Tips for a Successful VBAC

As published on the Essential Baby website

Author: Melissa Maimann www.essentialbirthconsulting.com.au

http://www.essentialbaby.com.au/parenting/pregnancy/tips-for-a-vbac-20090209-81a2.html

February 9, 2009

Are you planning or considering a vaginal birth after a caesarean (VBAC)? With the Australian caesar rate up to 31% more and more women are reconsidering a subsequent caesar. Read Essential Baby’s tips to help you put your plan into action.

Most women choose to have VBACs because they believe it to be safer for them and their baby. Many women want to attempt to have a different birthing experience for myriad reasons. Either decision will be hotly argued by differing camps, so it’s important you read up and make the best decision that you feel comfortable with.

For the majority of women, VBAC is a safe decision, for some women, an elective repeat caesarean section may be safer. This might be for reasons such as placenta praevia, previous classical incision, or a previous uterine rupture. Please discuss with your care provider and conduct your own independent research when deciding between elective repeat caesarean and having a VBAC.

The risk of VBAC is a uterine rupture, which affects between 0.2% and 0.7% women.  The risks associated with elective repeat caesarean section (ERCS) include:

• Hysterectomy
• Injury to bladder or bowel
• Reduced fertility
• Severe bleeding, perhaps requiring blood transfusion
• Increased risk of infection
• Increased pain after birth
• Blood clots in the lungs, legs, or elsewhere
• More difficulty establishing breast feeding
• Increased risk of breathing problems for your baby
• Possibility of separation of mother and baby, if baby is admitted to the nursery
• Delayed bonding

Australia-wide, the proportion of women having caesarean sections increased from 20% in 1997 to 31% in 2006. In 2006, the most common reason for a caesarean was a previous caesarean having been performed.  As more caesareans are performed, we are beginning to see more complications from this surgery.  In 2006, Australia-wide, only 16% of women had a VBAC.  ERCS occurred for 84% of women.

So, you might be thinking, “Wow, I’d really like to have a VBAC, but it seems an uncommon outcome. How can I increase the chances of my VBAC being successful?” Well, the good news is, there’s plenty you can do to have a successful VBAC. 

1. Choose your place of birth carefully.
Hospital birth, as you can see above, leads to an average VBAC rate of 16%.  Homebirth, on the contrary, has a VBAC success rate of at least 70% – 80%.  This is most likely due to the very low caesarean rates that primary midwifery care entails (home birth results in a caesarean rate of less than 5%).

2.  Choose your care provider carefully.
Obstetricians are specialists in providing care to women with complications in pregnancy and birth.  Midwives are specialists in normal birth, so midwifery care is far more likely to result in a successful VBAC.  If you choose an obstetrician, choose one who has a high VBAC success rate. 

3. Choose your birth support people.
If you decide to birth in hospital, consider hiring a private midwife or a doula to provide support and advocacy. A private midwife can provide support, advice and clinical care outside of hospital, whereas a doula can provide support only. Sometimes VBAC women need extra support – you have more hurdles to overcome and sometimes friends and family don’t often know how to support you well. Resist the urge to discuss your plan to VBAC with people who don’t support you. Just surround yourself with supportive people who believe in you. The right kind of support is most important!

4. Educate yourself!
Read widely, ask questions of your care provider, get second opinions from different care providers, take independent childbirth education classes and research on the net.  Learn about normal physiological birth. When we understand how labour and birth work, it’s easier to see why our bodies work with us and against us during labour. 

5. Value birth preparation
Birth preparation such as Calmbirth and Hyponobirthing can make the difference between natural birth and medicated birth for some women.  Affirmations and visualisations act like a rehearsal for your mind and body. Trusting your body and believing you can do it – the mindset – is critical.

6. Avoid interventions in labour
Typical interventions such as continuous monitoring and epidurals can really work against a successful VBAC.  Instead, get up off the bed, move, get in the bath, do whatever feels comfortable.  Plan to stay at home as long as possible, or even birth at home with a midwife.

Melissa Maimann, Essential Birth Consulting.

Tags: VBAC

Fetal Monitoring in VBAC Labour

For further information, contact Melissa Maimann at Essential Birth Consulting.

As published on the Birthrites website http://www.birthrites.org/

Caesarean section rates have risen in the past twenty years to a rate of approximately 20% - 25% in the United States (McMahon, 1998, p.369). Repeat caesarean section is cited as the most common indication for caesarean section (McMahon, 1998, p.369). It is hoped that by promoting vaginal birth after caesarean section, we will halt the increase in the caesarean section rates (McMahon, 1998, p.369). A trial of labour should be encouraged after a previous caesarean section, provided that there are no absolute contraindications to vaginal birth, such as placenta praevia or cephalo-pelvic disproportion (Wing and Paul, 1999, p.836). Due to the greater risk of uterine rupture in women having vaginal births after previous caesarean sections (Menihan, 1999, p.40), it is necessary to monitor the labour to minimise maternal and fetal mortality and morbidity (McMahon, 1998, p.369). The midwife plays a vital role in monitoring the well being of woman and fetus during labour, hence the focus of this options paper will be intrapartum fetal monitoring for women who have had previous caesarean sections.

It is known that changes in the fetal heart rate may signal an impending or actual uterine rupture (Menihan, 1999, p.40), so the monitoring of fetal heart rate is vital to the success of vaginal birth after caesarean section. There is indecision regarding the most appropriate method of intrapartum fetal monitoring in women attempting a vaginal birth after caesarean section owing to a lack of research in the area. Therefore, I have reviewed the literature regarding fetal monitoring in high risk women (including vaginal birth after caesarean section), and fetal monitoring in general. Unfortunately, there is no consensus as yet; fetal monitoring in labour remains a controversial issue.

Fetal bradycardia may be the first sign of an impending uterine rupture (Menihan, 1999, p.40). Late decelerations, variable decelerations, or prolonged decelerations may also occur (Menihan, 1999, pp.40-46). Furthermore, there is loss of variability, and reactivity may be poor (Menihan, 1999, pp.40-46). It is important that intrapartum monitoring enables the detection of these decelerations. The goal of fetal monitoring in labour is to detect fetal hypoxia early, so that interventions may be instituted to prevent a neonatal death (Mahomed, Nyoni, Mulambo, and Jacobus, 1994, p.497; Vintzileos, Nochimson, Guzman, Knuppel, Lake, and Schifrin, 1995, p.149).

Until the 1960s when the electronic fetal heart rate monitor became commercially available, intermittent auscultation was the only method of monitoring the fetal heart rate (Seymour, 1995, p.47). Intermittent auscultation may be performed by the midwife, using a doppler sonic aid, or a pinard stethoscope (Seymour, 1995, p.47). Alternatively, the midwife may monitor the fetal heart rate continuously with an electronic fetal heart rate monitor, either externally, or internally with a fetal scalp electrode. Since these methods rely on the interpretation of changes in the fetal heart rate, it was thought that a more objective assessment of fetal well being may improve outcomes (McNamara and Dildy, 1999, p.671; Greene, 1999, p.641). Fetal well being may be ascertained by obtaining a fetal blood sample and analysing acidity (pH). This is a medical intervention, and will be evaluated as a method of fetal monitoring that complements intermittent auscultation. The remainder of this options paper will describe and evaluate each of the above-mentioned methods of assessing intrapartum fetal well-being.

Intermittent auscultation involves periodically auscultating the fetal heart rate. Gilles, Norman, Dawes, Gee, Rouse, and Newnham (1997, pp.143-148) reviewed methods for intermittent auscultation. They found no consensus regarding appropriate intervals for auscultating the fetal heart rate. In first stage labour, recommendations ranged from auscultation every two hours to every ten minutes, with most sources advocating auscultation every thirty minutes (Gilles et al., 1997, p.145). During second stage labour, guidelines for intermittent auscultation ranged from Ôat intervalsÕ, to every fifteen minutes, to after every contraction (Gilles et al., 1997, p.145). It was generally accepted that auscultation should be performed after every contraction. Intermittent auscultation, as discussed in this options paper, will imply auscultation every thirty minutes during first stage labour, and after every contraction during second stage labour.

The pinard stethoscope was invented during the 1800s for the purpose of auscultating the fetal heart rate (Seymour, 1995, p.47). It is placed firmly on the womanÕs abdomen, at right angles to it, with the midwifeÕs ear in close contact with the stethoscope (Bennett and Brown (eds.), 1999, p.224). The pinard stethoscope is portable and readily available, and is an excellent tool for monitoring the fetal heart rate as long as the midwife is confident in interpreting what is heard (Seymour, 1995, p.47). The only disadvantage of the pinard stethoscope is that only the listener may hear the heart beat (Seymour, 1995, p.47).

Mahomed et al. (1994, pp.497-500) conducted a randomised controlled trial on the effectiveness of different methods of intrapartum monitoring. They found that abnormalities in the fetal heart rate were more reliably detected by doppler sonic aid, compared with a pinard stethoscope. They also found that auscultation with the pinard stethoscope was uncomfortable for the woman as it sometimes required a change of position, and that the woman remain still during auscultation (Mahomed et al., 1994, pp.497-500). Lower apgar scores were more common in the groups monitored with the pinard stethoscope, and neonatal seizures occurred only in the groups monitored with the pinard stethoscope (Mahomed et al., 1994, pp.497-500).

During the late first stage and second stage of labour, contractions are the longest and strongest; theoretically, this period poses the greatest risk of uterine rupture (Arulkumaran, Gibb, Ingermasson, Kitchener, and Ratnam, 1989, cited in Chua and Arulkumaran, 1997, p.7). Anecdotal evidence suggests that auscultation of the fetal heart rate with a pinard stethoscope is often difficult to perform at this time, as the baby has descended into the pelvis. This makes intermittent auscultation difficult to perform, at a time when uterine rupture and possible fetal heart rate abnormalities are the most likely to present. For these reasons, women attempting vaginal birth after caesarean section are best not monitored with the pinard stethoscope as the main method of fetal monitoring.

The doppler sonic aid is the electronic equivalent of the pinard stethoscope, and has the advantage of enabling the woman to hear her baby’s heart beat (Seymour, 1995, p.47). It is possible to auscultate the fetal heart rate with the woman in any position, and there are waterproof probes available for use in the shower or bath (Steer, 1999, p.858). In their study, Mahomed et al. (1994, pp.497-500) found that detection of fetal heart rate abnormalities was better with the doppler sonic aid than with the pinard stethoscope, and that the perinatal outcome was no worse than that achieved by intermittent electronic fetal monitoring.

The American College of Obstetricians and Gynecologists (1989, cited in Cibils, 1996, p.1382) recommends that intermittent auscultation and continuous electronic fetal monitoring are equally acceptable methods of fetal monitoring, even in high risk labours. In a Birth Centre study of vaginal birth after caesarean section, Harrington, Miller, McClain, and Paul (1997, pp.304-307) used intermittent auscultation as the main form of fetal monitoring. It was performed during at least one contraction, every fifteen minutes. In both the study and control groups, the average apgar scores were 8.5 at one minute, and 9 at five minutes, and no five minute apgar scores were less than seven (Harrington et al., 1997, p.306). Neonatal outcomes were similar among both study and control groups (Harrington et al. 1997, p.306). These studies demonstrate the safety and acceptability of intermittent auscultation to monitor the fetal heart rate in women attempting a vaginal birth after caesarean section.

Generally, the literature supports intermittent auscultation as a safe method of fetal heart rate monitoring. Enkin, Kierse, Renfrew, and Neilson (1995) conclude that intermittent auscultation is just as effective in preventing intrapartum death as continuous electronic monitoring. Thacker, Stroup, and Peterson (1995, pp.613-620) studied the efficacy and safety of electronic fetal monitoring, and found that neurological consequences occurred in similar frequencies in babies monitored by intermittent auscultation and continuous electronic monitoring. Kripke (1999, p.2421) describes intermittent auscultation as a Òhigh touch, low-techÓ method of lowering the caesarean section rate for fetal distress. Gilles et al. (1997, p.147) suggest that intermittent auscultation may also play an important role in neonatal outcome, as the personal support provided by a midwife during intermittent auscultation of the fetal heart rate may contribute to reduced pain relief requirements and improved progress of labour. These are important aspects of the care of a woman attempting a vaginal birth after caesarean section.

To conclude the literature review of intermittent auscultation, use of the doppler sonic aid improves neonatal outcomes when compared with the pinard stethoscope. Literature comparing use intermittent auscultation and continuous fetal monitoring, even for high risk labours, concludes that intermittent auscultation is at least as effective in preventing neonatal morbidity and mortality. Current and accepted recommendations are for the fetal heart rate to be auscultated every thirty minutes (minimum) in the first stage of labour, and after every contraction in the second stage of labour.

The alternative to intermittent auscultation is to continuously monitor the fetal heart rate internally via a fetal scalp electrode, or externally via doppler ultrasound (Bennett and Brown, 1999, pp.418-419). A tocotransducer, strapped to the fundus of the uterus, is also used to monitor the frequency, intensity, and duration of uterine contractions (Bennett and Brown, 1999, pp. 418-419). This form of monitoring is known as cardiotocography (CTG), and the electronic fetal monitor produces a print-out of fetal heart rate in relation to uterine contractions. The fetal heart response to contractions (and fetal movements) is monitored to determine fetal well being in labour (Bennett and Brown, 1999, p.418). Continuous fetal monitoring was introduced with the hope of detecting early signs of fetal compromise, enabling early intervention to reduce neonatal mortality and morbidity (Boehm, 1999, p.623; Parer and King, 2000, p.982).

Continuous fetal monitoring was seen as an important development in the reduction in neonatal mortality and morbidity, however, proponents of CTG failed to acknowledge the contribution that improved antenatal and neonatal intensive care have made to neonatal well being (Dover and Gauge, 1995, p.18).

In fact, it has been suggested that CTG, as a screening tool, has been far from beneficial for most women. There is a lack of agreed interpretation of fetal heart rate traces (Anonymous, 1997, p.1385; Low, 1999, p.725), with the result of increased intervention in the form of caesarean section and forceps deliveries (Boehm, 1999, p.623). The adverse effects of false positive and false negative CTGs suggests that, as a screening tool for fetal distress in labour, the CTG fails miserably (Low, 1999, p.725).

A study conducted by Vintzileos, Nochimson, Antsaklis, Varvarigos, Guzman, and Knuppel (1995, pp.1021-1024) suggested that CTG was superior to intermittent auscultation in detecting fetal acidaemia at birth. This conclusion was correct, however, the authors failed to state the false positive rate of CTG in their study, as opposed to intermittent auscultation. Cibils, (1996, p.1383) states that over 40% of fetal heart rate patterns are abnormal on CTG, yet Vintzileos, Nochimson, Antsaklis et al. (1995, pp.1021-1024) found that only 8.0% of neonates had acidaemia at birth. Although CTGs were able to accurately detect changes in the fetal heart rate suggestive of acidaemia, there must have also been a substantial number of fetal heart traces suggestive of acidaemia that were in fact perfectly normal. A meta-analysis by Vintzileos, Nochimson, Guzman, et al. (1995, pp.149-155), found that one perinatal death may be prevented by the continuous fetal monitoring of one thousand women in labour (p.154). The authors accept that this would occur at the expense of a higher rate of surgical intervention.

A benefit of continuous CTG monitoring in labour is a reduction in neonatal seizures (Greene, 1999, p.647; Boehm, 1999, p.625) and one minute apgar scores of less than four (Thacker, Stroup, and Peterson, 1995, p.615). However, the authors of these articles conclude that the long term effect of this reduction must be balanced against the increase in caesarean and operative vaginal delivery rates (Thacker et al. 1995, p.619; Boehm, 1999, p.623; Greene, 1999, p.647).

Wing and Paul (1999, p.843) and Scott (1997, p.536) advocate continuous CTG monitoring for women planning a vaginal birth after caesarean section because abnormal fetal heart rate traces are the most common signs of uterine rupture. The incidence of uterine rupture among women planning a vaginal birth after caesarean section is quoted at being between 0.3% and 1.7% (Chua and Arulkumaran, 1997, p.6). Fetal heart rate abnormalities occur in 50%-70% of uterine ruptures (Scott, 1997, p.538), but they also occur in at least 40% of labours with an unscarred uterus (Cibils, 1996, p.1383). The literature failed to address how the midwife or doctor may distinguish fetal distress related to uterine rupture, requiring emergency caesarean section, from fetal heart rate abnormalities resulting from occurrences such as cord compression or head compression (Menihan, 1999, p.45). In fact, Menihan (1999, p.40) states that there is “no single, specific change in fetal heart rate (FHR) pattern predictive of uterine rupture prior to the onset of a profound bradycardia”. Furthermore, since abnormal CTG patterns alone cannot accurately distinguish well fetuses from distressed fetuses, I question the accuracy of this form of monitoring in women planning vaginal births after caesarean sections.

A review of the literature suggests that continuous fetal monitoring affords no overall benefit; the reduction in neonatal seizures and low one minute apgar scores occurs at the expense of increased operative deliveries. The options presented thus far are not sufficient enough to conclude that intermittent auscultation is the safest method of fetal monitoring in the woman attempting a vaginal birth after caesarean section. These women require closer monitoring than intermittent auscultation can provide, however, they may suffer unnecessary intervention from the use of continuous monitoring. A compromise is needed.

Fetal blood sampling to ascertain pH (acidity) was developed in the 1960s with the aim of clarifying uncertain CTG patterns (Greene, 1999, p.641). On the basis of CTG patterns alone, false-positive diagnoses of fetal distress are likely to be made (Greene, 1999, p.645). A meta-analysis demonstrated that without access to fetal blood sampling, women who were monitored continuously experienced a four-fold increase in caesarean section rates compared with intermittent auscultation, with no improvement in fetal outcome (Greene, 1999, p.647). When fetal blood sampling was used in conjunction with continuous monitoring or intermittent auscultation, this rise in caesarean section rates was less marked (Greene, 1999, p.647). It is essential that all forms of fetal monitoring be supplemented by fetal blood sampling where indicated, to reduce unnecessary intervention (Steer, 1999, p.859).

Fetal blood sampling has some disadvantages: it is time-consuming to perform (Steer, 1999, p.859), it is unreliable if performed in the presence of oedema or caput succedaneum, and it can only be performed intermittently (Greene, 1999, p.648). However, when it is indicated it may accurately determine fetal acid-base balance in fetuses suspected of compromise on intermittent auscultation of the heart rate. Therefore, it may either confirm the diagnosis of fetal distress, or reassure care givers of fetal well being. Although it is not part of the midwifery management of fetal monitoring, it is capable of complementing intermittent auscultation in women planning vaginal births after previous caesarean sections, thus increasing the safety of vaginal birth after caesarean section, without increasing intervention rates unnecessarily.

In conclusion, the midwifery management of fetal monitoring in women planning vaginal births after caesarean sections is controversial. Standard practice is to continuously monitor the labour using technology that is known to increase operative delivery rates with no proven benefit. On the basis of a literature review, this paper has presented the available options of fetal monitoring. The evidence suggests that even without access to fetal blood sampling, intermittent auscultation is superior to continuous monitoring in correctly identifying fetuses in need of immediate delivery. In the presence of an abnormal fetal heart rate detected by intermittent auscultation, fetal blood sampling may indicate those fetuses that require immediate delivery, or reassure the midwife of fetal well being. Ultimately, the woman needs to be informed of her options for care, and their relative risks and benefits, as she will be the one to experience and live with the consequences (positive or negative) of labour care. This options paper is only a guide, based on the conflicting literature available at this time. Since we cannot say with 100% certainty that one method of monitoring is superior over another, perhaps midwives could best care for women by providing accurate information that facilitates involvement and choice.

Melissa Maimann, Essential Birth Consulting.

Tags: birth, Birth choices, Caesarean, Complicated pregnancy or birth, continuity of care, CTG, fetal monitoring, intermittent auscultation, midwife, Midwifery, Midwifery services, VBAC, women's rights

Birth by surgery: The skyrocketing cesarean rate

For further information, contact Melissa Maimann at Essential Birth Consulting.

Story By Mary Beth Pfeiffer • Photos By Lee Ferris • March 29, 2009

Two weeks before Kristi Ashley gave birth to a son in 2007, an ultrasound exam estimated the baby at a hefty 12 pounds, 10 ounces — too big, her doctor believed, for a safe vaginal delivery. After the child weighed in at 9 pounds, 4 ounces in the delivery room, Ashley came to believe that the planned cesarean section she had, with its attendant pain, long recovery and what she called “emotional damage,” may have been a rush to judgment.

It is well-known that ultrasounds are inaccurate for estimation of fetal size in the third trimester. Why is it still being used as a basis for clinical decisions??

“It’s very hard to go up against your physician, especially at the 12th hour,” said Ashley, 38, of Hopewell Junction. “I think doctors are very quick these days to get scared. They would rather opt for the surgical solution.”

Determined to avoid another surgical birth and aided by a supportive doctor, hospital and birthing coach, Ashley last month did something that has become increasingly rare for post-cesarean women today: She gave birth vaginally, to another son. … From 1999 to 2007, the proportion of New York babies born by cesarean section skyrocketed 42 percent. In 1999, just under 1 in 4 babies was born surgically. By 2007, the figure was 1 in 3 — or 34 percent of births — and there is nothing to suggest that the relentless uptick, evident locally as well, is showing any sign of slowing.

In Australia, the national CS rate is currently over 31%.

In Ulster and Dutchess counties, with cesarean rates in the top sixth of counties statewide, surgical birth rates increased from 1999 to 2007 by 64 percent and 36 percent respectively …

Don’t women question why their caesarean is deemed “necessary” with a wide window of suspicion? If the CS rate is 42%, that’s 280% higher than what is recommended by WHO.

At Vassar Brothers Medical Center in Poughkeepsie … 40 percent [of babies were born by caesarean]. In Ulster County, Kingston Hospital had a cesarean rate of 40 percent in 2007, the latest figure available, while Benedictine Hospital’s was 35 percent, nearly double what it was in 1999 …

The World Health Organization calls for a maximum cesarean section rate of 15 percent in any nation in the world. Anything above that “seems to result in more harm than good,” according to a 2006 research summary in the British medical journal Lancet.

Physicians, midwives, childbirth experts and researchers point to a confluence of factors behind the growing rate of cesarean section … Some say that more mothers are older, obese, more prone to multiple births and, in particular at Kingston and Vassar Brothers hospitals, less healthy, increasing risks of surgical measures. Others contend that overused interventions to induce and augment labor, manage pain and monitor for fetal distress have driven cesarean rates to unnecessary heights.

I disagree. The only important variable is the care provider’s support for birth as a natural process.

All agree that fewer women are opting for once-popular vaginal birth after cesarean, or VBAC, as Ashley did. But some believe doctors emphasize its risk – that the scarred uterus could tear – while minimizing the drawbacks of surgery. VBACs have declined precipitously at five local maternity hospitals … In 2007, just 3 percent of post-cesarean women birthed vaginally at Kingston Hospital, where the procedure is officially banned. The figure was 33 percent in 1999.

VBAC rates have also declined because they are not supported by care providers.

Amid the debate, there is widespread agreement that medical factors are only a part of the story. Cesareans have become so common and accepted that first-time mothers – frightened by societal depictions of overwrought laboring women — sometimes request them simply to avoid labor; doctors, hospitals and insurance companies acquiesce. Moreover, obstetricians, who pay $84,500 a year for malpractice insurance in Ulster and Dutchess and $137,600 in Orange, may see cesareans as a way to avoid lawsuits over injuries to infants from vaginal birth — as well to manage precious time. “I see colleagues around me who seem to operate out of fear,” said Dr. Ira Jaffe, a Rhinebeck obstetrician, [commented]. “They always have in the back of their mind, ‘How is it going to look in court?’ It’s the defensive medicine.” “It’s not in the best interest of women and babies to do this many C-sections,” he said.

….

For a community of activists who say the cesarean section rate is out of control, the question is whether women like Revak are getting both sides of the story – on one hand that cesarean sections no doubt save lives in high-risk circumstances and are generally safe, but that they contribute in other cases to prematurity, cause respiratory problems in babies and increase maternal bleeding and infection.

“Women are getting cheated by not being encouraged to believe both in their ability to birth and that birth can be a positive experience,” said Christie Craigie-Carter, Hudson Valley coordinator of the International Cesarean Awareness Network, or ICAN.

A Paulin bill, signed into law last year, requires the state to educate women on birthing procedures, such as the induction of labor and use of pain-numbing techniques like epidurals, that increase risk of cesarean section. Paulin, a three-time mother who had two midwife-attended babies at home, believes that cesareans are often performed for reasons of convenience, fear and liability. “We have a huge problem,” she said.

“There’s more fevers, wound infections associated with C-section,” acknowledged Dr. John McAndrew, chairman of obstetrics and gynecology at Kingston Hospital, where the cesarean rate hit 43 percent in 2006. “However, it’s safer for the baby.”

Physicians and researchers concerned with rising cesarean rates take issue with that assertion, which they say fails to weigh the risk that a baby will be damaged or die in vaginal delivery.

“In low-risk or no-risk mothers, studies have consistently shown higher morbidity (illness) in infants delivered by cesarean section,” said Dr. Lucky Jain, a pediatrics professor at Emory University School of Medicine in Atlanta … “There is no evidence that cesarean is safer for the baby,” said Dr. Jed Turk, newly appointed obstetrics and gynecology chairman at Vassar Brothers Medical Center and a proponent of lower cesarean rates. “It is not a good trend.”

…

Vaginal birth undoubtedly has risks. One in 5,000 to 10,000 babies suffers permanent shoulder damage, and one in 1,000 suffers moderate to severe brain damage, according to a 2006 article in the professional journal Seminars in Perinatology. These injuries, as well as 6,000 stillbirths, could be avoided nationwide if the nation’s 3 million annual vaginal births were performed surgically at term — but that would mean additional costs and maternal and infant complications.

…

“C-section is major surgery, which involves a longer recovery time for the mother and can have other significant consequences,” said Barbara McTague, family health director for the state Health Department.

The cost of cesareans in a cash-starved health-care system is just one consequence. A cesarean birth cost the state Medicaid program $7,200 on average for hospital care in 2007 – 49 percent more than a vaginal delivery. The state’s cesarean price tag was $189 million.

Of greater concern may be the effect of cesareans on babies that are increasingly being delivered early. Thirty-six percent of elective cesareans were performed before 38 weeks, according to a study published in January in the New England Journal of Medicine, producing infants who had high rates of breathing problems, prolonged hospitalization and sepsis, a severe bacterial infection.

As significant, the study found that 10.2 percent of all cesarean-born babies were admitted to neonatal intensive care units, and 4.4 percent suffered from respiratory distress syndrome caused by fluids that are normally wrung from infant lungs during labor and vaginal delivery. … death rates of C-section babies before 28 days were nearly triple those of vaginal deliveries, according to a 2006 study by researchers at the U.S. Centers for Disease Control in Birth: Issues in Perinatal Care.

Studies have also found 20 percent higher incidence in both childhood-onset diabetes and asthma among cesarean babies, who have one-third to three-quarters the level of healthy bacteria in their intestines as vaginally born babies.

“When a baby comes out the normal way, they swallow vaginal mucus en route and get a nice dose of healthy bacteria to jump start their digestion,” said Dr. Joseph Malak, a Poughkeepsie pediatrician who called “surreal” the number of cesarean babies he sees on hospital rounds. “This doesn’t happen when babies come out through an abdominal incision.”

Malak believes that the rising cesarean rate may be linked to “a dramatic increase” in recent years in infants with colic, acid reflux, eczema and milk allergies – effects that, some say, obstetricians do not consider when weighing vaginal versus cesarean birth.

While cesarean delivery is safer than ever for the mother, it is not risk-free. According to a 2008 report in the American Journal of Obstetrics and Gynecology, 2.2 women died for every 100,000 cesarean births – 10 times higher than for vaginal births. “Cesarean delivery is associated with an increased risk of postpartum maternal death,” concluded a 2006 report in the same journal.

In New York, the rate of maternal mortality rose 70 percent from 1997 to 2007, when 40 women died as a consequence of pregnancy … three of the major causes of maternal death as embolism, hemorrhage and infection – all of which occur at higher rates in cesarean section.

Growing complications
Indeed, serious obstetrical complications increased by 27 percent from 1998-99 to 2004-05, according to a 2008 report in Obstetrics and Gynecology. These included renal failure, pulmonary blood clots, shock, blood transfusion and ventilation — upticks that parallel rising cesarean rates.

“It looks like there’s an association,” said the study’s author, Dr. Susan Meikle, an obstetrician and medical officer at the National Institutes of Child Health and Human Development …

“There is an awful lot of lying to women about cesarean,” said Dr. Marsden Wagner, former director of women’s and children’s health for the World Health Organization and author of several books on childbirth. “All of those thousands of women who are getting unnecessary cesareans in New York state are at double or more risk of dying and the babies are at risk of dying.”

The argument over cesarean’s benefits is perhaps most pointed when it comes to vaginal birth after cesarean; many doctors fear that the scarred uterus will tear, resulting in hemorrhage and loss of oxygen to the infant.

“There’s a real risk,” said Dr. Maureen Terranova, obstetrics chief at Northern Dutchess Hospital. “They have to be willing to accept that 1 percent risk of uterine rupture.”

“When it occurs, it can be catastrophic,” said Kingston Hospital’s McAndrew.

Melissa Ptacek, 47, of Garrison in Putnam County, said it took her years to recover from a uterine rupture from which her daughter – now a normal 11-year-old – had to be resuscitated. “I wouldn’t want anyone to go through what I had to go through,” she said.

In a study published in the New England Journal of Medicine in 2004, 124 women suffered uterine rupture among 17,898 who attempted vaginal birth after cesarean — a rate of 0.7 percent. Seven babies suffered brain damage, including two who died. A 2000 research summary by the American College of Obstetricians and Gynecologists put the risk of rupture in vaginal birth at 0.2 to 1.5 percent for most women with one prior cesarean.

Proponents of vaginal birth after cesarean say the risks of rupture must be balanced against the downsides of surgical birth. “The conversation about VBAC doesn’t touch on dozens of other concerning outcomes that favor vaginal birth,” said Sakala of Childbirth Connection, noting that cesareans make breastfeeding difficult, lead to adhesions and cause significant pain for up to six months. More than 7,000 repeat cesareans would be needed to save the life of one baby from a ruptured uterus, she said, citing a 2004 British Medical Journal study.

Other proponents argue that not all ruptures are catastrophic and some have actually been caused by labor-enhancing medications, called prostaglandins, whose dangers for post-cesarean women are now recognized.

Melissa Maimann, Essential Birth Consulting.

Tags: birth, Birth choices, Birth trauma, Caesarean, Complicated pregnancy or birth, CTG, Epidural, fetal monitoring, hospital birth, intervention, Normal Birth, Obstetrics, Public and private hospitals, VBAC, women's rights

Sex after baby

As published on Essential Baby

For further information, contact Melissa at Essential Birth Consulting

Sex after baby
Melissa Maimann
January 12, 2009

Welcome to parenthood! New babies are amazing, wondrous beings, aren’t they? But, for someone so small, they can bring with them endless tasks. Is there any time or desire for sex?

Your new to do-list reads something like: nappies, feeding, settling, general household chores, shopping, washing, more nappies, more washing, feeding, tending to the older kids, work – the life of a parent is busy indeed. Sleep seems a pretty tall order, let alone sex. After the birth, it might be the last thing on your mind!

Both men and women can have issues with sex after birth. For men, the concern is often, “What if I hurt her?” Women, too have concerns about sex after birth, such as “will my stitches open up?” or “will it hurt or feel different for us both?” Women may not feel like sex for several weeks, months or even a year or more after birth. After giving birth, some women feel detached from their sexuality whilst they adjust to motherhood. This is a very normal response to having a new baby.

Women who have experienced physical trauma from birth are more likely to experience painful sex in the months and sometimes years after birth. In particular, a forceps birth and/or an episiotomy can often result in vaginal and perineal pain. Some other reasons why you might not feel like having sex are:

- Recovering from a long labour
- Exhausted from lack of sleep
- Sore and tender stitches
- A baby who is unsettled, perhaps having problems with feeding
- Experiencing an emotionally or physically traumatic birth
- Changing hormone levels
- Fear of another pregnancy

All of these concerns are normal and valid. It is important for couples to talk to each other about their fears and be sure to allow yourself the time you need.

When can we have sex again?
As a guide, it’s best to wait for any bleeding to stop before having intercourse, to minimise the risk of infection. This can take two to six weeks. Some women wait until they have their 6-week check with their doctor or midwife. Others wait longer. For some women, sexual desire returns soon after birth, while for other women, it takes many months. Generally speaking, you can resume sex as soon as you feel physically and emotionally comfortable to do so. It’s important not to have sex purely to please your partner as this can help resentment to build. Have sex when you’re both ready.

Tags: birth, sex

Birth Trauma

As published on the Essential Baby website http://www.essentialbaby.com.au/parenting/baby/birth-trauma-20081013-4zm2.html?page=-1

For further information, contact Melissa Maimann at Essential Birth Consulting.

October 13, 2008

birth trauma

 
Birth trauma can affect any woman who has given birth. Although it is experienced by many women, most women do not talk about it and many may not even know they have it. This silence does nothing to help women move past their trauma; it is my hope that this article will help you along the path to recovery.

What is Birth Trauma?
Birth trauma is a normal reaction to events in labour and birth that you perceive as being scary, out-of-control, helpless, or painful. Birth trauma can result from pregnancy, birth or even during the postnatal period. The woman’s response may be one of intense fear, helplessness or horror. Sometimes the events trigger memories of earlier trauma that remain unresolved. Symptoms might not emerge for many months after the birth, or even later, when you plan for the birth of your next baby. 

How will I know if I have Birth Trauma?
The symptoms of birth trauma are many and varied. A common theme is that the trauma interferes with your enjoyment of daily life. The trauma issues may surface at different times, and then completely disappear. Some women experience:

• Flashbacks of the event and sudden, vivid memories. You will usually feel distressed, anxious or panicky when you’re exposed to things that remind you of the event

• Avoidance of anything that reminds you of the event. Some women never talk about their births or avoid hospitals. In contrast, other women talk about their birth trauma all the time; this is their way of expressing their extreme hurt, anger and fear.

• You may also experience emotions such as anger, irritability, and hyper-vigilance (feeling jumpy or on-guard all the time)

• Nightmares of the birth

• Physiological responses when you are exposed to events resembling the traumatic event, such as panic attacks, sweating and palpitations

• Numbed emotions

What causes it?
Most of the causes of Birth Trauma can be avoided or lessened considerably by those looking after the woman, through simple measures such as understanding the woman’s needs and expectations and providing sensitive care in response. This is where continuity of care programs offered by midwives really benefit women! Explanations need to be provided before interventions are carried out, and your permission needs to be sought before any treatment, procedure or examination takes place in order for you to feel respected and safe. Women also have a role to play in clearly communicating their needs and expectations to their care providers. One way to do this is through a birth plan.

There is no standard cause of Birth Trauma. Some experiences than can result in birth trauma include:

• Traumatic birth – eg episiotomy, caesarean, forceps, a baby who was injured during birth
• Emergency situations, including caesarean section
• Lack of pain relief when pain relief has been requested
• Impersonal treatment
• Loss of control over the experience, or the perception that your wishes were not respected
• Being cared for by strangers
• Invasive procedures such as vaginal examinations, episiotomy, stitches
• Separation from your baby
• Feelings of loss of control - eg an induction that you did not want to have, a caesarean for a breech baby when you wanted a vaginal birth etc
• Invasive procedures without explanation or your permission
• Forceps delivery or suturing without adequate pain relief
• Post Partum Haemorrhage

Treatment Options for Birth Trauma
During your path to recovery, you will need a few helpers along the way. A trusted friend or relative can help enormously – someone who knows you well, understands what it’s like to be you, and who accepts you. They need to be empathic and non-judgmental. 

Some women see professionals to help them recover, such as psychologists and midwives. Psychologists are educated to provide therapy for people who have experienced trauma and they provide excellent services for as long as you need them. Independent midwives have usually studied counselling as part of their education, and they have the added bonus of knowing about pregnancy and birth. 

Family and friends can help too – for example, babysitting while you get some sleep or time out from your baby / toddler. Some women like to talk to other women who have experienced birth trauma as this helps them to see that they are not alone. Sharing experiences is very healing and allows you to gain perspective and validation about what has happened.

During these times, it’s easy to forget to take care of yourself. Remember to eat well and get some daily exercise. This will do wonders for encouraging a restful sleep and high energy levels during the day. Limit caffeine, sugar and salt, and tuck into veges, fruit and whole grains. Balance this with fish, chicken, eggs, nuts and seeds, and you have a recipe for health! 

Natural therapies can help a lot – therapies to try include yoga, massage, reflexology, aromatherapy, homoeopathy, naturopathy and yoga.

Journaling is a great exercise; some women also draw. This gives the added bonus of being able to use colour and “left brain” action to express yourself. When you’re journaling, you might want to record your birth story. Some women write it a few times. You might like to write your birth story from your perspective, then from the perspective of your baby, partner, midwife or doctor, and so on. When you’re writing about your experience, pay attention to any feelings that come up for you as you write. Notice how writing makes you feel in your body. As you write your story, you may begin to discover more clearly which events are particularly hard for you to deal with, or to clarify your emotions.

Read books or articles on birth trauma.

Some women also like to write a letter to their care providers (no need to post it), as this helps to express their emotions in a safe way. Other women explore the option of writing a formal complaint to the hospital or Health Care Complaints Commission.

Another option is to obtain a copy of your medical record. Simply contact the hospital medical records department or the Patient Representative. A fee may apply for this service.  Once you have a copy, it’s a good idea to go through your record with a professional such as a GP, midwife or obstetrician who can interpret all the “medical-speak” for you and help you to make sense of the notes. This exercise can go a long way to answering the “why?” for you.

In the end
There is a positive end for all women who have experienced birth trauma. The personal growth that this event affords you, the insight into your values and beliefs, and the journey of healing are all very positive outcomes that can help you move forward in all ways in your life. 

Advice for pregnant women
So, what can you do to avoid birth trauma? There are many things you can do!

• Be assertive about your needs.  Change your care provider if you need to; ask for help; research your options from a wide variety of sources
• Explore what sort of birth experience you would like and then set about finding a care provider who will support you in achieving this
• Write a birth plan so that your care providers know your preferences
• Consider home birth as this will allow you more control over the experience
• Get help early if you need it
• Consider what you will need in order to feel safe during your pregnancy, labour and birth

Melissa Maimann, Essential Birth Consulting.

Tags: Birth choices, birth debriefing, Birth trauma, Caesarean, Complicated pregnancy or birth, continuity of care, Home birth, hospital birth, intervention, midwife, Midwifery, Midwifery services, Normal Birth, Obstetrics, Public and private hospitals, VBAC, women's rights

Women’s Experience of Miscarriage

As published on the Essential Baby website http://www.essentialbaby.com.au/parenting/pregnancy/womens-experience-of-miscarriage-20081111-5m5v.html?page=-1

• November 11, 2008

 
For further information, contact Melissa Maimann at Essential Birth Consulting.

The experience of miscarriage is often misunderstood by women’s friends, families and the medical community, causing feelings of isolation, frustration and fear.

When Essential Baby asked me to write an article on miscarriage, I found several resources that addressed the medical side of miscarriage, but few resources that explored the emotional issues. In this article, I will not elaborate on the medical issues surrounding miscarriage: whether a woman has a 1% chance of miscarriage or a 50% chance of miscarriage is of little consequence when she has just discovered there is no heart beat. What she really needs in that moment is an empathic ear, validation of her experience, to be listened to and to be treated with compassion.

The emotional experience of miscarriage
Miscarriage can be a frightening and lonely experience. Your loss might have been so sudden that there was no way to prepare for it.  Or you might have suspected for a while that something was wrong. Or you may not have wanted to admit that this pregnancy just felt different to your others.   

Whatever your circumstances, there are many emotions surrounding miscarriage such as disbelief, anger, shock, confusion and a deep sense of loss and grief. These feelings come and go, with different intensities. You have some good days and some bad days.  But whatever your experience, you are not alone!

After a miscarriage, you grieve for a baby you never knew, and for a relationship that will never be. Your baby is a baby from the moment you find out you are pregnant. You grieve for the experiences you will not have – discovering what your baby looks like, what sort of personality she has, or how it feels to cuddle him. As Lia, an Essential Baby member found, “To us, this is a loss of life.  A life that was very much wanted, even if not planned. Women have already developed a bond with their baby, they’ve made plans, got hopes and dreams, just like any other new or expectant [mother].”

Women react differently to the experience of miscarriage. You might accept what has happened and look at it philosophically, or you might feel devastated. You might be feeling numb and be in denial that it has happened. Or you might feel guilty because you were unsure if you wanted to be pregnant, or you had a drink or smoked a cigarette. There is no wrong or right way to grieve.

Physically, you might be constantly tired, yet have difficulty sleeping. Some women cannot eat, while others eat constantly, trying to numb their raging emotions. 

For Nicole, an Essential Baby member, “the breaking point was when I found out it was a girl and that there was no obvious reason for her not making it.” Rebecca feels that “I don’t think that I will ever heal.” Miscarriage is such a profound experience and women deal with it in many different ways. “I just wanted to be pregnant straight away, to take away the pain,” Donna, Essential Baby member.

In contrast, Debra says, “I don’t think I really grieved that much. Perhaps deep down I knew it was going to happen. All my dreams had gone out the window and then I started to think of all the things I did that could have caused the miscarriage. We fell pregnant again… I didn’t feel confident from day one although I tried to tell myself everything was ok. I started bleeding at 6 weeks and knew it was all over again. I was much more upset this time. I cried and cried and cried. The first time it happened, I thought, we can do it again, it’s ok. The second time, I thought, so we can conceive, what if I’m never able to carry full term?”

Women who experience miscarriage and then go on to have pregnancies to full term often experience the pregnancy with disbelief and a lack of attachment to their baby. It wasn’t until about seven months that I admitted to myself I may be having a baby and started enjoying the experience. The innocence of a pregnancy is gone, at least until [you] and are safely past that week [that you lost your baby].

Men and miscarriage
Men and women grieve differently and each person’s emotions can seem foreign to each other. Some feel that their partner does not understand them and this can be hurtful and isolating. For some men, the dominant emotion is powerlessness ‘ they feel powerless to protect their partner and powerless over the events that have taken place. What can happen when someone feels powerless is that they sometimes react with anger and withdrawal.

Lia’s husband felt that the emphasis is placed on the woman, whereas men grieve too: “they were his babies that were gone!” Lia’s husband felt helpless watching her go through that pain. “No-one really acknowledged how badly he was affected.”

Melissa Maimann, Essential Birth Consulting.

Tags: Miscarriage

Home delivery too hot to touch

For further information, contact Melissa Maimann at Essential Birth Consulting.

Link to article

Supporters of homebirth are asking why the topic is still seen as too hard to handle in this country, writes Thea O’Connor | March 28, 2009
Article from: The Australian

WHEN Natalie Hemingway gave birth to her son 10 months ago, doing so at home seemed an obvious choice. She had already given birth to her daughter at home three years earlier, and both of her sisters had been born at home.

“That’s what I saw when I was growing up, so birthing at home was normal to me,” says Hemingway, 27, who lives on Sydney’s lower north shore.

Homebirth in developed countries was the norm up until the past 50 years or so. In Australia today, homebirth can seem a radical choice, and the women who chose it anything from brave and alternative to misguided and loopy.

The recent federal government review of maternity services has done little to help bring the practice into the mainstream. It has inflamed an already heated debate over homebirths by stating it does not support Medicare funding of independent midwives attending homebirths …

Part of the problem is that both advocates and opponents of homebirths have research evidence to support their arguments.

According to Hannah Dahlen, associate professor of midwifery at the University of Western Sydney and spokeswoman for the Australian College of Midwives, the best available evidence comes from a large prospective study of 5000 women planning a homebirth in the US in 2000.

The results, published in the BMJ in 2005, showed that the rate of babies dying during labour or within 28 days of birth … was 1.7 deaths for every 1000 uncomplicated intended homebirths. The study (2005;330:1416-1419) said this was similar to risks in other studies of uncomplicated home and hospital births in North America.

Dahlen says it is also similar to the risk of first-time mothers having an uncomplicated birth in an Australian birth centre … or Australian hospital … (2007;34:3:194-201).

When the high-risk births … were included in the analysis of the US study, the rate was two deaths for every 1000 births.

- When women have home births with a midwife, and they are low-risk (term, singleton baby, head down, no blood pressure problems etc), home birth has been shown in many studies to be safe. Not only that, women who have home births experience a greater level of satisfaction with their experience, and mush lower rates of intervention compared with hospital birth.

The highly regarded Cochrane database … concludes that “there is no strong evidence to favour either home or hospital birth for selected, low-risk pregnant women”.

Andrew Pesce, president of the National Association of Specialist Obstetricians and Gynaecologists, believes we have enough evidence to worry. He points to Australian data that indicates babies have a two to three-fold increased risk of death with homebirths.

A study of 7000 planned homebirths in Australia between 1985 and 1990, published in the BMJ (1998;317:384-388) reported that deaths occurring during labour and not due to malformations or immaturity were higher than the national average. …

Dahlen counters that this study provides low-level evidence: the study design was retrospective, it included births by non-registered midwives, it used a number of methods to collect the data, including searching newsletters for death notices …

- While there is strong support for midwife (registered, qualified) assisted home birth for low risk women, there is very little evidence that birth at home without a qualified and registered midwife, for women who have risk factors, will yield a good outcome.

Pesce also refers to the 12th report of the Perinatal and Infant Mortality Committee of Western Australia. It documents a 2000-04 death rate for babies that is three times higher for homebirths. The report said the numbers were too small to be conclusive.

… In December 2007 the West Australian Department of Health stated “a preliminary review of medical records indicates that it is likely the setting of the birth did not affect the outcome in at least five of the six deaths”.

- We need clarity on this matter. Babies die in hospitals and they die at home too. The question needs to be thus: In low risk, healthy women, is the home birth death rate higher than a low risk, healthy opulation of women birthing in hospital. The answer, according to a large North American study, is no.

Distinguishing the outcomes of uncomplicated births from high-risk births helps to make sense of the conflicting data …

The study concluded that while homebirth for low-risk women could compare favourably with hospital birth, high-risk homebirth was “inadvisable and experimental”.

The Australian College of Midwives supports this conclusion.

Dahlen says women should still have the right to attempt high-risk births, provided they are well informed of the risks, as well as their chances of success.

- A woman’s right to autonomy must be respected. It would be great if high risk women were supported to achieve the birth they want within a hospital setting.

“Women wanting to give birth vaginally after a caesarean, for example, have a 70 to 85per cent chance of success,” she says.

Versus hospital VBAC rates which sit between 2% and 15%.

“I don’t know of any other area where the battle over women’s bodies is as intense as this. We have to make sure we don’t end up with situations like those in parts of the US, where midwives are put up on criminal charges and women are arrested and taken from their homes to hospital if they are intending any birth at home the medical establishment considers risky.”

Keirse, who has also worked in obstetrics in the Netherlands, characterises the debate as a demarcation dispute. “Holland went through that in the 1970s. When midwives were granted free access to hospitals in the early 1990s, that made a big difference and contributed to improving safety rates.”

Britain’s Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives have managed to agree. Their 2007 joint statement, which supports homebirths for women with uncomplicated pregnancies, reads: “There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe.” … In the Netherlands, 30 per cent of all births take place at home.

“The culture is conducive to homebirths in Holland,” says Keirse. “It’s an accepted government policy and the midwives who conduct homebirths are considered part of the medical profession. They have rights that allow them to continue caring for their clients if they need to transfer to hospital.

“In Australia, there can be large distances between home and hospital, independent midwives have no hospital rights and they are not incorporated into the healthcare system.

“This means that training of homebirth midwives isn’t regulated, which it should be.”

- The training of midwives is most certainly regulated. All registered, qualified midwives have a university degree or two or three. Some are educated to maters level.

One research finding that is not disputed is that homebirths result in fewer medical interventions … compared with the relatively low-risk hospital group, intended homebirths were associated with lower rates of electronic foetal monitoring (9.6 per cent v 84.3 per cent), episiotomy (2.1 per cent v 33 per cent), caesarean section (3.7 v 19.0 per cent) and vacuum extraction (0.6 v 5.5 per cent).

Melissa Maimann, Essential Birth Consulting.

Tags: Birth choices, Birth trauma, continuity of care, Home birth, hospital birth, intervention, midwife, Midwifery, Midwifery services, Normal Birth, Obstetrics, VBAC, women's rights

Birthing your Baby at Home

As published on the Essential Baby website

For more information, contact Melissa Maimann at www.essentialbirthconsulting.com.au

http://www.essentialbaby.com.au/parenting/pregnancy/birthing-your-baby-at-home-20081027-596s.html

Author: Melissa Maimann

• October 27, 2008

Essential Baby member Azalia homebirthed baby Mason on 9 September, 2008. Photos: Fiona Colvin

Homebirth is increasingly being spoken about as an alternative to hospital birth. Some hospitals are now offering a homebirth program, and of course homebirth is available through independent midwives. Homebirth remains a less common choice for birth, with the majority of Australian women birthing in hospital. So why are some women deciding to birth at home?

For many, the belief in the safety of homebirth is an important factor. Women who choose homebirth do a lot of research into their decision. Isis, an Essential Baby member, states, “I began my parenting journey as a trusting, somewhat ignorant and yet positive 24-year-old. My resulting [birth in hospital] and recovery from it taught me a lot about myself and my birthing body. I learnt a lot about our maternity system, about research and evidence based practice. Interactions with hospital staff during that pregnancy and after my son’s birth angered me, witnessing the postnatal treatment/distress of a [new mother] only cemented the knowledge that I didn’t need, or want to be in the system, unless absolutely necessary for any subsequent children. So my third baby was a planned home birth even before conception.”

For some women, the decision to homebirth is made because of distance from the hospital and/or a history of fast labour, making homebirth a safer option: these women face the very real risk of birthing on the side of the road or in the car, unattended by a midwife. Heidi, an Essential Baby member recalls that in her first birth, she did not realise she was in active labour. The birth centre staff encouraged her to stay home. Eventually her “waters broke and I had an overwhelming urge to push. We drove in school hour traffic to the hospital and it was terrifying. I was so scared that I was going to give birth in traffic.  The pain during contractions while going round corners or over speed humps was unbearable.” When she got to the birth centre, she was full dilated.  

Cesca planned a birth centre birth with her first baby, but realised that in an emergency it would be a 15 min ambulance trip to hospital, whereas it was a 5 min trip to hospital from her home. 

For other women, the decision to have a homebirth is informed by the fact the fewer interventions are used at home, and therefore women having homebirths can avoid complications that often result from intervention that is commonly used in hospital – things like induction, epidural, breaking the waters and episiotomy. Suzy (an Essential Baby member) wanted to avoid having “midwives doing extensive internal exams causing extreme pain completely unnecessarily.”  KM saw The Business of Being Born, a documentary on home birth and maternity care in the U.S. “After seeing this, I knew that home birth was the best option for me due to it being safe and having less chance of interventions for birth (I had interventions for my first two births – induction and drugs through labour that I had more knowledge of the impacts of now 9 years after my last child).”

Essential Baby member and new Mum Reenie says, “The more I learned about intervention, the more concerned with hospital births I became as this state has an incredibly high rate of  Caesarean section. I found it bizarre that you weren’t allowed anything stronger than a Panadol while pregnant, but they wanted to put all sorts of drugs into you while in labour!”

For other women, the decision to involve children in the birth is important. Waterbirth is a common method used in homebirth, and this is not permitted in some public and private hospitals. This was a motivating factor for Suzy and KM.

What sort of care and services are available from homebirth midwives?
Isis states, “The care provided by my midwife was second to none. Having 1-2 hour appointments in my own home were such a treasure, compared to the rushed 5-10 minute face-to-faces that the hospital offered (and that doesn’t include the 20-80 minute wait times!). The relationship we built over the pregnancy was one that ensured total reciprocal trust and respect between us. The parameters set upon the birth were personalised to our requirements, not a faceless hospital policy. Labouring in my house meant no restrictions. After the birth – having my own lounge to sit on, privacy, security. My shower, my family, my home.”

New Mum Reenie states, “My midwives were completely focused on me. No running off down a corridor to some other woman.”

Typically, homebirth midwives book no more than four women each month. This allows the midwife time to get to know each woman during pregnancy – to find out what is important to her, her wishes for her pregnancy, labour, birth and postnatal period, and to build a firm relationship. Generally, each visit includes a physical check of the woman, antenatal education, health promotion, a discussion of what to expect in coming weeks and birth preparation. Midwives attend you at home when you are in labour, and then provide home visits (often daily) after your baby is born.

Heidi states, “Having a homebirth was the best decision I’ve ever made.  It was the most wonderful experience of my life. To experience birth like that – painless, blissful, profoundly beautiful.”

So then, what are the disadvantages?
For some women, the cost of homebirth with a private midwife is prohibitive. In Australia, homebirth costs anywhere between $2,500 and $5,000. Despite the cost, Heidi sees the benefit, “I wouldn’t have paid for a private midwife because they are very expensive where I live ($4k). I would now though, because I know how much better homebirth is.”

New Mum Reenie mentions, “I had to educate my fiancé so that he was comfortable with the idea. Like most, he viewed birth as potential disaster, rather than a normal process. He was reluctant at first, but after attending a ‘choices in childbirth’ talk and hearing all the facts, (as well as some hospital horror stories from people attending) he was all for it!”

Can I have a home birth?
Safety is an important factor. While homebirth is an excellent choice for some families, others may choose a birth centre or hospital birth. Women who choose a hospital birth may:
-    have a pre-existing medical condition
-    prefer the option of epidural pain relief
-    feel safer in hospital/birth centre
-    have a condition called placenta praevia, where the placenta covers the cervix.

Heidi points out that “there is the assumption in our society that (homebirth) is generally unsafe”, and therefore some professionals will encourage all women to birth in hospital, regardless of whether they are high or low risk. Gail (username Midwitch) was “told I couldn’t birth vaginally. When I did with no problems, I was told the next one would be too dangerous to birth vaginally. By my fourth homebirth I was also having very large, very late (14 days) babies, all increasing my risk. Luckily my midwife never doubted me or feared I couldn’t do it … I’ve now had seven babies, five at home. No complications, no problems.” 

There are some complications and pre-existing medical conditions for which a hospital birth would be a safer option. For further information about your individual situation, please speak with your midwife or doctor.

What happens if something goes wrong during my homebirth?
This question is commonly asked when the topic of homebirth comes up. Put simply, if something goes wrong, you transfer to hospital. There is a strong reliance on the midwife’s skills at ensuring that you are low risk at the start of your pregnancy, and that you remain low risk throughout your pregnancy, labour and birth. At any time the midwife has concerns, she will discuss them with you and will work together with you to devise a plan of action. This might involve getting a second opinion from another midwife, getting a consultation with an obstetrician or complementary therapist, or referring you to hospital.

KM had a post-partum haemorrhage which was managed by her midwives.

“Unfortunately my pulse and BP would not stablise afterwards and my midwife could not get a line in.” KM transferred to hospital and her midwife went with her, advocating for her at the hospital. Cesca also has a post-partum haemorrhage but “it was mild and the midwife could control it with drugs at home.”

Gail transferred in labour: “My third baby (second homebirth), I transferred in for foetal distress. He had the cord around his neck and two true knots in it. He birthed quickly in good condition so we went home two hours later.”

The other common reasons a women may transfer in labour are for a labour that is not progressing, or the woman’s decision to have an epidural.

What does the research say?
A Canadian study involving 5,418 women who had planned a midwife-attended homebirth found that 12.1% of those booked for homebirth transferred to hospital. 4.7% women had an epidural, 2.1% had an episiotomy, 1% had a forceps delivery, 0.6% had a vacuum extraction, and 3.7% had a caesarean section. In other words, 94.7% women had a normal vaginal birth! The study found that these rates were substantially lower compared with low risk US women having hospital births. The neonatal mortality rate was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America.  No mothers died. The authors concluded that planned, midwife-attended home birth for low risk women in North America was associated with lower rates of medical intervention and similar intrapartum and neonatal mortality to that of low risk hospital births in the United States. (BMJ  2005;330:1416)

Tags: Birth choices, Home birth, Maternity Services Review, midwife, Midwifery, Midwifery services, Normal Birth, VBAC, women's rights

Pre-Eclampsia During Pregnancy Could Indicate Future Heart Disease Risk, Studies Say

For further information, contact Melissa Maimann at Essential Birth Consulting.

Link to article

Women who experience pre-eclampsia during pregnancy have more heart attacks, strokes and blood clots later in life than women without the condition, according to several studies, the New York Times reports … Researchers do not know what causes the condition, which is marked by high blood pressure, protein in the urine, severe swelling, headaches and vision problems. Although pre-eclampsia usually disappears soon after delivery, a “growing body of evidence” indicates that women who develop pre-eclampsia have twice the risk of having a heart attack or stroke later in life, the Times reports.

….

According to the Times, most researchers do not believe that pre-eclampsia directly increases the risk of heart disease. Smith said that it seems more likely that the condition is an early indicator of the health of a woman’s heart … Williams now advises women with pre-eclampsia to have frequent screenings for cholesterol levels, blood sugar and blood pressure, and to seek treatment if the levels are high.

- This seems similar to gestational diabetes, which, rather than being a disease in its own right, is more a marker for the development of later-onset type 2 diabates.

Melissa Maimann, Essential Birth Consulting.

Tags: Birth choices, Home birth, hospital birth, midwife, Midwifery, Midwifery services, Normal Birth, Obstetrics

Is Homebirth Right for me?

For further information, contact Melissa Maimann at Essential Birth Consulting.

For most women, home birth is a safe and responsible decision. Homebirth is possible for women who:

Are having their first babies
Are having their second, third or subsequent babies
Are having a vaginal birth after caesarean (VBAC)
Have had a previous traumatic birth
Had a very fast birth last time
Prefer a more natural experience
Are healthy

Why choose homebirth?
Some women find that having their baby in the comfort of their home provides a supporting environment.

This helps to keep stress hormones low, and positive birth hormones high, making the birth easier and less painful.

Other women homebirth because they believe in their body’s ability to birth, wish to involve their partner and other children, or prefer to reduce the chance of intervention in their labour.

A number of different research studies have looked into the safety of homebirth – all reliable research has found that for healthy women, homebirth is a safe option.

Keeping Homebirth Safe
A common question I am asked is, “What if something goes wrong?” Private / independent midwives take several precautions to keep home birth safe. This includes things such as:

Screening women carefully so that only low-risk, healthy women birth at home
Careful monitoring during pregnancy and labour to ensure that any possible risks are detected early, allowing time for transfer to hospital or consultation with obstetric staff
Building a relationship with the woman that is based on mutual trust and respect. This is central to an effective relationship between woman and midwife.

Midwives who birth with women at home are educated and experienced to assess the wellbeing of mother and baby throughout pre-pregnancy, pregnancy, birth and the postnatal / neonatal period. Midwives use the ACMI Guidelines for Referral and Consultation to support clinical decision-making in consultation with the client. Of course, with a homebirth, you have the right to make your own informed decisions about your care and your decisions are respected.

The Cost of Homebirth
Some people believe that private / independent midwifery care is expensive. I have prepared the following table to explain how the services are broken down. Home birth services are very comprehensive, and home birth midwives spend many hours with women and their families, building a strong relationship during the pregnancy that carries through to the birth and beyond. Typical home birth services consume a whopping 86 hours of a midwife’s time, assuming 1 hour of travel to and from your home, 13 antenatal visits, 5 postnatal visits, and of course labour and birth attenance.

PLUS
On-call – 24 / 7 for 5 weeks
Phone and email consultations
Research
Attending related appointments with clients
Professional consultation with other professionals on the client’s behalf

As you can see, the service provided by a private / independent midwife is comprehensive and does not compare easily with other maternity services in terms of continuity of care, hours of contact, follow-up and availability. When you choose a home birth with an independent midwife, you are choosing gold standard service.

As you can understand, when midwives provide this level of service, it is impossible to book more than two or three clients each month. I could see women in a clinic setting for 30 minute appointments – that would eliminate travel time – but I know that you’re after a service that really meets your needs.

Some women ask me whether I will provide reduced services such as no postnatal care, one or two antenatal visits, a late booking, and so on, in order to reduce the cost. I prefer to provide a comprehensive service and the women who book with me see the value in this approach. A home birth is an investment in you and your baby, afterall. And you deserve the very best.

Melissa Maimann, Essential Birth Consulting.

Tags: Birth choices, continuity of care, Home birth, midwife, Midwifery, Midwifery services, Normal Birth