Podcast: Navigating Pregnancy Choices with Midwife Laura Green
Navigating Pregnancy Choices with Midwife Laura Green
Season 3, Episode 3
We talk a lot about decision making for birth- Where might you choose to birth your baby? Do you want an epidural? Should you have an induction? etc etc.. but the decision making (and the impact of those decisions) actually starts MUCH earlier on in pregnancy.
This week I am exploring all of this with friend and community midwife Laura Green, whose approach to informed choice, birth education and advocacy makes my heart sing! She brings a brilliant insight and balance to this conversation through her experiences both working inside the maternity system and supporting families privately outside of the NHS- always centring women and families at the heart of her care. It is a conversation steeped in warmth, evidence, nuance and honesty- everything I love a 'bit of' here at birth-ed!
In this week's episode we chat about:
- What's going on in maternity services and how is this impacting rates of intervention?
- What are the common things in pregnancy that might affect our birth experience? (Screening for Gestational Diabetes, Low PAPP A, Routine Scans, Growth Scans etc)
- How to navigate these decisions in pregnancy and understand the longer possible impact of these decisions.
- How to advocate for yourself once your decision has been made.
This episode is worth listening AS EARLY ON in pregnancy as you can. Though even if you're due soon or have had your baby, it will hopefully give you some perspective on your experiences so far.
So, set aside an hour, grab a pen and paper if you can, and enjoy!
TRANSCRIPT
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Let's go.
Hi, everybody.
Welcome back to The birth-ed podcast.
Today, I am joined by midwife Laura Green.
Laura is an NHS community midwife specializing in antenatal education, personalized birth planning, advocacy, and supporting informed choice.
Today, Laura and I will be discussing supporting physiological birth in the modern maternity system, a really, really sort of valuable and probably relevant topic for many, many people that are listening.
So Laura, welcome.
Thank you so much for joining me.
Thank you.
Thank you for having me.
I feel very honored to be in this space.
No, a really important voice and I'm sure Laura's gonna have lots of helpful takeaway tips for everybody listening.
So to kind of start us off, a bit of a kind of introduction, I suppose, to where we are.
We're recording this in 2022 in the UK and the kind of, I suppose, state of the maternity system as it is at the moment is that certainly kind of over the past few decades to even the kind of most more recent years, we've seen like a steeply rising rate of intervention in birth.
So through induction of labor and planned cesarean birth and unplanned cesarean birth.
And we know in terms of research that around 80% of women would choose or opt for a physiological vaginal birth if they could.
But really this is like far, far from the reality for most women in the UK and kind of worldwide.
Some countries much, much higher rates of intervention than in the UK and some sort of significantly lower.
But in the, I suppose, the essence of creating a, making sure we've got a really kind of balanced picture, I thought it would be kind of helpful to start just by kind of asking why, like acknowledging where has this rising rate of intervention come from?
Yeah, so I think that to start with, it's important to say that it is not the intention of health professionals to go out and intervene for no reason.
You know, we're not actually there to ruin your pregnancy journey and birth.
Even if it feels like that at the time sometimes, but that, you know, I would hope that for the vast majority of healthcare professionals looking after you in pregnancy, they want the best outcome for you and your baby.
But it's been, there's been a huge change in the maternity services and the kind of guidance that surrounds it.
So since the 1990s, our practice has been moving towards more evidence-based, but there is still quite a lot that we do that's just based on kind of culture and things that we've always done.
But a lot of the guidance that has come out is about trying to reduce the stillbirth rate.
Most things, when you look at them, when you look at the reports, the investigations into poor maternity services, saving babies' lives bundles, all of these things that shape the care that we provide and the services and maternity services, the overall aim is improving health for mothers and babies and reducing stillbirth rate.
Now, whether we are very successful at that is something to be argued, but that's the aim.
That's where we're coming from.
We're trying to improve health outcomes, and every three years they look at, for example, all the women that have died in pregnancy and they will investigate that and then they will come up with themes of how we can improve maternity care.
So the problem with this is that we're doing more and more.
So we're not very good at sitting on our hands.
So in order to try and reduce stillbirth rates, we're introducing more interventions.
So that might be screening test scans.
It might be inducing more labors.
We're certainly seeing that.
And these interventions come with a cost, but that is the idea behind it.
That's just a really, I think a really helpful place to kind of start the conversation because I certainly think there is a kind of culture and a narrative that I definitely think in some aspects, kind of the patriarchy and the kind of culture of maternity care has a lot to answer for in terms of why we are seeing kind of such high rates of intervention.
But just realizing that it isn't coming from a place of kind of inherent cruelty and like a desperate need to kind of disrupt and take control.
You know, it's definitely coming from a place of trying to improve things.
But it certainly leaves us with this conundrum of something that we kind of see throughout maternity care, and we have done for a long time, is the kind of too much too soon versus too little too late.
And we have started to see a small decline in the rate of stillbirth in the UK over recent years.
So it is very easy then to kind of jump to the conclusion that the rising rate of induction and intervention is therefore the reason for this.
But there are of course other things that have come in those introductions of those kind of care bundles and guidance and approaches.
Things like we are seeing kind of lower smoking rates in women during pregnancy and earlier booking in pregnancy.
And those things also would potentially be kind of contributing to better outcomes.
And it's also important to define what we mean by better.
And when we're looking at research, we are often looking at very, very short term outcomes.
So we're literally looking at, did a baby come out alive or not?
And that tends to be the kind of the only thing that is often taken into account.
And often ignores both the kind of long term physical impacts for women and for babies, and the actual kind of emotional experience of giving birth and the impact that that has on emotional health and actually how we then go on to kind of raise our children.
And those things are obviously take longer to research or are quite difficult to kind of quantify.
And so they're often kind of easily overlooked.
So I also think that interestingly in other countries such as Australia, where they've seen a kind of similar increase in induction and plant cesarean rates where it's kind of crept up year on year, but they have not seen a similar decline in stillbirth rates.
In Australia last year, it actually went up.
So it is certainly more a more kind of nuanced and complicated conversation than assume that this is what is sorting it in kind of inverted commas.
I'm just diving in here, September 2023.
It's been a little while since we recorded this episode.
And since then, the UK more recent data has come out.
And unfortunately, we have actually seen a similar trend in an increase in stillbirth rates last year in the UK as well.
But back to the original podcast.
Here you go.
So as an individual, obviously when we're talking about guidance and research and the recommendations of your midwife or your doctor, we're looking at things at a population level.
If we do this for absolutely everybody, will we see an improved outcome?
But when you're approaching your own pregnancy, actually what is relevant on a population level is potentially different to what you want.
And each of us as individuals will have very different interpretations of research, interpretations of what feels like a risk and what doesn't feel like a risk, and very different priorities in terms of what we experience for our birth.
So as an individual, how do we start to balance the kind of the safety versus experience kind of conundrum, I suppose, that it can feel like there is particularly towards the kind of the end of pregnancy, but kind of throughout?
Yeah, I think that is difficult.
And sometimes it feels to me like in order to navigate your pregnancy, you suddenly have to be an expert and to be able to know all of the things and know what every piece of guidance says and know what that means and understand the research and do your own research.
You have to turn up to your appointments with all the statistics and it shouldn't be like that.
You know, the owners should not be on the pregnant woman to do all of the things.
The owners should be on access health care professionals to be able to assimilate that information and present it, but also to be able to have those conversations to say, OK, what this might be applicable to you, but maybe this is what the, as you've said, this is population research.
Let's look at your individual situation.
And in the literature and the, all of the kind of guidance around maternity care in the last 10 to 15 years, individualized, personalized care is a key theme.
So that is, we should be doing that for every single birthing person that comes through the system.
We should be looking at them as an individual and what applies to them.
I think on a practical note, it is really important for us as healthcare professionals to listen.
I think that a lot of the time, your own wishes are not necessarily, they don't carry much weight.
It's the guidance says this, this is what we're doing, and then off we go on that path.
But actually, it's really important to ask that person what is important to them.
Because your experience will shape your priorities.
So, for example, if you have had a previous birth, and that birth you found quite traumatic, and there was lots of intervention in that birth, you may want a very different birth experience.
You may be very keen to avoid intervention.
You may want to birth at home, whether that is outside of guidance or not, and if I've inverted commas.
If you are someone who has experienced a stillbirth at 38 weeks, you are going to have different priorities.
And suddenly, an increase in stillbirth rates from 0.01% to 0.03% is much more significant for you as an individual than it is for somebody else that has not experienced that.
And even if it's your first baby, the things that you have seen or heard through your life are going to shape what you think.
So if all you've heard is, oh, yours was from your mum, yours was an awful birth, I was so unwell, this happened, this happened.
If your friends tell you all their horror stories, that will shape your experience and what you're going into, your perception.
Whereas actually, I often find women I'm looking after who plan a home birth, it's quite interesting talking to them.
Quite often, there's a link there, and one of their parents after them or their partner will have been born at home.
And I think that's really interesting about the way that actually it's like, yeah, I was born at home.
That must be okay.
That was safe.
And even if you don't necessarily realize it, that's in your subconscious there.
And so I think that it's recognizing that everyone has a different approach and trying to understand what is important to you.
And then you can then discuss that with the health professional in front of you.
Yeah.
And I think just kind of, again, in terms of that balancing the kind of safety versus experience thing, something really important to recognize that isn't often recognized in guidance is that the two things don't have to be kind of mutually exclusive and feeling listened to and feeling heard and feeling like you're the person in charge of the decision making is part of what contributes to a safe birth.
And the feelings of coercion or feeling like you were kind of rushed into a decision or feeling that you weren't being looked after from a kind of emotional perspective is not a safe way to give birth.
And so it is not a kind of a decision between do I pick what is most safe in inverted commas or what I want.
It's about kind of matching up the two and realizing that actually they influence each other and they are intricately connected.
And I know that you recognize that as a midwife, but I do feel like sometimes it is overlooked, I think, in a lot of women's kind of care.
And I think that, yeah, that's a really important point because emotional and psychological safety is as important as physical safety.
And we need to consider that when we are looking at what care we are offering.
And I think that as a midwife, and certainly as a community midwife, it's easier for me to see that bigger picture because I am seeing women from the beginning of pregnancy and afterwards.
So you have to remember that most midwives in the hospital or obstetricians, it kind of ends when that baby is out, you know, maybe the postnatal ward, but that very immediate postnatal period.
And so they don't necessarily see the mum in tears on a day five visit because her breastfeeding journey has been really difficult because she's got lots of pain from her cesarean, or someone who's struggling with postnatal depression or PTSD or intrusive thoughts after birth because of a negative birth experience.
And it may have been that on paper, we go, well, it all looked fine.
But if they did not feel psychologically safe in that time, then that's really significant.
And as you said before, we tend to base our evidence-based practice, in inverted commas, on quantitative data.
So that is randomized control tiles, that's looking at pure numbers.
Now it's much easier to say, well, this intervention reduces the stillbirth rate by X amount rather than looking at that quality data, which is when you're asking questions.
So you might take a small group of 10 women and deeply dive into their experience and pull out themes.
Now that is really valuable research, and we're very grateful for the midwifery researchers that we have now.
There's a small number of them, but they do amazing work.
But we're not really seeing that reflected in the guidance, because it's harder.
It's harder to put that into black, it's not black and white.
And so that is very difficult for people high up making decisions.
They can't, it's a much more nuanced conversation.
So that I think is why it's important to be looking at that whole picture.
But you're absolutely right.
And when I do individualized care planning with people, I'm always trying to be aware of, this is the evidence about physical safety, but it's not just, it's no longer good enough for the outcome to be an alive mom and an alive baby.
Like that bar is so low, we should be aiming way above that.
And actually in a developed world, in a developed country where we have a very good and excellent free health care system, we should be aiming well above physical safety.
You know, we should be able to be able for people to come away with a physically safe, but also emotionally and psychologically safe, and to come out with a positive experience.
Just kind of one final word on the research and the research that informs guidance that I think is actually really significant is that research only exists on something that somebody who is being paid some money has decided to research.
Say, for example, there is research at the moment around inducing for a baby that is suspected to be large.
And the kind of comparison that has been decided, what we are going to research is will induction reduce the rate of complications if we suspect a baby to be big versus not having an induction?
And that's what somebody has decided is going to be the thing that might improve things.
Now, somebody else might have decided what if we randomly assign every baby that's supposed to be big home versus hospital?
And that's what we're going to choose as our research.
And it goes further back to who's decided, you know, that's come from somewhere.
Somebody has come up with the theory that induction is going to be the thing that solves it.
And then if we get a bit of research that say, yeah, it does solve it by a bit, or no, it doesn't solve it, that is then what goes into guidance.
Now, they could very, very easily have picked a different intervention in inverted commas, and that intervention might have been one that is more palatable, more widely accepted by women, or less palatable, less widely accepted by women.
But so whilst that evidence does exist, somebody at some point has decided that that is the thing that needed researching.
And this is why it is actually really difficult to base all of your decisions as a kind of individual always on what the evidence says in inverted commas, because who has decided that that evidence is going to be researched in the first place and has other options actually been researched?
And often the kind of holistic ones, the ones that nobody's going to make any money out of, often aren't the things that somebody chooses to kind of actually research.
We've got loads of researchers on kind of stretch and sweeps to induce labor, but we don't have research on acupuncture to induce labor.
And it's a case of actually, sometimes the research around things just doesn't exist.
And that can make decision making tricky when it's presented as this is the best available research.
What it means when we say best available is literally the best available.
It doesn't mean it is the best research, it means it is the best available research.
And I think that's a really significant and important differentiation to make that if you're going into pregnancy, sometimes research doesn't exist at all if you've got a kind of very specific set of circumstances.
Sometimes that research isn't very good or is biased in some way.
And sometimes it's great, and it's a really helpful bit of research to base your decision on.
And hopefully this is going to be presented to you by the people that are looking after you, but often it's not.
And that's why digging, asking a few more questions, going away and doing your own reading and research is perfectly valid and probably helpful thing to do.
If you can come back with specific questions, specific bits of information that you want to know about, then opening up those conversations is a really good place to start.
And I think it's okay to challenge.
So you have to remember that only a small percentage, I think they think about 15 to 20% of national guidance is actually based on high quality evidence.
So all of the recommendations will be graded, and it's quite interesting that lots of them are just expert opinion.
So that may be a expert or a group of experts, usually middle class white men, that have sat around a room and decided.
And so as you say, I think that is important when you're being recommended something, ask is this based on high quality research?
And it might be that that person telling you that information does not know that.
They know what the policy is, but they haven't gone and looked.
And that's okay because we are all incredibly busy.
And I can't hold numbers in my head all the time.
I have to go back to my own Instagram post sometimes and go, oh, what was the rate of that?
But it's also okay.
It should be okay for us to say, oh, I'm sorry, I don't actually know.
But what I will do is I will gather that information and then I will come back to you.
And so when you are making decisions, it is almost always okay to ask for more time.
If you do not feel comfortable with a decision or you simply want a little bit more information, say thank you for that information.
I'm going to go away and think about it and then I'll let you know.
And it may be that that may be at the next appointment in three weeks, or it might be that you call them six hours later.
There is almost always very rarely a situation when it's so urgent that it needs to be done right there.
Yeah, absolutely.
I always think a really helpful thing, I suppose more so in labour, but when you're being presented with the decision, a really upfront question to ask is, is this an emergency?
Because sometimes something can feel like it's very urgent and like it's emergency and like you have to make the decision right now.
And you can ask that upfront question and you get a response of, oh no, it's fine, take your time, have half an hour, have three hours, have a week.
And then if it is an emergency, it becomes very clear and you know that you need to make that decision quickly.
And so that's just to kind of, it can feel like a scary question to ask, but more often than not, it actually just gives you the opportunity to find that time that you might need and that space.
I always say again, if you're making a decision, step away from the midwife, the doctor, the person that can sometimes feel like has the kind of edge in the hierarchy in that conversation.
If you can go away and make that decision on your own turf, your home, your car, if that's as far as you can get, or even just the kind of a room that's just you and your partner in it, or you and whoever's supporting you in your birth, that again can just feel like you've had the kind of, you've taken the power back to make that decision.
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Going back a little bit to thinking about why psychological safety is important in birth and the kind of emotional experience of birth is so important.
I think it might be helpful just to kind of describe what we mean when we talk about physiological birth and what it, you know, without giving like, we don't need to go into a full, this takes me about three hours on my course to talk through actually kind of what contributes to making birth work.
But just linking in why your emotional state in birth is actually important in terms of supporting the physiology.
So what are we talking about when we're talking about physiological birth here?
Okay, so the term physiological birth, I think is probably quite, we've only really been using it more widely in the last couple of years, and it's because there's a difference.
I think before we would talk about normal birth, so normal vaginal birth, or sometimes people will say natural birth.
Physiological birth, it just defines it because basically, because a lot of vaginal births now are not spontaneous.
They end in a vaginal birth, but there may have been lots of interventions leading up.
There needed to be a little bit of a differentiation.
And also the term normal is a little bit loaded.
Why is it normal?
Who is it normal for?
And again, the same with natural.
That makes caesarean or an assisted birth feel unnatural, and that's got negative connotations.
So physiology is your body working.
So we've got physiology and pathology.
Physiology is your body's systems working as they should.
Pathology is when we get a deviation from the norm.
So cancer is pathology because something has gone wrong in the cells of your body.
So physiological birth is a birth that occurs as your body's process, and it is not interfered with.
So generally what we mean is a labour that starts by itself.
So spontaneous onset, so your labour is not induced.
Your labour is not sped up.
So that might be it's you don't have your waters broken, and you don't have a hormone drip.
I think I'm not entirely sure on whether some people would include epidural use in physiological birth, but most people would consider not to use of an epidural because that interrupts the physiology of your body, and it ends in a vaginal birth.
So an unassisted vaginal birth, so not a forceps or a ventus birth.
Whether the birth of a placenta, whether you have the injection or not for that, again, I think that's kind of up for debate a little bit.
But it's a birth that starts by itself, and your contractions continue, and it ends in a vaginal birth, and there's no interruptions or interventions in that process.
And I think something that is helpful for us to point out in this podcast is that we're not saying that this is always the right way to give birth for every person.
We're not saying that this is better than another way of giving birth.
But what has been highlighted in research is that this is what a lot of women want, and it isn't what most women get.
So that is why we've got this podcast episode.
That's why we're talking about this today.
So if that wasn't your experience of birth, or you don't want that to be your experience of birth, this is absolutely kind of no shade on what those experiences might have been.
But for people that are thinking, that's what I really want to experience, we want to have a conversation about what influences that, what potentially disrupts that, going right throughout pregnancy, and obviously the kind of the labor birth experience itself.
So in lots of other episodes of this podcast, we have lots of information around what the benefits are of a physiological birth.
So for mum and for baby.
So we won't go into kind of huge depth of that now, but all sorts of things from kind of like reduced kind of perineal trauma to less birth trauma, kind of psychological trauma, improved kind of outcomes for baby, lower allergy rates, also like tons and tons of reasons why somebody might decide that this is the way that they would really like to give birth.
So that is what our kind of focus is going to be throughout from here on out.
But I just wanted to kind of make that clear, because I know that sometimes this can feel like a really heated debate that kind of pits people up against each other.
And hopefully, if you've kind of followed birth-ed's work for a while, you'll know that that is not our ethos at all.
Everybody is very, very welcome.
So, Laura, taking it right back to kind of the beginning, certainly anecdotally from the families that I'm working with over, say, the past five years, we are definitely seeing in pregnancy more testing, more screening, more scans, more reasons in inverted commas for consultant-led care, more hoop jumping to even get to the end of pregnancy without some kind of, in inverted commas, high-risk label attached to you, your notes, your pregnancy.
So can we chat a little bit about what women might be offered and the impact that these choices and decisions might make on the kind of experience they have of labour and birth?
Yes.
So I will try and make this brief, because as you said, I could probably spend the next few hours talking about this.
It will be my life's work.
But yeah, I think it's really important.
So I think a lot of people don't realise that the choices that you make in pregnancy hugely influence the type of birth experience you may end up with.
Not always.
Sometimes you can have the most low-risk pregnancy and birth still, something happens.
Pathology still happens.
It is very important to recognise that if you do all of the things does not equal, you will have this birth.
And actually, that kind of weight of expectation and that I must do this so that I have this birth can be quite damaging.
And it's important to recognise that sometimes things do not, physiology does not work.
And that is our skills as midwives and obstetricians and doctors to be able to step in when we are needed at that point to improve outcomes.
But yes, it starts in pregnancy.
There are many, many things that can influence the kind of course of your pregnancy.
It's actually very difficult now to, so in the UK, we have kind of two models of care, something we call midwife led care and then shared care or consultant led care.
So in order to have midwife led care, that means you have to be completely low risk.
You have to not have any of the medical conditions that we ask you about, and there's hundreds, and not have any kind of complications if you've had a baby before, be under a certain age, be under a certain BMI.
You know, there's a lot of hoops to jump for, as you say.
If you don't meet any of those, then you would be on that low risk pathway.
So some of the things that we are talking about would include something like having a glucose tolerance test, so a test for gestational diabetes.
That is often offered around 26 weeks of pregnancy.
Now in the UK, we do use a risk-based approach.
So some countries offer everybody a glucose test.
We do not do that, and that has not been shown to improve outcomes.
So that's one of the reasons we don't offer it to everyone.
But there are a variety of risk factors that if you tick that box, you would be offered a glucose test.
Now, it may seem innocent enough, and that is for some people, it will improve outcomes in pregnancy.
But you also have to consider that we're testing for gestational diabetes.
If you get a label of having gestational diabetes, then that will influence your pregnancy journey.
You will be seen in a specialist diabetes clinic.
You'll be offered additional scans.
You may well be offered induction of labour.
So it's understanding when you're offered a screening test, we should be able to explain all of the potential outcomes from that.
But often it's offered at a booking appointment, which is already probably an hour long, and you've got a whole mind dump of information, and it's almost impossible to get it all in.
So that's something that I would just like to point out here is that you are very clear when you're saying that women will be offered these things.
Now, this in reality isn't always what it feels like for women accessing their antenatal care.
So sometimes their midwife might say, we are recommending or we are offering a glucose tolerance test on X day.
Would you like it?
More often than not, in reality, I think most women are told, we've booked you in for your glucose tolerance test.
It's on this day.
And when something is presented in that way, it is unless you have a kind of real understanding of how the maternity system and healthcare works, it's often very difficult to realize that this is actually a choice, and this is actually something that even at this stage, you might like to be kind of actually giving some thought and consideration to whether it feels like something you want to do or whether it feels like something you don't want to do.
So whilst Laura is very good at presenting this as an offer, I do understand that that isn't actually everybody's reality, unfortunately.
Yeah, and I do some training for midwives in my current trust, and this is one of the examples that we look at offering a GTT.
Now, I'm not perfect.
I know that in the past I have said, oh, you've got a family member with a history of diabetes, so I do try and always say offer, but sometimes it's a bit of an off-the-cuff, so you'll be offered a glucose tolerance test.
At this point, is that okay?
And that's not really good enough, but I know that if I'm running late with a book, I understand, I do see it from both sides.
I know what it's like when you're in that appointment and you've got 1,000 things to do and say.
But yes, that is an important clarification.
All care is an offer.
You can opt out of whatever you like.
And a lot of people don't know that.
They don't know that they can decline things.
Even like your 12-week, 20-week scans, that just comes in a letter in the post.
You get a letter in the post, please come for your scan on this day.
There is nothing ever written in those letters of, we would recommend that you have a scan because of blah, blah, blah, blah.
You can say no to this scan if you want to.
That's just not how it's phrased.
And it's a real kind of light bulb moment, I think, when you go, oh, what that?
Oh, what the blood tests?
Oh, what giving you my wee every time I come in?
All of these things, some of them are really good.
There's plenty of good reasons why you might do some of these things.
I'm certainly not saying decline them all, but definitely recognize that they are decisions.
And in doing it, you have decided to accept that offer.
Yeah, I had a lady recently say to me, I said, oh, and would you like, are you happy to have your 20-week scan?
She said, oh, is it a choice now?
They didn't say, you know, is that changed?
I was like, no, it's always been an offer.
You may just have not had that language used before.
But no, it hasn't changed.
It's always been.
And actually, we tick a box.
You know, when it says, when we do the referral, it says, this patient has consented to the anomaly scan or this patient has declined.
So it's a choice.
Anyway, going back to some of those.
So glucose tolerance test, things like growth scans, that's quite a big issue.
So a lot of the recommendations for growth scans comes from the Saving Babies Lives Care Bundle.
So this is a package of care that is aiming to reduce the stillbirth rate in the UK.
It has had some success.
I think there's been about a 0.3% reduction in stillbirth.
As you say, we're not entirely sure whether that's because of additional factors, but it does mean that many more people will be offered growth scans.
So instead of having the midwife measure your tummy at the appointments, then you will have scans often at, say, 32, 35 and 38 weeks.
Now, every scan is a screening test.
So every scan, we are looking for your baby's position, the amount of fluid, the blood flow through the cord, and your baby's size.
Now, it may be that all your scans are perfect, or it may be that your baby's too big, too small.
It was too big, and now it's slowed down, so we get slowed growth.
It was too small, but now it's too big, so we've got accelerated growth.
There may be additional water, so we're worried about that.
There may be other concerns at your placenta.
We can't go into all of them, but the more information we have, we then have a duty to act on that.
So if we do a scan, and your baby is above the 95th centile, so on the larger side, then we then need to have a conversation about, this is information we have found out, these are the things that we would now like to discuss and offer.
So it's not as simple as, oh, we'll just go and listen to baby and check that baby's all okay.
Yeah, and I think from certainly speaking to clients, when they've been offered a scan, it's not questioned because it's nice to see your baby.
Oh, I thought we'd just take it as a chance to see our baby again.
It is important to recognize that this has wider implications than just a quick look at your baby.
So it is a decision, again, for you to make, deciding, do I want to have these scans?
Do I not want to have these scans?
I think that one, I mean, as I say, there's lots more that we could discuss.
And another thing that maybe comes up that I think shocks people quite a lot is the low PAPA.
So this is really difficult because it's not even actually a screening test.
So this is a result that may be found as part of your 12-week screening for Down syndrome.
So if you decide to have screening for Down, or Down, Edwards and Patels, which I think on the whole, and I don't know everyone's experience, but I think that midwives are quite good at having those conversations about that screening because that's something we've done for a long time, and I think we're quite clear about explaining it, and do you want it?
It's not an invasive test, going through all of that.
What we almost always fail to mention is that one of the incidental findings, so it may be that you have this test and they pick up that you have a low Pap A, which is a hormone level.
Now, that has been shown to be associated with some complications in pregnancy.
There's not a huge amount of data, which is part of the problem, but if that is picked up, so we're not testing for it, but if we find it, again, we will act on that information.
So if that is found, and you probably won't know it's been tested for, you will then be offered additional scans, consultant appointments, and potentially induction of labour, although some hospitals are removing that recommendation.
So that shocks a lot of people because they have no idea what it is and they have no idea that they were tested for it.
And there's not a lot of information available around that either, so I think that is certainly something that women definitely find very confusing.
And there are a few other things that can be found incidentally along the way in pregnancy, so things like if you have a urine infection, you might identify that somebody has a group B strep infection, which again isn't something that in the UK is routinely screened for.
And again, in some areas there will be offers to become involved in medical research during pregnancy.
So some areas might be offering routine group B strep screening or scans and things like that in terms of it being for medical research.
And again, these are your decisions whether or not you want to be involved in them.
I know our local hospital do a routine Doppler scan as part of the 20-week scan, which again isn't national guidance and again can sometimes just slip under the radar as something that you didn't realise you were consenting to when you said, yes, I'll go for the 20-week scan.
And so it can feel like there's a lot of things to suddenly be aware of, and it can feel really overwhelming.
So in part, it's about understanding that everything that you're choosing is a choice and that you can say yes or no to it.
But also, just kind of if something is picked up, just looking back in hindsight and actually being able to address it from that perspective of actually it was a choice, actually in other circumstances, we might not have this information.
What would I have done?
You can do things.
If someone's listening to this at 37 weeks and they're like, oh, but I've had all these growth scans.
You can look back and think, you know, if I'd made a different decision at a different point, what position would I be in now?
How might that affect my decisions moving forward?
So it is don't panic if you're suddenly listening to this at the end of pregnancy and you're like, I didn't know any of this at 12 weeks.
And again, I think this is what concerns me, is that I feel like we're putting this expectation on parents to say, you must know all of this stuff before you get pregnant.
And it's like, what?
Mind blown, if this is your first pregnancy, you're just at your 12 week appointment, you don't even know, or you're, you know, you're 10, 8 to 10 week booking, you don't even know if this baby is viable.
You're worried about a miscarriage, you're thinking, I've just vomited my guts up every day, and you're just trying to get through this, and suddenly it's like, would you like screening for X, Y and Z?
What?
I don't know what these words mean, let alone what you're talking about.
And so it's very easy for me to sit here as a midwife and say, well, you need to choose all of these things, and you should maybe consider opting out of this care, but surely that responsibility should be on us as healthcare professionals, not on the person who is receiving said care.
Yeah, it's definitely a really tricky path to walk, isn't it?
To work out who should be in charge.
Absolutely, it should fall on the shoulders of healthcare providers, but certainly some women do want to kind of take back some of that control because it isn't necessarily always forthcoming, either through the kind of the culture of it, but also just the kind of the workload, the midwife crisis.
I totally understand that to actually sit down in every anti-natal appointment and talk to everybody in the depth that most midwives would actually want to talk to people.
I mean, you probably get about three appointments done a day.
So there is that.
There is that to balance kind of as well.
And also, just to recognise that, you know, probably if you're listening to this podcast, this probably isn't your approach because if you've managed to listen to this much of this episode, you're probably really on board with kind of doing your research and kind of getting yourself informed.
But some people really feel very comfortable and very happy to turn up, to do what they're told, to hand over their care, and whatever the outcome is, they feel happy.
And actually, if that is what makes you feel safe and makes you feel relaxed and makes you feel happy, that is also your choice.
Like you are also allowed to go, I really don't have any interest in anything that we're talking about today.
I just want to kind of follow what the guidance says, and that feels right for me, and say it isn't, you know, it isn't that you have to have to have to do these things, but if you want to do them, you absolutely can.
So let's kind of move through then into very valuable to know how those things could potentially then impact the choices that you might have available.
So we're thinking, yes, it might mean that you're offered induction.
Some of these things might mean that you are recommended to give birth on a labour ward.
Some of them might mean that you are recommended to have continuous monitoring in labour.
Some of them might mean that you are recommended or not recommended, certain types of pain relief.
So it impacts things more than just what we're kind of looking at in pregnancy.
So whether or not somebody feels that the things that have been picked up are relevant to them.
Let's say they've had a test, something has been acknowledged, and actually they're ending up now at the end of pregnancy with some complexities to their pregnancy.
So some of these will genuinely be real complexities of pregnancy that nobody is saying that 100% of women are going to get to the end of pregnancy or even the beginning of pregnancy and be completely healthy with absolutely complicating factors or other things to consider.
So if someone is getting towards the end of pregnancy and they haven't just got this kind of tick box tick box in inverted commas, I hate the word risk, but low risk pregnancy, what kind of considerations, what choices can they have in terms of the actual experience and unfolding of their labour and birth in terms of birth choices, induction, what they might reach for, what that space might be like?
Yeah, so again, this is difficult because it's a highly individual decision.
And so I can't say, well, if you've had this, you should always go for this type of birth because it doesn't work like that.
And I think it's important to know that these are recommendations.
As we said, you can decline them.
So for example, if you have been so we know that we have higher rates of physiological birth in an out of hospital setting.
So that could be home birth.
So one study last year found rates of physiological birth of around 85%.
Compare that to, it's very difficult to find hospitals rates of physiological birth, but I think the best way of doing it is looking at the home birth rate because we know that's not going to be interventions there because we can't do them, we don't have the stuff.
And potentially the birth centre births as well, because generally those would kind of fall into that inclusion criteria.
And if you look at those for most hospitals, if you combine those two factors, we're probably looking at 15%, potentially up to 20% if they have particularly good rates.
So place of birth is definitely a consideration.
And as you say, sometimes it can feel like, OK, well, you've been advised to give birth on the consultant led or the labour ward.
Depending on the situation, that absolutely may be the best and safest place for you to be.
But it is also OK to ask about your options and to know that for a lot of people, giving birth on a at home or on a midwife led unit is a viable option for them.
It may be outside of guidance and you may need to be supported in an out of guidance care plan, but that's your choice and it's our responsibility to then back that up and do that kind of care planning.
But for example, if you have gestational diabetes that is controlled by your diet, then it may well be very reasonable for you to say, actually, no, thank you, I would like to give birth at home or I'd like to use your birth centre or midwife led unit.
And so place of birth is important.
There are some things that you can do to improve your chances of a physiological birth, even if you are on a labour ward or consultant led settings.
So things that we might think about are the actual physical environment.
Now, some of this is out of your control.
You cannot pull all the monitors off the wall because the hospital will not be very happy with you.
It's very expensive equipment, but you can change the lighting.
You can dim the lights, you can ask for the curtains to be pulled down.
Lots of hospitals now have got projection lights or tea lights or things like that, you know, or you can bring your own in.
You can push the bed to the side of the room and ask a midwife to get you a birthing ball and a birthing stool or a mat.
Movement in labour is very important and we know that it is linked with ability to cope.
If you've ever tried lying on your back whilst you're having contractions, you will know how uncomfortable it is and how it makes the pain worse in the majority of cases.
There are a few women that will want to lie down on their back in labour instinctively, but they're very few and far between.
So things like having freedom of movement is important.
And for some people that may be just simply kneeling up on the bed, but others it may be much more movement being able to move freely from the shower to the room, to kneeling, to walking around.
So those are things that you can influence.
Use of water.
So we know that use of water for labour and birth is associated with higher chances of vaginal birth, lower chances of tearing, decreased pain levels.
So it can be a really good option.
A lot of hospitals will have wireless continuous monitoring.
So if you are recommended to have continuous monitoring, then you can still get in the birth pool.
Continuous monitoring itself, that is something to consider.
You may well be recommended this.
It's important to note that the evidence for continuous foetal monitoring in labour is poor.
So a Cochrane review, which is the highest level of gold standard of evidence that we have, found that there was not enough research and we urgently needed more research on it.
So that is a consideration to note that actually we use it all of the time, but the evidence base for it has not particularly shows that it improves outcomes.
So again, that's a whole other topic that we can spend another hour talking about, but considering the options for your monitoring of baby.
And we also know on a kind of general level that continuous monitoring, whilst we don't know if it improves outcomes, we do know that it increases the unplanned cesarean rate in labour.
So that is, again, an option for you to decide.
And you mentioned kind of wireless monitoring.
So again, even if you're accepting it, it's about kind of exploring what actually the options are around that.
Actually, final thing with the wireless monitoring, or just continuous monitoring in labour, that I always think is a really easy shift to do.
I certainly found when you are on a labour ward, as soon as a baby is being monitored continuously in labour, the shift of attention by everybody in that room, including the person that is in labour and their partner, suddenly moves away from what she is feeling, how she is behaving, how she is moving.
And everybody is now looking at this machine that's like beeps, it beeps, quite loudly beeps.
Sometimes it churns out paper.
And just bear in mind that it takes midwives and doctors, like at least three, probably more years, to actually understand what these readings and paper mean.
And there is like continuous training in interpreting what this paper means.
So when you are in labor or when you are supporting as a partner in labor, the chances of you actually knowing what this means are absolute zero.
So just asking, you know, can we turn the volume of this machine down?
Can we turn this screen away from ourselves so that we are not looking at it?
And it just brings the focus back on, what am I actually feeling?
What, how are you actually behaving?
What do you actually need from me as a partner?
Rather than, I think what can often happen on a labor ward is that we rely much more heavily on external measurements, machinery, than we do on somebody actually describing what they are feeling, asking for what they think they need.
And that is so, so valuable and important in terms of supporting birth to unfold in a safe and physiological way.
So as a, like if you're listening and you're thinking, I'm going to be on a labor ward, I'm going to have continuous monitoring, first thing to do as a partner is ask to turn it down and to just twist it out of the way so that it's not kind of shining directly at you.
Absolutely.
And that's an important point about support.
So we know that continuous support in labor increases the chance of physiological birth, decreases intervention, so that may well be your partner.
Doolers, actually, in the research, were shown to be the most influential factor in terms of reducing intervention, but also continuous midwifery presence.
So having a midwife with you all the time, so that should be a gold standard for care.
And I think the CNFT is a 95% is the standard.
So if once you are in established labor, you should have a one-to-one midwifery care, but think about who else is going to be in that room.
I always say to people when I'm doing birth planning, consider what your birth partners are bringing to that room.
So what is their experience of birth?
What have they heard?
What is their kind of understanding?
Is that going to influence your birth?
And then lastly, the other thing to consider is things like pain relief.
So lots of people say, I just want really natural birth, and I don't want an epidural.
So epidurals are absolutely amazing for pain relief, but we do know that they increase the chance of intervention.
They increase the risk of having an assisted birth by about 30%.
And so that is something to consider.
And if you've done all of these things, if you have got continuous support, if you're able to freely move, if you're using maybe water for pain relief and not having continuous monitor, you may find that actually you don't need or want an epidural.
And using other techniques for pain relief may be really useful.
So there are so many things.
And again, I could do a whole kind of course on that and things to improve your chances of physiological birth.
But just know that there are things that you can influence.
We've got a very tiny visitor who's just come to join us.
So anybody that's listening to, she's got tons of info for input.
But yeah, just to kind of wrap up what Laura said, I always say that actually, if you're giving birth at home, you kind of don't need to really do much because you already feel safe.
You already feel relaxed.
You already feel unobserved, undisturbed in your home environment.
When you are giving birth in a labour ward, this is when actually having as many comfort measures to hand as you can manage, as much consideration around what that environment looks like is more important than ever.
So definitely, if you're putting together your birth preferences, your birth plan, that would be our top tips, top considerations if giving birth in a labour ward.
So I think we will wrap up there.
There have been hopefully tons of helpful information, considerations to go away and implement into your own pregnancies and births.
So Laura, thank you so much for joining me.
I'm sorry for the interruption.
The reality of parenting.
Welcome to parenting, everybody.
This is it.
This is what it looks like two and a half years later.
So just, if anybody is really keen to kind of keep hearing your incredible wisdom and sharing of information, where can people find you if they're keen to follow some more?
Yeah, so I'm mostly on Instagram.
So I'm at The Green Midwife and on there.
I put lots of free posts up, and I try and put as much free information available as I can.
But I also offer some group sessions.
So I do a session on home birth.
I do one on induction of labor, and we really delve into that.
I spend a whole hour going through that.
I've got a VBAP course, and things you can do to increase your chances of vaginal birth after cesarean.
And I also do individualized birth planning and advocacy.
So if you've been told, oh, your baby is this big and we want to do this, then we can have, you know, as long as you want to go through all of that and all of that information.
Amazing.
Thank you so, so much.
All right.
Well, thank you very much for having me on.
Thank you so much for listening to The birth-ed podcast.
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