AIMS IrelandChoices in Pregnancy & Labour
Period late? Feeling tired? Sore breasts? Over emotional? These are all signs of pregnancy. Most mothers choose to further confirm such physical symptoms with a pregnancy test. Once you have a positive pregnancy test then a world of choice presents itself!
Traditionally, women went to the family GP once they found out they were pregnant. From here they were referred onto specialist maternity care providers. However, now women are getting more and more advice and information from the Internet and social media. Some of this advice is useful and pertinent to Ireland and some of it highlights practices that are rarely used here or options that are as yet unavailable in Ireland. Some of the information is very subjective and based on the experiences or opinions of particular individuals. Ideally if you are searching the Internet for information on choices for pregnancy and birth you should try to find sources that are evidenced based. Unfortunately, many clinical practices in the Irish maternity services are NOT evidenced based and this can be confusing for mothers seeking choices that research states are best for them and their babies.
STOP right there!
There is so much more to choice of where to have your baby than a discussion in your GP’s surgery about your capacity to afford private health insurance. In terms of where to have your baby there is the initial choice as to hospital, home or something in-between. The vast majority of births in Ireland take place in hospital, either in a dedicated maternity hospital or in the maternity unit of an acute hospital, but some women choose to have their baby at home and others choose a more low-tech approach in which they are cared for primarily by midwives rather than obstetricians.
This brings us onto the key choice, which is not so much about where to have your baby as to whom is going to care for you and your baby. Whilst at first these two statements may seem to be saying the same thing there is a wealth of difference between them, especially in the larger maternity hospitals.
The below choices are just a brief outline of the different options available in Ireland today.
We strongly encourage service users to research all of these options more thoroughly before making a final decision. We also highly recommend hiring a doula to assist you to navigate your options and provide emotional support as you go through your pregnancy, delivery and postpartum period.
As you can see from the below options Ireland has a very highly medicalised birth culture and the word risk is thrown around a lot. However risk is simply another word for chance. It is up to you to ask questions and demand an individualised risk assessment that is absolute rather than relative (for example the phrase ‘you are twice as likely’ means absolutely nothing unless you know the real figures and the denominator.)
People invest a lot of time and money in their wedding days, seeing it as the most important day of their lives, however your wedding day is just one day and rarely does it have a lifelong impact on your physical, emotional and mental wellbeing and rarely does it have a similar impact on another human being. Whether your pregnancy is planned or not decisions around your pregnancy and delivery are yours only to make and deserve all the time, energy and resources you can afford. You can only birth your child once and it is the most important rite of passage in your life so treat so recognise it for what it is.
We remind you also that everything that is offered in pregnancy is simply that, an offer. It is up to you to make an informed choice and you cannot make an informed choice without knowing all of your options. We highly recommend that you read the national consent policy when engaging with the health service and understand fully your rights and your options.
We also strongly recommend that you invest the time and resources into researching the appropriate care pathway for your birth and your mode of delivery. The BRAIN acronym is very useful for all decisions regarding for pregnancy, birth and your baby.
What are the benefits?
What are the risks?
What are the alternatives?
What is your intuition telling you?
What if you do nothing or not make a decision right now?
Choice in Care Provider
The main categories of care providers for pregnancy in Ireland are your GP, a midwife and a consultant obstetrician, under whom work hospital registrars and hospital SHOs (Senior House Doctors).
Midwifery care
Midwives are the providers of care for normal birth, and research has shown us that more than 85% of births are normal. Obstetricians and those that work under them are there to offer care for pregnancies and births that are not normal and which have complications or which carry greater than average risks to the mother or baby. This is worth bearing in mind when you are considering your choice. Again, research has shown that women under the care of consultant obstetricians are more likely to undergo interventions than women under the care of midwives.
Midwives view birth as a normal physiological event in the life of the mother and treat all women under their care as low risk unless proved otherwise. Their primary role is to support the mother during pregnancy, birth and afterwards in achieving as healthy a pregnancy and birth as possible. Even when women are classified as high risk and may have to have births with a high number of interventions, the midwife is still there to normalise that experience. Historically the midwife was part of the local community and offered complete continuity of care to a woman that is from conception through to birth and beyond. This was well highlighted in the recent BBC TV series “Call the Midwife”.
Today midwifery has become more specialised and birth more compartmentalised and so most midwives only deal with a specific part of pregnancy or birth or afterwards. Nonetheless, midwifery is quite a distinct profession from nursing and other medical professions, one of the main differences being that midwives do not view their patients as being unwell or sick and in need of a cure, as do their medical counterparts. They view their clients as healthy and well. This is particularly so of midwives who have never studied nursing and who have only ever trained in midwifery, Ireland now has many such midwives practicing in its hospitals and communities.
Choosing a midwife as your lead carer is usually free, but is not available to all women, due to service provision issues (not enough midwives to offer the service), geographic disparity (only offered in some areas or units) and risk factors which determine that a woman and her baby are better off being cared for by a consultant obstetrician. There are many midwifery options that exist in Ireland and choosing this option means that your care antenatally, during the labour and afterwards will be provided by a midwife.
Public Midwifery Managed Care
Availability:
In all maternity units and hospitals in Ireland.
Advantages:
No fees or additional costs associated with this option. In outpatient clinic appointments you will generally be attended by midwives and a referral will be made to a registrar or specialist consultant should it become necessary during pregnancy. Care will be overseen by a named consultant. Your birth will be attended by the same midwives who attend all births and postnatal care will be led by the same postnatal midwives who care for all women also.
Disadvantages:
Whilst this is a midwifery managed clinic, ultimately it is obstetric led care and is associated with higher intervention rates, however many midwifery managed clinics work only with low risk women and prepare them for physiological birth. There is no guarantee you will meet the same midwife or junior registrar at antenatal appointments. You may never meet your named consultant though they are responsible for your care. Public wards can be rather crowded in the postnatal period (8-18 beds.)
Community Midwifery Teams
Availability:
In Our Lady of Lourdes, Drogheda MLU, Cavan MLU, Wexford, Waterford, The Coombe, National Maternity Hospital, CUMH, The Rotunda, UCHG, St Luke’s Kilkenny.
Advantages:
These midwives work as a team to provide continuity of care in various components of pregnancy to ‘low risk’ women. Women can get to know this team throughout their pregnancy before the birth of their baby. Appointments can be made in a satellite facility so there is less need to attend the maternity unit antenatally. Some teams provide low tech hospital birth and others a combination of hospital births and home births, and others do not provide or engage in the labour and birth. So for example some teams only provide antenatal and postanatal care either in the community or at home. Other teams provide full continuity of care from antenatal to intrapartum and postnatal care both at hospital and at home. Early transfer home is an option here (within 24 hours of an uncomplicated birth) with postnatal care continued in the community. With this option people can receive up to five days of postnatal care in their home by a community midwife following early discharge from hospital.
Disadvantages:
The strict criteria women must meet to remain at a ‘low risk’ status is becoming narrower and narrower so women can find they are ‘risked out’ of this pathway during pregnancy. Sometimes women will find themselves referred to an obstetrician for further evaluations and their care is not transferred back to the community midwifery team. It is not available to all women in all units. Staffing issues in some teams may mean early transfer home is no longer an option at the time a woman births.
Homebirth via the HSE homebirth scheme
Availability:
Limited geographic availability (contact your local DMO (Designated Midwifery Officer)local maternity unit or Self Employed Community Midwife (SECM) directly for information.
www.homebirthireland.com
https://homebirthwithcmaireland.com/
https://www.hse.ie/eng/services/list/3/maternity/homebirth-services.html)
Advantages:
For normal risk pregnancies and otherwise healthy women the literature shows that this is the lowest risk option for mother and infant. There are significantly reduced rates of intervention and the complications and risks associated with medical intervention. Labours are less likely to be ‘on the clock’ and induced or augmented to fit time restrictions and hospital policies. This is the only care option where 100% continuity of care is guaranteed from the antenatal period, through labour and delivery and postpartum. Antenatal appointments take place in the comfort of your own home, eliminating waiting times and giving you more time to build a relationship with your midwife. You will still be booked in with your local maternity unit so can avail of scans and have access to an obstetrician should the need arise and should you wish to consult with one. You will know your midwife very well and develop a trusting relationship with them allowing for individualised care. Midwives are trained to recognise complications and deviations from the norm and an ambulance will be on standby for rapid transfer to your local maternity unity should the need arise. Midwives are also highly trained in emergency situations and carry necessary equipment and medications in the unlikely event that they are necessary. The flow of oxytocin (the love hormone necessary for stimulating uterine contractions in labour and the release of beta-endorphins for pain management) flows much more easily in familiar surroundings where you feel relaxed, comfortable and loved. This means you are far less likely to suffer from labour dystocia and the need for augmentation and pharmacological pain management is reduced. You are in your own home immediately after birth and can eat, shower and rest in your own bed after labour (and have much more control of this environment than you would in a hospital.) You may also take this option and share care with your GP provided your GP is insured to provide you with care during your pregnancy. You may also share care with your maternity hospital, taking some visits at home and some in the maternity hospital.
Disadvantages:
There is a huge shortage of SECM’s meaning this service is not available in all areas of Ireland and midwives book up very fast. Ongoing changes with the provision of this service means that each individual maternity unit is assessing the ‘risk’ of women who wish to opt for this option so there is no longer a clear national protocol of who can avail of this service and who cannot. Some units (for example Limerick Maternity Hospital) are not engaging with the National Homebirth Service at present. As with the community midwifery scheme the ever tightening eligibility criteria means many women are ‘risked out’ of this option early in their pregnancy or throughout. Often when a referral is made for with an obstetrician care is not transferred back to the SECM. If you do transfer during labour or the postpartum period your midwife becomes your birthing partner and your care is transferred over to the hospital team (unless you are availing of a homebirth scheme via the hospital team for example The National Maternity Hospital.) You do not have access to a range of pharmacological pain relief other than gas and air and will need to transfer if you wish to have an epidural. If a caesarean is required you will need to transfer into the hospital (however a midwife will base her recommendations and her observations on this transfer time so will likely transfer before an emergency situation arises.) Some people also fear the ‘mess’ of a homebirth however midwives are experienced in this area and are well equipped to assist with the clean-up and you can plan ahead for this. Due to the insurance policy held by the majority of GP’s in Ireland many are no longer covered to provide shared GP care for women availing of the homebirth service.
Private Midwifery Care via Private Midwives Ireland
Availability:
As above limited by geographic availability of midwives. This is the only service in the country which provides fully individualised care and risk assessment so a decision is made on an individual basis whether a woman is suitable for this service or not. As with private obstetric options some health insurers provide coverage for this service depending on the policy held.
Advantages:
All of the benefits of homebirth outlined above apply here. The major advantage with Private Midwives Ireland is that because they hold a different insurance policy to those working within the HSE the strict policies, guidelines and hospital protocols that SECMs and other care models have to work within do not apply to private midwives. This means that they can evaluate the fully picture of a pregnant woman opting for this service and make an individualised assessment of the woman’s risk. This means women are far less likely to be ‘risked out’ of care when they ‘tick a box.’ There is more scope for midwives practising in this model to care for women who have had a previous caesarean, have tested positive for gestational diabetes and are taking other medications. You remain booked with your local maternity unit so you still have access to an obstetrician and all scans and screenings you may wish to avail of. Even if you choose to transfer to the hospital at any point you can still receive care in your home for up to six weeks after birth depending on the package you choose.
Disadvantages:
All of the disadvantages for homebirth apply here. There is a cost attached to this option. As this option is outside of the HSE an ambulance will not be on standby during labour, instead an ambulance will be called if necessary or you can transfer in by car or taxi.
Obstetric care
Obstetric care takes more of a medicalised approach to childbirth and its popularity is based on the cultural assumption that birth is dangerous unless closely medically managed, and that women do not have the capacity or inclination to birth without medical intervention. So those involved in offering obstetric care tend to have the philosophy that anything bad could happen at any time and therefore the more technology available the safer mother and baby are. This approach was heavily parodied in the Monty Python sketch from the 1970s entitled “The machine that goes beep”.
Again recent research has shown that more technology does not necessarily improve safety in terms of mortality for mother or baby. However, many women feel comfortable with obstetric care as the idea of a heavily medicalised setting makes them feel safer, and women will always birth best where they feel safest. For 15% of the birthing cohort with elevated risk factors, obstetric care is a necessity and may be a life saver.
Public obstetric care.
Choosing obstetric care can cost nothing too. You will attend a standard outpatient clinic and be attended by an SHO and midwives. You will be referred to a registrar if necessary, and your care will be overseen in general by a consultant obstetrician, although for many women this amounts to no more than having the name of the consultant on their chart. In the larger maternity units you will be unlikely to see the same SHO again. Whilst your care will be essentially obstetric antenatally, the birth will be attended by midwives and your postnatal care will also be provided by midwives in a public ward (around 8 – 18 beds).
Availability:
In all maternity units and hospitals in Ireland
except fully private hospitals.
Advantages:
No fees or additional costs associated with this option. In outpatient clinic appointments you will generally be attended by midwives and junior doctors and a referral will be made to a registrar or specialist consultant should it become necessary during pregnancy. Care will be overseen by a named consultant. Your birth will be attended by the same midwives who attend all births and postnatal care will be led by the same postnatal midwives who care for all women also.
Disadvantages:
This is obstetric led care and is associated with higher intervention rates. There is no guarantee you will meet the same midwife or junior registrar or junior doctor at antenatal appointments. You may never meet your named consultant though they are responsible for your care. Public wards can be rather crowded in the post natal period (8-18 beds.)
Semi-private obstetric care.
If you have private health insurance you may wish to attend a semi-private clinic in which case you will be attended by a registrar working in a team with midwives and under a consultant obstetrician. You may see the same registrar again, depending on the size of the maternity unit. Again, whilst they will provide you with antenatal care, the birth will be attended by midwives and your postnatal care will also be provided by midwives in a semi-private ward (around 4 – 8 beds).
Availibility:
In the Dublin maternity hospitals. Private health insurance provides some coverage toward this option depending on the policy held.
Advantages:
Your care will be managed by a named consultant but you will not necessarily meet your lead consultant at every visit. Antenatally, you may meet them or one of the senior registrars on the team and also possibly junior registrars. You will have access to a semi private ward in the postnatal period. If a caesarean is required or elected a Senior Registrar will normally perform the procedure.
Disadvantages
This is a costly option with fewer overall benefits than private care. Again the same midwives who care for all women will care for you during your labour and the postnatal period. Obstetric led care for normal risk women is associated with higher rates of intervention (as above.) Early transfer home is not an option with this care pathway. Contrary to popular belief this care option does not guarantee reduced waiting times for antenatal appointments in fact the opposite is true with semiprivate options having the longest waiting times for antenatal appointments. In this option you also do not have continuity of care as it is likely that you will not meet the same doctors consecutively..
Private obstetric care.
Fully private care means that you will have full continuity of care (always see the same consultant) antenatally. Even with fully private care, your labour will be attended by midwives. If you are not in a FULLY private hospital these will be the same midwives that attend EVERBODY, public, semi private and private. Your consultant obstetrician will be present for the latter part of the birth where possible, but your postnatal care will be provided by midwives. You may be offered a private room, but you may also end up in a semi-private ward (4 – 8 beds).
Availability:
In all maternity units and hospitals in Ireland. Private health insurance provides some coverage toward this option depending on the policy held.
Advantages:
One of the main benefits of this option for many women is the guarantee of antenatal appointments with a chosen named consultant for the duration of pregnancy. Other than homebirth this is the only setting where continuity of care is guaranteed. If a caesarean is necessary or an elective caesarean is the preference for the woman the consultant will perform the surgery on an agreed date. The woman may also have access to a private room in the postnatal period (however this is not a guarantee.) If not possible she will normally have access to care in a semi private ward (6-8 beds.)
Disadvantages:
Even with private health insurance this can be a costly option. This care pathway is known to lead to higher rates of intervention (induction of labour, caesarean births and assisted deliveries.) The consultant will be contacted should you present in physiological labour however your care will managed by the same midwives who care for all women in the labour ward and the postnatal ward too. Contrary to popular belief private obstetric care does not guarantee reduced waiting times in the antenatal period. Early transfer home in not an option with this care pathway. This option is being phased out as new entrant consultants will no longer be able to provide private care in public hospitals (but this will take time, roughly 10-15 years.)
GP care
Availability:
Most GPs offer this service.
Choosing your GP to provide you with the majority of your care will usually be in combination with midwifery or obstetric care. This is usually known as SHARED CARE. Whilst GPs can attend births at home, this practice ceased some years ago in Ireland.
Recommended further reading and resources:
Please access your maternity unit/hospital’s website and ensure you read their most recent maternity safety statements to receive an up to date breakdown of induction, caesarean and assisted delivery rates.
https://www2.hse.ie/pregnancy-birth/pregnancy-care/care-options/
https://www.hse.ie/eng/services/list/3/maternity/homebirth-services.html
https://www.hse.ie/eng/about/who/national-office-human-rights-equality-policy/consent/#:~:text=The%20HSE%20National%20Consent%20Policy%202022%20provides%20one%20overarching%20policy,with%20people%20in%20all%20locations.
https://www.hse.ie/eng/services/list/3/maternity/mpss/
https://www.rachelreed.website/
Down to Birth Podcast
The Midwives Cauldron Podcast
The Great Birth Rebellion Podcast
The Doulaverse Podcast
Dr Sarah Murphy: Instagram
Dublin Doulas: Instagram
What women said about their care providers:
“I found standard public care a very lonely experience as no one was particularly interested or personally involved in my care. I felt that I was just a chart number.”
“I went public with the doctors and I found that I had to keep repeating my story over and over at every appointment. As the appointments were very short I spent most of them just saying the same things over and over again to different people.”
“I chose private obstetric care as I assumed it was the best care for me and my baby, I liked the idea of not having to wait for antenatal appointments and I found the consultant very personable and pleasant, the only problem was when I wanted to discuss how the birth would go and the choices I wanted to make, then I found him quite evasive. I realised in the end this was because he was not actually going to be there for most of the labour! I didn’t know this at the start. He was very supportive at the end of my labour though and I had a natural birth. This meant that I did not get a private room, as they seemed to be reserved for the mothers who had had Caesareans, so I left the hospital early.”
“I desperately wanted evidenced based care, but because of my (non-evidenced based) risk factors I was denied the type of care I had hoped for. So in order to get the best I could I mixed and matched my care taking a combination of private obstetric care and public midwifery care.”
“I had had a very difficult first birth in hospital and I chose to have a midwife attend me at home for my second baby. It was an amazing experience and I found her attentive to my every need. My labour was fast and easy because I trusted her so implicitly. I felt so sad when the day of her last visit came!”.
“I had my first baby with a community midwifery team. I found them very supportive and was delighted that I was able to have my baby at home. I had my sister with me for the birth and she was a great support as she had had three babies at home herself. When I had a breastfeeding problem just after the baby was born the midwives came straight out to me and I thought that was an amazing free service”.
“I was expecting twins and as they only had one placenta between them I was put into a high risk category. I attended a public twins clinic and received excellent care. I had an elective section but recovered well afterwards. I was only disappointed in the way that my babies were treated in the special care unit. I thought that if I had been with a private consultant they might have received better hygiene”.
“I went for semi private shared care as my GP is great on birth and babies and so I wanted to have as many visits with her as possible. I went for semi private care as I couldn’t bear the thought of the long waits for hospital appointments with my 19 month old.”
Limitations on choice
Choices in terms of maternity care provider are limited by several factors. For example the capacity to pay for particular services may limit your ability to avail of them, if you want to have the option of a single room in a maternity unit after your baby is born you will need to pay for that choice. Nightly rates in maternity units can cost up to €1,000, double that if your baby is in private NICU care. It is always assumed that if you are a private patient, your baby will be too unless you explicitly state otherwise.
Risk factors may also determine the choices that are available to you. Identifying risks in pregnancy for mother and baby are a fundamental part of antenatal care, especially in an obstetric setting. So for example even though you may be asymptomatic you may still now be tested for conditions that it is unlikely that you have. Any unusual readings will automatically alter your risk factors and may for example eliminate you from midwifery-led care. Some commentators would argue that there is too much of an emphasis placed on risk, and that all births no matter how medicalised, carry some element of risk, and that risk can never be truly eliminated, only be kept to an acceptable level. Difficulties arise for mothers when the evidence identifies them as being in one risk category and the HSE in another, or when the evidenced based research suggests a particular course of action for an identified risk factor and the HSE another. Finally there is the problem of elevated risks being acknowledged on all sides for a particular care option, but mothers still seeking that choice of care provider.
Do mothers have the right to choose care provider or the course their care will take?
The European Court of Human Rights seems to think mothers (and fathers) have the right to choose the circumstances by which they become parents. This was a judgment passed in December 2010, yet in Ireland we have seen a mother taken to an emergency sitting of the High Court in March 2013 because she wanted to exercise her right to choose how she had her baby. It would appear that the HSE plan use this recourse when presented with women trying to fully exercise their choices in birth. For more on this topic see the AIMS Ireland blog space.
Geographic location also plays a major factor in determining choices available to women in terms of maternity care provision. For example, women living in Dublin have access to three maternity hospitals, all of which are national referral centres. They also have access to Our Lady Of Lourdes Drogheda if they are based on the northside, and to Mount Carmel private hospital. In addition they will have access to 6 self employed midwives. This gives them access to a wide range of care options. By comparison women living in Donegal have access to one maternity unit, which provides essentially one mode of care. Improving equity in geographic access to services requires impetus from the Department of Health as well as the HSE, and AIMSI, as well as other advocacy groups, have brought these issues to the attention of several Ministers of Health.
Service provision and availability will also limit choices that you can make about your care. Some choices in care provision that are widely available in other jurisdictions are completely unavailable in Ireland. For example Free Standing Birth Centres do not exist in Ireland and yet they are commonplace in the UK. Independent midwives no longer exist in Ireland, as self employed community midwives are bound by rules the HSE have set for them and therefore are no longer self autonomous. Private Midwifery Providers exist and they operate outside the rules the HSE have set as they are not insured via the HSE but they practice within the remit of a company and not individually. Independent midwifery still exists in some States in the USA, in Australia and still very precariously in the UK. Waterbirth in a hospital setting is a very popular choice in the UK and there are many videos abound with this on YouTube, however waterbirth in a hospital setting is not currently available in Ireland. It is however available from some midwives in a homebirth and labouring in a birth pool is available in some hospitals, notably Waterford, The Coombe, OLOL MLU, Cavan MLU and Cork University Maternity Hospital (CUMH).
Other choices, whilst available in Ireland, are very limited in their availability. In this category are options for midwifery-led care which currently only exists in six maternity units, OLOL MLU, Cavan MLU, NMH DOMINO, Wexford DOMINO, Waterford DOMINO and the Coombe Community Midwifery service. Only three of these midwifery-led options offer homebirth as part of their care options, NMH, Wexford and Waterford, and even as I write some of these are under threat. In the UK by comparison a homebirth service operated by the NHS is widespread. Caseload care and continuity of care (where you see one person all the way through) remains the domain of the self employed midwife, whilst the choice of bringing in second birth partners is still limited to specific units and even then usually only by prior request, yet doula care is as common as birth itself in the USA and even in the UK it is popular.
However, it’s worth noting that 20 years ago the only midwifery care option in Ireland was home birth, so a lot has been done in the last 20 years to widen and improve normal birth care for women in Ireland, but there is still a lot left to do. Choices will only improve if the care providers realise that there is a demand for particular types of care provision. So if your maternity unit or the HSE does not provide you with a care option that you would like, make sure that someone knows about it, because it’s us, the women, that will ensure change happens, if not for us, then for our daughters and granddaughters.
Remember if you feel that your care provider is not offering you the choices that you want ,it is always possible to change care provider at any point in your pregnancy and it is always your right to seek a second opinion.
Choices beyond care provider
Some of you may be reading this and thinking “I have made my choice as to care provider and I don´t feel I want to change that now, are there any other choices that I can make so that I can get the care I want and the most positive birth experience possible?”
The best way to ensure this is to be aware that all the way through your care during pregnancy, labour, birth and afterwards you always have a choice as to whether you accept a particular type of care or intervention, and that you make an informed choice to accept a certain type of care or to refuse it. This is usually known as giving informed consent or informed refusal.
Informed consent and informed refusal
Informed consent is a bit different to plain old “consent”. Plain old consent is where the care giver takes it as a given that you are agreeing because you seem to be accepting, or because you do not actively refuse. So for example if you “hop up on the bed” as asked, it might be assumed that you are giving consent for an internal exam and a sweep, even though you might be a bit surprised that that is the way things are going. Informed consent is where all the advantages of making a certain choice are outlined, as are all the disadvantages of that choice (if any) and the pros and cons of doing nothing at all is also discussed. Informed consent is a lifeline to ensure that you are a co-creator in your care plan and that you have the birth experience you are hoping for.
Choices you may be asked to make antenatally
Women who have opted for midwifery care, may have the option of attending a satellite clinic rather than their maternity unit for antental visits. Mothers report that these are usually easier to get to with better parking facilities. They also say that the waits for appointments are shorter which can make a big difference for second time mothers taking a toddler with them to appointments.
Other choices include what type of scan to have and when to have it. Research shows that scans for the purpose of dating the pregnancy are most accurate if carried out before 12 weeks. Some mothers also opt for nuchal scans to identify chances of Downs Syndrome. Other tests include blood tests to check blood type, Rhesus sensitivity, iron levels, rubella immunity, evidence of sexually transmitted diseases (including HIV). More and more units are now offering a Glucose Stress Test (GST) to all mothers. As with choosing to avail of any medical test it is always worth considering what you will do differently based on the results.
Another important choice to make during the antenatal period is what type of antenatal classes to attend. Most hospitals offer antenatal classes, but many focus on pain relief and informed compliance with hospital policy. Many mothers find that antenatal classes in the community give greater pointers as to how to prepare their bodies and minds for birth. Mothers find that antenatal yoga is very physically helpful and relaxing. Some mothers chose to prepare mentally and emotionally with visualisation exercises and other mothers find that complementary therapies such as acupuncture reflexology and homeopathy are helpful in preparing their bodies for birth. The best way to find a class that suits you is to talk to other mothers in your area.
As your pregnancy draws to a close you may be offered interventions to bring forward your labour such as a sweep or even an induction of labour. We will be talking in detail about these choices in a later post, but it’s worth noting that one of the reasons we have such a high Caesarean rate in Ireland is because of our high induction rate.
Choices you may be asked to make during labour
During labour there will be many choices available to you. The one that seems to get the most air time is how to manage pain. This of course builds on the assumption that birth is painful! There are low tech choices here and high tech ones. Low tech choices usually rely on some form of preparation and awareness, or perhaps simply on the right support, high tech ones rely on the use of narcotics from opiates to drugs that alter the way you perceive things. Whilst the birth of your baby may be a long way away these are choices that are worth considering and preparing for before you go into labour. You can find out more about these choices on subsequent posts.
Another big choice to make is when to unite yourself with your care provider! For the majority of women this will mean deciding when to go to hospital. It is a difficult choice to make for most first time mothers as its hard to self assess what the different sensations of early labour mean about your progress and the length of time left until the labour gets more intense. Also, you, or more likely your partner will need to determine whether the traffic or weather conditions will impede your trip to the hospital. As first labours tend to be longer than subsequent ones, most first time mothers generally have ample time in which to arrive. As each labour is different many second time mothers may find that the signposts from their first labour no longer apply to their second labour, and they also arrive too soon.
Historically, arriving too soon was not a problem, but in today’s busy maternity units where space is at a premium, mothers report that choosing to arrive too soon may diminish their choices about their subsequent care. For example, they may find it harder to make the choice to let their labour unfold slowly, or if they arrive in the middle of the night they may not be progressed enough to go to the labour ward proper and may instead have to labour on their own in an antenatal ward without their partner until visitors can be admitted. Arriving too late can also be shocking, but it is still a relatively rare occurrence in cities. If it does happen, it rarely happens because there is a problem, and nature will just take its course.
For mothers who are birthing at home the decision will centre on when to call the midwife. Most midwives ask that you let them know that things may be starting so that they can organise their day or night around you. If you are planning to have a waterbirth they will give you specific instructions on when to start filling the pool.
Another important choice to consider about your labour is who you would like to have with you as your partner or whether you would like to have a birth support partner in addition to your first birth partner. Most women chose to have their life partners as their birth partners and if this feels right for you it is probably a good idea to make sure that your partner comes with you to antenatal classes so that s/he is well prepared. If you would like to have an additional partner such as your mother or a professional birth partner (a doula) then it is probably wise to let the hospital or midwife know in advance that you plan to make this choice.
In addition to whom you bring with you to the hospital for support there are many choices as to what you will bring with you for physical or emotional support. The lists of such supports are endless but it is worth thinking of them in advance. They include things like a birth ball, aromatherapy oils, music, high energy drinks, comfortable clothes etc. For those birthing at home everything you need in terms of comfort should be readily available to you, but its perhaps wise to put them into a “birth box” so that your midwife doesn’t have to go rooting into the 4th drawer of the chest of drawers in one of the bedrooms to find something!
There are also interventions to choose from. Many hospitals will offer you the choice of interventions to speed up your labour or to make your labour more comfortable for you. Even though these interventions may appear to be hospital policy they are still choices that you have to make and it’s important that you are party to making them. Such interventions include breaking your waters (Artificial Rupture of Membranes), which will release the amniotic fluid that surrounds your baby. Many mothers report that this made labour more intense and less comfortable. Other interventions include repeated vaginal examinations which the research shows us make a mother more exposed to infections especially if the waters have been released. Other common interventions centre on pain relief. Commonly offered forms of pain relief include pethadine (by an injection into your thigh), gas and air which you breathe and epidural by a final needle into the epidural cavity in your spine. It is your choice whether you take any of all of these forms of pain relief, but each of them has consequences for you in terms of further choices in the birth process. For example, epidural requires a catheter be inserted and IV fluids hooked up and its use may also impede your chances of birthing your baby without assistance as you will have no sensation about which position bests suits your baby to be born.
Choices you may have to make during a vaginal birth
As the first part of the labour draws to an end and it looks like birth is close, there are other choices for you to make. You can choose which position best suits you and your baby. Most mums immediately hop up onto the bed for birth and many think that it is appropriate to lie on their backs. Neither of these is instinctive or the choices women would naturally make to enable an easier birth. Research shows us that choices in which gravity assists the birth make the process easier; these include kneeling, standing, squatting, being on all fours and leaning over the bed.
You also have a choice about how you release your baby or actually birth your baby. Most mothers believe that they have to actively push their baby out with all their might with every contraction. Again research shows us that this is not necessarily best for mum or baby. However if you have chosen an epidural you will find your choices here limited as you will need to be helped by your midwife with pushing as you will not have any sensation as to what your body needs you to do. Once your baby nears birth, you have the choice of who is going to catch the baby. 99% of the time it is the midwife, but sometimes couples choose for the partner to catch the baby as it is born.
Interventions you can choose to have during the birth of your baby range from mechanical assistance in which a doctor will use forceps, or a vacuum suction cup, to pull your baby out, to episiotomies where a doctor or a midwife will cut your perineum rather than allowing it to stretch slowly to accommodate the birth of your baby’s head. These types of choices are more commonly offered to mothers who have already chosen an epidural earlier on in their labour. Mothers report that the wound from an episiotomy takes longer to heal than the wound from a small natural tear and that the number of stitches used to heal the episiotomy cut afterwards can sometimes be extensive. Research seems to indicate that unlike previously believed ,choosing an episiotomy does not avert serious tears but sometimes can even be the cause of them.
Choices you may have to make during a Caesarean birth
If you already know that you are having a Caesarean birth, there are still choices that you can make. As with mothers having a vaginal delivery, you can choose whom to have with you in theatre, and also you can choose some small measures of comfort such as music. You may ask the surgeon to tell you when the birth is imminent so that you can release your baby. Some mothers report that putting a gown on with the ties to the front means that their partner can untie it easily to enable skin to skin contact with their baby once the baby is born. You can also choose to have contact with your baby, provided s/he is well immediately after the birth. Many mothers are now choosing for their baby to remain with them after birth in the recovery room. If this is a choice you are interested in, you should discuss this with your care providers before the event so that appropriate arrangements can be made.
Choices you may have to make just after your baby is born
Immediately after your baby is born you will need to choose whether you would like to have the umbilical cord clamped immediately and an injection given to you to force your uterus to expel the placenta, or whether you would like to leave the cord to pulsate for a longer length of time before it is clamped. Research shows that delayed cord clamping allows your baby to receive the maximum amount of oxygen possible after the journey of birth.
After your baby is born the midwives will carry out standard checks on your baby to determine how well s/he has coped with the birth. You can choose to have these carried out with the baby placed on your chest if you do not want to be separated from your newborn baby. Most maternity units now offer skin to skin for mother and baby directly after the birth as it has been shown to be the best regulator for body temperature breathing and warmth. It also helps the baby to initiate breastfeeding. If you do not want to have your baby placed on you or if you chose for your partner to hold the baby you will need make sure that your midwife is aware of that choice.
Most mothers choose to leave their placenta in the hospital for the hospital to incinerate or otherwise dispose of. However, you might choose to bring your placenta home with you. Some mothers are now using the beneficial products in the placenta by having it encapsulated, or alternatively some mothers want to bury the placenta in their own garden. If you choose to take your placenta home with you, you will need to advise the midwife in advance and you may have to sign some paper work before hand.
Breastfeeding babies are offered vitamin K, and you will need to choose whether you wish to have this at all or if you do, whether you wish to have this administered by injection or orally via drops. Some maternity units will also offer your baby a BCG jab whilst in hospital, and it is your choice whether you want to have it administered then or later by your GP.
Choices in the postpartum period
If you have had your baby in hospital, you may have a choice of whether you remain in a hospital postnatal setting or whether you would like to come home early and be cared for by midwives in the community for an average of five days. Mothers who have chosen this option in the past have unanimously commented on how helpful they found it as well as how calm and intimate their early days with their newborn baby was.
Most maternity units now assume that you will breastfeed your baby as the research shows us that this is best for your baby and for you. If you choose to give your baby artificial milk then you will need to ensure that your carers are aware of that choice and that you are not harried in any way to breastfeed.
Your birth. Your baby. Your choice
As you can see, pregnancy and birth are full of choices that need to be made. Different care providers are more likely to support particular types of choices so it is better that you know what type of choices you want to make in the beginning and that you align yourself with carers that are more likely to support those. Nonetheless, even if you find yourself in a care setting that seems to favour choices that you would rather not make, remember you cannot be forced into them, even if they might be general hospital policy. The one exception to this rule MAY be if your care givers feel that you are putting the life of your baby at risk, in which case legislation intended to prevent abortion may be invoked to prevent birth choice. This is a topic that AIMSI are very aware of and you can find out more about it on our other blogs.
As a parent you will need to make choices for your baby, toddler, child and teenager, choosing how they are born is but the first of many.
AIMS team – May 2024