Introduction:

Have you ever been swimming?

Years ago, when I was an English teacher, teaching working adults or students business, technical or academic English, I was sometimes able to slip away for an exotic holiday. (Things have changed a lot since then.) Once, while I was based in Singapore I spent an idyllic week on the tropical island that was used to film South Pacific. (You know, that one with the song ‘I’m gonna wash that man right out of my hair.’) And while I was there, I met a sailor… Say no more.

Actually, I am going to say quite a lot more, as you’ve probably gathered from the thickness of this book. (Hope you’ve got a cup of tea by your side.) This American sailor was extremely interesting to talk to, mainly because he was an ex-Marine, about halfway through sailing round the world and very knowledgeable on all kinds of relevant maritime topics.

In an email conversation with an obstetrician the other day, I suddenly remembered this man, for some strange reason. I was reminded of a story I heard, even further back into my long, complicated past. It was the tale of a teenager who got taken on as crew on a large ocean liner. He soon became friends with the Captain, who would regale the lad for literally hours with all kinds of maritime tales and fascinating trivia. (A bit like the ex-Marine and me, really.) Often, the Captain—being rather an arrogant man—would gently mock the boy and ask him, “Don’t you know anything at all about astronomy?” or “Haven’t you ever studied marine biology?” or even “Can’t you even explain the word oceanography?” Tedious as it was, since these two characters were out at sea, the situation continued for some time and I suppose both enjoyed these long conversations for different reasons. The teenager drank up information about all kinds of new subjects (which seemed much more interesting than school had ever been) and the Captain enjoyed gloating over this ignorant boy. Finally, one day, the boy came running into the Captain’s cabin, gasping for breath, shouting, “Captain! Captain! Have you ever studied swimmology?” Of course, the Captain was merely bemused and barely paid the poor boy any attention. But the lad persisted and eventually, in total exasperation, shouted, “Captain! Captain! Can you swim?” Well, it just so happened that this particular captain couldn’t. (All right! All right! It’s just a story.) So he died. And the stupid, naïve, poorly educated, inexperienced boy swam to the shore and lived on…

In case you haven’t already guessed, this book is about both swimming and swimmology, as it were. You might be able to swim or you might be a swimmologist—I really don’t know. Whatever your experience of birth I hope you find something of interest in these pages. If you’ve never swum in real water (i.e. experienced physiological birth for yourself¹), I hope that your expertise as a swimmologist will not put you off reading about that experience and perhaps thinking about it too. Recent developments in research certainly justify that...²

After all, as you may agree, recent research has confirmed many things that some very ordinary women have been trying to talk about for decades—the endorphins of labour, the emotional postpartum ‘high’, the all-round benefits of giving birth without pain relief. And my own personal research has convinced me that both swimmers and swimmologists need each other, if birth is going to be optimised from both safety and experiential points of view. While birthing women need midwives or other caregivers for the sake of safety, caregivers also need to witness the process of birth (and possibly even experience it for themselves) so they can gain a real insight into the processes and their particular role within them.

In case you’re wondering how I fit in, I’m not really sure if I’m primarily a swimmer or a swimmologist. I certainly started out as a swimmer, flailing around and gasping for breath, then I became a little better at swimming and I finally took up the science of swimmology myself. However, as you probably realise, there are all kinds of swimmologists… Midwives are hardly the same as obstetricians. And obstetricians themselves may also have a completely different perspective to researchers, whose whole focus is on a systematic collection of data. Then there are journalists, partners of women who’ve given birth physiologically, husbands of women who’ve had a traumatic birth, and mothers of mothers, who have their own perspective, based perhaps on an entirely different experience of birth. And what about antenatal teachers, doulas, maternity assistants, anaesthetists, neonatal nurses and paediatricians? GPs fit in there somewhere too, in a very significant position.

Anyway, my reason for beginning and continuing my own studies of swimmology were the numerous conversations I had with other women after giving birth myself. I was disturbed by what I heard, or read in facial expressions or other body language. And comments some women made, or experiences they described, left me upset and puzzled for days or weeks at a time. The first consequence was that I started working on a book, which was eventually published as BIRTH: Countdown to Optimal. (This has now been updated and improved, notes and academic references have been added, and it’s been republished under the title Preparing for a Healthy Birth: Inspiration and Information for Pregnant Women. I hope it’s a book you might find useful for use with women who say they want to ‘do without drugs’ if they can, but who are not entirely confident that they’ll be able to.) After the first book came out I was encouraged to adapt it for midwives and other caregivers… so I did, at great speed, for a conference (six weeks later!) on optimal birth. This book is a much extended version of that original edition, with references added in.

There seemed to be room for yet another book on childbirth because although numerous books about midwifery and obstetrics are available, there doesn’t seem to be one which has a clear focus on ways of supporting women who opt for safest or most humanitarian approaches, according to what most research has indicated so far, and/or who embrace the physiological model of birth perhaps for philosophical or ideological reasons, or simply because of a belief in a healthy body’s ability to grow and birth a baby effectively.

In most books on midwifery and obstetrics somehow, the advice which would be relevant when caring for at least 95% of pregnant women (if they chose a physiological birth) has got lost amongst the advice which relates to the other 5% or less, who are likely to need drugs or interventions from the point of view of safety. The focus on pathology or drug-based ‘pain relief’ (a misnomer, in my view) has meant that fewer and fewer caregivers feel confident about supporting normal labour—although thankfully this is now a major focus of midwifery training in the UK. Needless to say, perhaps, it really is vital that all caregivers know how to support normal labour and birth (following the physiological processes) because women who choose this safest route need and deserve excellent care.³ So this book has been written for midwives and other caregivers who want to consider, or reconsider, best ways of supporting women who want to have a physiological birth, if at all possible.

In the recent past the emphasis on pathology over normality, on medical management instead of watchful waiting, has meant that ‘normal’ almost came to mean ‘abnormal’, because women who were hoping for a straightforward, but safe, physiological labour and birth were being treated as unusual. Unnecessary interventions had become so commonplace in the labour ward and delivery suite that a woman who insisted on having none (unless they were needed for safety) was branded an extremist, even though research was very definitely on her side. Hopefully, this situation has changed radically, thanks to the Royal College of Midwives’ campaign for normal birth (of which ’optimal’ is definitely a subset), and thanks to ongoing inspiration and recommendations which are coming from reports such as Maternity Matters, NICE and local supervisors of midwives—who are potentially a wonderful support for both mothers-to-be and the midwives who care for them.

Nevertheless, in some places there may still be caregivers who are shocked or cynical about requests for a ‘natural birth’. Perhaps there are some very understandable reasons for this. Firstly, they may have come to associate this phrase with unrealistic idealists, whose births are actually not very ‘natural’. Secondly, they may never actually have witnessed a truly ‘normal’ birth, i.e. a physiological one with no complications. (Of course, this is because many women are requesting pain relief, or are consenting to it when it’s offered. And while some caregivers may have witnessed a normal birth—without any anaesthesia or analgesia—they may not have witnessed one which has proceeded in optimal conditions, according to the true physiological processes.) Another reason why certain professionals may react negatively to any request for a ‘natural birth’ is perhaps their worry about things going wrong. Although even the most superficial study of statistics will make it clear that there is always a maternal and fetal mortality rate, the reality of an individual death is horrifying, particularly given the high risk of litigation. In fact, the risk of a criminal investigation might be what puts many caregivers off supporting other women. They may be concerned that their superiors may fail to support them if there are not sufficient records, which will in turn lead to excessive (and probably intrusive or invasive) monitoring. Perhaps it’s time a ‘normal birth’ consent form was introduced, requesting non-disturbance!

Whatever your own views, feelings or experience, the aim of this book is to support you if you want to help improve the safety of the births you facilitate⁴ and if you want to help women actually have the natural or normal births they request. While I have tried to avoid giving patronising advice, I have made some tentative suggestions which are all based on research, feedback and suggestions I’ve received and/or my own experience as a mother who has given birth three times, entirely physiologically. Of course, I have at all times tried to take NICE guidelines into account and typical protocols. In any cases where I suggest changes or extensions to these I hope you will view these in the spirit they were intended—as a springboard for thought, discussion and possibly even action! Most often, I have presented questions to aid reflection.

If, as you embark on reading this book, you doubt the value of supporting physiological birth (perhaps because you have seen so many women request pain relief after all), please suspend your disbelief for as long as it takes you to read the whole book. After all, we have to recognise that while Queen Victoria set in motion a hope for painfree birth in 1853 (when she agreed to try out chloroform for the birth of her eighth child), this hope has not yet become a reality. Even women who have the best of anaesthesia complain of pain beforehand or afterwards, and side effects are unfortunately all too common.⁵ As we all know, but maybe sometimes prefer to forget, the use of any unnecessary drugs or interventions during labour and birth compromises safety. For this reason alone it’s well worth knowing how to make labour and birth as good as possible for women who opt out of this artificial approach, perhaps after reading research evidence or simply because they trust that the natural, physiological processes will be pretty effective, thank you very much! From personal experience and from the extensive research I’ve carried out (over a period of over 12 years now), I’m convinced that the physiological processes are much more effective than we often assume. I’m also sure that they’re worth ‘enduring’ because outcomes really do seem to be better for both mother and baby, not to mention families and the caregivers who provide care.

Before I sign off—in case you’re still wondering who on earth I am—I’ll give you a little more information. After teaching for around 20 years and finally meeting the man who is now my husband, I had three babies. I mention my own experience of birth here and there because I think it’s important to convey how difficult it was to arrange my own ‘optimal’ births. I had to fight long and hard to exercise my right to give birth as I wanted, perhaps because the trend for evidence-based care hadn’t taken hold back then, and perhaps also because Lord Darzi hadn’t yet validated a woman’s right to choose. (Even now, I wonder how much real choice it’s possible to have, for practical, financial and logistical reasons, apart from anything else.) Anyway, when I started writing, since I wasn’t a midwife myself, I wanted to add ’weight’ and authority to my own words, so I also conducted a great deal of research—both academic and personal—and made contact with many professionals, some of whom have joined me on these pages. Comments or accounts from mothers are included so as to provide a window into the world of increased safety and satisfaction… and its alternative, help you gain insight into the processes and stimulate thought and reflection. After all, there are still many practical issues to resolve.

Notes & references

To find abstracts for any studies, go to www.pubmed.com and search using year and key words (e.g. any author’s name and main words in the title). If you work for the NHS or are studying at a UK higher or further education institution, you may well also have access to an Athens username and password, which you can use at zetoc.mimas.ac.uk to check out contents pages of around 20,000 journals. (Of course, this will allow you to check out whether or not any others studies—not mentioned in these notes—follow up on any of the issues discussed or extend the research. By the way, if you notice errors of any kind in the Notes & references here, email info@freshheartpublishing.co.uk. Amendments will be made in future editions. Also, please make contact if there’s anything in this section which you disagree with, or would like to add to.

1 If you’re wondering why I don’t say here that swimming is like giving birth, full stop, i.e. in any situation, it is quite simple… Giving birth with drugs in your system, with EFM and other interventions such as ARM and forceps, would be the equivalent to being ‘swum’ across the English Channel under sedation, in a harness, pulled along by someone else in a boat. We’re talking here about active and aware swimming—the only kind of swimming, I would suggest, which will really give you an insight into what birth can be like. If you’ve only been ‘swum’ how can you understand real swimming? How can you know how to make it as good as possible?

2 There are no references here as I provide plenty—with commentary—later, as topics come up. You are probably familiar with the research which generally shows that ‘natural’ is generally better, in terms of safety, than any kind of unnecessarily managed approach. If you haven’t done so already, see:

· The book co-authored by seven researchers (Enkin, et al) Guide to Effective Care in Pregnancy and Childbirth. Oxford University Press, 2000 and the Cochrane database at www.cochrane.org

· Enkin’s book, written with another eminent researcher Jadad: Randomised Control Trials: Questions, Answers and Musings. Blackwell, 2007

· The book edited by professor of midwifery and director of a research group, Soo Downe: Normal Childbirth: Evidence and Debate. Churchill Livingstone, 2004

· Denis Walsh’s discursive overview of evidence which points us back to physiological labour and birth as best ‘first’ options: Evidence-based Care for Normal Labour and Birth. Routledge, 2007

· The book written and researched by former WHO director Marsden Wagner: Born in the USA: How a broken maternity system must be fixed to put women and children first. University of California Press, 2006

· The book written by Jennifer Block, former journalist and co-editor of the revised classic Our Bodies Ourselves: Pushed. Da Capo Lifelong, 2008

Beyond this, it’s interesting to observe that as studies are increasingly published, initial conclusions about the superiority of ‘natural’ approaches are being confirmed.

To take breastfeeding as an example, if you read any book on the topic, the advantages will be well documented, for both mothers and babies. Nevertheless, newer studies are still revealing still more advantages. For example, the following study found that breastfeeding decreases a baby’s chance of getting rheumatoid arthritis later on in life:

· Pikwer M, Bergström U, Nilsson JA, Jacobsson L, Berglund G, Turesson C. Breast feeding, but not use of oral contraceptives, is associated with a reduced risk of rheumatoid arthritis. Annals of the Rheumatic Diseases, 2009 Apr;68(4):526-30. Epub 2008 May 13

3 If you don’t believe you really can be a woman’s advocate, whatever her choices, read the Darzi report at the following URL: www.healthcareforlondon.nhs.uk/a-framework-for-action-2/. If you have no direct, first-hand experience of birth, this book is intended to help, using of narrative accounts and reflective questions.

4 If you are an experienced midwife, or even if you’re a student, I’m sure you’ll have your own views on how best to support and facilitate physiological labour. Nevertheless, there may be factors you haven’t considered or behaviours or procedures you often engage in, which you consider innocuous, which are actually very disturbing for the labouring and birthing woman. In my own pregnancies, labours and births I was aware of a great range of midwifery approaches and I have since read about many more variations. I have also been alarmed by many accounts I’ve received from new mothers. For these reasons, I would like to ask you to be open-minded about how physiological labour is best facilitated. Even though he’s a man, who you might say cannot possibility understand birth as a woman does, Michel Odent has considered this issue in depth and after attending over 15,000 births, he has drawn certain conclusions. In the following article, he outlines what he considers to be important in terms of facilitating the natural processes:

· Odent M. New reasons and new ways to study birth physiology. International Journal of Gynecology & Obstetrics 2001, 75:S39-S45

(He expands further on these ideas in his book Birth & Breastfeeding.)

In case you feel wary of facilitating the physiological processes of labour and birth without pain relief you may be reassured to note (in case it’s a surprise) that not all women who have normal labours find them painful and outrageously unpleasant—even if they are making all kinds of strange noises! Quite a few people who’ve contacted me have mentioned their surprise at the lack of pain in their labours or the surprising nature of the sensations. Others—including myself—experienced intense pain but found they were able to travel through it, thanks to the strange hormonal processes which were taking place, which inevitably have an effect on the mind as well as the body. Motivation to face the pain comes mainly from thoughts about the baby, who may be affected by any drugs, and for me the knowledge I have now would convince me that facing the pain of labour ultimately means less pain overall, if postnatal pain (both physical and emotional) is also taken into account.

5 Actually, research into the causative associations between drug use in labour and things such as alertness postnatally and breastfeeding is in its infancy, but results are already suggesting that drugs do have side– or after-effects; these are constantly discussed in the literature on anaesthesiology. Possible (or probable) side– or after-effects are widely accepted as including nausea and vomiting, feelings of confusion, lowering of the blood pressure, sedation, urinary retention, slower emptying of stomach contents and itching (pruritis)—and the pain relief is not always effective. Of course, in all cases, it’s not easy to establish what causes what.

Looking only at the issue of alertness for now—we’ll come back to breastfeeding later—studies do not provide a clear overall picture. Years ago, some practitioners were apparently concerned about the observable depressive effects on newborns of analgesia used in labour. I deduce this because researchers (Bonta, et al, 1979) discovered that another drug (naloxone) provided an effective ‘antidote’ and restored what apparently seemed to be an acceptable level of alertness in newborns. However, is naloxone (or any equivalents) really a solution to reduced alertness or is the mother-baby dyad losing out when natural alertness is not present? (Would you prefer natural sexual arousal when you meet your life partner, or passion produced by sedatives, counteracted by Viagra? Of course, we need to remember that these early interactions can never be repeated, and also that they might have a significant effect on later interactions too.) Mothers, incidentally, are sometimes assessed by anaesthetists for alertness using a four-point scale (1. awake/alert, 2. drowsy, but readily responsive, 3. drowsy and requires shaking to rouse, 4. unconscious). But how awake and alert do people expect women to be just after they’ve had a baby? Physiological labour usually results in extreme alertness, which is, of course, beneficial for the bonding process.

In a more recent study (Volikas, et al, 2005), which looked at potential side-effects of patient-controlled opioid analgesia (remifentanil) postnatally, 22 out of 50 women were reported to have experienced some drowsiness. (44% seems rather a high percentage…) The researchers reported that at the dose used in the study, remifentanil had ‘an acceptable level of maternal side-effects and minimal effect on the neonate’ (i.e. the newborn baby). Personally, I question whether any level of drowsiness is acceptable during this one-time encounter between new mother and baby. And I wonder how it could be established that there was only a ‘minimal’ effect on the neonate if there was no control group, i.e. if researchers did not compare these 50 neonates with 50 others, who were born entirely physiologically. What seems a normal level of alertness in a neonate might change if researchers were to document the extreme alertness many people have anecdotally reported when babies have been born without any drugs in their systems. There is an enormous difference, I would suggest, between a dull-eyed look and a vibrant gaze, in terms of bonding and simple joy in new motherhood. And when a newborn looks at his or her mother it’s helpful, perhaps, if the mother isn’t one of the 22 out of 50 women who were reported in this study ‘to have experienced some drowsiness’. Hill (2008) later strongly recommended remifentanil, although Van de Velde disagreed in a follow-up article. Although remifentanil is more effective than pethidine and diamorphine (which perhaps explains why it is popular in Belfast), what price are women paying for their reduced alertness in terms of effective early bonding?

Another study (Wittels, et al, 1997) compared the alertness (amongst other things) of newborns exposed to either epidural morphine or intravenous patient-controlled analgesia. Of course, because the focus was on newborns of mothers who’d had a caesarean it was impossible to compare the alertness of babies born with drugs in their systems and that of babies who’d been born with absolutely no drugs in their system, so only ‘relative’ alertness could be tracked. Yet another study, back in 1981 (Rosenblatt, et al) looked at the influence of maternal analgesia (epidural bupivacaine) on the newborn. Significant effects were found: “Immediately after delivery, infants with greater exposure to bupivacaine in utero were more likely to be cyanotic [blue-skinned] and unresponsive to their surroundings. Visual skills and alertness decreased significantly with increases in the cord blood concentration of bupivacaine, particularly on the first day of life but also throughout the next six weeks. Adverse effects of bupivacaine levels on the infant’s motor organisation, his ability to control his own state of consciousness and his physiological response to stress were also observed.” A recent study by Henrichs, et al (2009) considered whether alertness could be affected by a factor such as fetal size in mid- or late pregnancy. (The conclusion was that it could.) In a study such as this, I would imagine there could be numerous confounding factors, the principal one being the use of anaesthesia or analgesia (or not) during labour. Personally, I would only trust the results of this study if all fetuses measured in utero had been born without any drugs in their systems. After all, while the motivation of these researchers appears to have been a desire to investigate behavioural problems in newborns (e.g. infant irritability), they do not appear to have taken into account the fact that one of the primary characteristics of narcotics-addicted neonates is that they are ‘substantially more irritable’ (Strauss, et al, 1975).

Given the vital importance of good bonding in the sensitive one-hour period following birth (from the point of view of later mothering behaviour), I very much hope that other researchers will look further into the issues of alertness and breastfeeding success (or lack thereof), particularly in relation to drug-use in labour.

See:

· Bonta BW, Gagliardi JV, Williams V, Warshaw JB. Nalaxone reversal of mild neurobehavioral depression in normal newborn infants after routine obstetric analgesia. Journal of Pediatrics, 1979. Jan;94(1):102-5

· Volikas I, Butwick A, Wilkinson C, Pleming A, Nicholson G. Maternal and neonatal side-effects of remifentanil patient-controlled analgesia in labour. British Journal of Anaesthesia, 2005, Oct;95(4):504-9. Epub 2005 Aug 19

· Wittels B, Glosten B, Faure EA, Moawad AH, Ismail M, Hibbard J, Senal JA, Cox SM, Blackman SC, Karl L, Thisted RA. Postcesarean analgesia with both epidural morphine and intravenous patient-controlled analgesia: neurobehavioral outcomes among nursing neonates. Anesthesia & Analgesia, 1997. Sep;8(3):600-

· Rosenblatt DB, Belsey EM, Lieberman BA, Redshaw M, Caldwell J, Notarianni L, Smith RL, Beard RW. The influence of maternal analgesia on neonatal behaviour: II. Epidural bupivacaine. British Journal of Obstetric Gynaecology, 1981. Apr;88(4): 407-13

· Henrichs J, Schenk JJ, Schmidt HG, Arends LR, Steegers EA, Hofman A, Jaddoe VW, Verhulst FC, Tiemeier H. Fetal size in mid- and late pregnancy is related to infant alertness: the generation R study. Developmental Psychobiology, 2009, Mar; 51(2):119-30

· Strauss ME, Lessen-Firestone JK, Starr RH Jr, Ostrea EM Jr. Behavior of narcotics-addicted newborns. Child Development, 1975. Dec;46(4):887-93

· Hill D. Remifentanil patient-controlled analgesia should be routinely available for use in labour. International Journal of Obstetric Anesthesia, 2008, 17(4),336-339.

· Van de Velde M. Controversy. Remifentanil patient-controlled analgesia should be routinely available for use in labour. International Journal of Obstetric Anesthesia, 2008 Oct;17(4):339-42. Epub 2008 Jul 9