Birth Centres, with Issy Bourton

This episode is essential listening if you’re trying to decide whether to labour in a birth centre or midwife-led unit.

I’m exploring everything birth centres, with my friend, midwife, Issy Bourton. 

Issy and I look at what a birth centre/midwife-led unit is, how your experience there can differ from a hospital birth, what you can expect to happen during your labour, how to request a birth centre labour if you are not low risk, and transferring to a labour ward.

For more information about speaking to your consultant midwife about out of guidelines care plans see Series 1 Episode 12 Birthing Outside of Guidelines with Guest, Midwife Rebecca Savage

You can follow Issy on Instagram @issythemidwife

Please subscribe, rate and review, so we can get this vital info to as many parents-to-be as we can!

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Transcript

Megan Rossiter  00:00

Ad - This episode is brought to you in partnership with iCandy. I've been using our iCandy peach pushchair almost daily for the last seven years and counting. And I've really put their five year warranty to the test using it for both my boys on muddy walks in aeroplane holes in and out of my car boot and aside from being completely filthy, my fault not theirs. It's still going strong. I can't wait to tell you more about my experience with eye candy later in the show.  

Megan Rossiter  00:25

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Megan Rossiter  00:49

You're listening to the Birth-ed podcast. I'm your host and founder of Birth-ed, Megan Rossiter. If you're looking for the evidence, the nuance the detail that's missing from your antenatal appointment, then I've got your back. The Birth-ed podcast is here to help you sort the facts from the advertising the instinct from the influences and the information you're looking for from the white noise of the internet. I hope you've got a cup of tea in hand and a notepad at the ready. Let's dive in. 

Megan Rossiter  01:15

Hi, everybody. Welcome back to the Birth-Ed podcast. Today I am delighted to be joined by midwife and friend of mine Issy. Issy is a registered midwife currently working on an attached midwifery led unit or birth centre, and has a wealth of experience working in the community in a continuity of care model as a home birth midwife and supporting families with social vulnerabilities. Now a little bit of fun background for you ahead of this episode I think we can impart blame is if my very first steps into the world of maternity care. We actually went to college together when we were just 16. And it must have been then I can't remember it as a 10 or so years ago when you had either either just qualified or about to just qualify. And we met for coffee and I picked his his brains about whether I should retrain in midwifery or not. And I suppose the rest from there is history. So Issy, I'm really, really excited to have you on the podcast. Thank you so much for joining me. 

Issy Bourton  02:12

Thanks, Megan. It's so nice to be here. 

Megan Rossiter  02:15

So today's episode, we are looking at the birthplace choice of a birth centre or sometimes called a midwifery led unit. So if somebody is listening to this, and they potentially haven't heard of this as an option, or they're kind of just exploring where they might choose to give birth to their baby, can you explain what a birth centre is and how this differs from the kind of other places that you might choose to give birth to your baby?

Issy Bourton  02:44

Yeah, sure. So a birth centre is somewhere you can choose to give birth where care is entirely midwifery led, so they genuinely promote what's often referred to as a home from home environment. And they aim to be overall kind of less medicalized as a setting and to promote physiological birth. So usually, they'll have equipment designed to help you be active and mobile and labour. They're generally you know, a nice, relaxed environment. And as you mentioned, they can be either alongside a maternity unit, so either in the same building, or sometimes even on the same floor as the kind of obstetric led unit, or they might be entirely separate from the hospital and they are called freestanding or standalone birth centres. And so often in kind of communities like community areas, where it's further to, to the obstetric units.

Megan Rossiter  03:44

When you're talking about the obstetric unit, can you explain the sort of what that is and how that differs from a birth centre?

Issy Bourton  03:51

Yes, so I guess that's leading into kind of who would go to a birth centre in terms of kind of their own pregnancy. So generally, women who have had healthy straightforward pregnancies, it'd be recommended for them to give birth on a birth Centre in terms of what is safest. And I mean that based on low chance of a poor outcome for mum or baby. So this all relates to a study called the birthplace study, which is it's actually quite old now. But it's a fantastic study. It was done in 2011. And they essentially looked at helping women with straightforward pregnancies and their outcomes when they gave birth in different settings. And what they found was that women birthing in free standing or alongside birth centres had far fewer interventions than women working in obstetric units. Now, an obstetric unit is your traditional maternity unit in a hospital, where the care is generally overseen by doctors There are still midwives working there and midwives carrying women in labour. But there are also obstetricians, they will have you know, the operating theatres access to a nice the tests for things like epidurals, certain sections can be performed there, etc. So what they kind of realised was, even when these healthy low risk women went to an obstetric unit, they were more likely to have this is Aryan and instrumental birth and appease your tummy and induction. So all of these are what we refer to as interventions in in birth, even if they'd had no complications in their pregnancy, or in their labour, these things kind of ended up happening. And so that's why we really encourage women to think about their place of birth options, and consider birthing in a birth centre. Because wherever if it's your first baby, being in a birth centre is kind of seen as the safest for you and baby, because it's the place where you're least likely to have these kinds of potentially unnecessary interventions. But also, they did compare all of the statistics, they looked at home birth as well. And there's a slight increased risk for the baby, if you're having your first baby. Based on that birthplace study, there has since been some research that kind of contradicts that. But if you're having your second baby, then it's at home that it is often recommended that you consider because that is becomes the safest in terms of those risks associated,

Megan Rossiter  06:38

I think that's often sometimes surprising to people is that, you know, if you don't know anything about how birth works, birth, physiology, all of that kind of thing, that because of the what we see about birth in the media, and our kind of understanding of what we expect her to look like is that it's very easy to assume that being near a hospital being near doctors is going to therefore be the safest place. And I think, understanding that there's actually really robust research to support that kind of out of hospital birth place choices can sometimes be surprising, but hopefully really reassuring to women or families that are choosing where to give birth to their baby. I wonder if we can kind of dive a little bit deeper. I'd love to hear your thoughts on like, why why do you think that? You know, I've certainly got my my own theories and thoughts on this. But I'd love to hear from your perspective as well. What what is it you think that a birth centre home potentially offers that improves these outcomes that potentially you don't see on a kind of labour ward environment?

Issy Bourton  07:43

Yeah, so I think, as you're kind of alluding to that, if we're really thinking about what happens during labour, and what women and birthing people need for labour to unfold in a physiological way, it is going back to the basics of trying to ensure that you're in a calm, relaxed environment. But I think most importantly, it's a feeling of safety for someone. And that's very individual, person to person, what safety will look like. And I think that a birth centre is such a fantastic space, especially if you're having your first baby because it is a massive unknown. You don't know what labour feels like, you don't know how it's all going to unfold. You know, that's true if you're if you're having a subsequent baby as well, because every labour and birth is different. But I think those kind of feelings of unknown sometimes, although we know there's, it's really safe to give birth at home for first time moms. I feel like maybe we see fewer first time moms choosing home birth because of that feeling of, well, I just don't know what it's going to be like and what it's going to feel like and all of those unknowns. And being truly at peace with that can be quite tricky. So I think a birth centre may be feels like a safe space for many women in that regard. Because I guess maybe it is to do with those notions of us seeing hospitals are safe, even though maybe that you know is sometimes questionable. I won't delve into that but women feel like you know, this is an environment that is totally geared at supporting normal, normal in in quotes, labour and there's all of these you know, the kind of centering of, of normal labour on a birth centre is, you know, looking at individualised care and that whole philosophy of promoting the physiology of birth is what a birth centre is really about. So I think that's why they're such a great place. I think they attract a midwife. moves that really want to support informed choice. And often midwives working on birth centres have, you know, a wealth of knowledge in what kind of undisturbed birth looks like but also they might have other skills. So things like aromatherapy skills and training in biomechanics, some birth centres, they offer kind of acupuncture and acupressure and things like that. So, I think the care is very holistic and individualised. And I think often when we think of those obstetric settings, sometimes, you know, there's been a lot said about women feeling like they're almost on this conveyor belt system going through. And I think a birth centre is or should be a far cry from that. 

Megan Rossiter  10:57

Yeah, absolutely. I love what you said about the kind of it being a holistic approach to care. And I think sometimes, that can be the bit that people find as missing in the kind of more obstetric led unit where everything is a birth is looked on more so as like a physical experience, like something that your body is going to do. And often kind of missing that connection with just how much of a emotional and mental beat actually labouring and giving birth to your baby can be and when we've got those feelings of relaxation, and then there's feelings of safety, when you start to kind of unpick actually how the physiology of birth works, you begin to see just how, actually it isn't just a physical thing that your body has to do. It is a real, like there's a real mind body connection and what how we are feeling emotionally, really does impact how birth then kind of unfolds. The other thing that I often find with the kind of the difference I suppose between an obstetric led unit and a birth centre or an obstetric led unit and home is when you're in a birth centre, they don't have continuous electronic foetal heart monitoring, there's much less. Now we'll talk about care, because you definitely are monitored and cared for on a birth centre. But it's much less sort of machinery based and much more individual would you say? I definitely agree with that. And when we start to try and kind of put things in boxes, as soon as we start to kind of deviate from that sometimes it can feel like there's less space to not fit the status quo when we're on that, what we talked about that kind of conveyor belt of care. And the other thing that I find with the kind of obstetric clergy unit sometimes is that basically, the closer we are to intervention, the more likely we are to reach for it. And that goes both from a kind of care provider perspective and us in labour perspective, if Labour is stalled, and slowed down, and we want to speed it back up again, on a labour ward, we can do that often quite effectively with a a hormone drip that goes in your hand. And if that's all it takes, then we're quite likely to reach for it. But on a birth centre, you might do things like make sure somebody has been for a week or tried a different position had some time on their own before we start to kind of leap towards kind of medical intervention. So do you think those things are reflected in the kind of care that you provide on a birth into versus the care that somebody might see on a labour ward? Yeah, definitely. So let's imagine somebody has either made the decision in advance or they were waiting until they were in labour to decide where they wanted to be. And they came in and this will depend slightly Won't it on whereabouts in the kind of in the world in the country they are as to what happens next. But let's say they've gone into spontaneous labour. They've laboured at home, and then they have reached the point of wanting that kind of one to one support from a midwife. What should they expect?

Issy Bourton  13:54

So yeah, once you're kind of admitted to a birth centre, you'll have a allocated midwife to care for you throughout your labour, and anyone in labour should receive one to one care, in the sense of, you know, we're talking about if someone's in active labour here, and whether that's been determined by someone having a vaginal examination or whether it's determined by just observing their contractions and their behaviour, you'll start to have kind of regular observations of you and your baby. So we're listening to the baby's heart rate every 15 minutes when we observed that those contractions are regular and strong. And we're always listening after just after a contraction, because then we can hear if there's any kind of deviations from normal once a baby has kind of recovered from a contraction. Also, we kind of do baseline observations on on the woman. And so that involves checking blood pressure, temperature, pulse, and those are done You know, quite, they are done quite infrequently, actually. So we only need to check blood pressure every four hours, if it's normal, which, you know, hopefully it would be if you were to birth into and pulse we do a bit more regularly just to ensure that there's that kind of a differentiation between mum and baby. But also, pulse is more likely to change if there are concerns in the labour might kind of increase if, if there are, for example, the woman's in more pain or, you know, if there's any other kind of concerns identified, we often see it in the maternal pulse changing more quickly than then our observations. So those are the kind of baseline things that we do 

Megan Rossiter  15:45

in terms of listening into the baby that is generally done with the sonic aid that people might recognise from their antenatal appointments if they've chosen to listen. And so it's not something that is kind of being attached to them, they shouldn't need to change position, and it shouldn't be genuinely too disturbing for people should it?

Issy Bourton  16:03

Yeah, exactly. So it's, ideally is kind of discreet as possible. So it's usually like a Doppler like you say, or a sonic aid, which, you know, you can hear audibly, the baby's heart rate. But if that is something, you know, I think, in my experience, women quite like having their baby's heartbeat. But if you want to keep things really quiet, the midwife can turn can turn the volume right down. And some midwives will choose to use a Pinard, which is almost like a little trumpet, which one and the midwife places against her ear, and the other end is placed against the abdomen, which we kind of estimate around about the anterior bit of baby's shoulder. And that's where we're listening. Now, if you were in a birth, we wouldn't be able to listen with a pin odd, that would be a bit tricky, a bit wet. I mean, we do often get a bit wet. But hopefully not for that reason. Yeah, so we listen in every 15 minutes. And that's our kind of general guidelines. And, you know, as with anything, it's your right to decline any aspect of care when you're in labour. But that generally is determined as being a way of us, essentially, monitoring baby's reaction, following a contraction, but also looking across the course of a labour, that that baby's heart rate is, is staying steady in a kind of range, which we call the baseline. So that helps us to determine that and once a woman or birthing person gets to the stage of labour, where they're pushing, and we listen in more frequently, we listen in every five minutes, or after each contraction, whichever is kind of occurs first. So So that's the kind of general monitoring and we also keep an eye on things like how often someone's going to the toilet, to empty their bladder. They're eating and drinking just generally kind of how they're coping. So this is as well where we think about kind of what coping methods someone might be wanting to use in the birth centre. And generally speaking, all birth centres will have birth pools. Usually, there'll be several rooms with a birth pool in some, but I've worked at one kind of alongside midwifery unit, were actually the pools were in separate rooms to the bed. 

Megan Rossiter  18:40

I know the one you mean, that was really weird. They felt like they were in a cupboard. It's really odd.

Issy Bourton  18:47

But you would still have a birthing room and then there's a separate pool room. I remember a woman saying to me, and so how many people get in the pool when I was like just getting I think she imagined like a swimming pool in another room or something. So we talked about kind of them being this environment that's gonna promote, you know, an active and mobile labour so that can involve you know, having birth balls, Mat, beanbags. Some birth centres have these lovely like kind of hanging ropes from the ceiling, birth stalls, a personal favourite of mine. So yeah, all of those kind of aides for helping you to mobilise 

Megan Rossiter  19:33

and if you're listening to this and you're like, but I don't know how to use any of those things like that is what your midwife is there for on the birth centre is to set it up in a way that provides you opportunity to utilise these things if you want to try them to show you how to do them. So don't you don't necessarily need to know how to hang on a rope or Yeah, and you don't have to use all of them. It's not an obstacle course.

Issy Bourton  19:57

It's just about throwing your you're as comfortable as possible. And you're absolutely if you're, you know, your midwife might have they one of the main things we do when you first come in, in labour is we feel your tummy. And we see what baby's position is. And, you know, we can tell a lot by baby's position combined with your contraction pattern gives us a really good idea often of what's happening, and why your contractions are a certain way. So it might be the baby's in a fantastic position, and you've got really strong regular contractions. And, you know, we don't really need to intervene in any way. Or it might be that we think that baby isn't a certain position, and maybe your contractions are a little bit irregular. And we can then suggest in different positions that might help. So that's something as well that, you know, might be commented on when you arrive at hospital in terms of like, Oh, would you try? Do you want to try and use the ball, for example? Or do you want to try being you know, fours, or kneeling, or all of those kind of upright forward and open positions that we're, we're really keen on in labour.

Megan Rossiter  21:09

And I think something that's helpful if you're pregnant, and you're listening is that some people really appreciate and want that, like guidance and direction, and some people just want to be ultimately left to it. And if you know, in advance that you have got a really strong feeling one way or the other, that is something that you can put like, into your kind of birth plan to communicate with your midwife is like, actually, I feel like I don't know what I'm doing, I just need somebody to kind of really be really present and be really a part of it and support me by suggesting things. And some people are like, No, I just kind of want you to blend into the background, I always say midwives are like chameleons, they're very good at being, if you need that, like quiet cheerleader very close to you offering that reassurance, they can be that or if you need them to sort of almost melt away into the background, they can be there as well. And we're all very different in terms of what, what we kind of need, from the support that we're getting. 

Issy Bourton  22:06

Yeah, and a lot of it is about trusting your instinct. And, you know, I always find it quite funny, because on one of the birth plan templates that you get on the NHS website, it kind of says, you know, you have to tick which positions you want to use in the labour and I just think, how on earth, you're going to know, which position do you want to be in, and you know, women just tick every single box, and that's something you just don't know. And you know, a lot of the time, you're gonna find a position that is the most comfortable for you based on, you know, factors that no one else has any knowledge of, you're just going to instinctively do what feels right. And, you know, there's so much information out there now, like on Instagram, and about all these things we can do to help promote physiological birth. But it's not like a tick box exercise, like you have to do this position and this position and this position, and then a baby pops out, it's, you know, it's about just that knowledge, I guess, in the back of your mind of like what's possible, but you will be led towards things instinctively when you're in labour, and equity, like I remember in my own labour, and just feeling just unbearable tension and nothing felt comfortable. And I did need my midwives in that moment to suggest different positions and offer me massage. And yeah, like you say, that's, that's the job of the midwife as well is to kind of find, you know, where you need to be met. 

Megan Rossiter  23:39

Yeah, that process, I actually don't talk a huge amount other than what you've said about knowing what's available to you in terms of kind of birth positions and stuff, because I remember similarly in my first but having a really strong idea that I wanted to be like upright and have like gravity on my side. And then there was a period of labour where the only position that was comfortable, was lying on a bed with the back of the bed propped up in basically like a semi shoulder stand with my bum propped up on this back bit of the bed. And that was like the only place that felt even vaguely comfortable. And now I can kind of look back in hindsight and be like, Oh, actually, it was in a dodgy position, he wants you to come out, turn himself around, and then I was more comfortable to turn back over again. But it's that kind of, actually what we want, is if we can create an environment where we can behave in a way that is like, utterly uninhibited. So we're not going oh, what's the midwife gonna think if I do this with my leg, or if I make this sound, or if I suddenly decide that I want to go sit on the toilet or whatever it is. And so when you're thinking about where you want to give birth to your baby, thinking actually, in what kind of environment can I behave in that way that is uninhibited is a really sort of helpful starting point, I suppose in terms of really then being able to tune into your instinct, as you said,

Issy Bourton  24:55

Exactly, yeah, I really agree with that. And it's about having a space where you Walk into it. And it is entirely designed with you in in mind, like the whole space is open and dimly lit. And there's, you know, lovely lighting, whether it's very lights or just dim light. So lots of the pools these days have really nice kind of coloured lighting, although I did have a birthday the other day where one of the lights got stuck on green, and it was just not the colour for

Megan Rossiter  25:30

Witchy!

Issy Bourton  25:33

frantically trying to find a tiny remote to change it. There Yeah, it is all about just having that space. And for the midwives as well like having a space where everything is where you need it. And it's all very discreet. So I think one thing to say as well as, you know, if you're deciding where you want to give birth, and you're not sure, and you've come to it with no prior knowledge, other than maybe what we'd see in in media and TV and films, lots of people's first thought will be Oh, but don't I need to be close to help if it's needed, and save lives if you know, these similar thoughts come to mind when people are thinking about homebirth like, but what if I need help? And you know, what a birth centre we have absolutely everything that is needed for an emergency. It's just not on display in the room where you're labouring. It's usually tucked away in discreet cupboards, or just out the room in a trolley or you know, everything is everything we need is there, but it's just out of the way so that you don't have to look at it and think, oh, gosh, what's that bit of equipment for? I hope that's, you know, that looks a bit scary. And, you know, what, what might happen for me to need that, you know, you just don't want that thought, where as often or obstetric unit in every single room, you know, there's a recessive tear, which is a piece of machinery, we use to assess babies and you know, help them at birth with breathing if needed. You know, there's one of those in every room. And that in itself can feel a bit worrying. There's lots of metal trolleys and cupboards filled with all sorts and you know, that in itself can be a bit alarming. If you're not used to hospitals, and having a baby might be the first time they've actually been admitted to hospital. So I think that's also really important in kind of a birth centre, as you know, everything is where we need it, basically.

Megan Rossiter  27:42

Yeah, yeah, that I think that it's, I think sometimes you're like, what, I'm just going to be left here with a midwife and nothing else. And some of the things that you've been saying about like the space and the ability to mobilise and all of these things, if you're listening to this, and you're thinking, Yes, that's what I want, or you're listening to this, and you're like, Oh, but I can't be on a birth centre, because of X Y, Zed, there is so much of this that is transferable to a labour ward. So everything that we're talking through, like the benefits that these bring, there is so much of it that we can transfer over, it just doesn't necessarily happen automatically, without you kind of asking for it. But particularly if that hospital hasn't got a birth Centre in it, you can borrow. I'm not the birth centre. Midwives won't be happy with this, but you can borrow birth balls and mats and some labour wards will even kind of have those things on them as well. So it doesn't necessarily mean you have to like lay in a bed and wait for your baby to come out. Exactly.

Issy Bourton  28:35

I mean, if you go into a room on a obstetric unit, there will always be asked to bed but you can move it out the way you know, lots of them now, most units will have birth balls and peanut balls. They might even have some lovely nice lighting, that there is a real kind of breakfast of things available. And some labels do have buckles on as well. So it's not that that is entirely out of reach.

Megan Rossiter  29:05

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Megan Rossiter  30:18

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Megan Rossiter  31:30

So we've been talking so far, sort of with the idea in mind that the most of the women that are accessing care on a birth centre have got uncomplicated pregnancies or sometimes they might have room on a bit of paper that they have a low risk pregnancy. And there may be women listening who are potentially have had things like a caesarean in a previous birth or maybe have diabetes, gestational diabetes that is reasonably well controlled, or potentially have a slightly higher BMI, or they might be 40 years old, or there might be things that it's basically ticking a box on their bit of paper that doesn't automatically set them up for the kind of recommendation of and we think you should give birth on a birth centre, that doesn't necessarily mean automatically that that is totally off the cards as an option for them. How does the kind of does the care differ in any way if you've got families accessing care with kind of more complexities of pregnancy, and how would they go about getting a plan in place that felt personalised to them, so they could reap the benefits of a birth centre birth, if that's where they really wanted to be. And that's where they felt that their care was most suitable or most best supported

Issy Bourton  32:46

I would this is fairly common at the birth centre that I work at. And I would say, and speaking from my experience, I had not worked in, you know, all different birth centres around the country I've worked in to both, you know, within London and Greater London. So I would say, if you feel like you want to give birth on a birth, and it's definitely something you should explore, and the earlier in pregnancy that you can kind of discuss that with your midwife the better so that a plan can be made and your options can be explored. And you know, it is largely dependent on the kind of senior midwifery leadership team. So often a consultant midwife will be available although saying that I think only about 50% of maternity units have a consultant midwife, but someone senior within the midwifery team, you should be able to meet with them to talk about your wishes for your labour and birth. And they should be able to counsel you on what the actual risks are, if there are risks associated with your pregnancy, and how those can be mitigated as much as possible or supported or, you know, to make as safe a plan as possible. But equally, it should be that if you're making an informed choice, and you're aware of those potential possibilities of being slightly more in increased risk, for example of bleeding or heavily after birth, or whatever it is that's associated with your pregnancy, then, you know, it's it's up to you to make that decision. And to kind of take on that responsibility as well. And it's up to the midwifery team to ensure that you know, what those potential risks are, and is there anything we can do to accommodate you? So I would say what we generally refer, if you're kind of out of guidelines for birth centred care, there should always be a kind of plan in place, and you should be supported in your choices. So sometimes it might be that you come to the decision that you do want to be on a more kind of Traditional labour ward, but you want to incorporate as many of those aspects of midwifery led care of it into your, into labour and birth. Or it might be that that you do just think actually, I understand the potential risks, but I feel like for me individually, a birth centre is where I want to be, it's where I'm going to feel safest and most kind of happy. I think it is important to have that kind of foresight, because if you turn up in labour at a birth centre, and you know, it's the night shift, and there aren't, you know, more senior midwives available for you to have those discussions with and you know, those kind of discussions are tricky to have in labour, you just wouldn't want to be disappointed, I guess, or told that, you know, you couldn't birth there. And that would be, you know, the worst outcome for you. So, yeah, I would say that's probably the best way to go about it. I mean, even if it is, you know, you're 36 weeks pregnant, and you suddenly think, oh, no, I do want to be on a birth centre, there's still time, and just reach out to your midwife. And there should be pathways for accessing that kind of individualised care, because it's what we should be providing to everyone. Yeah, absolutely. But I definitely think it's helpful for people to know like, this isn't a decision to go, oh, well, I'll just see how I feel in labour. 

Megan Rossiter  36:16

Because if you show up, and actually there were conversations that maybe needed to happen beforehand, you can just put yourself in a difficult position. And you're exactly right, you're not when you're in the throes of labour, the brain is not working in a way that is able to really engage in even very informed decision making, but also sort of advocating for yourself and communicating is, is going to be hard. So if you've got that plan written into your notes, we've actually got a really good podcast episode, I think it's way back in series one that is with a consultant midwife that is all about putting together out of guideline care plans, and it's kind of 5050. So those people that either want a home birth or a birth centre that otherwise wouldn't ordinarily have kind of been offered it straight away. And then the other half is pretty much people that are requesting us as Aryan birth equally wouldn't have been recommended it straightaway. And there that whoever fills that role within the trust is definitely a useful person to kind of have on your on your team. A helpful thing I think, to point out about that person, if you haven't listened to that episode yet about the consultant midwife role. I think sometimes we hear the word consultant and we assume that that is like a an obstetrician or a doctor. But they're, they definitely come from a kind of midwifery background. So they are hopefully bringing together the kind of understanding of complexities of pregnancy that the obstetrician consultant would bring, but also really coming at it from a kind of midwifery perspective. So real understanding of facilitating physiological birth, which is often what if you're, in this circumstance, hoping to be on a birth centre, presumably that is one of the main reasons why you're wanting to choose that birth place. So definitely a kind of helpful person to chat to. So I suppose the next thing that kind of comes up for people is we talked about kind of if emergencies occurred, and you needed support actually on the birth centre. But if there was a like a shift or a change, or something that happened in the labour itself, like before the baby was actually born are incredibly close to being born. Sometimes they may, you may kind of recommend transfer to an obstetric lead unit or labour ward, what are the kind of most common reasons why somebody might transfer? And what does the process of transferring? What does that tend to look like? Or does it differ from place to place?

Issy Bourton  38:39

So I'll start with common reasons to transfer and that they're very similar to the reasons you transfer from a home birth into a maternity unit. So the two most common reasons are wanting additional pain relief, other than what's available on the birth centre.

Megan Rossiter  38:58

So generally, that's an epidural isn't it? 

Issy Bourton  39:02

Yeah, exactly.So an epidural is administered by an anaesthetist, you need some additional monitoring, once you've had an epidural, you need IV access. So that's a drip in your hand. And often you'll end up with a catheter as well. So that would require transfer. And how quickly that happens is always is dependent on many things. Another very common reason for transferring is what we call slow progress in labour. So labour is just taking a very long time. Other things which are fairly common, but maybe slightly less than those are, they're being conium in the waters once they've broken. And so that is when babies don't appear inside and lots of birth centres will have a kind of threshold for when they consider that the amount of meconium present is significant enough for us to want to offer continuous monitoring of baby's heart rate. Other reasons may be so actually transferring after the birth can be quite common. So that might be more to do with if repair is needed of the perineum for a more severe tear, or there's been a heavy blood loss, or occasionally, the placenta has remained inside. So these kinds of things. So sometimes, it can be incredibly frustrating. If you have your baby on a birth centre, and everything is gone really well. And then something happens after the birth, which means you do need to go but it all really depends on what kind of birth centre you're in. So if you're in a long in an alongside birth centre, you're attached to the hospital, it's going to be a fairly simple process for you to move over to the labour board, obstetric unit, if you're in a freestanding unit, it would be a case of the midwife transferring you in an ambulance, which would be the same as if you were at home, and you needed to go into hospital. Actually, I was looking at the rates as well, because I know very familiarly, I'm really well known with the home birth rate to transfer actually had to look up what the birth centre rates are. And then to be honest, they're quite similar. So if you're having your first baby, and these are quite old statistics, these are the 2011 Birthday statistics. But it was 36 to 40% of women having their first baby do transfer to an obstetric unit, which does sound quite high. But you know, it can be for a kind of wide range of reasons. If you're having a second baby, it's much lower at around 10%. 

Megan Rossiter  41:43

These statistics are basically the best that we've got nationally at the moment, that if you ask your midwife, they will be able to find out what the actual statistics currently are at the hospital that you're in, or you can kind of email the hospital. It's it's should be, it's not always publicly published, but it is public information. So if you want to access it and get something a little bit more specific you can do, but I think it is a helpful thing to know so that we can kind of set up our expectations of like, actually, what is it that we need to make sure we are prepared for what do things look like? And what kind of control do we have over these decisions? You did mention when you were talking through things like stitches for tears and birth of the placenta and stuff. I wonder if we could just touch on the kind of care that is available for those things on a birth and because it's not just a case of unless everything is totally intact and comes away totally on its own. Otherwise, you'd have to transfer it you can offer a little bit more care than that kind of you. 

Issy Bourton  42:44

Absolutely. So all midwives, especially midwives on a on a birth centre will be skilled at repairing tears perineal tears. So I don't know if you've discussed this before, but in your podcast, but essentially, there's different kinds of grades of a tear. And a midwife can can repair a first or a second degree tear. So a second degree tear means that when some of the vaginal muscle or perineal muscle has been torn, that's very simple for a midwife to repair we provide. So after birth, once baby's born and the placenta is out, that's generally when a midwife will offer to examine you again just to see and that's just a visual examination, kind of gently looking kind of parking your labia looking all down from the top where your clitoris is checking the urethra and the vagina itself to see if there's any damage and we then can repair most of the time we can do those repairs on a birth centre

Megan Rossiter  43:54

with local anaesthetic 

Issy Bourton  44:00

Exactly so we use local anaesthetic, just like you have at the dentist to numb the area. And then you can also continue to use gasoline. So I think that's something I didn't mention before. I can talk about that in a sec just about pharmacological options for pain relief on a birth centre. So you can use Gassner and then also, of course, we would use the local anaesthetic to repair and yeah, so with percenters again, you might choose to have either a physiological birth of your placenta and which is where we allow your body to to expel the placenta itself. I would say though, if you're choosing to give birth in a birth centre, you've you've kind of already subscribed to the idea that you you want to follow your body's physiology as much as possible. And so often with that comes, you know the wish to Have a physiological Burfield presenter as well. And I think that sometimes people think it will just kind of come out itself, your body will just expel it, and it will just kind of come out. And I would say that you, you sometimes have to be a little bit, there's a little bit of effort to it, sometimes some people's bodies will expel the present very quickly. And sometimes it will be a case of having to get up to do a we change your position, get gravity involved and put a bit of effort in. So sometimes you do have to work with once your baby's born, you will continue to have contractions, they won't feel as intense now that your uterus is mostly empty, but you will feel there'll be more of a cramping sensation. And often women find that they need to push with those cramps for their placenta to come out. And you can also have an active management. And so that involves having an injection in your leg to administer a drug, usually oxytocin, sometimes oxytocin and ergometrine, which kind of acts on on the smooth muscle in your body. So it helps your uterus to contract. And the midwife would then help to deliver the placenta. In a more, that's why it's called active because we're actively doing something by kind of pulling on on the cord. So those are the two options. Sometimes, you know, if a presenter doesn't come within, you know, the time that we imagine it would or should, our first go to, is to try and get you up to do away. And if you're unable to, we can also offer something called an in and out catheter. I would say an in and out catheter is one of the things that one of the interventions on a birth centre that that probably happens more than anything else. It can be really tricky sometimes to empty your bladder when you're in labour. And this is literally a small thin tube that the midwife inserts into your urethra, which is where you pass urine to essentially manually drain your bladder, because if you are a baby's still inside, sometimes their head is so low that it's actually really tricky to empty your bladder like even though you feel like you need to when you're sat on the loo it's just not coming out. And what the reason why we worry about that is because if your bladder is getting full and you can't empty it, then it can cause some damage to your bladder. And it can also stop baby's head coming down. Because it almost acts as like a bit of a balloon in their way. So these are kind of little interventions we can do if your baby's been born. And your placenta still inside and it's not coming, or it doesn't appear to be coming, then sometimes getting up to the go to the loo or Australia bladder can really help. That's just one example really of, of ways that we can work with your physiology to aid, labour and birth and keep you in this setting, which is calmer and more relaxed. There's lots of kind of different things we can try that don't require transfer in all manner of different situations. 

Megan Rossiter  48:24

Yeah, amazing. Thank you. So then the final sort of question, I suppose is that I imagine a lot of people listening to this will either be thinking I either want to be on a labour ward or a birth and try and I don't know which one, or I either want to be a home birth or a birth centre. And I don't know which one that if you're exploring the idea of birth centre, you tend to be sitting either slightly above it or slightly under it, and you're kind of not sure. Do you have any kind of final parting tips in terms of how somebody might like, what should they be thinking about if they're trying to make this decision for themselves?

Issy Bourton  49:04

That is a good question. I mean, I would say

Megan Rossiter  49:10

because you and I have both had have both had babies and we've had to make this decision like what is it that would lead you to finding the place that felt best for you?

Issy Bourton  49:22

I think it's thinking about how it feels being you know, where do you feel safest? Is that place home? Is your gut telling you? No, I'd rather be in hospital because that's the first decision if you think no, I just really want to be at home and a home birth. Because a birth centre isn't home and as much as we make it feel as relaxed and comfortable and calming as possible. It isn't your house. So if you're feeling like that, then I would say you should plan homebirth If you're feeling, oh, I think I do just want to be in hospital, then I think you should be planning to be on a boat. Because, as we've mentioned, you know, if you want to have a physiological birth, if it is important to you to birth your baby vaginally, a birth centre is going to be the most supportive environment for you. And statistically speaking, it's the place where that is most likely to happen. And I know you're not a statistic as a person. And you know, we have to think about these decisions in an individualised way. But you also have to be led by, you know, if you want to be in hospital, you're subscribing to a system and in some sense, as as individualised as your care is you're entering a system. And you have to kind of think, Where is best for me in this system. And if you want to plan us as Aryan, then the best place for you is absolutely to be on an obstetric lead unit. But if you want to give birth to your baby vaginally, then you really want to be an environment, it's going to promote all of that physiology and normality, that's going to help you to do that, and have all of the equipment you might need or just the philosophy. So you know, you can have a lovely space with all the equipment, perfectly designed and in place, but it's also about the people caring for you, and their philosophy of care. And on a birth centre, you will be cared for by midwives that want to do all they can to assist in you birthing your baby safely, but also working with your physiology. So that was a very long way of saying 

Megan Rossiter  51:54

no, that's good. Yeah. It's hard to articulate, because obviously, there's going to be very individual circumstances where actually there might be very clear, like better places to give birth. But I think, you know, if you're listening to this episode on birth centres, then the thought of birthing on a birth centre is gonna be on your radar. So it's I hopefully we've explored, or hopefully, all of the things that people might be wondering about whether this option might be best for them or not. So thank you so, so much for joining me. If people want to, like follow along or learn any more from you, where is the best place for them to find you?

Issy Bourton  52:35

I do have an Instagram. Totally, utterly rubbish at posting on it. So yeah, I feel like I am. What is the even @issythemidwife 

Megan Rossiter  52:49

I'll put it in the in the show notes so that people can come find you.

Issy Bourton  52:54

Um, but yeah, I'm not I'm not amazing. But it's one of my resolutions to think about how I can maybe provide some more interesting information.

Megan Rossiter  53:05

So right, you're doing that in real life wonderful care, which is a hugely important job. So we were very, very grateful. Thank you so much, and we'll see you next week. 

Issy Bourton  53:15

Thanks, Megan. Bye.

Megan Rossiter  53:24

Thank you so much for listening to today's episode of the Birth-ed podcast. It's my actual life mission to get these conversations in front of as many expensive families as possible and you can be a part of this mission. Don't worry, I'm not recruiting you into my cult. But if you leave a five star rating and review of the podcast then we creep up the charts getting more ears, change more births, change more lives and come on, you know you want to be a part of that change.