Thinking about where and how to give birth
Ideas about where and how women should give birth are constantly evolving. Many women, midwives and doctors feel strongly that the natural process of birth has become too medicalised, with most births taking place in hospital and rising caesarean and induction rates. Others stress that having the chance to have good pain relief and use interventions such as caesareans has made birth easier and safer for many women. The reality is that each labour and birth is an individual experience for each woman, and it is impossible to predict how it will turn out.
Birth is a time of transition and change, especially for first-time parents. What happens during birth can help them feel empowered and confident, or it can leave them feeling abused, ignored and disrespected. An important factor is how parents are treated, whether they feel listened to, and whether they feel that any intervention was used for a good reason, with discussion and choice. Some of the learning disabled mothers we talked to felt that they were not listened to or given a choice in how to give birth which was upsetting (see Learning disability and pregnancy).
Some women emphatically wanted as natural a labour and birth as possible. One employed an independent midwife and planned a home delivery to help achieve this. Doctors and midwives supported her choice, but her family were doubtful. She really wanted a home birth, but was reassured to know there was a hospital nearby.
Her GP and independent midwife supported her choice of a home birth, but her family were doubtful.
How difficult was it to persuade your family that you were going to do this and it was going to be okay? I mean, how much pressure did you feel under?
Well, when I was trying to persuade my family members that it was a good idea to have a home birth, I would say I did feel under some pressure to change my mind. But the way that I dealt with it was basically not to discuss it with, with my wider family, but just to discuss it with my husband. And after the reading that we did together, he came round, he came round to it and I think that he decided that the, if, whatever I was going to be happy with was going to be the best option. So that was decided on. But there was quite some pressure, I would say, from family. It's just a matter of whether you take it to heart [laugh].
What was the midwife's advice about a home birth?
The midwife's advice about a home birth was that she was 100 per cent behind me, I would say 200 per cent behind me. Independent midwives are really used to delivering babies at home and I would say that's their main work, actually. And so when I asked her, for example, because this was my first child, 'Would that be an indication that it would be risky to have a home birth?' she, and the other midwives that I spoke to as well, said, 'Absolutely not', that, 'There, there are hardly any indications that would prevent you from having a home birth'.
Most women wanted to have a hospital birth, and some were able to choose a community hospital or midwife-led unit. One woman felt she was not given enough information and support by her GP to help her choose which hospital to go to.
She felt she was not given enough support and information in choosing which hospital to go to.
Would you have liked more at that stage?
Yeah, [laugh] to be honest.
What would you have found helpful?
I suppose to know what the hospitals are like. I've been to, well, especially maternity, I've never been to any of the maternities in each of these hospitals that I was given a choice of, so it would have been nice to say, for her to actually recommend one for me and tell me what each hospital was like, or
So you were just given the names and you had to choose straight away?
Yeah. And I knew the names but that was it, so. And I'm, even the one I've got now, a friend of mine had hers there and it's nice, but I prefer mine to, I would have preferred to have gone to another one. And I've seen it now, but I think it's too late to change it because I'm too late, too far gone now....
So I'm not too sure how it works. But my doctor, the way, the way she seemed to me she didn't even seem like she just tried. She just said, 'Well, there's a long waiting list, so there's no point in you trying for that. You'd better stick to the one you've got, that one's nicer'. And that was it. So even if I was determined to do that, she was like throwing me off anyway, so maybe if I'd pushed it a little bit more, then she would have tried it [laugh].
Most women's main priorities were having a safe birth and a healthy baby, even if they had clear ideas about their ideal birth. Some women had been clearly advised to think of their birth plan as a guide, and not to be disappointed if things turned out differently. On the other hand, one woman felt angry that some pregnancy books created unrealistic expectations that everything would go according to plan and made people feel a failure if it didn't.
Ideally she wants to be able to move around during labour, but her birth plan is only a guide....
What are the pros and cons in your mind of that?
Well, I think you, you're going to be in one place. Obviously you can't move around if you're sat in a, in a pool, you can't move around as much as if you were up and walking around. And I think one of the main things I, after reading a lot in my textbooks, I think - I think I've read a little bit too much this pregnancy actually [laugh] - but I think reading the textbooks I think I've decided that moving around, you know, as much as you possibly can is meant to be a good thing. Pain relief, I've got a TENS unit that I've borrowed from a friend, which I will try, but that works for some ladies and not for others, so just have to wait and see I guess. And I think I will have to say that I will have an epidural on standby, just in case. I'm not going to be that brave, I don't think, if it comes to it. [laugh] So, yes, so, you know, the plan is to be as natural as possible. But I'm sure most women when they go into labour think that, and different things take over and, and happen. And it doesn't always, you know, they say your birth plan is only there as a guide, don't they? So that's what it'll be, but that's the plan.
I mean, no doubt you're aware that you can make a plan and then things don't turn out as you planned they will. Will you be very disappointed if you can't have the birth that you imagine?
No, I don't think so. I think as long as the baby's healthy and, you know, is delivered fine, I think, you know, any plan that I've made, if it goes out the window then as long as the baby's fine then I won't really care, I don't think [laugh]. It's just something to think about, you know, and if it, if it all does go to plan and the baby's healthy and it all works out, then that's, that's great. But, you know, certainly if, you know, if things don't go as we wanted it and something else happens, then that's fine.
Some pregnancy books set unrealistic expectations about the perfect natural birth. Women who need...
That's very interesting. When, what do you think is a more realistic approach to that issue?
I think, I think people should be told to be much more open minded, and that often you don't have any control and that it's important not to feel that it's anything to do with you, ultimately. And to listen to medical professionals who know what they're talking about, and if they say you need to be induced, they probably have a good reason for that. And if they say you need forceps then they probably have a good reason for that. And sometimes you have to surrender control, I think, because you just can't say, 'I'm going to do this at home and it's all going to be wonderful and natural", because I know lots of people for whom that hasn't been the experience and it's ultimately been right that they should have some sort of medical intervention for the sake of their health and the baby's health.
Another woman who knew she wanted an epidural felt others at her antenatal class disapproved of her choice. (See 'Antenatal classes and preparation').
Views were mixed about whether a written birth plan was a good idea. Some felt it was unnecessary or 'a waste of time', but others felt very positive about it and valued the discussion it generated with their midwife. One woman was particularly impressed with the way her community midwife discussed evidence with her about clamping the umbilical cord. Some people felt more in control with a written plan, even if the birth did not turn out as they hoped. A birth plan can help staff who may not have met the woman before know more about her original intentions. On the other hand, it can be difficult to use a birth plan effectively when the midwife present at the birth has not seen the woman before and so neither of them has had the chance to discuss worries and expectations in advance.
The birth did not go as expected, but having a written birth plan was still useful.
I did make a birth plan but it sort of went out the window half the way through [laughs].
And what was in this fantasy document?
In the fantasy birth plan we had that we were going to start with the TENS machine for pain relief and then work our way through the analgesia up to an epidural, but hopefully a normal delivery. But because I had to be induced everything, everything changed, because they had to artificially rupture my membrane and use prostaglandin gel and then put up the drip so it was, it was all completely different from the very start.
Do you think there is much point in people making birth plans?
I think it is a good idea to make a birth plan because I think it is a good idea to have thought about what you would like to do in labour before you actually get there. I think you have to realise, though, it would probably have to be very flexible because things change, things happen and you can't predict entirely what's going to happen. But I think if the birth plan is there, and it's written down then at least the midwives and staff know what your original ideas were and what you originally thought you would like to do. And try and stick with that and bring up things that are just, that are written in the birth plan.
She was impressed by the way her midwife discussed evidence with her about clamping the umbilical...
That was an example of, of her sort of collaboration with me I suppose in terms of how to proceed with my care, and it always felt that I was in control, which is very important to me. I suppose I was fairly well informed as a patient, as it were, and she of-, she said a couple of times to me, “That's not the sort of thing most people ask me”. Or, she did say to me, “You are very well informed”, you know, and gave me that feedback.
But she, there was one example where I discussed with her at the late stages of pregnancy the fact that I didn't understand the need to clamp the umbilical cord straight after delivery, because I'd done some reading around it and I'd talked to a couple of friends and I couldn't appreciate why that was done. And the only conclusion I could draw from what I'd read was that it was actually sort of from a clinical expedience point of view that that was done, in order that, “Let's clear up the mess, let's get this baby sort of separated, and then we can get onto clearing up” [laugh], at a basic level. Whereas I was, was reading some stuff that would suggest that there was actually some benefits in retaining the umbilical cord intact for several minutes after delivery, in order that some of the goodness, nutrients, oxygenated blood from the placenta could be taken in by the baby before that supply got finally cut off.
Because otherwise the baby would possibly have to reproduce those blood cells and so on for itself. And that for me seemed a much stronger set of arguments in terms of the baby's needs and to some extent my needs as a mother than some need for a doctor to sort, to clear up the labour room quickly [laugh]. And so I went to her and sort of explained what I'd read and said, “Am I missing something here?” And she, and she was very honest with me and she said, “That is to do with clinical protocol, and yes, you're right, that to a large extent the protocols around clamping and cutting the umbilical cord are not necessarily based on the baby's best interests”.
She ended up essentially saying that to me, which confirmed my suspicions, and I don't sort of have a problem with that as such, although I think it's a bit curious. What I was then concerned about was, was my ability to express my wishes to not have that protocol followed tightly with my delivery if possible, and that I could benefit from having, to leave, leaving the umbilical cord intact for some time before then, until it stopped pulsating, until it, before it was cut. And so we got into that level of discussion and I felt it was very important from my point of view to be able to have those conversations.
And did you, were you able to put it into your birth plan?
Exac-, yes I did. I did put it in and it happened and, you know, I felt, I felt very happy about that. But I needed her guidance to some extent and I think I - you see, I'm not even sure that if she'd have come back to me and tried to sort of, tried to give me, justify the protocol-based approach, I don't think I was particularly open to persuasion, because the evidence wasn't there that that was sensible from my patient, my own perspective. And so she could, she could deal with me as a fairly challenging patient, I think, and I think, you know, that helped to build a rapport and helped me to respect her and to trust her.
One mother went through a birth plan questionnaire with her community midwife but could not make real choices about things that were important to her. For example, she was told she could not have all the people she wanted to come with her for the birth; being able to choose their birth companions mattered to most women.
She went through a birth plan questionnaire with her midwife but could not make real choices.
Hmm, yes, but brief, it was really brief. How do I want to give birth? Do I want an epidural? I was offered an epidural from like day dot, but me not liking needles turned it down. And I think if anything that was what was pushed onto me, more than anything else. An epidural was the most frequent word used [laughs] when it came to labour terms.
Had you got a written birth plan? You know, things that you wanted to happen, things you didn't want to happen?
Yeah, yeah. I had one sheet, and basically I had to write down who I wanted as my birthing partner, how did I want the birth, did I want music. But the form kind of went into "Did I want music? Did I want ' - it specified something else as well, something like therapeutic - but the midwife was like, 'You get offered that, but it's not really like that. You either get the bed or you get the bath, you don't really have music and candles.' And you know, she basically put it to me like that, it was one of the two and it's not really cosy, that's the kind of impression. And it wasn't. It wasn't that cosy, it was the bed, and I wasn't allowed to move to a comfortable position that I thought was comfortable. I had to stay sitting down, sort of thing. So it wasn't good. At first I could stand up but where they had the monitor thing over my belly I had to sit upright. And it was like, "I want to lie down," and she was going, "No, you're going to pull the needle out and I can't hear the baby," and it was just like, "Sit up and shut up," sort of thing.
Did they ask you about that, when they were talking through the birth plan, whether you wanted to be monitored?
So it wasn't offered to you as an option?
And it sounds like this is a sort of form that the have that they fill in with you?
Yeah, it's just a standard form. I think I filled, I remember filling that in myself and bringing that back to like my next appointment basically, and going through with her and she basically said oh, kind of like, "Oh well, you can't have that person' or 'You can't have too many people," she said. "You can only have one," and then that turned into two. And I wanted my mother-in-law there as well, or my mother-in-law wanted to be there as well and basically I had to say to her, "Well you can't," because I wanted my partner and my best friend there. So there was a little over that as well but...
So kind of you ended up feeling that some of the things you would've chosen didn't happen the way you wanted?
Didn't happen no, yeah. That's right.
Another woman was unsure whether to make a plan and would have liked more discussion with her midwife. In the end it did not matter because she knew what she wanted and the midwives present at her baby's birth listened to her. She thought a birth plan might be especially helpful for women who did not speak English.
She was unsure whether to make a birth plan and would have liked more discussion with her...
I mean, it was probably just those last stages of anxiety. Also because like, because I did quite a lot of reading, yeah? I read quite a lot of books, like I read like, you know, all the books about natural childbirth and all this. And you're reading all the books and they say you should have a birth plan, and you should have this and that. And so I went and said, “Oh, you know, it says, it says you're supposed to have a birth plan” and they did have a thing in the folder, a page in the folder which said about, you know, a birth plan or something like that. And I hadn't got one, and I was coming up towards the end sort of - it was quite far in - and I said, “Oh, it says in all these places 'make a birth plan'.” And she says, “Oh, no, no, no, don't worry about that,” and stuff. And so I wasn't sure if it was like normal to, to not have a sort of a written down birth plan. I mean, in my mind, because I'd done quite a lot of reading and research and I'd read all the horror stories of people who had emergency caesareans, so I thought well, for me personally I'm quite - as long as the baby comes out hap-, in one piece - I didn't want to have too much intervention in my pregnancy, and I was doing antenatal classes and stuff, like yoga and stuff. So, so I knew in my mind that I was going to go for as long as possible without any intervention, and I was prepared to try and learn things to help me do that.
But I think if you were the kind of person who didn't read books, and stuff like that - I spoke to a younger mother, actually, in the, when I was doing my washing in the launderette and she hadn't read anything about having a baby. And I think in that situation you might be, you, it might make you more stressed out in the birth if you haven't had someone sit down with you and say, “These are the options and this is what might happen” and stuff like that. I think other mothers who don't inform themselves would find that would make their, could ruin their birth [laughs].
So did you actually make a birth plan anyway, whatever she said, or?
I had in, as I say, I had it in my own mind, really, how I wanted things to go. And when I did the final, when I did the NHS antenatal class, and they talked of the different pain reliefs I knew which ones I didn't want to have and which ones I was prepared to have, in whatever, in the event of needing that.
So in my mind I kind of made my own, had my own idea of exactly what I would and wouldn't do, want in there. So I, I suppose I felt relatively prepared in myself, because I knew in my own mind, and luckily we've got a very good maternity unit here, where they actually will listen quite carefully to what you want. And you've got one midwife who stays with you for the whole of her shift in the birth, when you're actually in the hospital. So that made it quite easy to communicate with what you would want, sort of thing, and didn't want. So I think, so it didn't matter so much in the end, but I did sort of - yeah, I don't know. I wasn't sure if it was like standard that you have a birth plan with your midwife that you see every week, or if it was something that they just say in all the magazines and books, say, “Oh you'll be doing this and doing that”, but then it doesn't happen in reality.
One woman who had recently come from Pakistan had got most of her information from the pregnancy book her GP gave her, but would have liked more information and discussion.
She had read the pregnancy book the GP had given her but would like more information and...
So have you thought about how you want it to be when it is time to give birth?
No, not at all.
You have not thought that far ahead?
No not that far [laughter]. I will see near the time. Whatever the will of God is. I have left it up to God.
Yes. The book has information right up to the time, hasn't it?
From that, what do you think will happen?
You know the pictures that are in it, there is too much discomfort on the faces, during labour - but you have to go through all that.
Do you know what they can give you to reduce the pain?
They said that if I wanted they could give me an injection.
But Aunty says that we should not have the injection.
For two or three weeks your legs become weak, you cannot walk. It happened to her daughter, that is why -
There are many kinds of injections-did they tell you about the back injection?
Or one on the leg?
I thing it was about the one on the leg.
There is one injection for the back, have you heard about it?
No, I have not.
OK - and the mask they put on for gas, have you heard about that?
Yes, it is written in the book.
So what do you think about that?
I do not have the experience, but I don't know how it will----
So no one told you about gas?
No, no one.
How much did you know about it?
They just say that if you want and need it you can use it.
Do you think you will use it or are you thinking about something else?
No, nothing yet.
Do you think that it should be used or not?
Has anyone talked to you about it?
Right - some women give birth in water, what do you think about that?
I don't know if it would be right or not, I don't know.
Sitting in the bath-
Yes, I have read about it in the book.
If someone asks you that you should do it this way, what would you say?
I don't know.
When the time comes-
Yes, I will see when the time comes.
But don't you want to say that
Some people were happy to accept that intervention might be necessary, but worried about being rushed into a decision during labour without having discussed it and thought it through beforehand.
She is worried about being rushed into decisions during labour without thinking it through, but...
Another worry for some people was feeling pressured into having an induction if they went overdue. Two mothers from families with a history longer than average pregnancies had contrasting experiences. One felt supported in waiting for labour to start naturally, but the other felt under pressure to have her labour induced.
Women in her family have long pregnancies. She was pleased there was no pressure to have an...
And I'd, from my reading I'd just learned that if you start down that path you may end up with a lot more interventions than, than you planned on. And I, so I just didn't want to start down that path in the first place. I was really impressed with the NHS care in that regard, because even though they have this guideline in our area that after 12 days after term you should be induced, they were quite flexible with that, with that guideline in accordance with my wishes, which I really appreciated. Instead of using, instead of inducing, the alternative that we used was to monitor the baby after 42 weeks, because the pregnancy went to 42 + 3 I think, and to use the health of the baby as a reason to go forward with the pregnancy, instead of just to induce according to any guidelines, but to look at the individual case. And fortunately my baby was healthy up, right up until, until birth, even though he was so late.
She would have preferred a caesarean, but agreed reluctantly to an induction. She had a long and very unsatisfactory labour, and in her next pregnancy employed a doula (independent birth companion) to help support her choices.
She felt under pressure to have an induction when she wanted to wait. If the baby was at risk,...
I went away and I thought, 'Right. Well, if you're, if you're actually so concerned this baby has got to come out and you think it's going to get stuck because it's so big and I'm not a big woman, well, caesarean it is. I'm not messing around with induction if you think there's going to be problems anyway and it's a big baby and it's going to get stuck.' And I did some more reading about it, and I didn't like the sound of the Syntocinon drip, and I thought, 'I don't want to go down this route at all.' [Coughs] 'Oh right, okay,' says the midwife. 'Well, if you're sure you'll have to go in again and talk to anther doctor.' So I went in the following night, bearing in mind all this time I didn't have a car, and I'm in a rural area, it would be an hour and a half on the bus or I had to get my parents to drive me over each time, ten miles away in the dark in the middle of December, great. Lot of stress that I really didn't need, I just wanted to hibernate at home and just wait for it to happen naturally.
And I kept saying to all these people, I said it to the midwives, I said it to the registrar I'd seen that day, I'd said it to the other guy, 'Isn't there anything else you can do to check this baby's alright, rather than just saying, 'Oh, it's late. The placenta might break down at any moment, could be still born, have to get him out of you.' Isn't there anything else you can do to check that everything is fine? Because I think everything's fine, and surely I'd have some inkling that things weren't fine if they weren't fine? And every time you check his heartbeat's beating fine.' 'Ah yes, but that just checks at that moment.' 'And every time he moves he's moving the same amount, for the past four weeks.' 'Ah yes, but that just checks at that moment, and it could change the next moment and it could happen at any time. The placenta could break down at any time, and it's really unsafe because you're, you know, you're so late.'
Doing things differently another time was important for other women, even when there were good reasons why their first birth had not been as planned. Some women who had an emergency caesarean section wanted to try a vaginal delivery next time. Others preferred (or were advised) to have another caesarean.
After an emergency caesarean first time, she wants to try a vaginal birth next time.
Well, I'm not allowed to, I have to go straight to the main hospital. So I don't have any choice on that, but I'm, I've got to back at thirty-six weeks to have a chat with the gynaecologist to see how the baby's lying, how it's presenting etcetera. Because I would like to do what they call trial by scar, which is natural childbirth following a caesarean. But there is a danger of a rupture so - which I hadn't realised until I'd sort of chatted to her - so we're going to have a discussion at that point and see how things are and sort of make a decision from there.
So I suppose that's not the sort of thing they can really explain to you fully when you're actually faced with the choice initially.
Hmm. It's, again it's one of those difficult things. Only you can decide what to do. There's pros and cons. I mean the C-section's the easiest answer, really. You just book in and go in, and it's no distress on the baby and there's no rupture. But then you've got to recover from the operation, which I don't really want to have to do, so. And I'd quite like to experience birth, you know, so I'm, I'm hoping to go for as natural again as possible, but I'm quite happy to be guided by the professionals.
She considered trying a vaginal birth after her previous caesarean, but decided to have another...
After having the first caesarean section, yes. You can, you have the choice of having another elective caesarean section or a vaginal delivery and I had to be under consultant care this time so that they could discuss that fully with me. And there are advantages and disadvantages. There's a slightly, well, there's a ten times increased perinatal mortality which is, you know, the baby dying around the time of birth with a natural delivery because of the risk of the uterus rupturing after a caesarean section but then - after a normal delivery I should say. But there's actually a slightly higher risk to the mother having a caesarean section. So you're weighing one set of risks against another. So I had to discuss that all with the consultant and come to some decision about what to do.
How did you make that decision? I mean...
It was very difficult to decide whether to have an elective caesarean section or whether to go for a vaginal delivery. There were several factors, one was that the consultant felt that if I was trying to have three or four pregnancies then she would very much advise that I tried for a vaginal delivery because each section technically gets more difficult to do and you're slightly more at increased risk of having complications. I also had to weigh the fact that there is an increased risk to the baby having a vaginal delivery but an increased risk to me having an elective caesarean section. So it was a very difficult decision but in the end I decided that probably we were only going to have two children, so probably the safest thing for the baby to have the elective section. And as I recovered very quickly from the last time and I didn't have any complications and I'm hopeful that it will all be the same this time.
For some women who discovered the baby had a serious health problem, giving the baby the best chance of survival became the overriding factor in making birth choices. (See also Healthtalk sites on 'Antenatal screening' and 'Parents of children with congenital heart disease').
Her original plan to have a home birth changed when she found her baby had a heart defect. She...
Where my consultant was very good, she was trying to identify the fact that I was going to have issues about wanting to make the birth as simple as possible and also she talked about how it would help the paediatricians to know when my unborn baby was going to arrive. So she was saying if we could do either a caesarean or an induction then we could plan to have a daytime birth for your child. Which means the paediatrician's going to be more awake, there will be more of them around and they'll know that he's en route. So I went to the speak to the paediatricians who ran the special care baby unit. Because I was sort of incredulous that it would make much difference to them when he arrived really, and I didn't want an induction and I didn't really want a caesarean.
In fact before I got into all of this I was planning a home birth, and, and if not, then as much of it at home, much of my labouring at home as possible. So, I went to speak to the paediatrician who ran the special care baby unit and she said, 'It would make a big difference to know that your child was going to arrive at a particular time of day and in fact lunchtime would be good' [laughs]. She said, 'No, but seriously, daytime when there's more of us around, we haven't been hauled out of bed'. Because I think the consultants come and work during the day, and then come into the SCBU, special care baby unit, at night if there's a real need for them. So if she could do it within her regular hours when she was going to be wide awake, then she was going to be happier. So I said, 'Fine, okay well, in, if that's the case I think induction's going to be a less exact science.' So I said, 'All right, let's have a caesarean'. And that really surprised me because I really - oh I did resist, I did really investigate whether it was going to be worth it and it was, it seemed to be. So against all my previous plans I went for a caesarean, and I have no regrets at all. It was really the right thing to do and I'm actually really grateful to the consultants who were really being quite honest what would help. Because firstly when it came to the crunch I didn't really want him to come out, I didn't want to give birth. Having since given birth naturally, vaginally, I know that it's not easy and you have to really want to push and to release your baby into the world, and I don't think I was in the mental state to really want to do that.
For more information see our pregnancy resources.
Last reviewed May 2017.
Last updated May 2017.