Considering the invisible parts of the birth environment

ISSN 2516-5852 (Online)

AIMS Journal, 2023, Vol 35, No 1

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Nicole Schlögel profile picture

By Nicole Schlögel

Last Sunday morning, when witnessing the birth of a little boy, I was reminded once again that the environment we create around the birthing mother matters…a LOT!

This mum had chosen a home birth despite her previous caesarean section. Her waters had released some 22 hours previously by the time her little man tumbled into the world. Anyone who has practised midwifery in the NHS will know that those details, the caesarean birth a few years ago and the length of time since the waters had released, could easily ruffle some feathers.

Luckily not last Sunday. My colleague and I were entirely on the same page when it came to supporting this mum after the first trickle of clear fluid revealed a spontaneous rupture of the membranes. The history of the previous caesarean birth had been addressed long ago. The team I have been so fortunate to become a part of has figured out a solid structure to navigate out of guideline care. The parents had been counselled well about why a history of an abdominal birth prompts the suggestion of labouring in hospital. They were facilitated in thinking about their options. They considered the 1 in 200 chance of having a scar rupture1 and what having this happen at home could mean. Waiting for an ambulance, transfer time to the nearest hospital, the possibility that by fluke no ambulance would be available; they considered all of that. When it came down to it, they felt that true birth physiology was most likely to unfold at home and that birth physiology in itself was most probably a protective factor on the large scale of things. Their little boy was born straight into the heart of this family in his parents’ bedroom. The older siblings were admiring his cute little face within minutes of the placenta landing on a pad on the floor whilst I helped the mum into a supported squat. It came physiologically, no synto2, no prodding, no pulling, no fuss and no major blood loss. All was well.

According to a major systematic review published in the leading medical journal The Lancet in April 2020 homebirth is just as safe as hospital birth for both mother and baby.

Altogether, around 500,000 births were included in the meta analyses which makes this a very reliable finding. All the women in the studies were having their first babies. They were all considered to be at a low risk of birth complications.

The interesting part is that women who gave birth at home were more likely to breastfeed their babies, less likely to have major tearing of their birth passage, less likely to bleed so heavily that a blood transfusion was required, less likely to have an emergency caesarean or instrumental birth and more likely to find their birth a positive experience3,4.

Whilst none of the women in the systematic review had had a caesarean birth before, those benefits were important to the parents I met last Sunday. Birth physiology can unfold best at home and that’s what made the decision for them.

Over the years of practising as a midwife I have come to recognise that a birth environment that allows birth to unfold is created not solely by addressing the physical space but also the mental environment of the parents and all those present at a birth. It is also created by the environment we have created collectively as a society nationally and globally.

What I bring to a birth matters. My mental landscape matters. The birth of my own daughter, what I read in the paper, and the birth I attended yesterday; no matter how much time I spend on gaining perspective on my own individual experiences, I can’t help but bring them to the birth. They have shaped me, my own way of looking at it continues to shape me and that goes for every one of us.

No matter how dim the lighting or how serene the soundscape, fear and apprehension hinder the process as much as fluorescent lighting does. Fearful thoughts release adrenaline in the birthing parent, we know that. But what about the doubts and fears that are brought to the birth space by birth partners, other family members and care providers? Our collective consciousness as a society even? Do they disrupt the fascia of a birth space?

Take for instance a ‘big’ baby. What does the suggestion ‘your baby is big’ do to parents? Even if we disregard the fact that the maternity system is likely going to suggest an induction of labour (despite a lack of evidence to support this practice), the mother will have associations with the notion that the baby ‘is big’. Her care providers, too, will be on high alert because of the associated increase in the risk of shoulder dystocia. What does that do, this fear of shoulder dystocia? And what about the often poorly researched reports in the media about individual tragedies? Could all of this prompt practitioners to act when no action is required? Could we continuously disrupt a process5 and in doing so nurture our distrust of physiology?

The vast majority of ‘big’ babies arrive perfectly fine when we let birth unfold. In fact the biggest baby I have ever seen being born was born in the birthing pool. The baby was 11lb 3oz (5.1kg). None of us expected the baby to be this big, and so the baby ‘wasn’t’ big - until he was born. So, to an extent, your baby is as big as you think - until your baby is born6.

Our internal environments matter as much as our external environments do and this is why it is important to get clear on what our fears and doubts are before giving birth or attending a birth. Asking yourself how you really feel about birth physiology, how much you trust it or how deeply you are conditioned not to trust it, is a worthwhile exercise and learning how to let go of niggling thoughts and fears quickly as they arise, can be very helpful for everyone in the birth room, not just the parents.

The families I have cared for over the years have guided me to the R.O.A.D. acronym. In the R.O.A.D. acronym, I talk about overcoming internal and external obstacles to your dream birth scenario. The external ones are almost exclusively posed by guidelines and policies and by the apprehensions and fears present in society today. R.O.A.D. stands for Recognise and release fears, Overcome the obstacles, Accept what you can’t control and Do the work. I use it to help families understand their own internal landscape as well as the external backdrop of modern maternity care. Birth has gotten pretty complicated. Physiology is generally only allowed to unfold if it does so within a set of policies and guidelines - unless parents assert their intentions. Learning how a baby emerges from a body is no longer enough, parents must also know how birth is observed in modern obstetric care. They must learn what the guidelines for routine care are in order to be able to put them into perspective and then interpret them within the context of their own values and beliefs.

No matter how we prepare for giving birth, getting to know our minds and exploring our internal environments with curiosity, love and compassion, will help us on our journeys. In doing so we can maybe create a collective birth space that allows for birth physiology to be celebrated rather than feared.


Author Bio: Nicole is a midwife, aromatherapist and yogi and has recently published her first book. ‘7 Secrets Every Pregnant Woman Needs To Hear Before Giving Birth: The New Midwife’s R.O.A.D. To Birth Hypnobirth System’ is available on Amazon.


1 Royal College of Obstetricians and Gynaecologists (2015). Birth after Previous Caesarean Birth (Green-top Guideline No. 45). Accessed via: https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/birth-after-previous-caesarean-birth-green-top-guideline-no-45/

2 Hutton, et al. (2019). Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses. EClinicalMedicine. 2019;14:59-70. Published 2019 Jul 25. doi:10.1016/j.eclinm.2019.07.005 Accessed via: https://pubmed.ncbi.nlm.nih.gov/31709403/

3 Reitsma, et al. (2019). Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses. EClinicalMedicine, 2019. Accessed via: https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30063-8/fulltext

4 Reed R. (2019) Big Babies: the risk of care provider fear. https://midwifethinking.com/2019/09/02/big-babies-the-risk-of-care-provider-fear/

5 Editor’s note: Synto is short for syntocinon, which is artificial oxytocin given via a drip.

6 Editor’s note: In the words ‘disrupt a process’ the author is recognising how medical intervention is known to alter the physiological process resulting in one intervention then requiring another. This has been referred to as ‘the cascade of intervention’. Thus, if it is fear (rather than actual need) that triggers the first intervention, it is fear that may be the root cause of us distrusting the physiological process.


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