Moved over to main website blog: Obstetric Cholestasis

Obstetric cholestasis

It has a number of names : Intrahepatic cholestasis of pregnancy (ICP), obstetric cholestasis, cholestasis of pregnancy, jaundice of pregnancy, and prurigo gravidarum.

What is it?

Obstetric cholestasis is a disorder that affects your liver during pregnancy. The main symptom is itching on the palm of your hands or soles of your feet. Another symptom is persistent itching of the skin (anywhere on the body) when there is no skin rash.

How common is it?

Takes from the RCOG : Obstetric cholestasis is uncommon. In the UK, it affects about 7 in 1000 women (less than 1%). Obstetric cholestasis is more common among women of Indian- Asian or Pakistani-Asian origin, with 15 in 1000 women (1.5%) affected.

Iching is a really common part of pregnancy, caused by the stretching of skin as your body accommodates your growing baby/babies. However, it can be one of the warning signs of cholestasis. It is important to flag any concerns with your care provider (midwife or obstetrician). They can preform a simple blood test to rule out any concerns of cholestasis. 

So what happens if you are diagnosed with obstetric cholestasis? 

Once diagnosed with obstetric cholestasis, you will be advised to be under the care of a consultant and have your baby in hospital with a neonatal unit (NICU). 

There is no cure for obstetric cholestasis but all symptoms generally disappear once your baby is born.

Most women will then have additional antenatal checks. This will include regular liver function tests, until you have had your baby. You will also be offered additional monitoring of your baby. Often this will involve extra ultrasound scans checking growth and measuring the amount of fluid around your baby.

When you are in labour, you will be offered continuous monitoring of your baby’s heart rate. There is some evidence that it is safer to birth your baby early if your symptoms are severe. You will have an opportunity to discuss the option of having labour induced after 37 weeks. 

Early induction (before term, 37 weeks) may carry an increased chance of having interventions such as assisted birth (forceps etc) or having a caesarean birth. It also carries an increased chance of your baby being admitted to the special care baby unit (SCBU) with complications of preterm birth. Your care provider or obstetrician will discuss what they feel is best for you and your baby in your individual situation so that you can make an informed choice.

Remember to take time to ask lots of questions. It can be helpful to have a notebook and pen ready to take notes as in unexpected situations it can be hard to take in all the medical information you are being told. 

Take time to weigh up all the pros and cons and understand each step before making your informed decision. 

Our doulas are an amazing support through this process - walking the journey with you - offering emotional and physical support. If you would like more information on how we can best support you pop us an email on info@doulacare.ie 

A response to Barbara Ellen’s “Meghan Markle’s home birth should not blind us to the risks for most women” published on The Guardian, 13th April 2019.

A response to Barbara Ellen’s “Meghan Markle’s home birth should not blind us to the risks for most women” published on The Guardian, 13th April 2019.

I am deeply disappointed in The Guardian for publishing Barbara Ellen’s ill-informed, fear-mongering article on the dangers of Meghan Markle’s decision for a home birth in influencing us, common plebeian women, who couldn’t possibly have a safe home birth without the royal treatment she will receive.

Based on research and reliable medical evidence, the World Health Organization (WHO) states “It has never been scientifically proven that the hospital is a safer place than the home for a woman who has had an uncomplicated pregnancy to have her baby.” No evidence that the hospital is safer for uncomplicated, low-risk pregnancies. You can also find, on the NHS website, information regarding revised guidelines issued by NICE (National Institute for Health and Care Excellence) which “recommended that women with low risk of complications in childbirth should be encouraged to either give birth at home or at a midwife-led unit.” The HSE, here in Ireland, also states that “research shows that a planned home birth is an acceptable and safe alternative to a planned hospital birth,” again, for healthy women with uncomplicated pregnancies. The HSE itself offers a homebirth scheme as one of its maternity care options, as does the NHS.

I could stop here. But I won’t.

I’m offended personally by the assumption that we, common women, wouldn’t carefully plan a home birth, or any kind of birth for that matter, as we have learned to do so from horrific hospital experiences. Anyone who has been listening to Joe Duffy lately would know all about that.

Among the inaccurate information contained in the article, I’d like to clarify a few:

• Homebirths are not attended by one midwife, but two. That’s how it works under HSE guidelines. Besides, with a midwife, at home, you get continuity of care, which hospitals fail to provide due to the way they are structured. This continuous care, provided by one person who you have come to know and trust, is associated with shorter labors and lower rates of intervention; hence the ever-growing popularity of birth doulas (in all birth settings; hospital, birth center, home, etc).

• When women who are giving birth at home need to transfer to the hospital, they don’t get there by “any means possible”; they use an ambulance service which has already been notified of the start of their labor and has coordinates to their home.

• The article mentions the “risks to most women”, which is also untrue as high-risk complications occur in less than 15% of all pregnancies, as stated by UC San Francisco Health.

Furthermore, if Barbara knew anything about the physiology of childbirth (because yes, newsflash: it’s a physiological process, not necessarily a “serious, bloody business”, as she hauntingly states), she would understand that in fact “splashing about in a birthing pool […] surrounded by Jo Malone candles […] and Enya on Spotify” makes an enormous difference to the progress of labor and can be the crucial difference between a straight-forward, uncomplicated delivery and a cesarean.

Our Co-owner Mary Tighe seen supporting her doula client during a home birth

That is because the physiology of childbirth is dependent on intricate, sophisticated hormonal dynamics. The driver’s seat is taken by oxytocin. They give you a synthetic version of said hormone in the hospital to start or augment labor. They also give it to you to facilitate the delivery of the placenta and to prevent hemorrhage. Oxytocin also aids in bonding with baby and the start of breastfeeding, both of which the synthetic version can’t do, by the way. But how is oxytocin brought about naturally then? Well, it’s the hormone of love and intimacy. So it’s raised through touch, massage, kissing, being in a safe, quiet, intimate place, with dimmed lights and privacy, with freedom to move around, have some water, eat something if you so wish; with no strangers walking in and out, asking a million questions, poking and probing at you. And for some people that might very well be a warm tub of water or shower, surrounded by candles, with Enya on Spotify. Delivering a baby is much more like making a baby than we seem to want to recognize. So, the answer is: whatever floats your boat, as long as it’s a safe option for you. Feel safer in a hospital? Then by all means, have a hospital birth! Have a complication that may require medical attention? Again, the hospital is probably a safer option for you. But this commonplace, ignorant discourse demonizing something you obviously know very little about is unacceptable. As a woman, I find that adding even more fear to this process, which can be a beautifully empowering one, is unacceptable. It’s like bullying women, more than they already are in this “serious, bloody business”.

There are various, researched techniques, or methods, that can attest to the efficacy of supporting this hormonal interplay, as they usually translate into calmer, quicker labors, with less unnecessary intervention (which means less risks for mother and baby), and better memories to cherish forever, because you will. forever. remember. that day. They are the likes of Lamaze, HypnoBirthing, and Ireland’s very own GentleBirth techniques, devising an informed birth plan, or hiring a birth companion, such as a doula, all of which work to empower and support the laboring woman and her baby, her feelings and desires, and in turn, this miraculous hormonal process.

You might wonder how you may benefit from having a doula, a hired birth companion, at a home birth, like Meghan is said to be doing. Doula support might indeed look a bit differently at home, because they can focus on you and your partner completely, and not have to deal with the hospital environment. They arrive before your midwife and are by your side the entire time. It gets to a point sometimes where midwives actually need to rest, to make sure they are well able to identify your medical needs, while a doula, in quite a different mindset, will still stand by you. Additionally, should you transfer to the hospital, they will accompany you and provide invaluable continuity of care. 

General areas in which doulas focus their support include: emotional and psychological preparation, guidance, and ease; physical comfort, positioning, and nurturing touch; supporting you in your confidence, decision-making, learning, gathering information and understanding your preferences. Although doulas and midwives both value those components as part of a satisfying birth, doulas get to focus on them entirely, while midwives are tending to clinical tasks. So together, at home, they are a wonderfully powerful team.

Of all the fashionable trends out there, I think this would be an absolutely lovely one to get informed about—and yes, if it’s a suitable option for you and your specific circumstances, maybe even follow.

Anita Petry

Birth and Postpartum Doula with DoulaCare Ireland

Member of the Doula Association of Ireland

Originally from Brazil, Anita now lives in Dublin with her husband David.

The Irish Maternity System - Birth Trauma (Joe Duffy stories)

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DoulaCare Ireland have (like many others in Ireland) been listening to the stories that have been shared by families in Ireland on the Joe Duffy show over the last week. They have made very emotional listening at times. Unfortunately as doulas and childbirth educators we have been privy to similar stories over the years from women who have reached out to us, looking for someone to talk to. To know that women finally have a public platform to share their stories and to truly be heard is one of the positives to come out of the show. 

At DoulaCare Ireland we support clients nationwide, and of course some will have had past birth trauma. These women and their families often feel they cannot speak about their experiences or they will be treated badly on subsequent pregnancies. Those who do speak out often feel they are brushed aside or their trauma is belittled by hospital staff. 

There is very little support within our maternity service for those who have had challenging birth experiences and need someone to talk to. Many of these women often apologise for feeling upset about their experience. After all, they have a healthy baby. Shouldn’t they be OK with how things went? Everyone else seems to think they should be grateful that all is well with baby and move on. But just because you are thrilled to have a healthy baby doesn’t mean you don’t get to grieve for the birth you had hoped to have. It is OK to be upset at how you were treated during your pregnancy and labour. It is such a vulnerable time in a woman’s life and while we may be nervous about the unknown, most of us don’t think that this will be compounded by being spoken to harshly or mistreated by the people we are supposed to trust. 

At DoulaCare Ireland we work closely with other supportive organisations and refer our clients to available services. 

If you have an experience (negative or positive) within the HSE care you can leave your feedback on their site called Your Service Your Say. This information does get reviewed and will be brought to the person in question. 

https://www2.hse.ie/services/your-service-your-say/your-service-your-say.html

We feel it is important to highlight the fantastic work that AIMS Ireland have done since 2007. They are campaigners for safe and respectful maternity care for the women of Ireland and they work tirelessly on a voluntary basis to do so. If you need advice or supports please do contact them on www.aimsireland.ie

We are also proud partners with Nurture Health, who are a national counselling service. They specialise in the care of women and their families during pregnancy and the postnatal period. They have counsellors nationwide who offer space and time to women who have traumatic experiences or have postpartum mood disorders. Irene, the CEO, always ensures their clients are seen quickly and matches them with the best counsellor for their needs www.nurturehealth.ie (and some of your hours may be covered by health insurance - Irish Life Health for example, offer hours with Nurture Health through their Parenting Path packages for new families.)

Some women find it helpful to get their notes from the hospital. They can be requested by writing into the Freedom of Information Officer in the hospital attended, with Name, Date of Birth and any other relevant details. The applicant must mention that they are requesting their notes under the Freedom Of Information Act in order to receive them free of charge. They will write back  with a standard letter saying they will give a response within 28 days, before sending on the notes on. If desired and the Mum feels able to do so they can then request to meet with the Head of Midwifery or with your Obstetrician to have a review of your notes (AIMS Ireland also offer this option). 

Many of the stories shared over the last week have mentioned women being alone and frightened or not understanding what was happening. With DoulaCare Ireland these situations never arise. With our agency model, each client has their chosen doula but also a back up doula. They also have the support of our full team of 35 doulas - all fully Garda Vetted. This means no matter how long a labour and birth lasts (4 day induction for example) our clients will have constant support from a known doula. They also have the knowledge and experience of 35 doulas to tap into at any point. We have women with diverse backgrounds in our team, from women health physiotherapist, midwives, nurses, yoga instructors, antenatal educators and much more. While our role is not to speak for you during labour we are there to help facilitate conversations between client and their health care provider, encouraging the Mum to ask questions if it looks like there is a lack of understanding on their part. 

Doula support is scientifically proven to reduce traumatic experiences and postnatal mood disorders. A Cochrane Review 2017 showed:

Women who had doula support were:

• more likely to have spontaneous birth

• more likely to have shorter labour

• less likely to use pain medication

• less likely to have Caesarean birth

• baby less likely to have low Agpars

• Lower levels of Postpartum Mood Disorders

Women who had doula support had:

• 31% decrease in use of Pitocin

• 28% decrease in Caesarean

• 12% increase in Spontaneous Vaginal Delivery

• 9% decrease in use of pain relief med.

• 14% decrease in baby going to SCBU

• 34% decrease in risk of being dissatisfied after birth

We welcome the discussions on Joe Duffy show and thank the team in RTE for opening up the space for these women to share their story and finally be heard. It is shocking how many women have experienced trauma and remain silent. We hope that women will be able to find their voice, to speak up for their rights and to get the support they deserve. We also hope that those working in the maternity system listen and work to implement change. It must be hard for anyone who works in this area who actively supports and cares for women in kind and compassionate ways to hear these stories, as this is not how they would ever treat anyone in labour themselves. However, the myriad of stories from all over the country show that there is a systemic approach to treating women that needs to be addressed and changed for things to improve. 

Sharing these stories is the first big step. Well done to every single woman/partner/supporter who has spoken out. Your strength will be a part in driving change for all the women and their families who will be entering into the Irish maternity system. 

We are here to support all women and their families. Get in touch if you need compassionate care postnatally to help you recover from a traumatic experience, or if you are embarking on a subsequent pregnancy. Your voice will be heard.

info@doulacare.ie

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