My baby is due on 3rd January 1998, and I am planning a home confinement. Below follows a description of how I would like my birth to happen, and what I would like in case of various emergency contingencies.
I would like to spend much of early first stage alone with my partner and my sister, and probably my daughter. I would prefer not to have the midwives or my GP attending until labour is established (about 4 cm dilation) and progressing well, although I will of course keep in touch with them over the phone. I am happy for them to come once earlier on to check me out and monitor the fetal heart tones to ensure everything is fine, but unless I am about 4 cm dilated, I would request they leave again unless it appears that dilation is progressing very rapidly. I anticipate since this is the first time my cervix has dilated that this part of labour may be quite prolonged.
I wish the midwives to keep internal exams to an absolute minimum during established first stage labour, certainly no more frequently than one every 6 or 8 hours up until the time I begin to feel "pushy". If I feel the need to know how much my cervix has dilated, I would prefer to check it myself, or if that is uncomfortable, have my partner check. I do, however, reserve the right to change my mind about this at the time.
If my membranes should rupture early, I request that after an initial exam to check for cord prolapse and presentation, and later, if indicated, one to take a high vaginal swab to check for infection, no further internal exams be given in order to reduce the chances of introducing an infection. I will of course monitor for any signs of infection, taking my temperature regularly, and lacking any signs, and with good strong fetal heart tones, I do not wish any arbitrary time limit to be put on the length of labour following early rupture of membranes. I understand that the protocol in Colchester is not to allow longer than 24 hours after PROM without progressing labour being established before recommending induction, but I also know that the protocol in other places (such as Ipswich) is 4 days. Therefore I take responsibility for refusing induction measures should my membranes rupture more than 24 hours before labour is established. I do not want my membranes to be ruptured artificially at any time during first stage labour, although I reserve the right to change my mind about this.
In fact, as long as the baby is doing well, my contractions are continuing, I am not exhausted, and there is no pain at my scar site or any other signs of problems, I want to be allowed to labour for as long as it takes, even if it is 36 hours or more. I anticipate that if first stage continues much over 48 hours, then I will begin to be exhausted, and transportation to hospital will be a reasonable option, but I want that judgment to be made on my condition and the baby's condition at the time, not on some rigid predetermined cut off point.
During early first stage (up to 4 or 5 cm dilation) I anticipate I will be doing a lot of moving and walking, to encourage labour to progress. I may also wish to employ nipple stimulation or possibly (in the absence of ruptured membranes) sexual intercourse to encourage the progress of labour. I may also choose to use the herbs Goldenseal and Raspberry leaf, both of which have a well established reputation for maintaining strong and productive contractions. During this time I will be using visualisation and relaxation techniques to handle pain.
I plan to use a birthing pool for pain relief during later first stage labour. I do not anticipate actually giving birth in the pool, but I want to leave that option open depending on how I am feeling at the time. I anticipate not only will the pool help me to relax and handle the pain, but it will also soften and loosen my perineal tissues, reducing the likelihood of tearing during second stage.
Throughout labour, I will be eating lightly and drinking herbal teas, fruit juices, and sports drinks (for electrolyte balance) regularly to keep my strength up. I do not wish to use any chemical means of pain relief (e.g. no pethidine or entonox), but I also reserve the right to change my mind at the time.
When I feel the urge to push, I will allow an internal exam by the midwives to make sure I am fully dilated. If there is a small remaining "lip", but the urge to push is quite strong, I may ask the midwife to manually assist in the final dilation (although I know this is a very painful technique).
I would like to push in a variety of upright positions to enable gravity to help the process. If, however, second stage is proceeding very rapidly, I may elect to lie on my side, to allow for a slower and more managed delivery. I request that hot compresses and perineal massage with warm oil be performed during second stage to help the perineum to stretch and to reduce tearing. I request manual perineal support during pushing contractions to reduce tearing. I reserve the right to change my mind about any/all of these measures at the time if I find them too distracting, uncomfortable, or unhelpful.
I do not wish to have an episiotomy performed. I would prefer, if it came to it, to tear than to be cut, since research has shown that "natural" tears heal more quickly and with less pain than episiotomies. One possible exception to this is "buttonholing", where a cut would be performed to direct 3rd degree tearing away from the anus and rectum; or situations of severe fetal distress, where the baby needs to come out extremely quickly.
As long as the fetus is not distressed, I am not exhausted, there is no pain at my scar site or sign of problems, and my contractions are continuing productively, I request that second stage be allowed to continue without intervention for as long as it takes, even if it is 4 hours or more. I want measures such as change of position, lunges, stretches, and other manual exercises to be used to try to improve the baby's presentation, if this is deemed necessary. For example, in cases of shoulder dystocia, a very effective method is for the mother to immediately get on all fours.
I wish the baby, once out, to be placed immediately upon my bare chest, and the two of us wrapped up warmly together, if necessary. I would prefer my partner or I to discover and announce the baby's sex. Unless it is particularly indicated, I would like to avoid routine suctioning of the baby's nose and mouth. No cleaning or bathing of the new baby is necessary. Unless there is some particular reason to the contrary (like it is wrapped so tightly around its neck that it needs to be cut before the body is out), I would like to delay the cutting of the cord until well after it has stopped pulsing.
As long as I am not losing too much blood, and there are no other problems, I wish to be allowed to deliver the placenta without intervention, even if it takes two hours or more. I wish to put my new baby immediately to the breast to help the contractions and aid the passing of the placenta. In the absence of excessive bleeding or any other problem, I do not want the midwives to use oxytocin or cord traction to assist delivery of the placenta.
I see the time between the delivery of the baby and the delivery of the placenta as a quiet time to be spent with my partner and my new baby, and I wish my attendants to be as unobtrusive as possible during that time.
If after the birth it is necessary to suture me, I wish my partner to take our baby and cuddle it whilst I am being attended to. If many stitches are required, local anaesthetic would be welcome.
I understand that there may be circumstances in which it is necessary that I be transported to a hospital. Some of these situations are completely unambiguous (e.g. uterine rupture, haemorrhage, severe fetal distress) while others may be more of a judgment call (e.g. failure to progress). I will of course rely heavily on my attendants' expertise in these matters, and I wish to reassure them that I am not a fanatic devoted to having a home birth at all costs. My primary concern is that the baby and I come out of the process as healthy and happy as possible. My last birth was an emergency cesarean due to placental abruption and haemorrhage, and far from being disappointed at the loss of a home birth, I was overjoyed that appropriate medical intervention was available to save my baby's life and my own. Although I believe that home is the best place for a baby to be born in the absence of complications, I completely acknowledge that sometimes medical intervention is necessary and life saving.
If a repeat cesarean is necessary, I would prefer, if circumstances allow, to be given an epidural rather than a general anaesthetic. I would like my partner to be present at the birth, and I would like either my partner or I to hold the baby immediately upon delivery. I would like the baby to be in my partner's care during the time it takes to stitch me back up.
If the baby should require transportation to an intensive care unit, I wish my partner to go with the baby and my sister to stay with me. Should the baby need to stay in hospital, I would still plan to breast feed, and request that nothing else be given to the baby by bottle. If necessary, I would express breastmilk to be bottle fed to baby, if for some reason I could not be there in person.
If I do give birth in hospital, I would like to be released home at as early a date as possible. When my daughter was born, I checked myself and my baby out after 2 days, and I feel it was a very good thing I did. I had (as I will have this time) several support people in place at home (my partner, mother, sister, mother-in-law), and I was able to rest and recover far more easily and with more focused individualized support than I would have in a hospital ward.
I look forward to a rewarding and productive partnership with my birth attendants.