Instinctive versus directed pushing: which is best for you?

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The second stage of labour.  This is the time between the cervix being fully dilated and the birth of the baby.  It is also called the pushing stage.  Typically, if we watch births on TV, we will see a woman lying on her back in bed with her knees drawn up and a team around her yelling, “Push!” “Keep pushing” “Keep going, keep going, we can see your baby’s head” and so on.

The reality can be very different, if we choose.

Directed pushing can increase the chance of tearing, is thought to contribute to fetal distress and can lead to exhaustion.  This can necessitate the use of forceps or a vacuum.  Assuming a woman has not had an epidural, she will be able to feel when to push.  With an epidural, these pushing sensations are dulled and so directed pushing will be necessary.

Instinctive or spontaneous pushing is pushing that is directed by the woman herself.  She tunes into her body and pushes as and when her body tells her to.  I think it is unnecessary to elaborate here on the various bodily functions that we experience daily for which no directed pushing is ever felt necessary.  Vomiting is another experience for which any form of coaching is truly not needed.  Just as our bodies know how to perform all of these bodily functions, so, too, do we know how to birth.

When we observe instinctive and directed pushing, we notice that women who push instinctively tend to have more pushes per contraction, with each push being shorter.  When women are told when and how to push, they tend to have fewer pushes per contraction with each push (and breath-holding) being for longer periods.  This is thought to contribute to fetal distress as the baby receives less oxygen through directed pushing as compared with instinctive pushing.  It is also thought to contribute to more tearing as greater force is delivered to the perineum.

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Reasons that women don’t engage private midwives

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  1. She doesn’t know what a private midwife does.
    A private midwife is a midwife who works in a private practice.  Women who elect to be treated as private patients choose their care provider, so this means that a midwife who works in private practice works with women in the private health system providing complete continuity of care.  Private midwives usually consult with women in the midwife’s office or consulting rooms, or in the woman’s home.  Private midwives attend births in women’s homes, in birth centres and in hospitals.  They work with doctors to ensure that women and babies receive the very best care possible.
  2. It’s not recommended by their doctor.
    If your doctor is recommending against going with a private midwife, this could possibly be due to a lack of awareness of the ways in which private midwives work.  Your private midwife is able to contact your doctor to explain more about the way that private midwifery care is offered.  Many doctors remain unaware that there are Medicare benefits for care with eligible midwives in private practice, and that eligible midwives in private practice may order all the tests and scans that are needed during pregnancy, birth and in the care of a new baby, as well as ordering the necessary medications relating to pregnancy, birth and postnatal / newborn care.
  3. She doesn’t plan to have a home birth.
    Many women erroneously believe that one would only engage a private midwife for a homebirth.  Certainly, there are midwives who do work exclusively in home births, however many private midwives attend births wherever the woman feels is safest for her, and this may well include birth centres and hospitals.
  4. Only hippies would choose a midwife.
    Private midwifery care is not chosen by any particular group of women.  Women from all walks of life choose private midwifery care.
  5. She worries that private midwives cost too much.
    Cost is certainly an issue for some families.  Medicare benefits are available for services provided by eligible midwives in private practice.  Through my service, there is a range of options available with costs starting from $0 (after claiming back through Medicare).

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Early discharge and private midwifery

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When I talk about early discharge with women, they often seem concerned.  It seems the media has a lot to do with this, with reports of women being sent home from hospital unable to feed their babies and with little assistance from visiting midwives.  This can be very far from the reality for most women.

Early discharge with a private midwife is a different experience.  Within 12 hours of leaving hospital, your private midwife visits you at home.  It is the same midwife that you have seen all through your pregnancy, and the same person who cared for you during your birth.

In my practice, I visit women and babies in their home every day for the first week.  After that, I see women and babies twice in the second week, and then in week 3, 4 and 6.  The care is very comprehensive.  I find that rates of successful breastfeeding are very high: 97% women remain exclusively breastfeeding at discharge from care at 6 weeks.  On reflection, women are happy to have come home earlier and report enormous satisfaction with the frequency of visiting in the days and weeks after birth.

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Independent childbirth education classes: a midwife’s perspective

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Women who book with me for care will know that I am a firm advocate of independent childbirth education classes.  Why do I feel that these classes are so important?  It’s not that I believe that women need to be taught how to give birth, because I know that women’s bodies are designed to birth babies, and for the most part, women birth their babies without any help from anyone else.  Yet I still believe these classes are important … vital, even.

This is because all pregnancies and births involve choice.

And to exercise our choices responsibly, we need to have knowledge.

It is that simple.

If we do not know what choices we have, we do not have any.

If we are aware of our choices but lack any information about the implications of each path, we may not make responsible choices that lead us to a healthy birth and baby.

We have choices around care providers, place of birth, testing in pregnancy, interventions in birth, type of birth, methods of feeding a baby, postnatal care issues and early parenting choices.

Labour and birth and early parenting are not the times to be learning new information for the very first time: these are times in our lives when we are not in a state to take in new information and assimilate it.  This learning is best done in pregnancy, so that the time we get to labour, birth and baby, we are already aware of our options and our preferred choice.

Independent childbirth education classes cover more than basic hospital classes, in my opinion.  They will teach you everything from late in pregnancy to labour, birth and caring for your new baby.  They will provide all of the content of hospital-based classes and much more: more time, more resources and more attention.

The couples I have worked with over the years have been delighted with the classes they have attended, coming away feeling relaxed and calm, confident and knowledgeable.  They have helped enormously with birth planning and preparing for birth and baby, and with choices and decision-making.

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A Tale of Two Births: what is the post really about?

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I have received lots of comments about yesterday’s post, “A Tale of Two Births”.

What is the post really about?

The women in the post are not individual women: they are my reflections of many women whose birthing journeys I have come to know over the years.

Both women in the post made very different choices, and for different reasons: none less valid than the other, as their outcomes are the same: both women were well and healthy, and both babies were well and healthy.

Both women experienced similar pregnancies, although their journeys were slightly different.  None-the-less, both women were very happy with their care and care providers. This is important.  When we trust our care provider, we tend to reflect more positively on our pregnancy and birth experience.

Both women experienced a similar final few weeks of pregnancy, and this the point at which the stories become the most different, because we were presented with an almost identical situation that was managed very differently by two different care providers.   The obstetrician in this post could well have been a midwife making such recommendations to a woman; the midwife in the post could well have been an obstetrician making such recommendations.  The post was actually not about the choice of care provider.  It was about the care that was provided and the choices that were made.

The outcomes are very different, but they are not right or wrong.  Both women had happy, healthy babies.  Both women were happy with their choices.  Both women trusted their care providers and had great confidence in them.

What the post is really about is to say that nothing in birth is black-and-white or right or wrong.  There is no single formula for what to do in any given situation.  What is right is what is right for you.  It is about asking questions, being happy with your choices – owning your choices – and knowing that there can be several ways to achieve the  outcome of a healthy mother and baby.

A suspected big baby can be a good reason to have a caesarean – or not.

Going past your due date can be time to discuss options: induce, caesarean, or wait?  Wait for how long?  How can we be sure that the baby is ok if we are opting to wait?

A high head in a woman having her first baby – again, controversial.

No birth is the “best” type of birth to have.  No care provider is the best type of care provider.  They are all individual choices for each woman to make.

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A tale of two births

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When Sally (not her real name) became pregnant, she asked her friends for advice.  “Who is the best obstetrician?”  “What is the best hospital to go to?”  Various recommendations came back and Sally was a bit confused but eventually met an obstetrician who was available to see her and who delivered at the hospital that most of her friends had recommended.  Her appointments went smoothly.  She liked her obstetrician and really valued his advice and opinions.  When he made recommendations, she knew that he had the very best intentions for her and she took his advice every time.  All of her blood tests and scans were perfect.  There were no complications in her pregnancy.  Baby was healthy, she was healthy.

Being a first pregnancy, it was expected that Sally’s baby would engage well before labour started.  Sally’s doctor believed the baby should engage by about 37-38 weeks.  As the weeks went past and her baby’s head did not engage, her doctor recommended she have a caesarean on her due date, if not a few days before.  He warned that an induced labour may be long and painful, and perhaps result in a caesarean, and advised that an elective caesarean was a safe choice with minimal risks.  He was also concerned that Sally’s baby was not engaging because it may be a big baby, too large to fit into Sally’s pelvis.  Although Sally had wanted to have a natural birth, she was keen to meet her baby and so her caesarean was scheduled.  Although labour started a few hours before her scheduled caesarean, her doctor suggested that a caesarean was now the safest choice.  Her baby weighed 3.3Kg and was well and Sally recovered well from her caesarean.

————————————————————————————————————————————

By the time Louise (not her real name) became pregnant, she had already read two books on pregnancy and birth that had inspired her enormously.  She was excited by what she had read and was hungry for more information.  She had some understanding of the differences between the public and private health systems, and was aware that the private system offered her the opportunity to choose her own care provider, being an obstetrician or midwife, as well as choosing her place of birth.  While Louise had heard about home births and read about them, she felt that for her first baby, she would prefer to birth in hospital with a private midwife.

Louise made initial enquiries with a midwife and after meeting her, booked in for ongoing care.  Through her pregnancy, she attended childbirth education and birth preparation courses, read widely, spoke at length with her midwife during lengthy appointments, and became an equal partner in her care.  Her appointments went smoothly.  She liked her midwife and really valued her advice and opinions.  When the midwife made recommendations, Louise knew that she had the very best intentions for her and she took her advice (almost) every time.  All of her blood tests and scans were perfect.  There were no complications in her pregnancy.  Baby was healthy, she was healthy.

Being a first pregnancy, it was thought that Louise’s baby may engage well before labour started.  Louise’s midwife knew that while many first babies engage before labour, it is quite normal that some babies won’t engage until much later – even in labour.  As the weeks went past and her baby’s head did not engage and labour did not start, Louise’s midwife discussed her options with her.  Louise opted to wait for labour to start – she felt that this would be a sure sign that her baby was ready to be born, and she knew that labours that started on their own were more likely to progress well.  Louise had been very keen to have a natural birth, and when labour started – ten days after her due date – she was delighted to birth her baby in an active, drug-free water birth.  Her baby weighed 3.6Kg and both Louise and her baby were well.

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Pre-labour: what to expect?

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Pre-labour is a topic that has come up recently with some of the women I have cared for.  In particular, women have asked what the difference is between pre-labour and labour itself.

I’ll start by saying that pre-labour has many names: false labour, early labour, practice labour and prodromal labour.  I like the terms pre-labour or practice best as they describe the phase of labour (ie, before labour starts) and the purpose (practice for labour).

Many women experience pre-labour, but not all women will experience it.  For women women, the very first contraction is the start of active labour and from that point, their baby arrives very soon.  However, for most women, a period of contractions occurs as the body warms up for labour and as the baby shifts into a more favourable position for birthing.

Practice labour can last a while.  Several hours, several days, even a couple of weeks.

It is characterised by contractions that are irregular in frequency, intensity and duration.  This means that there is no pattern to the contractions that persist for more than an hour.  Some contractions will be long, while others will be short; some will be quite intense while others will be very mild; and some till come close together while others will be spaced apart.

They can feel like strong Braxton Hicks contractions or strong period pain.

They may also become more apparent when you are active, and die down when you rest.

When labour starts, there will be a regular pattern to the contractions and they will not be affected by your level of activity.

In terms of your body, practice labour is the time when your baby is moving to an optimal position for birth and it is a time when your cervix is softening, thinning and opening a little.  So we bring respect to this process, understanding that it is the key to a healthy start to labour.

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Ultrasounds and antenatal care

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Reflecting on the past new months, I have noticed that some women derive an enormous amount of satisfaction and meaning from ultrasound scans.  It seems the more ultrasounds, the better, or at least the more reassured the woman feels.

I have wondered if we have lost the art and meaning of hands-on antenatal care.  You know, the chat, the hands-on-belly, the discussion about baby’s movements, talk about what is happening in the woman’s life and of course the good old blood pressure check.

These are the things that as a midwife, I believe are really critical for good care in pregnancy.  It is about getting to know a woman and baby over time: what is normal for them, and perhaps what is not normal; and also providing skilled advice and information that is meaningful for the woman.

I understand, though, that all of this is no match for seeing your baby on a big screen, finding out what type of baby you are having, seeing his/her facial features and movements, and of course getting the DVD.

As a midwife, while I really value the information that I receive in an ultrasound report, I am always much more interested in how a woman and her baby are changing and progressing through pregnancy.  I value the one-one-one relationship that exists across time and sometimes over several pregnancies, and I believe that this is what makes a difference.

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Breastfeeding and blood pressure

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More good news about breastfeeding!

The University of Western Sydney’s research has found that women who breastfeed are less likely to develop high blood pressure later in life than women who have never given birth, and even less likely than women who had given birth but not breastfed.

The research found that the longer a woman breastfeeds, the less likely it was that she would have high blood pressure later in life.

The recommendation is that women breastfeed exclusively for at least six months, and preferably for 12-24 months.

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What is driving our rising caesarean rates?

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The answer seems quite clear, according to BMJ Open.

Caesarean rates were calculated according to the woman’s admission status / funding source (public / private) and type of hospital (public / private). The study found that most of the increase in the caesarean rate could be attributed to an increase in caesareans that were performed before labour had started in first-time Mums who were having their babies as private patients in private hospitals.  The study found that reasons such as breech presentation, placenta praevia and twins did not explain the increase.

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Epidural rates in Sydney

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The NSW Mothers and Babies Report (2010) reveals much about epidural rates in Sydney.  The highest epidural rates occurred in two private hospitals in Sydney’s St George and Sutherland areas.  More than 80% women birthing at these hospitals had an epidural.

The State average was 46.5% in public hospitals and 68.4% in private hospitals, so the rates for the St George and Sutherland private hospitals were far higher than the average for private hospitals.

Does this matter?  I think it is important to know this when you’re looking into birth options.  The statistics apply to each woman equally, so being aware of this can lead women to question their appropriateness of these birthing hospitals if an epidural is not part of plan A.

These same hospitals also topped the State when it came to elective caesareans, with more than a third of women giving birth by this method in 2010.  Elective caesarean refers to a caesarean that is performed before labour has started (it is an emergency caesarean if it is performed once labour has started).

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Birthing statistics

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The statistics listed below are for the births I have attended at home, in birth centres and in hospitals.  They reflect the care that has been provided to women in my care and may or may not represent your individual experience.

The number and type of interventions in a birth will depend on many factors:

  • Health and safety factors
  • The decisions that are made by a woman and her care provider
  • A woman’s motivation to achieve the birth she has planned

Statistics:

  • Normal birth (no forceps, vacuum or caesarean): 89%
  • Caesarean 5%
  • Vacuum 3%
  • Forceps 4%
  • VBAC 88%
  • Episiotomy 3%
  • Intact perineum 65%
  • 5% women use an epidural for labour
  • 82% women use no medical forms of pain relief in labour
  • 12% women are induced
  • 50% women have a waterbirth
  • 49% women birth at home
  • 60% women have a physiological third stage
  • 97% babies are exclusively breastfed at 6 weeks discharge
  • Homebirth transfer rate 19%
  • Women considered to be “low risk”: 45%
  • Women considered to be “high risk”: 55%

Statistics for first babies:

  • Normal birth (no forceps, vacuum or caesarean): 90%
  • Caesarean 5%
  • Vacuum 3%
  • Forceps 2%

I feel it is important to compare the measurable benefits of private midwifery care against the statistics for the State as a whole.  These statistics are taken from The NSW Mothers & Babies Report 2010 which are the latest statistics available.

Private midwifery care can increase the chance of a normal birth

  • In NSW, only 58% women birth their babies normally.
  • This rate increases to 89% through this service

Private midwifery care can reduce the need for an epidural

  • 47% of all women used an epidural in labour.  This commonly leads to an assisted delivery, possibly with an episiotomy.
  • The epidural rate is a mere 5% through this service

Private midwifery care can increase a woman’s chance of having a drug-free birth

  • NSW-wide, only 10% women birth their babies drug-free.  90% women use some form of analgesia.
  • Through this service, 82% women use no medical form of pain relief for labour.

Private midwifery care can reduce the need for a caesarean

  • 30% of women in NSW had a caesarean in 2010.
  • 5% women require a caesarean through this service.

26% of first time mothers had caesareans in NSW compared to only 5% of women who chose private midwifery care.

Private midwifery care increase the chance of a successful VBAC

  • In NSW in 2010, only 12% of women who had had a previous caesarean achieved a vaginal birth
  • This increases to 88% when women choose this service

Private midwifery care can increase the chance of  homebirth

  • Only 0.3% babies are born at home in NSW
  • 49% babies are born at home through this service

Choosing a private midwife more than doubles your chance of starting labour without medications

Choosing a private midwife trebles your chance of needing no stitches after birth

Private midwifery care reduces your chance of an episiotomy by 83%

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Syntocinon in labour

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A new study from the US has questioned the safety of syntocinon use in labour for induction and augmentation.  Syntocinon is an artificial form of Oxytocin which is a naturally-occurring hormone that causes the uterus to contract in labour.  When we need to induce a labour, or seek to make a slow labour quicker, Syntocinon is a medication that can be used via an infusion into a vein to make the contractions stronger, longer and more intense.

We know how it affects women in labour, and now this research questions its effect on babies.

The study has found that induction and augmentation of labour with Syntocinon was an independent risk factor for unexpected admission to neonatal intensive care unit for term babies and for low APGAR scores at birth.

This research suggests that Syntocinon should be used with caution.

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Fetal heart rate monitors – reassurance?

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During pregnancy, it is very normal for women to crave reassurance that their baby is healthy.  The purpose of regular antenatal care is to ensure the health and well being of the mother and baby, but for some women, it is this period between visits with their midwife or doctor that concern starts to build.  Is the baby ok?  How do they know?

Some women purchase or hire fetal heart rate monitors (dopplers) to keep track of their baby’s heart rate.  They feel that if they can hear a heartbeat, all is well and they feel reassured.  Midwives and doctors general recommend against this practice.  But why, if it provides women with reassurance?

When a midwife or doctor listens into baby with a doppler (or pinards), they are interpreting several aspects of the baby’s heartbeat, and they are putting this piece of clinical information together with the other aspects of the antenatal visit to create a complete clinical picture of the health and well being of the mother and baby.  It is simply not as simple as listening to the baby’s heartbeat in isolation and without reference to the overall health and well being of the woman.

As well, the interpretation of the baby’s heart rate and rhythm requires a degree of clinical training.  The mere presence of a heartbeat is not necessarily reassuring, and by the same token, it is very common for there to be some difficulty in locating the heartbeat and in differentiating the heartbeat from the other sounds that emanate from the uterus.

So, if midwives and doctors recommend women do not use monitors to reassure themselves of their baby’s well being, how can a woman feel reassured?

The simplest and most effective way for a pregnant woman to monitor her baby is to monitor the baby’s movements after 28 weeks of pregnancy.  A healthy baby moves, and often quite a lot!  Monitoring the baby’s movements after 28 weeks, and reporting a reduction in movements to your midwife or obstetrician is by far the safest and most effective way to monitor the health of your baby between appointments.

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The AMA and Maternal Decision Making

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The Australian Medical Association has recently published its position statement on women’s decision-making rights and responsibilities in relation to pregnancy- and birth-related issues.

A lot of positive feedback has emerged from this position statement.  But what does it say?

It speaks of a woman’s right to privacy, bodily integrity, and to make her own decisions.  Importantly, it recognises that a woman’s “capacity to make an informed decision should not be confused with whether or not the doctor (medical practitioner) considers her decision to be reasonable, sensible or advisable … Recourse to the law to impose medical advice or treatment on a competent pregnant woman is inappropriate.”

It is important that women are aware of this in light of situations where women are denied certain birthing options such as VBAC, VBAC after multiple caesareans, vaginal breech birth and so on.

The position statement recognises the important role that doctors (and presumably midwives) play in supporting pregnant women to make fully informed decisions by providing advice and impartial information.

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Placental encapsulation

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Placental encapsulation is gaining increasing interest from women as they consider their options for their placenta after birth.

Essentially, when a woman births her placenta, there are three options available:

  1. Disposing of the placenta at the hospital or via their midwife if birthing at home
  2. Planting the placenta deep under the group, perhaps under a tree
  3. Consuming the placenta.

This third option is the most controversial, attracting much interest from women and health professionals alike.  Why would you consume the placenta?  And how would you consume it?

There are three ways to consume the placenta:

  1. Cut the placenta into very small tablet-sized chunks that can be frozen.  Consume small chunks (frozen), or swallow small chunks of the placenta in its raw and non-frozen state.
  2. Cook the placenta in (eg) a stew or casserole
  3. Encapsulating the placenta

Of all the options for consuming the placenta, it is this third option – encapsulation – that attracts much attention.

Encapsulation means dehydrating the placenta, grinding it to a powder, and then placing that powder into capsules that can be consumed.

Consumption of the placenta is thought to have many benefits such as a reduction in the incidence of postnatal depression, minimisation of postnatal blood loss, regulation of hormones, boosting of iron levels, increased milk production and less fatigue postnatally.

Now, a small study has been done in Las Vegas that suggests that some of these benefits may be experienced by the majority of women who consume their placenta.

I remain slightly sceptical of the purported benefits because the cohort of women who are most likely to consume their placentas are also the cohort of women who are most likely to be motivated to have a positive birth and breastfeeding experience (therefore experiencing the purported benefits of placentophagy) and are also the cohort of women who are likely to be cared for by private midwives, and we know that women cared for in this way are highly unlikely to experience postnatal depression, breastfeeding issues and the types of birth interventions that lead to excessive blood loss after birth.

All of that said, placentophagy is not harmful, and may well contain the purported benefits.  I think that the study results are very encouraging and would love to read a randomised controlled trial on placentophagy.

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Holistic midwifery care

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Holistic midwifery care is care that assesses and incorporates the needs of the pregnant woman, rather than merely focusing on her pregnancy.  A midwife who is working holistically will be interested in a woman’s family, her health and medical history, her previous births, her emotional well being, any fears that she may have around birth and parenting, her work life, and her relationships.

A midwife who is working holistically will tend to see women for longer appointments, around an hour each, so that there is plenty of time to get to know each other and for the woman to feel safe and comfortable and supported.

A midwife who works holistically believes in the mind-body connection.  When we consider pregnancy and birth, a holistic midwife will understand that issues in life can impact a woman’s pregnancy, and s/he will recognise when fears, uncertainty and doubt are affecting a woman’s labour.  The midwife works with the woman through her pregnancy and birth holistically to help the woman to birth naturally, safely and calmly.

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Re: Challenges of private midwifery

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A midwife colleague of mine in QLD, Barbara Cook of Serene Births, has recently experienced a challenging time with a client.  This was a situation where she offered to support a planned hospital birth, rather than a planned homebirth for a woman when her care needs escalated, and the midwife’s attendance at a homebirth would not meet the standard of care that private midwives offer in Australia.  The client had had a previous caesarean section, and she had found this to be a traumatic event.  In the last paragraph of her blog post, Barbara comments,

“Yet if this woman had been supported well in her first birth with a known midwife she may not have required the caesarean, she now would be in control of her destiny and probably be able to birth at home.”

This is something I wanted to draw on: the choices that women make – sometimes knowingly, but most often unknowingly – in their first pregnancies, and the far-reaching impact that this has on future births.

Many women have a “see how it goes” attitude to their first births, perhaps not realising how important a first birth is in terms of bonding, breastfeeding, attachment, how a woman feels about herself, how she reflects on her birth in years to come, and the choices she makes in subsequent births.

In my practice, I meet a large number of women who feel traumatised by their first births, and I work with them as they journey through their second pregnancies.  The path is usually not smooth, and there are many bumps along the way: fear, uncertainty, doubt, anxiety, tension, sadness, grief, guilt – a whole gamut of emotions.  It is necessary to unpack and process all of these emotions before we can plan for a positive birth.

When women are supported well in their first births with a private midwife, they are highly unlikely to require a caesarean, and they tend to reflect on their births as a wonderful, positive experience.  Whatever comes up in their next pregnancy, they know they can do it (they have done it before), they are considered low risk (previous normal birth is the most likely outcome with a private midwife), and all the care options are available to that woman.  A previous caesarean means that a woman may be viewed as high risk for all of her subsequent pregnancies, with all of the emotional trauma that often accompanies an emergency caesarean when a woman was planning to “see how it goes”, thinking, “it’ll never happen to me”.

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Admission CTGs

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An admission CTG is where the midwife uses an electronic fetal monitor to monitor the baby’s heartbeat for a period of time when the woman is admitted to the delivery suite in labour.

In years gone by, it was standard practice in hospitals across the country, but in recent years, it has fallen out of flavour.

An admission CTG is different to continuous monitoring, in that continuous monitoring is employed when the midwife or obstetrician has a concern about the baby, whereas an admission CTG is used when there are no concerns.

So what are the issues with an admission trace?

The first issue is that the more often we use a CTG, the more often we discover slight irregularities in the baby’s heart rate patters that are highly unlikely to cause problems, but which cause midwives and obstetricians some concern.  Hence, it is often the case that the CTG that was only ever meant to be on for a few minutes after arriving, tends to stay on for the duration.  We know from lots of research that CTGs do not improve outcomes at all in healthy women, however they do increase the caesarean rate with no benefit to the baby.

The second issue is that the CTG tends to require that the woman remains still.  This can increase her level of pain and discomfort, prompting her to request pain relief that she otherwise may not have required.  Pain relief can often lead to other interventions such a medication to speed the labour, forceps delivery and episiotomy.

So in essence, an admission CTG serves to increase the rates of intervention in low-risk, healthy women, with no known benefit to the mother or baby.

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Which birth choice is right for me?

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In the blog post below, I am going to go through a few scenarios or preferences, and suggest a care option that may best suit that woman.

I am going to choose from only four options, even though there are many many different models of care for pregnancy and birth.  The options I am going to choose from are:

Private midwifery care either for a planned homebirth or a planned hospital birth

This is a continuity of carer model whereby a woman is cared for by one midwife from early pregnancy through to birth and the postnatal period until the baby is 6 weeks old.  Where the woman has complications in pregnancy or requires a higher level of care, the midwife is able to refer the woman directly to an obstetrician, or the baby to a paediatrician.  The midwife is also able to order all the necessary tests and scans for the woman.

Private obstetric care for a planned hospital birth

This is a continuity of care model where the woman’s pregnancy care is provided by one obstetrician.  The labour is attended by hospital midwives who are not known to the woman before labour starts, and the birth is attended by the obstetrician with whom the woman has a relationship.  The postnatal care is provided by hospital midwives who are not known to the woman, and the obstetrician provides a final check at 6 weeks postnatal.  This model of care is available in public and private hospitals.

Shared care: either with a GP or a private midwife

This is where a woman attends a private midwife or her GP through her pregnancy (continuity of carer for pregnancy), however the birth is attended by the hospital midwives and obstetricians at the hospital at which the woman is booked, as a public patient.  Once the woman is discharged from hospital, she may again be cared for by her private midwife or GP.  This is a model of care within the public system, where some of the care (ie, the pregnancy care) is provided by a private practitioner.

Standard public hospital care

In this model, a woman is cared for entirely by the public hospital staff.  Generally the woman attends the antenatal clinic for her pregnancy care, where she is seen by the midwives who are on duty that day.  From one visit to the next, the woman may be seen by different midwives.  Some hospitals have a midwife clinic where it is possible for the woman to be seen by the same midwife for most of her pregnancy (antenatal) appointments.  In labour, the woman is cared for by the midwives and obstetricians who are on duty.  These midwives and obstetricians will not be known to the woman ahead of time, and they work in shifts.  Once the baby is born, the woman moves to the postnatal ward where she is again cared for by midwives she has not met before, who work in shifts. This model of care is absolutely free to Medicare card holders, and in Australia, our public system delivers a very safe standard of care.

I want to build a relationship with the midwife who will be caring for me during birth.

This woman would be best to choose private midwifery care. This is the only model where all of your care is provided by one midwife.

I want to feel prepared, informed and confident as I approach my birth.

This woman would best be cared for with private midwifery care, or with private midwifery shared care.  In both models, midwives work very closely with women, through education, preparation, support and lots of time for questions and discussion.

I want basic care: just a quick check and basic education to be safe.

This woman could be cared for with private obstetric care, GP shared care or public hospital care.  It might be best suited to a woman who has had a normal, straightforward birth before, who just wants the basics to be safe.

I want to build a firm relationship with the obstetrician who will be present if something goes wrong.

Private obstetric care might be best here, however there are models of collaborative private midwifery / private obstetric care that might also be helpful.

I am planning an elective caesarean.

Probably private obstetric care will be best.  You will get to know your obstetrician well during your pregnancy, and s/he will attend your caesarean.  This is very reassuring care for women planning a caesarean.

I want to have home visits from my midwife after my baby is born.

Private midwifery care would be best.

I am planning a waterbirth / home birth

Private midwifery care again.  Public hospitals generally don’t provide homebirth services, and waterbirth rates can be quite low.  Private midwives have the highest rates of homebirth and water birth.

I am planning a VBAC

Private midwifery care will give you the best chance of a VBAC (vaginal birth following a previous caesarean).

 Learn more about private midwifery care and antenatal shared care

Financial Planning advice for when baby comes

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Many families ask me about issues relating to budgeting for a family, and also about their options for paid parental leave and the Baby Bonus.  Boris Glushankov is a Financial Planner at In Advance Financial Management, and he has a special interest in all issues relating to budgeting and financial planning for new families and couples who are considering having their first baby.  This is what he has to say:

You often hear new parents say that having a baby is an amazing life-changing experience. Nothing is ever the same again! At a time when every aspect of your life is changing, the last thing you want to think about is money. It may not be always possible to reduce your financial commitments, but there are things you can do to plan and manage them more effectively.

“In Advance Financial Management” has created a unique “Before Having a Baby Essentials Package” to help with your changing financial needs.
We have brought together a group of professionals from different areas (Financial Planning, Mortgage consulting, Accounting and Legal Services) to offer you a complete solution for preparing your finances for the arrival of a new member in your family.
The base “Before Having a Baby Essentials Package” includes:
• Two(2) written budgets – one for your current circumstances and one for when the baby is born
• A review of your debts to maximise cash-flow when your baby is born
• A review of your Insurances, both inside and outside of superannuation.
In addition to the “Before Having a Baby Essentials Package” we can also offer you:
• A review of your mortgage to free up cash-flow and see if any other benefits can be attained
• Advice on maximising Centrelink benefits and help with related Centrelink forms
• Review of your new Estate Planning Needs including creation of a Will
• Accounting service
Please see attached document for further explanation of each service and pricing.

If you decide to purchase or vary an AMP product, your financial planner, AMFP Financial Planning Limited and other companies within the AMP group will receive fees and other benefits, which will be a percentage of the premium you pay or the advice fee you agreed with us. You can ask us for more details about this.
This is general information only. It does not take into account your objectives, financial situation or needs. Before relying on the information, please consider the appropriateness of the information in light of your personal circumstances. No AMP company or AMP financial planner receives any payment for the general advice in this flyer.

In Advance Financial Management Pty Ltd
Shop 83, BKK Eastlakes Shopping Centre,
19 Evans Ave, Eastlakes, NSW, 2018
(02) 8970 0531
email: [email protected]
web: www.inadvance.com.au

In Advance Financial Management Pty Ltd, ABN 83 149 130 405, is an Authorised Representative of AMP Financial Planning Pty Limited.

Physiological (natural) third stage

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The third stage of labour begins once the baby has been born, and ends with the birth of the placenta.

Many women are now requesting a physiological (natural) birth of their placenta.  A safe physiological third stage requires oxytocin to be produced by the mother to stimulate the uterus to contract and expel the placenta.  Generally, this requires:

  • Natural birth: without medication to induce or augment (speed up) the labour, without an epidural, without forceps, vacuum or caesarean.  So, in other words, a labour that starts on its own, progresses on its own, where the mother does not use medical forms of pain relief, and where she breathes out or pushes out her baby unassisted by forceps or a vacuum (or caesarean).  This is because these natural processes prime the woman’s body to release lots of oxytocin once the baby is born, to stimulate the uterus to contract to expel the placenta.
  • An environment that supports oxytocin release: this would be a private, dark, calm, warm, quiet environment.  Not the hustle and bustle of a busy delivery suite, but perhaps a water birth setting, home birth setting, or a birth centre setting.
  • No distractions: the mother and baby should be left (but observed by a midwife) for uninterrupted skin-to-skin contact, bonding time and breastfeeding if the baby is ready for this.
  • Leave the cord!  No-one should be fiddling with the cord, checking pulsations or pulling on the cord.  So long as the bleeding is not excessive, the woman should be left and observed.

In time, the placenta will emerge.  Often the woman feels more contractions and an urge to push.  If she is upright (eg squatting, sitting on the toilet, standing or kneeling) the placenta will come on its own, or perhaps with a gentle push.  It can be supported as it emerges and collected into a bowl, ice cream container (sans ice cream) or other receptacle.  The midwife would then check the placenta and membranes to ensure that they are complete.

 Learn more about private midwifery care and antenatal shared care

Fear and caesareans

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A new study suggests thatfear of birth has a negative impact on women’s pregnancy and birth outcomes.  High levels of fear were found in around a third of Australian women who were surveyed.

The research identified three profiles: self determiners; take it as it comes; and fearful. Women who belonged to the fearful profile had the most negative outcomes including higher rates of elective caesarean and more negative feelings about pregnancy and parenting.

In my practice, the caesarean rate is 5%, and this is within an all-risk private midwifery practice.  I am often asked by new clients why the caesarean rate within my practice is so low, compared with the National and State average of around 30%.

I believe the answer lies in the work that we do during pregnancy that really addresses fears, doubts and uncertainty.  We spend a lot of time on birth preparation, birth planning, debriefing of previous births and re-education.  When I ask women at discharge how they felt as they approached their birth, 90% indicate they felt extremely confident and 5% were confident.  All women comment on how well prepared and informed they felt, and I believe this allows women to completely relax into labour and let their body birth their baby with the minimum of effort.

Learn more about private midwifery care and antenatal shared care

Continuity of midwifery carer under-valued?

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An article published three years ago asked, “When a woman arrives at hospital in labour, who do you think will do an assessment, care for the woman and deliver her baby? If you ask most women they will tell you this person was a midwife, because in most cases the birthing experience is normal despite the rising rate of Caesarean sections.”

“Australia continues to ignore recommendations of the WHO and doesn’t fully recognise the extensive professional skills and education of midwives; skills that allow hospitals and birth centres to leave the birthing of most of the nation’s babies in their capable hands.”

in 2009, the Federal Government’s initiated a Maternity Services Review which made several recommendations for continuity of carer models, access to the MBS (Medicare Benefits Schedule) and PBS (pharmaceutical Benefits Schedule) for midwives, together with midwife admitting rights.  These recommendations would being private midwives greater autonomy to care for their private patients within a hospital setting, along with Medicare benefits for services provided and the ability to order diagnostic tests and prescribe medications.

Midwifery models of care, such as private midwifery care, are about women being cared for by a health professional who they get to know and trust.  Most women who are birthing through the general hospital system will meet as many as thirty care providers from the very first booking-in appointment through to discharge from hospital after the baby is born.  Even within the private hospital system, women still see many care providers: their obstetrician, as well as many midwives during the standard four- or five-day stay.

The Maternity Services Review recognised that continuity of midwifery carer through pregnancy, birth and in the postnatal / new baby period is safe.  There are many other benefits to having your own midwife: lower rates of unnecessary intervention, a more positive and empowering birth experience, greater preparation for birth, a shorter labour, higher breastfeeding rates, and better support during the new parenting period. Overall, women who are cared for by one midwife report increased satisfaction with their care, greater self confidence after the birth of their child and reduced vulnerability to post natal depression.

Learn more about private midwifery care and antenatal shared care

Is it possible to be induced and not have an epidural?

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Yes, it is absolutely possible!

An epidural is optional with an induction, and many women will opt to “see how it goes” and often surprise themselves!

An induced labour is not necessarily a horribly painful event, and in my practice, I am yet to have a woman be induced and request an epidural.

Important factors are one-on-one care from a known and trusted midwife, a strong belief in the natural birthing process and lots of strategies for a drug-free labour and birth.

Learn more about private midwifery care and antenatal shared care

During a homebirth, do midwives give oxytocin?

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Many women who choose a homebirth opt for a physiological / natural third stage. This means that the baby’s cord is not clamped immediately – at least not until the cord pulsations have ceased; the midwife does not pull on the cord, but rather waits for the placenta to be born naturally; and syntocinon (oxytocin) is not given.  Instead, the woman is assisted into an upright position, skin-to-skin with her baby.  This tends to stimulate the release of the hormones that make the uterus contract to expel the placenta.

Midwives do carry syntocinon (oxytocin) at a home birth so that it is ready to use if it is needed for excessive bleeding, but most often it is not needed and instead, we support the natural processes of birthing the placenta.

Learn more about private midwifery care and antenatal shared care

Childbirth trends by postcode

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The Australian Institute of Health and Welfare recently published data about birth in Australia.  The report found that caesarean section was now one of the most common interventions in pregnancy.

Combined with the most recent (2010) report of birthing in NSW, we know that the rate of natural birth in NSW decreased from 60% in 2006 to 58% per cent in 2010, while the caesarean rate rose from 29% to 31%.

In NSW, mothers receiving private obstetric care were more likely to have operative births (forceps, vacuum or caesarean) than those in the public system or those being care for by private midwives.

In particular, Kareena Hospital in Sydney’s South topped the State’s private hospitals for the highest number of epidurals (83%), while caesarean rates were highest in several private hospitals: North Shore Private, the SAN, Hurstville, St George Private and Norwest Private all had caesarean rates between 46% and 47%.
The average caesarean rate in a private hospital in NSW was 41%, while the average NSW-wide was 30%.  The average with private midwives is consistently under 10%, in line with the World Health Organisation’s recommendations.

Fairfield Hospital had the lowest rate of epidurals of all hospitals in the State, with 15% women having an epidural for labour.  Roughly 5% private midwifery clients opt for an epidural.

These reports are significant in that they help to determine maternity service resource allocation.

Learn more about private midwifery care and antenatal shared care

Pets and home birth

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I am sometimes asked about pets and home birth.  I am an animal lover and I think that our pets are an important part of our families, so my views below might be a tad biased, but here goes:

I find that most pets are fine during a home birth.  You’ll know if your cat or dog loves the water a bit too much (so much that they’d hop in the birth pool with you), and in this case, some people prefer to have their pets in a separate room.

Dogs always seem to know what pregnancy means (ie, that a baby is on the way) and seem to be protective of the pregnant woman throughout her pregnancy.

I think dogs tend to know when labour is about to begin, and sometimes their behaviour changes very subtly.

During labour, dogs tend to be quiet and respectful, and I find that cats just tend to do their own thing.

If you have other pets, such as fish, rabbits, chickens, birds and so on – these animals tend to be fine during home births.

The main things with pets would be to ensure that they have enough water and food, and if you think they might need their own support person, to consider this ahead of time and have someone handy in case they are needed.

Learn more about private midwifery care and antenatal shared care

Do obstetricians and midwives attract different clientele?

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New research has suggested that women who see themselves as active participants in the birth of their first child, and prefer a collaborative role with their healthcare provider are more likely to opt for a planned home birth with a midwife.

On the other hand, women who perceive their role in the birthing process more passively and are more fearful of birth are more likely to seek obstetric care for a hospital birth.

Women’s answers indicated whether they perceived the Mother’s Role as active or passive, the Provider’s Role as dominant or collaborative, and the Delivery Experience as fearful and painful, or as a positive occurrence.

Women who perceived their role as active, the provider’s role as collaborative, and the delivery of the child as a positive experience, were more likely to prefer midwifery care, birth at home, a vaginal delivery and the avoidance of pain medication.

The more painful and fearful a woman expects her birth to be, the more likely she is to prefer a caesarean to a vaginal birth.

Learn more about private midwifery care and antenatal shared care

Top tips for a healthy pregnancy

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Folate

Folate is a B vitamin that is found in food.  Folate helps to produce and maintain new cells – especially important during early pregnancy when the baby is developing.  Folate is found in green, leafy vegetables, citrus fruit, beans and peas.  As well as dietary sources of folate, it is recommended that women take an additional supplement of folate in the form of folic acid.  500 mcg daily is recommended for women from 3 months prior to pregnancy, until three months into the pregnancy.

Alcohol and smoking

Both are best avoided in pregnancy,  Alcohol crosses the placenta and directly affects the baby.  Alcohol can cause miscarriage, premature birth, stillbirth, a small baby and fetal alcohol syndrome.  Smoking reduces the amount of oxygen that is available to your baby, and can cause low birth weight.  As well as this, there are many chemicals present in cigarette smoke that can be harmful to a growing and developing baby.  Smoking can increase the chance of a miscarriage and preterm birth.

Sleep

Rest and sleep are really important in pregnancy.  Early pregnancy, especially, is often a time of tiredness and fatigue, and in general, the first trimester is easier when you are well-rested.  Some women will need an afternoon nap or sleep-ins on the weekend to get through the first trimester.  Likewise, the third trimester is also a time when some extra ZZZZZs are need.

Exercise

Exercise is great during pregnancy!  Any exercise that you have been doing consistently prior to pregnancy is safe during pregnancy, but it is a good idea to run this past your care provider.  Contact sports, high impact exercise and vigorous sports may need to be avoided.  The best exercises are walking and swimming, and some women also like to do pregnancy yoga and pregnancy pilates.  These are both very gentle.

Exercise has numerous benefits to you and to your baby:

  • Maintenance of a healthy weight
  • Reduction in the risk of gestational diabetes and high blood pressure
  • Promotes more restful sleep
  • Stress management
  • Improved sleep
  • More energy to get through your day
  • A shorter labour, perhaps with fewer interventions

Healthy diet

A healthy diet is the foundation of a healthy pregnancy.  A healthy diet can help to prevent gestational diabetes, high blood pressure and obesity.  Every mouthful of food helps to grow a healthy baby.  You want to give your body the best nutrients, frequently throughout the day (ie, several small meals throughout the day), to allow your baby to develop healthily.

Learn more about private midwifery care and antenatal shared care

What do midwives do?

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Not everyone knows what a midwife is and what we can and cannot do.  Some people think midwives only assist doctors in the care of women during birth, or that we care for babies and children.

I think that the role of the midwife in antenatal (pregnancy) care and labour and birth care is sometimes not well understood.

Midwifery in Australia is undergoing a period of change, thanks to maternity reforms almost three years ago which have helped midwives gain more autonomy and an increased scope of practice.

Midwives care for women from early in pregnancy, right through to birth and the first six weeks with the new baby.  Midwives listen to women, talk with women, educate and prepare women for birth and parenting, support women and care for women and babies through pregnancy and beyond.  Midwives help new mothers care for their babies and adjust to parenthood.

Midwives are on-call 24/7 for the women and babies that they care for.  Babies come at all hours of the day and night, and sometimes women have urgent health concerns and they want to be sure that they can contact their midwife when they need to.

Most midwives pour their hearts and souls into their work.  Midwives are privileged to touch the lives of families in a very special way.

Learn more about private midwifery care and antenatal shared care

Independent Childbirth Education

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Those who know me will know I usually recommend women attend independent childbirth education courses.  Julie Clarke of Transition into Parenthood has provided this excellent guide to the differences between hospital-based classes and independent classes.

I am interested to hear your thoughts!

Learn more about private midwifery care, antenatal shared care and antenatal classes

Westmead Hospital Birth Unit Tours

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Women who are seeing me for shared care and who are planning to birth at Westmead Hospital are now offered a one-on-one tour of the birth unit.  Appointments are necessary.  There is no cost for the tour.  It is offered as part of the private midwifery shared care program.

During the tour, we will talk about:

  • Positions for labour and birth
  • Active birth and equipment available
  • Types of monitoring
  • The process of birth
  • Discharge planning
  • Where to come in when in labour
  • Where to park
  • Length of stay in birth unit after birth
  • What to bring for labour
  • Environment for labour and birth

To book in for shared care, enquire here.

Learn more about private midwifery care, antenatal shared care and antenatal classes

What equipment do women need for a homebirth?

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A while back, we looked at what equipment midwives bring to a homebirth.  But there are also a few things that women will need to supply for a homebirth.  Most of the items are found around your home, so it’s really just a case of gathering the supplies together.

  • Face washers
  • 3 old bed sheets: one for the bed, one for the couch and one spare
  • 15 old towels (especially if you’re having a waterbirth)
  • 3 large plastic sheets (eg painter’s drop sheets or plastic shower curtains) for covering the couch, bed and for under the birth pool.
  • Plastic supermarket bags for rubbish
  • Plastic container with lid for placenta
  • Large rubbish bin for rubbish
  • Laundry basket for soiled towels
  •  Fan
  •  Candles and matches (optional)
  •  Pillows and bean bags for comfort (optional)
  •  Loose clothes and comfy socks for labour
  • 4 packets maternity pads
  • 2 packets regular pads
  • 1 box of tissues
  • Massage oil
  • Hair bands
  •  Mirror for you to see the birth
  • Music
  • Bendy straws
  •  Baby clothing, jumpsuits, singlets, etc
  • Nappies
  • Cotton wool balls
  • 6 baby wraps
  • Thermometer
  •  Birthing pool
  • Electric pump for pool
  • Hose for filling
  • Connections for hose
  • Mattress or couch to lie on that is close to the pool (cover in plastic)
  • Hand-held colander for “floaties”
  • Camera and/or video recorder
  • Snacks and drinks
  • Present from sibling/s for the new baby

All in all, most of these items are found at home, and your midwife will bring all the medical equipment that is needed.

Learn more about private midwifery care, antenatal shared care and antenatal classes

Your perineum in labour

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A while back, I reported on the 2006 data with regards to tears and episiotomies, and wrote:

The NSW 2006 data reveals interesting statistics about the fate of your perineum in NSW hospitals. Overall, 13% – 56% did not have stitches after their birth. The average was 27%.

3% – 35% women had an episiotomy. Huge variation, don’t you think? The average was 15%.

When we look at first time mums, 12% – 51% birthed their babies and needed no stitches. The average was 32%. And episiotomy rates varied from 2% – 45% (average 18%).

How does this compare with our 2010 data?

Overall, 23% women did not have stitches after their birth, down from 27% in 2006.

18% women had an episiotomy, up from 15% in 2006.

When we look at first time mums, 17% birthed their babies and needed no stitches. This is down from 32% in 2006.

 

This is quite different data!  I am astounded at the drop in the number of first-time Mums who are birthing with an intact perineum.  I have no answers for why this is the case; I have re-checked the data and it is correct.  Do you have any clues?

Learn more about private midwifery care, antenatal shared care and antenatal classes

Home birth: how messy is it?

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Homebirth generally isn’t messy at all.  Many women labour and birth in a birth pool and any bodily fluids are easily contained.  Towels and plastic sheeting come in handy and midwives are very good at leaving the house as it was found.  Plastic bags collect any garbage, the placenta is collected in a bowl or container, and sheets and towels can be washed.  All in all, a homebirth is nowhere near as messy as people think.

Learn more about private midwifery care, antenatal shared care and antenatal classes

What equipment do midwives bring to homebirths?

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Typically, midwives bring a range of safety equipment and supplies to a birth. These include:
- Oxygen for mother and baby
- Suction equipment
- Suture material and local anaesthetic in case of any tears (generally there are no tears)
- Medication to stop any excessive bleeding after the baby is born
- Vitamin K for the baby
- A doppler to monitor the baby’s heart beat
- Blood pressure equipment
- Urinalysis sticks
- Scales to weigh the baby
- Resuscitation equipment for the baby
- An oxygen mask for the mother
- A catheter in case the mother is unable to pass urine
- General equipment such as gloves, a mirror, needles and syringes, sterile water and normal saline, gauze, cotton wool, tape, cord clamps (unless the family prefer to use a cord tie) and so on. It’s quite a big kit when it’s all put together.

Learn more about private midwifery care, antenatal shared care and antenatal classes

Top 3 myths about waterbirth

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Waterbirths are great, and about half of the women who chose me to be their midwife birth in water.  But when I’m out and about, I come across some interesting ideas about waterbirth ….

1. Babies drown during waterbirths

Um, no, not quite.  I am quick to point out that babies are swimming around in amniotic fluid before they’re born … and they don’t drown on amniotic fluid.  So long as the baby is brought to the surface soon after birth, babies do not drown during water births.

2. The midwife has to get in the tub to deliver the baby

Apparently this is so that the midwife can “pull” the baby out.  Midwives don’t “pull” babies out; women either push their babies out, or breathe their babies out.  So we don’t actually get in the bath tub / birth pool and pull.  Rather, we guide and catch, or the mother guides and catches, or the partner guides and catches.  And the baby is brought to the surface.  The only part of the midwife that goes in the pool is her hands and arms.

3. Waterbirth causes infection

Research has shown this not to be the case.

All in all, waterbirth is a great way to give birth and has many benefits for mother and baby.

Learn more about private midwifery care, antenatal shared care and antenatal classes

Homebirth transfer rates

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We hear a lot about transfer rates, and I am not sure if a transfer rate is a good thing or a bad thing! It seems that high and low rates appeal to different audiences and mean different things to different people.

I have always regarded a transfer rate as a sign of safety.  A 0% transfer rate might be a bit worrying; likewise, a 50%+ transfer rate might also be a bit worrying.  By transfer, we mean a situation where a woman had planned to give birth at home, but ends up birthing in hospital.  A transfer can happen at any stage of the pregnancy or labour.

So what is a woman really asking when she asks her midwife what her midwife’s transfer rate is?  I consider that the woman is really asking, “If I ask you to be my midwife and care for me through my pregnancy and birth, what’s my chance of being transferred to hospital?” and when women ask the same question of several midwives, they are most reassured by the midwife with the lowest transfer rate because they perceive that they have the lowest chance of transferring if they go with the midwife with the lowest transfer rate.

Is it a fair assumption to make, that the midwife’s transfer rate, representing her previous client’s outcomes, are a valid gauge for the current woman’s likelihood of transfer?

Often, I find that transfers can’t be predicted. If we could predict it, we’d recommend a planned hospital birth. Considering transfer rates from this perspective, a midwife’s transfer rate has no bearing on the current woman sitting with her. As well as this, some transfers occur because the woman has requested it – eg a request for transfer for an epidural, but not on the advice of the midwife as the labour is actually progressing very normally. The other situation that can arise is that the midwife foresees problems occurring and makes some recommendations to avert those problems, but the woman considers the recommendations and decides against them. In these cases, again, the midwife’s transfer rate has no bearing on each new client who interviews a midwife.

So what’s a “good” homebirth transfer rate?

Well, many might argue that the lowest transfer rate is the best transfer rate. You’re setting out for a homebirth, right?

I did some scouting around on the lovely internet and found that transfer rates range from 10% through to 50%. The Netherlands has a transfer rate of 52%! This surprised me. In the Netherlands, 86% women start in “primary” care (midwifery care), 28% are transferred in pregnancy and 17% are transferred in labour, leaving 41% women birthing with midwifery care. Of this 41%, 30% occurred at home and 11% occurred in hospital.

The St George hospital homebirth program reported a transfer rate of 37% for its first 100 births and this was in a low-risk clientele (at the start of pregnancy). Their outcomes were excellent, and the satisfaction of the women and midwives using / working in the service was very high.

Private midwives’ transfer rates vary – anywhere from 10% to 40% in some States of Australia as well as overseas. So there’s a wide fluctuation. What can we deduce from these transfer rates?

Well, with the exception of the Netherlands – which has large numbers – we can’t really deduce very much at all. You never can when you’re dealing with small numbers. Private midwives in Australia typically don’t attend more than 20-40 births a year, and some as few as 5 births a year. One transfer in 5 births is 20%, whereas if that same midwife had attended more births without complication, perhaps the transfer rate would have only been 10%.

There are a few things to consider with transfer rates:

  1.  The health needs of the woman at booking
  2.  Safety guidelines
  3. The decisions that the woman makes
  4. The recommendations that the midwife makes

Midwives with low transfer rates might only book the lowest of low-risk women: those who have previously had a vaginal birth without complications.  Midwives with high transfer rates might not be transferring willy-nilly, but might be taking on a higher risk group of women and adopting a wait and see approach – eg, “yes, you have a family history of high blood pressure and you had it with your last pregnancy, but let’s try some preventative measures and see what happens this time”, and continue with homebirth plans. If this woman’s blood pressure went up, she would transfer, contributing to the midwife’s “high” transfer rate. The low risk / low transfer rate midwife might not have accepted this woman for homebirth at all, hence the difference in transfer rates.

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Why is choosing a care provider one of the most important decisions you will make in your pregnancy?

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A woman’s choice of care provider for pregnancy and birth is one of the most important decisions she will make. This decision has the most important influence on how her birth will go and how she will experience her care.

Some things to consider when deciding on a care provider are:

• What sort of relationship would you like to have with your care provider? Are you merely looking for physical check ups in pregnancy and someone to turn up for the last few minutes of the birth? Are you wanting to be cared for by strangers who do not know you or your wishes for birth / would you like to feel nurtured? Would you like to know the person who will assist you in birth?
• How much information do you expect to receive? Are you happy with “It’s normal” in response to your questions, or do you need more information and a better understanding of your situation and progress and health?
• Do you wish to be actively involved in the decisions made about your care or are you happy to leave all decision-making up to others?

It may take some time and energy to find the right care provider for your pregnancy and birth. It is very helpful to interview several midwives and obstetricians before deciding on the one that is right for you.

What about place of birth?

There are three options for place of birth: home, birth centre and hospital. Midwifery care is available at all three locations. Obstetricians generally work only in hospitals, however a few will attend birth centre births. Knowing where you would like to birth your baby can help you in choosing a care provider.
What should I look out for when I am interviewing care providers?
One of the most important issues to consider really doesn’t need much consideration at all. How do you feel about your care provider at the end of the initial consultation? It’s a gut feel. You can trust your gut.

You will want to ask your care provider about his/her practices to ensure that their practices are consistent with what you’re wanting for your pregnancy and birth. If waterbirth is important to you, you need to find a place of birth and care provider who can provide this. It’s best to find this out at the initial consultation stage rather than at 38 weeks.

You will also want to explore your care provider’s philosophy on pregnancy and birth to ensure that there is a match with your own.

Are there any poor reasons for choosing a care provider?

Yes! And I hear them very often. It is not wise to choose a care provider because:
• They are close to your home / office
• Your mother used them
• You feel you don’t have any other choices (there are always choices; it’s not a question of resources, it’s a question of resourcefulness)
• They are female / they are male.
• Your GP recommended them (unless you are sure of the basis for that recommendation and you agree that they are right for you)
• They are cheap
• They do an ultrasound at every visit
• They delivered you
• It would offend Aunt Bessie if you didn’t go to Dr X
• Although you don’t like the person, you’re sure they’ll be fine on the day (your gut is always right)

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Continuous care in labour

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What do we mean by continuous care in labour?  Continuous care means having care one-on-one from a known midwife.  It is considered to be the “Rolls Royce” of labour care, where a woman has a midwife by her side for the duration of her labour.  Why is this form of care so beneficial?

Women who access continuous care in labour are less likely to:

  • Have an epidural
  • Have any analgesia/anesthesia for labour and birth
  • Give birth with vacuum extraction or forceps
  • Give birth by caesarean
  • Have a baby with a low 5-minute APGAR score
  • Report dissatisfaction or a negative rating of their experience.

Women receiving continuous midwifery care were more likely than those who did not to have a shorter labour.

Private midwifery care provides women with continuous care from a midwife who is known to the woman and trusted by the woman. Typically, the private midwife would have provided all of the woman’s pregnancy care and then attends the labour and birth, providing continuous midwifery care. Private midwives have only one woman in labour at a time, and are able to dedicate their whole time to this woman and family.

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Can you have a private midwife in public hospital in Sydney?

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Yes. You can engage a private midwife early in your pregnancy to provide all of your pregnancy, birth and postnatal care.  At this stage, this type of care is available through this service for a birth at Westmead Hospital (or at home).  Private health insurance is not necessary, and you don;t need to reside in the local area.  Enquire here.

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Midwife-led, birth centre care

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A recent study has found that women receiving care in midwifery-led birth centres in the US experience very low rates of intervention with an excellent safety record.

Of 15,574 women who planned to give birth in a midwife-led birth centre, 84% actually gave birth at the birth centre. 4% were transferred after the birth, and 12% were transferred in labour after admission to the birth centre.  Regardless of where the women gave birth (ie, birth centre or hospital transfer), 93% of women had a normal birth, 1% an assisted vaginal birth, and 6% a cesarean.

This study is significant because in the US, as with Australia, intervention rates in labour and birth are increasing.  Rates of continuous monitoring, epidurals, induction and of course caesarean are increasing in both countries. The study suggests that if birth centre care was more widely available, we may be able to reduce the intervention rates.

In Australia, we don’t have any birth centres that are separate to hospitals: all birth centres exist within hospital grounds.  In the US, this is not the case.  Regardless, I have often wondered if the model of care is more important than the place of birth.  The women who experienced birth centre care in the US accessed midwifery care.  Likewise, in Australia, midwifery care is available either privately (through a private midwife) or through the public hospital system (if a woman is low risk).  I think what is needed is the promotion of midwifery care as the norm for women; I am sure that intervention rates would drop one this occurred.  Nevertheless, it is great that we have this study to back-up midwifery care and birth centre care as safe and effective models of care for women and babies.

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My pregnancy is high risk. Can I have a midwife?

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Yes, midwifery care may well be an option for you.  Your public midwifery options may be limited as public hospitals will generally steer women towards either midwifery care (if the pregnancy is low-risk) or obstetric care (if the pregnancy is high risk).  However, private midwives can care for women of all levels of risk in consultation with an obstetrician for the issues that may need obstetric input.

Although there is not a lot of research, it would appear that high risk women who have some midwifery input / care through their pregnancy, have better outcomes than women who are cared for by obstetricians alone.

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Continuity of care

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Private midwifery is the oldest form of continuity of midwifery care.  Recent research has demonstrated that this form of care – where a woman is cared for by the same midwife throughout pregnancy, birth and the postnatal period – is beneficial for women and families. It results in increased satisfaction with the birthing experience and enhanced safety.  When multiple care providers are involved in a woman’s care, the chance of errors is high because care is provided in pieces. When a woman is cared for by one midwife, she has one point of reference, no conflicting advice, she can develop trust and a sense of security and the birth will generally proceed naturally.

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First time mothers and homebirth

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What a great choice!  Discuss your situation with your midwife for more advice. Generally, first babies are ideal for home births. Why? Most first births go really well with the care and support of a midwife.  In the hospital system, a first-time Mum stands a 25% chance of having a caesarean, a 25% chance of needing forceps / vacuum, and only a 50% chance of a normal birth.  Compare this with the chance of a normal birth at home with a private midwife (around 90%) and you can see why there is such a benefit to planning to birth your first baby at home.

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Can you have an epidural in a birth centre?

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Birth centres are set up to provide natural birth services, and cater to women who prefer to use natural methods for pain relief such as hot packs, the bath, shower, different positions and so on.  If a woman needed an epidural, she would be transferred to the delivery suite where this type of care can be provided.

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One step forward

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Rules have been revised on water births in Western Australia.

There has been some debate over the safety of water births and paediatricians at a particular hospital do not support water births.  Therefore, it is no longer an option at the (major tertiary referral) hospital or the birth centre that is attached to it.

Note: this decision is not based on evidence, but rather the fact that, “some doctors are reluctant to have anything to do with water birth, with a reference to controversy regarding its safety for the baby during the second stage of labour”.

Did anyone bother to consult the literature on waterbirth that shows it to be safe?

If women want to have a water birth, they have to “sign a consent form … and agree they will not be able to have one if they have to be transferred to KEMH’s main labour suite”.

I routinely offer waterbirth, and about half of the women who birth with me opt for a waterbirth.  None has reported that they wished they had not birthed in water; they have all found it to be helpful.

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Questions to ask on your hospital tour

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Most hospitals offer the opportunity to view the delivery rooms while you are pregnant so that you can gain a sense of what it is like, how you might wish to prepare and what to expect.

There are some questions you might like to ask while you’re on the hospital tour, so that you can be better prepared for when you come in.

What equipment is available to support me in a natural birth?

Things like birth balls, bean bags, floor mats, a bath, shower, hot packs and so on.

How long are the midwives’ shifts?

Midwives generally work in three shifts a day, with each shift being 8 hours (the night shift is often 10 hours).  Why does this matter?  The more shift changes there are, the more likely it is that you will be cared for by more than one midwife during your labour and birth.

What are the options for fetal monitoring?

If continuous monitoring is needed, does the hospital provide an option where you can still move around and use the bath and shower? Is the doppler encouraged if all is well?

How many support people can I have in labour?

What should I bring for my hospital stay?

Can I have a water birth or labour in the bath?  What percentage of women give birth in the bath?

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FAQs

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What are the disadvantages of birthing in hospital?

Most women who birth in hospital do not have the same midwife with them throughout pregnancy, birth and the postnatal stay. They have different midwives for each antenatal (pregnancy) visit, then another lot of midwives for the birth (sometimes 3-4, depending on how long the woman is in delivery suite and whether the midwife has a student midwife working with her), followed by another group of midwives who work in shifts in postnatal. The lack of continuity means that the woman does not have the opportunity to really develop a deep sense of trust with her own midwife, something that is intrinsic to positive and safe birthing experiences.  The other issues are around the potential for things to “fall through the cracks” and the need to repeat yourself at every visit.

When women have their own midwife with them, they have the full range of options open to them and they are fully informed and able to make their own decisions around pregnancy and birth care.  The continuity of care that this provides is central to a safe birth.

Birthing option?

To learn more about pregnancy and birth care options, why not book an appointment?  There is no cost with a Medicare card.

Can I have an epidural with a midwife?

Absolutely!  Although many women find that they don’t need one when they’re cared for by the same midwife and well supported in labour. In my practice, only 5% women need an epidural in labour, and 80% women birth their babies with no pain relief at all.  However, epidurals are a good option for some women in some labours.

Can midwives administer oxytocin at a home birth?

Yes, to manage excessive bleeding after the baby is born, but it cannot be used to induce or augment the labour. Those interventions are attended in the hospital as they carry risks to the baby. Midwives routinely carry oxytocics to births in case they are needed.

Does having gestational diabetes mean a C-section?

This would be a good one to ask your care provider. Generally speaking, gestational diabetes does not automatically mean having a caesarean.

Private midwife public hospital Sydney?

Yes, it is possible to take your own midwife with you in a public hospital. This service provides this as an option. Women book with their private midwife and receive all of their pregnancy care from their midwife, including pregnancy, birth and postnatal care for 6 weeks.

Private midwives in Sydney’s east?

Yes, this service provides private midwifery services in the eastern suburbs.

Water birth private hospital Sydney?

None of the private hospitals in Sydney allow waterbirth. Waterbirth is the norm in a homebirth and may be an option in a public hospital.

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