how to get the best care during labour - Kings

[Saila]

Hello

I was wondering if i could pick wise-mum's brains on how to get decent care during my next labour/birth?

I'm pregnant now (still early days) and really really worried already about the birth already

During my next labour i REALLY want:

1. to be admitted into hospital when i'm in unbearable pain without being sent home.

2. to be given pain relief on request. I want an epidural this time please and gas and air.

3. to have a midwife or doctor with me for the majority of the time (or private help?)

4. to not have my partner sent home

5. to minimise the risk of episiotomy infection, should i have another one.

Does anyone have tips they can give me (or pm me) such that i can try and get at least one of the points above?

Also - any recommendations at all i.e. private midwife or doula a good idea? i can pay upto ?1k for help.

i not fussed about 'natural' birth - my priorities are that the birth is safe and second to that, as painless as possible - so preferably doula/midwife with views that are sympathetic to these above needs.

[oimissus]

I've pm'd you

[GentleStrength]

As a mum who gave birth at King's, student nurse, and Doula who has helped clients labour at King's, this is my advice:

1. The Trust's policy is to only admit women who are in active labour. This means you must be more than 3cm dilated. The reason for this policy is to keep the overcrowding to a minimum. There is a horrendous shortage of beds as is, and when women who are not yet in active labour are occupying a bed, it increases the number of women who are forced to deliver their babies in cars, in the waiting area, etc.

2. Be assertive about asking for analgesics. Entonox will be available to you as soon as you are admitted. The medical staff are required to be a bit resistant when it comes to the epidural due to the risks. Just stand your ground and assure them that your decision is an informed one.

3. You should have a midwife with you most of the time, but it's not always possible to have one at your side 'round the clock. Emergencies on other parts of the labour ward require all hands to be on deck. I highly recommend hiring a doula to ensure constant professional and emotional support and advocacy.

4. You are allowed to have two guests with you at all times on the labour ward. Read up on the Trust's policies so you know your rights. King's now allows partners to stay overnight on the antenatal ward, but they are not allowed bedding, to shower, or free hospital meals.

5. Whether or not you have an episiotomy is usually up to the doctor's discretion. Some doctors believe that a natural tear heals more easily, others believe that a straight incision does. Both a tear and an incision pose a similar risk of infection, so it's up to you.

As I said, I am a fully trained doula. Don't hesitate to get in touch. I met my last client on this forum.

:)

[Fuschia]

Saila, bit of an aside, but I can really recommend christine neillands, hypnotherapist, to help you relax between now and the birth

X

[edanna]

Hi Saila, if you had a long and painful birth first time then it's totally understandable that you want to try to control it this time and it's great to plan as much as you can. But the chances are your next birth will be much faster so although it will still hurt, the pain may be much more bearable if it's shortlived and you're not already exhausted after many hours/days of labour. My second was 90 mins from waters breaking - the first sign - to baby out. And we only just made it into the delivery room. I had about 3 puffs of gas and air and there was no time for anything else. I was all geared up to have an epidural but there wasn't time to even mention it. And yes it hurt but then it was over and the pain never got to an unbearable level. Hopefully you will find the same. Good luck.

[Saila]

Great, I'm not worried about episiotomy itself. In fact i'd rather that than risk an uncontrolled tear. It's just the infection I found debilitating. So understanding how to reduce that risk of infection is important to me.

My last experience was dreadful (laboured on my own in the loo of antenatal ward, partner sent home despite being in labour, begged to have him back, when he arrived he found me pushing on my own on floor by my bed, finally got to labour ward, the baby was in distress, I never had midwife care, straight to doctor who told me I had one push to get him out, episiotomy, ventouse, infection and special care for hoim - all in disaster)

Asked for epidural all the way thru but was refused.

Will pm you

Thanks!

[Saila]

Ps Thanks fuschia/edanna for advice and tips

[Belle]

saila, your first birth sounds horrendous! poor you. There have been improvements at Kings sinced then thankfully, including the above mentioned policy to allow partners to stay, thank goodness - i found this made a big difference second time around.

I'd say use the fact that this is not your first to advocate for yourself more strongly...i def think the 'i've been through this once already' argument is quite convincing! I also think it's wise you're planning as you are. For me, my second birth although quicker was more intense than my first, and in retrospect I wish I'd planned for pain relief all along. As you know, there comes a point of no return with epidurals, so I think it's better to ask early on.

Also - def mention to the labour ward that it's second baby when trying to get admitted - they should factor in that second deliveries can be quicker, and I know for e.g. the brierley tell first time mums to call them when their contractions are 3 in 10, but second time mums they say call when you're just 2 in 10, i.e. because everything can develop v fast from there.

I think a doula is a good idea too. Maybe talk through the first birth with your midwife (not necessarily in counselling way, though that can help too, but on a practical level so that they take your fears into account when planning for the birth).

PM me if you want any advice, I felt v similarly to you early on in my second pregnancy, and there are steps I didn't take which I wish I had (but some I did which were helpful too).

[Saila]

Just quickly on the episiotomy infection thing. Is it as simple as insisting on being 'cleaned'

With anti-septic before any cut is made? Or is it more complicated than that?

What about being completely clean shaven etc? Sorry for tmi but just wondered if steps like that

Would make a difference?

Also, how frequently can your cervix be 'checked' in terms of dilation without causing more risks?

I was told no more than 1x every two hours? Is that bollox?

What's the kings rule for admission in terms of contractions? Is it 3 in ten definitely?

My labour was actually relatively quick (6x hours) albeit with just reception staff monitoring me...

But is it true epidurals could lengthen the process? If so I'd much rather have a longer less traumatic birth

Than my last one

Finally, what is the dilatiion 'allowed' for epidural at kings? And can I measure it myself?

I don't wanna be fobbed off with 'you're not dilated enough-bullshit'

Excuse language... Slightly bitter

[Cora]

If you can afford it I would definately go for a independent midwife to ensure continuity of care and have someone 'on your side' who is also qualified in the medical side.

[sillywoman]

Hi Saila, I think a lot of the advice given by GentleStrength is good, but there area couple of small inaccuracies that I'd like to pick up on.

1) For some time now (since about 2007-ish) the policy has been to admit women to the labour ward at Kings once they are 4cm, not 3cms. At this point they are in 'active' 1st stage of labour. Given your anxieties it would be awful if you went to hospital at 3 only to be turned away again :(

The reason for this is not to do with bed shortages, but rather to do with the nature of how women labour. labour can be very stoppy-starty - you might labour for some hours and then it stop altogether for a while, or you might not notice the early stage. It can be very hard to tell what is happening. In order for you to be admitted to the labour ward they need to be fairly certain that your labour is 'established' & going to continue at a reasonable pace ending with the birth of your baby within a reasonable timeframe. I'm sure no-one in their right mind would want to spend, what could potentially be days in the hospital waiting for their labour to really get going! This, combined with the fact that labour - being completely hormone driven - will progress much quicker for most women in their own homes, is why they might send you home - not because of bed shortages.

So, this begs the question for you Saila "how do I know when I'm 4cm dilated?". The main form of measurement you have is your contractions. A really rough rule of thumb is that by the time you're getting 3 contractions within each 10 minute time block, & they're lasting a minimum of 45 seconds (minimum), and they are so strong that you can't hold a conversation through them, then you are probably about 4cms dilated. Apologies for the many qualifications, but this is a very rough science, though the best I have to offer.

2) The medical staff aren't 'required' to be resistant to you having an epidural. They are on the whole as supportive of your choices as possible; if you want it you can have it. However, it does sound from your description of your last labour that your body went very rapidly through the 'established labour' phase. Certainly on the antenatal ward you cannot have an epidural because - in theory - you should only be on the antenatal ward for the early part of your labour (up to 4cms) and an epidural for pain relief is only offered after that point. If you are coming to the end of established labour & moving into the pushing stage (it sounds like you were well into that by the time you got to the labour ward), then an epidural would have been a hinderance to you, your labour and your baby, rather than a help, so it's probable that that was why you weren't able to have one. If that was the case then, as edanna describes, it's likely that your 2nd labour will be even quicker - it's certainly a possibility you should discuss with your midwife.

3) Episiotomy. The reason that will have an episiotomy or not is not because "Some doctors believe that a natural tear heals more easily, others believe that a straight incision does". It's due to whether, at the point of birth, it looks as though you may tear badly. If it looks as though this is a probability (all sorts of signs midwives & docs look out for) then they will be suggesting an episiotomy to redirect any tearing away from your bottom (apologies for TMI!). Also "Some doctors believe that a natural tear heals more easily, others believe that a straight incision does. Both a tear and an incision pose a similar risk of infection" this isn't accurate. Research has shown that in general tears heal more speedily and efficiently than cuts. Doctors know this and will on the whole avoid doing an episiotomy unless they feel that it is the best option for you in the circumstances. So the reason you had one last time will have been because of the mode of your delivery (ventouse = rapid birth = stronger likelihood of tearing badly).

It's definitely worth discussing with your Midwives avoidance strategies for tearing/ episiotomies in the first place, as there are a lot of things you can do beforehand & during labour to help you avoid either scenario.

Your partner will not be sent home once you are on the labour ward, and in fact the policy change at Kings now means that partners can stay with you all the time if you wish wherever you are in the maternity unit; antenatal ward, labour ward, or postnatal ward. Yay!!

As I say, GentleStrengths advice is mostly good. I particularly agree that a good, knowledgeable, birth doula would be a very good option for you to consider. You might like to take a look at http://doula.org.uk/ the professional organisation where most trained & qualified Doula's list their services, or put a post on the forum -personal recommendations are often the best way to go.

Sorry for the essay, I hope some of this can be useful to you (and anyone else who might be reading).

SW

P.S. Might it be worth asking for a birth debrief from your last labour? It could help you get a clearer picture of what happened & why so that you can get a sense of what was controllable & what was changeable. Your midwife should be able to organise this.

[Saila]

Thanks very much SW

I was definitely past epidural stage by the time my partner found me on the floor. Although he still asked for one as that was my only brief to him before the birth (demand an epidural!)

But I knew it was too late at that point

The receptionsit midwife just didn't believe I was progressing and

Kept saying I was 1cm dilated without even checking

She just kept dismissing me and saying I'd be in labour well after she'd gone off shift.

She was very wrong.

From all the feedback I've had from nct and friends, I have to say asking for an epidural seems to always be resisted when I first went into labour I said I wanted an epidural at some point, the midwife just bragged about how all her births were natural that day. As if to say she didn't want to break that run of luck. Grrrrr.

Do you have any tips on infection prevention? Would my steps make a difference?

[Saffron]

Hi Saila- Was there anything which could have interfered with your healing? Poor healing is often associated with increased infection risk. Are/were you diabetic, high blood sugar in pregnancy? Were you taking any meds that could potentially interfere with healing, eg steroids, blood-thinners, aspirin etc?

Did the infection occur at or immediately after labour, or in the days following the birth? In other words, do you think poor surgial hygeine/technique was a contributing factor?

If none of the above, you may just have been incredibly unlucky. Talk to midwives/GP about the possiility of using sterile wound washes on a tear/stitches. I don't know in particular about perineal wounds, but would washes are sometimes used on other areas to prevent infection. You should have someone look at your stitches frequently too maybe. A nurse might be able to spot the first signs of infection before you're actually feeling any different, given that everything will be a bit sore for a while. Treating an infection early will certainly minimise it more rapidly. xx

[sillywoman]

Hi Saila,

Firstly just to say I'm not SillyWoman - I'm a friend, and student midwife currently working at Kings and just saw your last post and wanted to reply myself.

When you have an episiotomy there is nothing you can do before hand to reduce the risk of infection. There is too much 'happening down there' at that moment for any cleaning to make any difference, and shaving won't help either. It's what you do afterwards that makes the difference. Keeping the area as clean and dry as possible (which I know is easier said than done) is the best way to help reduce the risk. Having said that don't go overboard with cleaning either as this can irritate the area. Baths have been shown to be good as they provide good pain relief as well as aiding cleaning. Cold baths are better but aren't as nice so a warm bath is fine (not too hot though.) TMI warning now - keep an eye (or nose) out for smell - it shouldn't smell bad. But mostly I'd say if you are worried at any point get your midwife to have a look...

At King's (and nationally) your cervix is checked every 4 hours once you are in established labour. There are certain circumstances where you may be checked before you are 'due' for the next one but these are exceptional as regular checks increase the risk of ascending infection. 2 hours I'm afraid is too frequently.

As SillyWoman said, you need to be 4cm dilated before you can be admitted onto the labour ward.

Colloquially, epidurals can lengthen your labour, although this is inconclusive in current research. Due to the risks involved with an epidural you have to be in established labour before you can have one, as your midwife needs to know that you're labour will continue and you will deliver - having an epidural in too long when you are not contracting isn't an ideal situation for you or your baby. Unfortunately it's pretty impossible to examine your own cervix - you won't be able to reach! Also bear in mind that if your labour is progressing really quickly, or if you are 8-9cm and moving into pushing your baby out your midwife may advise against an epidural for two reasons - firstly and most importantly an epidural is no help to you or your baby whilst you're pushing. It can actually cause more problems at this stage. Also - and less importantly but has to be mentioned for practical reasons - there is always a chance that there will be a queue for the anaesthetist, especially if they are in theatre, and so they may not get to you before you are pushing your baby out.

Also, I think it's worth mentioning that although an epidural may slow your labour down, it increases your chances of needing an assisted delivery (ventouse or forceps) by around 80% and therefore also your risk of tearing/episiotomy. Has anyone talked to you about labouring and giving birth in water - it can provide good pain relief as well as reducing your risk of tearing. Might be something to think about?

Finally, on the independent midwife vs doula argument, for you it may be better to have a doula. Independent midwives are great, but they aren't insured to practice in hospitals, so if you are planning a hospital birth you would be paying an independent midwife to basically be a doula (and it will cost you more.)

Hope this is helpful!

SM2

[Saila]

Saffron - I was and am very fit and healthy. Not problems during pregnancy etc. The infection came about 2 days post birth. I was in hospital at the time. I knew there was something wrong but again, sadly, was fobbed off and told it was normal to hurt the way it did. But it didn't feel right. I was finally diagnosed with infection on day 5 and was put on incredibly strong antibiotics. This triggered thrush and struggled to pump so that I could beaker feed my son in special care with breast milk. God - it was such a nightmare.

SW - I had a ventouse last time and thought it was great! I know I'm not meant to say that, but it got my son out quickly and safely.

So ventouse has my vote. Helpful to know the infection thing is out of my control as I can imagine stressing about that as and when it happens again.

For me, the fact my birth felt so completely out of control and I was so very alone, in huge pain and scared which gave me huge anxiety and outright depression for a longtime after the birth. Plus a great feeling of anger and bitterness for being made to feel so weak and vulnerable. All these medical alternatives feel much more appealing. I'd feel like I was actually being helped and monitored which is exactly what I want and why I want a birth in hospital.

I know this view is unusual but it's how I feel. I'm really angry about the whole thing tbh.

[sillywoman]

saila - it's me again BTW not my midwife friend (though she is sitting next to me :)) )

I can completely see where you're coming from with wanting your next birth to be quite medicalised because it will make you feel safe. Please don't think that you're "not supposed to say" that you thought the ventouse 'was great', you can say what you want. It was your birth, & your experience - no-one else's. I guess what you need to do now is look as objectively as possible at what that birth experience was & decide how it will influence what you want to do with labour number 2.If you want the full monitors & medicines approach then that's fine too. Your labour, your way - as long as baby plays ball.

With this in mind I really do think that you might want to get hold of your notes from last time & discuss with a professional what happened. I know that Kings do a birth debrief if you ask. I think it's with a consultant midwife, but don't quote me on that. Either way it will be with someone who knows their onions & can interpret the medical notes & jargon for you.

[Saffron]

That's very discouraging Saila. I'm very sorry to hear that. It sounds like poor aftercare on the part of the staff was a major factor in your infection. Let's hope it doesn't happen that way again. If it does, phone NHS Direct from your hospital bed? Worth tucking the number into your hospital bag?

Also, find out what other antibiotics would be available. Some people are more/less prone to thrush with different antibiotics. And since you're had a history of thrush, it might be worth asking for prophylactic treatment against thrush if you must start a course of antibiotics.

[Saila]

good plan on the notes - although they are pretty sparse as no one was officially looking after me. So not much was written down.

thanks again for advice

[jennyh]

I went to kings during my labour when I was having contractions every 2.5 mins lasting 45-60 second each. I was only 1cm dilated when I got there and so they suggested I go home, as I was contracting so frequently I was scared to go home as I didn't feel confident I would know when to go back in. Anyway despite being full on the labor ward they let me stay on the postnatal ward (can't recall the name). I was with 3 other labouring women in a ward of 4 beds and after a bit of a freak out my partner was allowed to stay. Now I didn't actually have a midlife come and see me for hours but at least I was able to stay there which was enough for me...although I did send partner out to get drugs every ontraction but there was never anyone around so I went without.

Anyway, my point is that despite being very busy they made room for me and for that I am grateful. I did have to be very forceful using the labour as they were busy and I felt I wasn't bring heard (pushing for hours with no progress, turned out baby was stuck, had to request episiotomy as they were being fairly inactive despite saying we had 5 mins etc etc). Ultimately they were kind, caring and I had a positive labour experience and no episiotomy infection so hopefully you will have the same. I did take lots of arnica so not sure if tht helped healing. I was just told to keep clean etc.

My issues were with my aftercare and I will def be more forceful next time around!

And I second fuchsias recommendation for Christine, Ive seen her and she is great and very supportive.

Sure you will be fine although you're right to address your concerns.

[simonethebeaver]

You say you're very early stages-if this is the case, have you tried registering with the Lanes or Oakwood midwives? The reason I ask is that midwives from both these teams will come to hospital with you (and stay with you throughout) and fight your corner, and are able to deliver your baby. They will get to know you during your pregnancy. Although their first priority is women having home births, they almost always attend hospital births too. Also, they will examine you at home before you head for the hospital so you avoid being sent away.

I managed to be 3-10-45 with contractions I couldn't talk through for two days without going beyond 3cms and if not for the midwives visiting me, I would have been in and out of Kings like a yoyo!

Good luck. I'm sure this time round will be better.

[Belle]

It's so arbitrary isn't it with the contractions - with both my labours, my respective midwives didn't really realise how advanced I was because I was quite lucid and the contractions weren't too long or intense early on. That's why i was glad to have community midwives in both cases, as I do wonder if the labour ward would have said I couldn't come in because I could still talk etc. If you do get someone like the Lanes/Brierley/Oakwood, it's so helpful having someone else do the liaison with Kings.

[Nickiw]

Join a gp practice that has a community midwife team! I had amazing care where they visited at home intermittently in the early stages of labour then came into kings with me and were there throughout! Got to know the team really well and they were so supportive! I would highly recommend it! They know u so well cos do all your pre and post stuff too! I mostly saw the same person all the time but met the others along the way (think it was a team of 6 or 7) x x

[GentleStrength]

Apologies if any of my information was inaccurate. The info about doctors and epidurals was something an obstetrician told me while I was on my first medical placement when I began my nursing training. It's also something that my mother-in-law has echoed, and she's the Director of Midwifery at Guy's Hospital. The risk of infection from an incision and natural tear are similar, but not the same. I would alway opt for a natural tear during an uncomplicated delivery, as the risk of infection is slightly less. Either way, broken flesh exposes us. During my labour, I had to have a ventouse delivery. Three different doctors came in to debate whether or not to cut me. They decided to in the end, and I tore anyway. Medicine is far from an exact science, but they did they best they could for me. Every doctor is different and every NHS Trust is different, so there are inconsistencies everywhere. I can only speak from my own experiences.

The best thing, of course, is to avoid perineal trauma altogether! Perineal massage can really help. It doesn't necessarily improve the elasticity of the perineum, but it helps the woman learn how to relax through the discomfort caused by stretching. Being able to relax keeps you supple, which decreases your risk of tearing.

[sillywoman]

GentleStrength if your Mother in law is Lynne Pacanowski of St Thomas' (there are no midwifery or maternity services at all at Guys) then she is holding a very important position & you need to be very careful about posting statements in her name.

There's other stuff too but I won't highjack the thread.

Saila The community midwife advice is very sound, but get in quick as places get taken. You can refer yourself to The Brierly Team (caseload Midwifery), they specialise in homebirth & PND, so though the homebirth bit doesn't apply to you the PND bit might particularly as you are so clearly traumatised by your last birth.

[Fuschia]

It's possible to meet with key midwifery staff at kings - director of midwives, labour ward manager etc, to discuss your care plan in advance. Everything agreed will then be noted and put into your file. You can have a similar discussion with your consultant (ask to see the actual consultant)

If you don't manage to get in with community midwives, or even if you do, I would arrange a meeting at kings to talk it all through.