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Discussion Forums » General Discussion
My OB said WHAT?!
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5 Apr 2011, 11:35
Mojo Jojo
Post Count: 278
I think the major reason for the difference in UK and US obstetric care is money. The UK health service is nationalised and funded, so more concentrated on avoiding expensive drugs, intervention and caesarean. The main pain options offered are entonox (gas+air), pethidine, diamorphine in SOME places and epidural. But the whole outlook of midwifery vs obstetric run care is so different. When you're in labour in the UK, if everything's gone to plan, you phone and speak to a midwife and they tell you to go and take some paracetamol and have a bath. They tell you not to come in until your contractions are coming so many minutes apart and lasting so long. They actively discourage you from panicking and going in until you're well into established labour. If you go in too soon (before 5cm), they send you home again unless you really can't cope. The OB is only involved if there's a problem. When I have my homebirth, I'll be attended by two midwives. They'll be there to stitch me up if I rip (I did first time round), and are trained to deal with all sorts of relatively minor complications. I don't expect to need a hospital transfer unless the baby becomes distressed. I get told this is 'brave', but really there's no greater risk at home than in hospital, as long as the birth remains uncomplicated.

I was lucky to have a brief labour with my little boy, but I could only NOT deal with the pain for the last couple of contractions during transition, when I needed to push but couldn't coz I wasn't in a safe place. I did the whole thing on one paracetamol.
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5 Apr 2011, 14:51
starsmaycollide
Post Count: 408
mojo jojo- agreed, the fact that the UK has a nationalized system makes a huge difference in approach as well as the way we tend to do things in an overly cautious way due to risk of litigation.

here they also tell women not to arrive until labor is well established or they will send you home. my plan was to go in when contractions were 5 minutes apart, lasting a minute for at least an hour. the '411' or '511' is the common guideline. but I had prodomal labor for 4 days, so my '511' was with weak contractions and then they never got where they needed to be with time. not sure how many cm you have to be to be admitted at my hospital, since I went in on day 4 after my water broke at home.

I definitely wish I had the option of gas and air, but they don't do that here for whatever the reason. (at least not yet, where I am.)
and the funny thing about how they insist we have OBs is, they are barely there at all. my nurses are the ones who did all the work! I saw my OB twice. once after hours of labor to tell me I needed pitocin, and then at delivery. so it's strange to me that we can't just have midwives then. as I've told Alison many times, the UK system/approach makes a lot more sense to me.
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5 Apr 2011, 17:08
Mojo Jojo
Post Count: 278
See, if you'd been in the UK, your delivery would have been handled very differently. Once your waters break, you have 24 hours to dispel the baby before they admit you, and start you on IV antibiotics, and augment the labour with syntocin, if you're not dilating. When I had my son, the guideline was 48 hours (my waters broke a few hours before active labour kicked in), but they've reduced it since then. If you're transverse, you're given a section at approx 38 weeks. If you're breech, they're reluctant to let you deliver vaginally. All guidelines are drawn up centrally and have to be obeyed right down the line, to stop litigation, basically. BUT you have the right to refuse anything you're not happy with and ask for different care options all the way through, provided it doesn't compromise yours or the baby's immediate safety.

Everyone labours so differently. Here, it's around 511, but I was contracting for 40 seconds every 4 minutes at 9cm. By the time I was in transition, I was contracting for 90 seconds every 2 minutes. The time between that change was 10 minutes, during which we were driving to hospital with me desperately trying not to push! Hence, homebirth this time, lol.

For instance, in the UK, it's standard to be offered induction of labour between 10 and 14 days post term, some places are 7d though. The risk of stillbirth increases quite a bit after 42w and quite a lot more after 43w. However, if you refuse (and they put all sorts of pressure on you not to refuse, they seem to think being pregnant for a few more days than they deem fit makes you MENTAL), you're offered daily CTGs until the baby chooses to come out. Personally, I'd rather have the more intensive antenatal care than be buggered up by a unnecessary induction and all the problems that can lead to.

Birth isn't a medical emergency, 70% of the time. I don't get why people treat such a very natural thing so clinically. Yes, it can go horribly, hideously wrong and I certainly don't advocate unassisted birth at all (although I can see that it's a rebound on the overmedicalisation of the process, esp in the USA), but most of the time, left to get on with, a baby WILL get out without assistance.
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5 Apr 2011, 20:32
starsmaycollide
Post Count: 408
@mojo jojo-Well I imagine it would have been handled differently at first- but I think given my specific circumstances it went the only way it could, honestly. Even if waiting hours ( or days, if I waited an additional 48 hours) before going to the hospital would have given me time for progress, I was too entirely exhausted several hours in to continue any further than what I did without medication. I has zero energy left, whether or not I needed augmentation , after I was up for over 24 hours. That, the back labor/ his poor positioning, combined with all the contractions in the day prior had me done.

No doubt augmentation and induction are used too often here, I totally agree. But I also feel like I should say my situation was one where I think it was actually used properly-after I did my best to go med free, I got pitocin and the epidural only when I could go no further and my body needed to help to get into active labor. Only the last 3 hours were medicated- my labor sped up completely after the pitocin was given, and my epidural worked beautifully.

In contrast to the comment below re: bee- I had the opposite experience. without meds, I would have been so loopy from lack of sleep I would have been useless. I already was before getting the epidural. With it, I got rest and was totally mentally present and alert for the birth itself. What's nice about the epidural rather than using another medication in an IV was that while my legs were numb, my head was entirely clear and I was quite happy and myself when it was time to push.
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5 Apr 2011, 20:38
Mojo Jojo
Post Count: 278
@ Stars: I agree, my point was that your case would have been one which the NHS would have intervened much quicker than the intervention actually happened. You probably would have ended up having an emergency section. Your way sounds much better. I think epidurals have their place, especially in very prolonged labours. I just think they are offered too often and too soon. An epi at 4cm in a normally progressing labour is going to slow it down. An epi at 7cm in a well established but painful or prolonged labour is going to be more benefit.
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5 Apr 2011, 20:53
starsmaycollide
Post Count: 408
@mojo jojo- This is true. I actually do think I narrowly avoided a section because things got a bit difficult at the very end with pushing, and it was because of his position.
I was totally taken my surprise by it, unfortunately. as far as we knew before labor, he was head down and anterior. Then he went a bit sideways and was born with his hand by his face. (thanks, son. lol.)

I was 6 cm when I got my epi. I am proud of myself for sticking it out that long-I was always worried about getting it too early and having it slow things down. I think getting it when I did definitely helped it go well.

Best wishes to you with the home birth! Since your first was fast, hopefully your second will go smoothly too if not even quicker!
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5 Apr 2011, 20:55
Mojo Jojo
Post Count: 278
@stars I pushed for 55 minutes with my son. I could feel it, and it was SUCH hard work because I was on my back (shit position for pushing) and he was 9lb 1 and had a 37.5cm head circ. If I'd gone for another 15 minutes, they would have started prepping me for intervention.
I hope it's not TOO fast. Fast labours sound much better than they are - I was in shock for days afterwards.
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5 Apr 2011, 21:02
~RedFraggle~
Post Count: 2651
@mojojojo I really disagree with that comment that Lauren would have had a c-section here. I know her birth story AND work on labour ward in a UK hospital and to me it seemed to be handled in a very similar way to she would have been treated here. I also disagree that epidurals are offered too early. Our midwives encourage women to wait until labour is well established. The occassions where I put them in earlier than I'd like it's because the woman is insistent she wants it, and doesn't want to wait.
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5 Apr 2011, 21:07
Mojo Jojo
Post Count: 278
@Redfrag I've not read her story, just going by the local (Norfolk) NHS guidelines on transverse babies, which is currently do a presentation scan and offer caesarean before 39w, same for breech. I know this is current because I was threatened with it last week after a midwife palpated mine as oblique breech, when he's LOA ceph.
I meant epidurals in the US, not here.
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5 Apr 2011, 22:39
~RedFraggle~
Post Count: 2651
@mojojojo: my understanding of Lauren's labour (and I'm sure she'll correct me if I'm wrong) is that her son was NOT in transverse lie (which is what you describe, and requires delivery by c-section), but was head down, but in OT (occipital transverse) position. That means his head was down but he was turned to one side (usually the back of the head faces forward, OA or backwards, OP). That is a completely different situation to being transverse lie, and doesn't mean a c-section is necessary. Usually they'll turn themselves, occasionally they require forceps to turn them, but vaginal delivery is possible, and is usually tried, unless other complications necessitate a section.
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5 Apr 2011, 23:56
starsmaycollide
Post Count: 408
@Alison-yes that's right. I didn't specify earlier that he was OT and not transverse lie, so I understand now why she said what she did because she didn't have more specific information from the post . :-P
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6 Apr 2011, 08:04
~RedFraggle~
Post Count: 2651
I should also clarify... you went in on day 4 of contractions, which was the day your water broke? I think mojojojo thought you went in 4 days after your waters broke (in what she was saying about here you would be induced before that).
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6 Apr 2011, 08:10
Mojo Jojo
Post Count: 278
@Lauren @Redfrag I read it as Lauren went in 4 days after her waters broke with a transverse baby.
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6 Apr 2011, 14:08
starsmaycollide
Post Count: 408
Yes, my apologies to mojojo for confusion earlier. I had contractions regularly for 4 days and my water broke at 10:45 PM on day 4. We went in immediately after that, I was shaking and the contractions got considerably more painful and were regular. I said so because after dealing with them for days (as well as the after breaking in a gush, not a leak), I wasn't the least bit interested in stating home any longer and wanted to know what was going on.
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6 Apr 2011, 16:53
~RedFraggle~
Post Count: 2651
I honestly think you and your doctors made all of the right decisions regarding your delivery. And I really think you'd have been treated in the exact same way here. I'm really glad, given some of the birth stories I've heard from Americans!
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6 Apr 2011, 18:24
starsmaycollide
Post Count: 408
well thank you, and I agree. I feel we did what we could and had the best possible outcome. :) Also, I am glad you heard my story too, because I really don't think it's always as 'bad' as it sounds here when it comes to maternity care. For obvious reasons it's not an ideal healthcare system anyway (you know I like yours better! lol) , and there are a lot of things that should be done differently for sure, but it's not all negative. And more specifically, medicated births are not negative experiences. My only regret about the whole thing is that if we have another baby, we'll be living somewhere else by then due to Chris graduating-because I would really like to do it all again with the same caregivers.
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6 Apr 2011, 08:23
~RedFraggle~
Post Count: 2651
@mojo jojo: Although this doesn't apply to Lauren's birth, I think women in the US are induced far earlier for prolonged rupture of membranes (far earlier that 24 hrs). In the UK it is 24 - 48 hours usually, and I think they are veering more towards the 24 hrs. That is because peri-partum sepsis is still a big cause of maternal mortality, and I know that locally we've had a few REALLY nasty cases of sepsis in women post-delivery in the last year or so, and it has resulted in a number of changes to protocols to try and reduce this risk. That said, they do let them go longer if they're pre-term. I've seen pre-termers go for 4 days after SRM, or more. They just induce then if they become concerned about infection. It at least gives them a couple of days to give steroids to help the baby's lungs, so in that case is a balance of the risks of sepsis vs the risks of really pre-term delivery.
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6 Apr 2011, 08:51
Mojo Jojo
Post Count: 278
Length of labour is usually genetic. In my family, my mum's first labour was about 6 hours, her subsequent ones were between 4 hours and 20 minutes (that was an augmented labour after 3 days prodromal). My first was 4 hours, but that includes an hour of transition. My younger sister just had a 6 hour labour with her first baby.
Your family seem to labour silently - although my labour was quick, it was intensely painful. I was 2cm dilated and in no pain at all at midnight and fully dilated in AGONY by 2:30. There was no slow build up or traditional contractions, once they started coming, they were intense. But, my god they worked! lol

To be fair to my local hospital, they were extremely busy that night - every room was full and two sets of twins were born while I was there. I'd gone in at 9:30 the previous evening with a hindwater leak, and was told I was not only not in labour, but unlikely to go into labour for some time. I don't think they were expecting me back quite so soon! The postnatal ward was similarly heaving, so I wasn't checked the next day for 5 hours at one point :S But I know many many women who have delivered there, and stories vary. The delivery ward were far better than the postnatal ward, despite being swamped with labouring women. If it was necessary, I would happily deliver there again, but I wouldn't want to be on the postnatal ward again.

They've recently reduced the PROM->induction time to 24 hours here. It was 48 hours when I had my son, 2 years ago. The longest I've heard of a pretermer going from ROM to birth is over two weeks, but her water went at 21 weeks and she was expecting twins. Miraculously, one twin survived despite being born at 23w. That was in the mid-90s, I don't know what the protocol would be now in the same situ.
Here, if you do have ROM before 35 weeks (I think that's the cut off) they admit you for IV antibiotics and steroids, but the baby usually follows fairly swiftly.
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5 Apr 2011, 20:51
~RedFraggle~
Post Count: 2651
We use diamorphine (and remifentanil, which is even rarer). Pethidine is a horrible drug. Diamorphine is illegal in the US though because of fears about heroin abuse (quite ridiculous as there's no connection between it's use in inpatients and use as a street drug).
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5 Apr 2011, 20:53
Mojo Jojo
Post Count: 278
And it's JUST pethidine here, mixed with delicious phenergan. They have to pre-prescribe it to take out to homebirths, with it being a CD, and the midwife couldn't believe I didn't want it as a backup.
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7 Apr 2011, 06:58
Meghans Follie
Post Count: 433
we call diamorphine - Dilaudid (according to webmd they both are a form of hydromorphone but I could be wrong) here and its commonly used for post op- and in place of the "old" standard morphine. I was given it with Ki in early labor because of my allergies to locals, having been up for 48 hours they thought it would help me sleep until I was in more active labor.. (first water had been broken but was only 4 cm for HOURS)
However with Chey (youngest) I was given pitocin (sp?) and only allowed to have stadol and no pain medication as it suddenly in the span of 4 yrs was frowned upon to give narcotics during labor
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7 Apr 2011, 09:09
~RedFraggle~
Post Count: 2651
Diamorphine and hydromorphone are two completely different drugs (although both of the opioid variety). I've never seen hydromorphone used. Diamorphine is the same as heroin, and I'm sure I read somewhere that it is illegal in the US because of fears over drug addiction (even although we only use it acutely in the UK in very specific types of pain, like labour, and palliative medicine). According to what I can find on google, dialaudid is the trade name in America (we generally use generic names for most drugs, I think the reason you guys use so many trade names is because of the private healthcare system) for hydromorphone, so that is different. I'd doubt you'll find a trade name for diamorphine, if it's not actually used there. But I'm pretty sure it's NOT dialaudid.
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5 Apr 2011, 20:55
~RedFraggle~
Post Count: 2651
@mojojojo but really there's no greater risk at home than in hospital, as long as the birth remains uncomplicated.

It's that last bit there that is important. Because there's no way of predicting who will have complications. I believe home births should be permitted but I also think woman should be fully aware that it DOES carry a risk, and happy in their own mind that they're prepared to take that risk. I think it should be their choice, but a fully informed choice.
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5 Apr 2011, 21:01
Mojo Jojo
Post Count: 278
Well, just to use my situation as an example - I'm having a homebirth coz I had precipitate labour with my eldest, because my postnatal care was shit last time and for social reasons (me and my husband split up a few months ago, I have no transport, he's unsupportive and I have a toddler - best they come to me, and I think I would crack completely if I had to sit and look at all the happy families on the postnatal ward).

However, I have had to be really careful because if my BP goes high, I can't have a homebirth. If my baby came before 38w or comes after 42w, I can't have a homebirth. If my B12 level becomes unmanageable, I can't have a homebirth. If my baby's growth remains static, I can't have a homebirth. There are so very many boxes to tick. However, should everything remain dandy and then go horribly awry at some point during labour, I'm less than 10 minutes from the hospital by blue light. Otherwise, as soon as I phone them, they shall come and help me deliver nice and messily in my lounge.

I think women need to have the choice to deliver at home, or unassisted childbirth will become more common in this country. I've never forgotten reading someone's blog on OD after having a UC and delivering a stillborn baby.
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5 Apr 2011, 22:27
~RedFraggle~
Post Count: 2651
UC? 10 mins is a REALLY long time when a baby is in distress. If a baby becomes severely depressed in hospital, or if for example a woman has a cord prolapse, we can do a crash section and have that baby out in 15 mins (5 mins prep, 5 mins anaesthetic 5 mins surgical). If this happens at home, even if you're 10 mins away, by the time you wait for an ambulance, get to hospital, get to labour ward and the operating theatre, get your anaesthetic, the baby won't be out for 30 - 45 mins. Which could well be too long. The mother has to understand that risk.

Quite ironically I just had to take a break from this discussion to go do an epidural!
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