Home births again - new gadgets
London - For Katrina Caslake, giving birth was not the terrifying, painful ordeal most women experience. Far from it. The midwife, from Wallington, south London, says she found it blissful, even orgasmic. “I found giving birth very sensual,” says Caslake, 44, who didn’t take painkillers for the birth of either of her sons, Aaron and Tomas, now 18 and 17.
“All my erogenous zones were stimulated. I was making sounds very similar to a sexual climax. And it was a very definite climax. I was doing the most feminine thing a woman can do and it felt fantastic.” (Sensual Birth by Anastasia Stephens at Birth buddies)
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Each to his own. I am sure that Birth Buddies have many happy clients and even more supporters, but I cannot buy into it. We are back to the thorny subject of home births because, earlier today, an email arrived from Leah Rucchetto of Racepoint Group UK
Dear Dr. Crippen,
I'm writing to you regarding natural childbirth. As the NHS guidelines are moving towards more natural births I thought it might be a topic that was of interest to you. I work for a company called Cook Medical in a division called women's health. Currently we are discussing the issue of natural childbirth. You may already have experience with a cervical ripening balloon - if not we would like to give you some information. If you already know about the cervical ripening balloon I apologise.
If you think that you or any other doctors you know would be interested in information please let me know. Either way I would be very interested to hear your opinion on the device as only some doctors know about the technology. I have attached the press release about the CRB for some more information.
I hope that this information is of use to you.
Thanks,
Leah
So what is this all about? It is about a new gadget which seems to be being marketed as a useful tool to facilitate "natural births". By which I think they mean home births.
The Cook Cervical Ripening Balloon catheter is comprised of two silicone balloons and uniquely engineered to allow the cervix to naturally and gradually dilate prior to the induction of labour. The first of two balloons is inflated on the uterine side of the cervix; the second is then inflated in the vaginal side of the cervix. The two balloons adapt to the contour of the cervical canal minimising discomfort for the patient. When the catheter is removed, cervical conditions should have improved to a favourable state to allow for induction of labour and active labour management.
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I do not have the expertise to comment, and so I won’t. But I would be interested to hear from anyone who has experience of a gadget like this. Full details from Cook Medical here.
I am more interested in the first two sentences of Leah’s email
I'm writing to you regarding natural childbirth. As the NHS guidelines are moving towards more natural births I thought it might be a topic that was of interest to you.Home births are always of interest to me. As regular readers will know, I am implacably opposed to them. The government is keen because they are much cheaper. They have no other merit in this country.
The use of the expression "natural birth" is, as always, a red herring. Natural child birth is about squatting under a bush, grunting twice, smearing the brat with mud and getting back to hoeing turnips. Perinatal and maternal mortality rate unacceptable.
Right on, trendy “natural” child birth is about jumping into the birthing pool with husb... sorry, “life partner”, the vicar and the independent madwife, singing ten green bottles whilst the baby struggles to get out and then eating the placenta with a rocket salad. Perinatal and maternal mortality rate unacceptable.
I cannot see what a cervical ripening balloon has to do with “natural” child birth but it might beat the old fashioned Prostin pessary. Personally, I would always prefer to allow labour to start spontaneously in a safe environment. And, in my view, the only safe environment in the UK is in a hospital, as far away as possible from the home birthing brigade.
Labels: cervical ripening balloons, home births
31 Comments:
Do they use laminaria anymore? What's the advantage of the balloon? If a home birth is anticipated, who is placing that catheter/balloon device?
What I'd worry about with that balloon is, in a home delivery, someone would get impatient, apply too much pressure, and lacerate a cervix.
But not doing obstetrics, so not up-to-date. With our last child, it was Misoprostol to induce labor.
The child abuse professionals in our rural community, told me a scary story about pregnant drug-abusing mothers using the midwives because the "natural" nature of the practice allows them to avoid any testing for drugs of abuse.
Though not using that story to paint midwives generally, I'm really not.....just that in the USA, midwife practice and home birth is not regulated.
I've inherited complicated pregnancies, in abnormal labor, from the Amish community and midwives that practice like it's 400 years ago.
At least in fairness, the Amish are willing to accept the risk that goes with that. Will of God. They will accept modern intervention when things get bad enough.
...........arf
Oh but a cervical ripening balloon sounds so nebulously lovely! It speaks of blue-skies and fecundity. I do believe I want one, and if possible I'd like it in mulberry but not mauve. Mauve reminds me of polyester but mulberries are natural and earthy. Like me.
What? Oh no, I'm not actually pregnant but I do want to drop my mulberry cervical ripening balloon into conversation with friends. I favour harps for musical birth accompaniment. Harps and, of the facilities will allow, a dolphin.
If I ever have children I won't be having a home birth. I strongly believe that squeezing something the size of a watermelon out of a hole the size of a lemon is a process that requires drugs, lots of them. So I will be going into hospital and asking for all the drugs I am allowed. I will also take a back up sack of my own drugs just in case their's don't work. There's nothing like being prepared and I intend to be prepared by getting as stoned as possible to minimise the pain and so that I'm too high to notice someone stiching up my nether regions. Or I may just not have children, haven't decided yet.
Obstetrical & Gynecological Survey. 51(10):621-627, October 1996.
Sherman, Dan J.; Frenkel, Eugenia; Tovbin, Joseph; Arieli, Shlomo; Caspi, Eliahu; Bukovsky, Ian
The present series and other studies suggest that oxytocin use for induction and/or augmentation of labor is increased after balloon ripening, compared with its use in spontaneous labor or after cervical ripening by prostaglandins.
**********
Sounds worse if this is correct.
Natural birth isn't synonymous with home birth. When I was pregnant and discussing birth with other women and the midwives, the term meant choosing, if at all possible, to have as little intervention as possible. But it's a fairly meaningless term. I had to have oxytocin and an epidural for my 1st birth, but just used a Tens machine for the next 2: I don't see any as more natural than the others and have 3 fine children which is what really matters.
Semantics first, I think that the term 'natural' is being used here when the term which would be appropriate is 'normal'. Yes, the Government would like there to be more home births, but this is to maintain 'normality' as there is sometimes an initiation of 'minor' intervention, the woman being encouraged to remain recumbant or bedbound a good example, within some units, or by some midwives, which may then lead to a 'cascade of intervention'.
'Personally, I would always prefer to allow labour to start spontaneously in a safe environment. And, in my view, the only safe environment in the UK is in a hospital', I'm sure you didn't mean that labour should start in hospital, I'm certain that even such a die-hard oponent to homebirth as you Dr C would agree that in a 'normal' pregnancy a spontaneous onset, preferably at home is preferable.
I worry about these cathaters from the infection point of view but I feel sure that I can reassure people that these would never be used in the homebirth environment. Homebirth is only considered appropriate in a 'low-risk' situation where there has not been any need to interfere, the use of these interesting little gadgets would certainly be considered a deviation from the norm.
I see there's been quite a lot of interest in the details I sent about the Cervical Ripening Balloon. But I did just want to set the record straight. By 'natural', I did not mean to imply a home birth, rather one that avoids the use of drugs to induce labour. Cook's balloon was designed as a drug free alternative to prostoglandin or oxytocin, to be used solely in a hospital environment and to be administered by healthcare professionals.
I hope this is clear!
If the policy to move deliveries from hospitals into homes/polyclinics is implemented it would be interesting to know on what statistical grounds it would be justified. I found this on the National Stats Office website whilst looking at mortality rates (I’m a bit of a train spotter).
1.7 Although Maternity HES was intended to cover all deliveries, very little data has been available about those that occur at home and even less about those that occur in private hospitals. The Independent Midwives Association (IMA), which provides private midwifery care for both home and NHS hospital deliveries, has recently developed a database that holds similar information to that held in HES. Summary information about 337 deliveries attended by Independent Midwives in 2003-04 (representing 83% of all deliveries attended by
Independent Midwives) is in Annex B.
It went on to say
2. ANALYSIS AND
COMMENTARY
2.1 Overview
2.1.1 About 593,600 deliveries took place in England in 2003-04 an increase of 5% over 2002- 03. The vast majority of deliveries take place in NHS hospitals though about
2% are home deliveries and 0.5% occur in private hospitals.
I am not surprised Katrina had an orgasm the Obstritrician has got his kit off too and I am sure the BDSM brigade could put a CRB to good use although not the one for which it was probably intended.
http://en.wikipedia.org/wiki/But_plug
I used to work in OBS in H.K. We had a flying squad dealing with failed home deliveries. Most mothers preferred to be delivered in our seven-storey single purpose maternity hospital. We had capability to C Section in 5 minutes. Hong Kong shared the lowest infant mortality with Japan. Of course it is only a small place with 6 million people. I nearly became an obstetrician.
The Cockroach Catcher
Dr C - where does it say that a 'natural birth' was a 'home birth'?? It didn't. You made it up.
As a mother who had two children in hospital (one section, one VBAC) my interpretation of 'natural birth' would be one without medical intervention - ie no forcepts, induction. My second son I would term a 'natural birth' as he was born 'naturally' - ie without intervention.
Vicola - hand on heart - my section was one of the worst experience of my life - pain beyond belief and incredibly debilitating. In contrast my 'natural birth' or 'normal delivery' was a complete and utter breeze. Yes, some people have pretty awful experiences and I count my first birth as one of those. However, my second birth was pretty uncomfortable, yes, but I wouldn't rate it on the same pain scale as the section. The key to everything progressing well, is, I think, being as active as possible in pregnancy and keeping fit. The after pains after my second child were way more painful than the birth. Don't forget, a woman's body was designed to give birth - lemons might not stretch much, but your body will! :-)
And hand on my heart, my c-section saved both mine and baby's life. I could not care less about my subsequent discomfort. Hell,i was alive and so was my son.
Its horses for courses.
Where possible, let's go with as little intervention as we can balancing the best interests and welfare of mum and baby WHen we need intervention, you go with balancing medical advice and your own decision making.
Oh but a cervical ripening balloon sounds so nebulously lovely! It speaks of blue-skies and fecundity. I do believe I want one, and if possible I'd like it in mulberry but not mauve. Mauve reminds me of polyester but mulberries are natural and earthy. Like me.
What? Oh no, I'm not actually pregnant but I do want to drop my mulberry cervical ripening balloon into conversation with friends. I favour harps for musical birth accompaniment. Harps and, of the facilities will allow, a dolphin.
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Joy.
Pure joy.
I wish I'd written that.
John
Sorry, Dr. Crippen, but I'm a statistical epidemiologist, and your claim that non-hospital births have "Perinatal and maternal mortality rate [that are] unacceptable" is simply incorrect. Study after study has shown near equivalent peri and postnatal death rates in certified midwife births. I'm happy to provide links, if you have the temerity to contradict me on that one.
Hospital births carry their own risks--from MUCH higher rates of intervention to acquiring nasty, even life threatening infections.
You do a disservice by continuing your pro-doctor propaganda, unchecked by fact.
anonymous @ 16:14
can you provide those links so we can all see
Just as Dr. Crippen and so many comments highlight, we are driven to make policy decisions based on anecdote, not data. And if the data aren't clear, then argue with them(the numbers)...But the home birth fad is a reaction to an historical trend that I believe was as imbalanced as the "Militant Perineal Protection Society".
I talked with an old doc who said he delivered 400 babies a year in the 1950's....And another guy across town did 1000 one year. In that setting(Baby BOOM) I can imagine lots of halothane/ether and forceps...Drag em out, move to the next....
But then I had a young full term granola labor at home for two days, come in finally, head high, true CPD, get a section, baby and mom OK....Then DEMAND a trial of labor for her second babe....At Home... I felt putting herself and kid at risk...Again, ended with a section, healthy babe and Mom and we all get what we want...
statistical epidemiologist -
I would love to see these links too. I assume that these studies are well powered, based in the UK, and not showing too much obvious bias. Bear in mind that high/moderate risk pregnancies tend to get funneled to hospital and this can skew the data a touch.
Dr Sniper
Yes, Anon @ 3:20 my emergency section saved my baby's life too and possibly mine as he was an oblique breach.
However, recovering from it was wretched as the incision became infected and I couldn't walk properly for weeks. Don't get me wrong, I appreciated the fact that we were both alive, but we didn't get the best start and the experience lives on with me today...
Yes, the cervical balloon is a well-known method of cervical ripening. It has its own risks (ascending infection, need for subsequent oxytocin..) and benefits. What perplexes me is the use of the phrase "natural childbirth" in conjunction with the device. It is an intervention, to be used only with specific indications and appropriate supervision, at which point we do not have "natural childbirth" we have medically managed childbirth--not always a bad thing. I don't understand though how a woman who is hoping to have actual natural birth could be interested in such a thing, unless someone is teaching her "drugs bad, instruments good" or some such hogwash. It is ridiculous to equate "drug-free" with "more natural"--forceps are drug-free after all!
Very well,
http://jech.bmj.com/cgi/content/abstract/52/5/310
http://www.nacerencasa.org/bibliografia/parto%20en%20casa%20british%20columbia.pdf
http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000012/frame.html
http://acogjnl.highwire.org/cgi/content/abstract/88/5/823
Doctors have a culture of intervention; they are trained to cut, lacerate, and cauterize. Naturally, when presented with an opportunity to do so, they will do more of such things than midwives who emerge from a different treatment culture.
Going off at a bit of a tangent - what is the view of the GP readers on the recent proposals to screen sections of the population for various disease? If the answer is - load of bollocks, waste of money etc, does this apply to all screening - ie breast and cervical? Or is there some differentiation? Would you just be treating 'The Worried Well Middle Classes'? Are Doctors simply trained to identify and treat illness or disease, or is there a role for disease prevention?? What role has the GP to play in disease prevention?
As someone non-medical, surely prevention is better than cure?? Wouldn't most women prefer a breast cancer to be picked up at an early stage than a later one when it may have spread and the treatment required be more aggressive?
In times past, there was a National Twilight Sleep Association, a group of women who advocated "Twilight Sleep" (morphine and scopolamine) at childbirth.
They pressured medical associations to advocate and use the technique. They advised women to ask for it, and advised women to find other physicians if their doctor was less enlightened and did not use the "modern" technique.
The group fell out of favor when the leader of the organization died in childbirth under the influence of morphine and scopolamine.
I've been around long enough to see the full leather restraints in labor and delivery units. Just old enough to see them still stocked. Not old enough to see them actually used.
I believe the technique originally came from Germany. Did the technique ever enjoy any favor in the UK?
........arf
'Bear in mind that high/moderate risk pregnancies tend to get funneled to hospital and this can skew the data a touch.'
But that is the whole point though. Homebirths in the UK, with NHS midwives are 'aimed' at low-risk pregnancies as statistically ths is where the morbidity/mortality is on a par, if not lower, than low-risk within the hospital, plus the 'normal' birth-rate is improved.
I'm not a GP, but feel like answering Anon's question re screening. The problem with screening tests used indescriminately is that they pick up a large number of false positive results.
I'm not a statistician, but as I understand it, the fewer people in a population who have a disease, the more likely it will be to have false positive results. (For example, if using a test with 95% sensitivity and specificity for a condition with a prevalence of 1%, only 1 out of 6 positive results will represent a true positive. That's 5 people in this particular population who now think they have the condition when they actually don't.)
Diagnostic tests are much better at picking out individuals who actually have a condition when used on a population who is more likely to have that condition; i.e. if a test for pneumococcal disease is used in patients with fever, cough, and chest pain instead of in the entire population.
It can be confusing to understand, and boils down to the statistics of interpreting the test results, and how "normal" values are determined. Suffice it to say, indescriminate testing for diseases which are relatively rare would be unhelpful because of the large number of false positive results.
And statisticians out there?
I had a homebirth with my third child ... wonderful experience, would recommend it to anyone. Well, when I say "wonderful" I mean it hurt like hell, just as the previous two had, but at least I could get in the bath for pain relief and eat ham sandwiches on demand. Not in the bath, obviously. Nothing worse than a soggy ham sandwich. Except possibly a placenta transformed into pate
Did the designers of the cervical ripening balloon not realise that it gets pretty crowded up there? I mean, what with the baby actually being *in* the womb, trying to get out of it and everything.
The continuing invention of new spins on the ritual humiliation of women in childbirth never ceases to amaze ...
Statistical epidemiologist
Like most people who don't actually understand the issues, you provide no analysis of the papers you quoted. Is study design not part of your "expertise"? Obviously not.
http://jech.bmj.com/cgi/content/abstract/52/5/310
Not valid. Not a randomised controlled trial. Based in the USA which has much higher intervention rates than the UK and few hospital based midwives. No details on whether analysis was by intention to treat - unlikely, given the abstract hasn't mentioned it. Selection bias certain.
http://www.nacerencasa.org/bibliografia/parto%20en%20casa%20british%20columbia.pdf
Not a randomised controlled study. Highly likely to have a large selection bias. Massively underpowered for a study attempting to show significant mortality differences in low-risk women. You need tens or hundreds of thousands of participants.
http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000012/frame.html
At last! A worthwhile reference with some proper RCTs!
There was a trend towards higher perinatal mortality in the home-like setting (five trials; n = 8529; RR 1.83, 95% CI 0.99 to 3.38).
In other words the risk of death nearly doubles when midwives look after low risk pregnancies, even if the medical unit is in the same building. Simple - less intervention but more death. Who'd have thought it!
http://acogjnl.highwire.org/cgi/content/abstract/88/5/823
Again massively underpowered to show any difference in mortality, but at least analysed by intention to treat. Still not a RCT therefore selection bias highly likely.
So, the better the study the more likely to show a mortality increase if midwives run the show without doctors.
Here in WA the government have just announced a 0.7% perinatal mortality figure for so called "low-risk" home births. That doesn't include the ones with brain damage by the way, just the dead ones. Nearly 1%. Think about it.
Anonymous, as you say, you would need a randomized study involving thousands of births because of the low frequency of adverse events. However, this isn't possible in the UK because we do not have the necessary infrastructure for that many home births. Maybe we can turn this around a bit? Can you quote the research evidence that resulted in the move from home to hospital in the first place?
I think the best we can hope for from research today is large samples over time, research in countries with large populations like America or comparisons with countries that happen to have a higher home birth rate but with similar levels of care otherwise (if that exists).
Here are a couple of interesting research links, I'd be interested in your comments:
Collaborative survey of perinatal loss in planned and unplanned home births
Northern Region Perinatal Mortality Survey Coordinating Group
http://www.bmj.com/cgi/content/full/313/7068/1306?ijkey=7e1644e0cd415b6b6876139372c403b65b8015ab
Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome
http://www.bmj.com/cgi/content/abstract/313/7068/1313?ijkey=3ceead2ef04c560c9ea53c8b890b8c5a1d08db25&keytype2=tf_ipsecsha
Have seen an ordinary Foley catheter used for induction where Prostin contraindicated (mainly prev LSCS) - deflated balloon inserted through cervix, inflated, and then put under slight tension by taping to the leg. Once the balloon has come through an ARM is possible.
Hmm, isn't the average home a more controlled environment than a typical NHS hospital?
Who knows, the woman might actaully have someone assigned to care for her if she opts for a home birth, rather than being left to rot on a trolley...
I can't give much comment, I am not a medical professional but am employed 'within industry'. I purchase a report entitled 'Why mothers die'. It's part of the Confidential Enquiry into Maternal and Child Health (CEMACH). It's available here:
http://www.cemach.org.uk/Publications/CEMACH-Publications/Maternal-and-Perinatal-Health.aspx
You may be interested to know that between 200-02 (being the most recent report) the UK maternal mortality rate was 13.1 per 100,000. The leading direct cause was thrombosis and thromboembolism. Interestingly, the leading causes were actually indirect. Firstly, cardiac complications and secondly SUICIDE.
Why suicide, I don't know? Presumably associated with post-natal depression?
Before anybody comments, I strongly believe that babies should be born in hospital BUT let us not make assumptions about the leading causes of maternal deaths.
Very Good article , this article make some interesting points.
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