the desired effect (reducing negative birth outcomes).
The literature does not suggest that having midwives as primary attendants at births increases the risks to babies or mothers. It does however show that positive outcomes are associated with 1:1 midwife care throughout the labour and birth process. This is something which is sadly lacking on the NHS, where there are simply not enough midwives to go round.
Diverting doctors away from where their particular expertise is needed (at high-risk, complicated or surgical deliveries, and available on call for emergencies) to normal births where they would just be performing tasks that a midwife could do equally well, could even have the reverse effect of increasing adverse birth outcomes.
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Has anyone looked at similar stats for other medical specialties? I would think that the out of hours risk is higher whatever ward you've been admitted to.
Also not mentioned is the fact that there is/was a big push (no pun intended) for vaginal births, hospitals are expected to meet targets limiting sections. Mothers too feel under pressure to have a "perfect" birth, according to their carefully written birth plan, and want as little medical intervention as possible. Increasingly many are choosing to give birth at "birth centres", or at home, with no doctor on site.
I had my first (low risk) baby in a South London hospital most people would probably shun for a bigger, flasher, more central foundation trust. I got into difficulties very quickly, midwife called a junior doctor, who called the senior doctor, and off I went to theatre for a section within 10 minutes. As it happens this was at 9.30 on a weekday morning, but I don't think it would have been different at any other hour.
The problem is the pervasive one within the NHS in general, not enough staff, not enough recruitment, not enough money filtering down past management to the ground floor level. On the Post natal ward I was on, fully staffed meant 4 midwives to a 32 bed ward.
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Stand by ALL my posts thus far which are neither 'knee jerk', similar or otherwise.
Plus, am very disappointed at 'clips' of critiques, thus far, from midwifery journals.
This not only supports the increasing 'professional' distance between midwives and the patient within the NHS?
Yes, women in labour and childbirth ARE patients, yet do not receive the same rights and duty of care of other patients within the NHS?
These women are not another 'client' or 'lady' to be tolerated, just because 'they are only having a baby'? A women having any other treatment in the NHS has more rights and more considerate and empathetic care?
Reiterate - go to RCOG website and learn something new outside of your inward looking journals. Our family suspect that some midwives are getting rather big for their boots, or taking on caseloads they can't and won't admit they can't handle? There is nothing safe or professional about that is there?
So, who suffers in the above professional 'evidenced-based' journal scenarios - mother and infant - is anyone getting the point yet?
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I'm familiar with RCOG and don't think that their views or public statements can be interpreted in the way you imply.
They support consultant (rather than junior doctor) backup on hand in hospitals during labour and recognise "the central role of midwives as autonomous practitioners of normal labour and birth, together with their role as partners with obstetricians, anaesthetists and paediatricians, in the care of women with complex and complicated labours".
Exactly which papers / press releases on their website are you thinking of?
Re-reading your original post, it's clear that your family have had a traumatic experience and this is the major influence on your assertions here. I wish your sister a speedy recovery.
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I'd just like to present my experiences which show the opposite... I have had two "low-risk" pregnancies, and apart from the usual 12-wk and 20-wk scans, I only had contact with midwives. I planned homebirths for both of my children; both labours began spontaneously, and both children were successfully delivered at home at weekends (one Saturday 3.30pm and one on Sunday at 12.50pm). Two midwives attended for each birth - albeit midwives I had never seen before - and I was reassured that an ambulance would be 10 minutes away and would take me to the nearest hospital (20 mins away), should any unforseen problems occur. I had full confidence in the midwives' ability to handle the situation (and refer me if required) and indeed both labours were straightforward. For me, the fact that it was "out-of-hours" made no difference at all. I would agree with a previous person that the problem isn't necessarily the ability of the midwife, it is the lack of midwives in the NHS which inevitabily increases their case loads. My 1:1 care was excellent and I am sure this contributed to my straightforward deliveries.
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Thank you for your response 'Togarama' post #11.
"No assertions" as you describe, have been made by me. If you had read my original post, as you say, you would know that my sister's experience of labour and childbirth was in the early 1980s? Her trauma was such, that she never had another child.
Nevertheless, the whole point of my posts on this issue, was our family's shock at the, still unacceptable shortages of staff and little improved outcomes for mothers and infants of normal gestation in the UK in 2010.
As for your question regarding the RCOG - Dr Mahmood's contribution is the point of reference regarding 'availability' of 1:1 care of midwives AND obstetricians on the labour ward in the NHS in the 21st century.
Kind regards.
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Corum-populo-2010
Apologies for misunderstanding the time you were referring to in your original post. The phrasing is actually open to misinterpretation: "Our sister had an horrendous labour from 7am on Thursday etc...because she was afraid of spinal anaesthestic that was 'pushed' in the 1980s." To me this meant that your sister gave birth on the most recent Thursday and that she was afraid of the spinal anaesthetic because it was a type which was commonly used over 20 years ago. An easy mistake to make.
You have made a number of assertions on this board including the following:
1. Obstetricians must be brought into the whole scheme of delivery wards immediately, and be on-call too [NB They already are involved. The problem is that the NHS does not require ob consultant presence on site out of hours. This means that junior doctors have to act as medical backup for births at these times.]
2. Midwifery is NOT up the job of safe delivery of babies and care of mothers during that process
3. The NHS have a deep-rooted disregard of the dangers of childbirth and the unborn child AND use 'unsupported midwives' as a 'cost-effective' alternative to 'expensive medical care' to the most vulnerable
4. Childbirth may be natural and normal, but is never 'low risk'
I assume you're referring to Dr Mahmood's response to the recent BMJ article? This has some relevance to the first point quoted above, taken in the context of my bracketed note.
The others appear to be your own opinion, not RCOG-supported, and based mainly on one unfortunate personal case. If you're going to make radical and sweeping statements, you should back them up with evidence.
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Well done and thank you 'togarama' post #14 on 18 July on an own goal.
Your post, with our comments, selectively, taken out of context, tell our family and friends, ALL we need to know about what, and who, your post represents?
Kind regards.
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This is not the first study to identify greater birth risks outside normal working hours, and is further evidence of the potential risks of planning a vaginal delivery (particularly in an NHS hospital with staffing issues). In fact, at any time of day in some overstretched wards, there can be increased risks due to insufficient maternity staff levels.
Some of the posts above talk about birth being natural and normal, but it is worth remembering that death (albeit rare) and many birth injuries are natural and normal too. Because of this, many women, myself included, are not comfortable with the unpredictability of a trial of labor, and particularly the risk of assisted vaginal or emergency cesarean delivery.
I decided to schedule a planned cesarean delivery for both of my births, and they took place during normal hospital working hours. And while my reasons for this decision were many, it is true to say that included amongst them was my desire to know exactly who would be delivering our babies (my trusted OBGYN or her practice partner), and when.
People can sometimes be quick to criticize women who schedule a cesarean delivery for ‘convenience’, but the convenience of scheduling a date and time is an entirely secondary benefit to the genuine belief that a cesarean is the optimal birth plan for our baby’s (and our own) safety.
Pauline McDonagh Hull
Editor, electivecesarean.com
Blog, cesareandebate.blogspot.com
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What a refreshing change post #16 on 1:20pm on 18 July. 'Pauline McDonagh Hull'. Thank you so much, we have just breathed out.
Our family are feeling rather battered right now by a few posts focused on our experience (and getting it wrong); and intent on taking selective slivers of all our posts defending a 'model' of childbirth within the NHS that continues to fail all expectant 'mothers to be' during childbirth and their infants?
Any critique, or criticism, should never be taken personally if you are a professional.
In fact, we should be happy to celebrate those mothers at 'normal gestation' in the NHS who HAVE delivered safely - AS they are the most ignored during third trimester, during labour/and childbirth?
All pregnant womens anatomy should be considered with the size of the infant due. Why is so much money spent on scans - yet no consideration on the pregnant female ability to deliver vaginally? This issue alone exposes the lack of inter-action between professionals on the health and safety of maternity services et al in the NHS?
Furthermore, we know that our sister would have had another child if she knew she could have access to a C-section for another pregnancy
Labour, childbirth IS very personal indeed for those affected and feel vulnerable under the current NHS system approach to women during childbirth in the 21st century.
Have looked at your site and links too. Which are to be congratulated and may be helpful for women who have undergone traumatic and unsupported first time labour and delivery via the NHS without due care, can be assured they can enjoy a second pregnancy knowing that trauma will not be repeated?
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Corum-populo-2010
Please don't take my comments as a personal attack. They are intended to politely highlight and correct inaccurate, unsupported statements which you have made on a public board.
Incidentally, I don't represent any group or ideology, as you seem to be insinuating. I'm not even defending the current NHS model of childbirth.
I'm from a scientific academic background with professional experience in public policy. I would like to see evidence-based improvements made to NHS birth provision as well as increased public awareness and accurate understanding of risks around pregnancy and childbirth. I have no agenda on here beyond questioning misleading information and claims.
"All pregnant womens anatomy should be considered with the size of the infant due." Well, in principal yes, but there is no scan which will give a sufficently accurate gauge of infant vs maternal size to be of use across the whole population of pregnant women. Nor is size the only consideration in a woman's ability to give birth vaginally.
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I gave birth to my fourth child in September 2008. I will never forget the experience. I went to hospital at 05:00am and gave birth at 09:45. during that time,I was being berated by my midwife for acting like a first time mother. I had my gas snatched from me while a contraction was coming with comments like,"you just want to get high, give me that and get on with it".
During the course of my labour, I was told by her that the baby's heart kept going down, I needed to push etc. However, not at one given point did I see an Obstretician being called. I kept trying to explain to her that this labour felt different. I had given birth to my previous 3 children only using gas and air. She would have none of it. Towards the end, I had trouble pushing and then there was a huge commotion as the midwife ran out, collected other midwives and literally pulled the baby out, in the process giving me a 3rd degree tear.
There were huge cries of "it's a big baby" but no one bothered to explain to me that the baby had suffered shoulder dystocia until I learned of it 8 days later when I had to attend A&E for my daughter who had formed a subcutaneous fat necrosis due to the trauma during birth. With shoulder dystocia, there is only a window of 4 minutes during which the baby must be born other wise it could be fatal. When I learned of this information later, I was able to work out why there was such a huge commotion at the end of my labour.
When I complained about the treatment, I was informed that the midwife would be sent for Customer Service training. I was told that the baby had not suffered any heartbeat problems according to the notes. This leads to two conclusions; either the midwife was lying to me,or the hospital is lying to me to. Either way, I have a paranoia and fear of midwives and maternity units now.
If the midwife had listened to me and sought the advice of a doctor, things may have turned out differently. I may have asked for a cesarean rather then have a tear that is still giving me problems. At the end of the day, a woman knows her body best and can sense when something is wrong. Until our maternity wards employ home grown midwives, we will forever have these problems to contend with.
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togarama post # 18.
Indeed your comments are deeply personal and offensive due to your persistence on only our posts?
From someone with a scientific academic background on public policy? Perhaps your time would be better spent on not tracking our family's ACTUAL experience and distress, but more on the reality of what purports to be NHS maternity 'care' in 2010?
Would suggest you read the abstract on the bmj website. Furthermore, refer you to the charity Sands website and their concerns and experience on latest findings as reported by BBC health correspondent? Perhaps that will give you something better to do to improve maternity services?
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I have had 2 children at my local NHS hospital - on in hours and one out of hours. Despite issues with my community midwife that I wont go into here both times I have recieved excellent care while in labour - my eldest daughter now 4 arrived 3 weeks early. My labour started about 7.30 on a hot Saturday evening, went to hospital about 3 and a half hours later. The midwife looking after me examined me shortly after we arrived to discover I had an undiagnosed breech baby and I had an emergency caeserian just after midnight. THe midwife was excellent, stayed with me the whole time through and supported my very nervous husband! The fact she remained calm but got the necessary experitese quickly was much appreciated! My second child (now 21 months) was born in the same hospital as a VBAC birth - due to the "high risk" nature of the labour (previous section) I had the most senior midwife and an assistant there (also due to a large baby as I'd had gestational diabetes). She was born without pain relief (although not through choice) less that 2 hours after I got there - and apparently I had walked past the duty consultant on my way in who said that I wasn't in labour!
Unfortunately not everyone will have good experiences of any medical process as human beings are involved, whether this is having a baby, getting a filling at the dentist or even visiting a GP - we are all human and while as a health care professional myself we try not to inflict our beliefs on our patients it is not always possible salthough unintentional. Any medical procedure is safer "in hours" - at nights and the weekends there are generally less staff, especially less senior staff and unless we in the UK are prepared to pay much higher taxes this will always be the case (as well as train twice as many healthcare professionals than there are already)
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corum-populo-2010
Let us be very clear, I have made no personal comment about you or your family, only the factual accuracy and evidence basis of your broader assertions on this board.
My comments relate largely to your posts since the others appear to be either genuinely evidence-based, opinion pieces which don't claim to be something more, or pure accounts of personal experience. They do not make the same kind of misleading claims which someone unfamiliar with the subject could accidentally take as fact when reading this page in the future.
You, in contrast, have made several offensive personal comments (e.g. implying that those who question you are informed only by "inward-looking journals", insinuating that I represent some shady unspecified group or ideology, accusing me of somehow targeting your family because I have asked you to justify statements such as "midwifery is not up the job of safe delivery of babies and care of mothers" etc..). These kind of personal remarks are simply not worth my responding to in any depth and do not add anything to the discussion on this blog.
I suggest that you re-read everything you keep referencing. Your sources are sounder than most of the conclusions and recommendations you have posted here.
Finally, in the interests of allowing others to continue the discussion without distraction, I also suggest that you and I now stop posting on this particular topic.
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Togarama
In the interests of everyone - let me be very clear on your last post? I would politely request you withdraw the word 'shady' (your word) that you incorrectly imply and purport that I have insinuated?
The word 'shady' may have crossed your mind, but certainly not mine.
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I think sometimes it's the calibre of the professionals that you meet, the circumstances and situations in a the hospital however I think the article rings true. I 've had 2 children. 1st born on a weekend, fetal distress, during the labour, the midwife and both junior dr who attended kept falsely reassuring me but leaving soon after instead of staying and checking out the baby's heart reading which was being monitored by the machine. unfortunately during contractions, there was loss of contact with the baby and even though there was the sound of the heartbeat dropping, no attention was taken to attach the machine properly. baby then was born very distressed, anaesthetist, neonatal registrar were on other emergency calls and could not attend. sadly my baby has cerebral palsy as a result. There are real people suffering due to these hospital policies and staffing issues. In contrast my 2nd baby was born on a weekday but during the night and in another hospital and I had very good care. The midwife stayed with me from 1000pm till 0643am when the baby was born.
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A brief summary of my own experiences: 1st child was an undiagnosed breech and only picked up by the midwife who examined me when I arrived at hospital. An emergency section followed as the second stage of labour started. Not a pleasant experience and very disappointing for me.
Second child 4 years later - same hospital. I asked to be scanned so we knew whether the baby was head down or not - he was. The O&G SPR (Specialist Registrar) apparently wrote in my notes that I 'wasn't in labour'. Advised to go for a walk etc. Decided to stay put since my last labour had progressed without me being that aware of it.
Baby was born about 1 1/2 hours after I arrived at hospital and my second stage of labour (the pushing bit) lasted 6 mins.
My own feelings are: corum-populo-2010 - doctors are not always right! Even those who are relatively senior. To put all your faith in Doctors in these circumstances, I feel, would be a mistake. Sadly things don't always go to plan and I was gutted that I didn't have the birth I had wanted first time round. Second time round it was a doddle when compared to the first. A section is not a easy option and not something to be untaken lightly IMHO.
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corum-populo-2010 - just reread some of your postings and this para stood out "I would suggest that the NHS have a deep-rooted disregard of the dangers of childbirth and the unborn child AND use 'unsupported midwives' as a 'cost-effective' alternative to 'expensive medical care' to the most vulnerable?"
It would not be cost effective to the NHS to do what you describe because the legal bills would be enormous! If women were left routinely with very substandard care the infant mortality rate would soar and the costs of compensating those damaged would be huge, would it not??
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This comment was removed because the moderators found it broke the House Rules.
Having had a baby four months ago in a very well regarded hospital, I can say that maternity provisions fall somewhat short making the entire experience hectic and traumatic. Many women including myself were kept crammed in a ward for long periods past the time they should have been taken to the delivery unit simply because there were not enough delivery rooms available. There was also a considerable time to wait for an emergency c-section. The midwives were great although the consultants got my notes confused with another patient. Following a c-section I was sent home the next day! It seems maternity care is understaffed and underaccomodated. Given the risks, effort and pain involved in birth I should have thought mothers would have been better provided for.
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I was induced on christmas eve and had our lovely daughter at 7:30am on Christmas day 2008. There were loads of staff packed into the compact delivery room when I opened my eyes following the pushing stage, from the trainee midwife and midwives through to the registrar. I cannot fault the staffing level. The hospital Christmas dinner was another matter though!
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