Monthly Archives: April 2012

Gestational Diabetes

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Gestational Diabetes Mellitus (GDM) is a condition where the body can’t control blood glucose levels effectively because of incorrect insulin production or resistance to the insulin that is present. Or because of excess glucose intake.

GDM is a specific form of diabetes that occurs during pregnancy and usually disappears once the baby is born. Although it is present during pregnancy, if you had diabetes in pregnancy, you are likely to develop it later in life as well. It is most common in women with a family history of Type 2 Diabetes, older or overweight women and some ethnic groups. If you have gestational diabetes for one pregnancy, you are more likely to have it in subsequent pregnancies.

Gestational Diabetes is usually detected by a Glucose Tolerance Test which is attended at 26 weeks of pregnancy. If your care provider feels that you are at high risk for developing gestational diabetes, they may ask to test you earlier than this. You’ll be asked to fast before the test, which is done first thing in the morning. The pathologist will take some blood from you while you are fasting, and then give you a sweet drink. Thereafter, blood tests will be done one hour later and then two hours later. Bring a book to read, as the whole proces can take 2 – 2.5 hours.

Most people manage gestational diabetes through a low GI diet and exercise. Your care provider will work with you and provide you with much information in this. A small percentage of women will require insulin injections. All women with GDM will be asked to monitor their blood glucose levels at certain times during the day. This will indicate whether your diet and exercise program are efeective, or whether you would benefit from Insulin.

GDM usually doesn’t affect the mother, but it can affect the baby. The baby may be larger than normal, and this may translate to problems during birth for you. Such as a longer labour. Your baby’s blood sugar levels will be tested after birth to check for any abnormalities, but this is uncommon.

To reduce your risk of gestational diabetes, keep fit and healthy during your pregnancy with regular pregnancy exercise and a healthy diet. talk with your mdiwife or osbtetrician early on in your pregnancy(once your morning sickness has ceased) and aim for a diet that is low in complex carbohydrates and high in proten, healthy fat and fibrous vegetables.

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Going out with a new baby? What to pack?

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It can be quite daunting to go out for the very first time with your new baby, and if you’re like many new mums, often things get left behind. Many women find it helpful to have a list of things that are needed when going out with a new baby. You can refer to this list before you leave home and feel confident that you’ll be prepared. Here’s a handy checklist of essential items to pack in your nappy bag when you’re out and about with your new baby. When you’re out, keep a note of what you go through, so that you can re-stock your nappy bag when you get back at home. Many women find it helpful to have a stocked nappy bag ready at all times, so that if you need to leave home in a hurry, you don’t need to be rushing about the place trying to re-ctock your nappy bag.

Nappy changing
Nappies (6)
Nappy rash crean such as Lucas Pawpaw ointment
Plastic change mat
Wipes (travel pack)
Sanitising lotion for your hands
Plastic nappy bags for disposing of nappies and wipes, or for transfer back home for washing
two changes of clothes, one for warm weather and one for cooler weather
Breast pads
A change of top for you

For feeding
Bib(s)
Food in small containers
Cloth for burping
Breast pads
Wipes for hands and face

General

A blanket or wrap (x 2)
A hat
Sunblock
Insect repellant
Teething rings
Plastic bags for rubbish

Things for you

wallet
keys
mobile phone
sunglasses / hat
sunscreen lotion
bottle of water
moisturiser
hand sanitiser
notepad
pens
diary
list of emergency contacts

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Pregnancy to-do list

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The following is a helpful check-list of things to do when you discover you are pregnant:

When you think you might be pregnant

Purchase a home pregnancy test kit … it comes back positive … congratulations!

First trimester

See your local private midwife for confirmation of your pregnancy and to calculate your due date
Discuss options for birth with your midwife and engage a pregnancy care provider
Choose your model of care
Investigate your maternity leave entitlements
Prepare a budget for pregnancy and beyond

second and third trimesters

Buy maternity clothes
Get fitted for a maternity bra
See your chiropractor
Participate in an exercise program and enrol for pregnancy yoga
Start your independent childbirth education classes
And also enrol for Calmbirth (R) classes
Have a regular pregnancy massage (eg once per month)
Practice your pelvic floor exercies daily
Read, read, read
Ask lots of questions of your care provider to ensure that you go to your birth feeling confident and empowered
Start preparing your baby’s room

Preparing for birth

Have a baby shower … or blessingway …. or both!
Choose some baby names
Pack your birthing bag, or prepare your supplies for your homebirth
Have your car seat fitted by 37 weeks
Ensure you are booked into hospital, regardless of your intended place of birth
Pack your hospital bag and have it by the front door, or even in the car
Prepare some home-cooked meals and have the freezer well-stocked
Stock your pantry of all non-perishables you might need
Register for Coles on-line

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When is a water birth not recommended?

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Each hospital will have different policies on when waterbirth will not be recommended. Generally, a woman who needs continuous monitoring of the baby’s heart beat will not be able to labour or birth in water, because most of the monitors are not waterproof. Fortunately, at the hospital where I attend births, we do have water-proof monitors so women can have a waterbirth with a VBAC, for example.

Certain complications during labour may require a water birth to be abandoned for safety reasons. This might be bleeding, fetal distress, excessively prolonged labour, high blood pressure, shoulder dystocia and premature birth.

Water birth can slow down the progress of labour in some cases, especially if the woman is less than 5cm dilated when she enters the pool. If this is the case, simply exit the pool and re-enter when labour is further established.

It is perfectly safe to birth the placenta in the pool, however you can expect your midwife to assist you out of the pool if your blood loss is thought to be excessive.

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What are the benefits of a water birth?

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It is true that very few women will have a waterbirth for one baby and then choose a land birth for the subsequent baby, however many women will have a land birth with one baby and then opt for a waterbirth the next time. Occasionally a woman will choose a homebirth specifically so that she can experience a waterbirth, perhaps because her local hospital cannot support her in this.

Waterbirth is an effective way for a woman to manage the sensations of labour.

Waterbirth often results in fewer perineal tears because the water has a softening effect on the perineum.

Waterbirth also helps a woman to be more active in her labour and birth because it helps with a sensation of weighlessness.

Babies who are born in water are often calmer than babies who are born on land.

Because warm water promotes good circulation and oxygenation to the uterine muscles, a baby is less likely to suffer from a lack of oxygen which can lead to fetal distress.

Labouring in water has also been shown to lower a woman’s blood pressure and assist with dilation of the cervix in a labour that is considered to be “slow”.

In my practice, about 50% women birth their babies in water.

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What is a water birth?

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A water birth is when a woman gives birth to a baby when submerged in water (usually in a birth pool or large bath). A midwife should always be present, the same with every birth.

With proper care and attention, a water birth is a safe way to birth a baby, and it has important benefits for mothers and babies.

Soap, essential oils and salt should not be added to the water. Ordinary tap water is fine. Generally, when a woman is birthing in a birth pool, she will need an electric pump to pump up the pool, a hose to fill it with water, a net for any “floaties” and a pool liner (if desired).

The water temperature should be warm, at around 35-37 degrees.

Waterbirths may be possible in some hospitals, and they are always possible at home if you have a bath that is large enough to birth in, or a birth pool.

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Private and public pregnancy options

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I am often asked what the difference is between the private and public options for pregnancy and birth.

Private care generally affords women:
- Choice of care provider
- Choice of place of birth – home, hospital (public or private)

- Greater comfort and a more personalised service

Public care options often mean:
- a midwife or obstetrician will be assigned to you; you will not be able to choose your care provider
- Choice of place of birth is limited. Homebirth is only an option at a minority of hospitals and women generally have to go to the public hospital that is closest to their home
- Services cater more to the immediate physical needs with little appreciation for the emotional and mental journey of pregnancy and birth.
- Services are standardised by hospital policies. The same policies will apply to all women birthing at that hospital with little scope for movement.

The good news about medicare-eligible private midwifery care is that families are able to claim Medicare benefits for the care that is received from a private midwife. This rebate will significantly bring down the prices for private midwifery care, making it an affordable option for women wanting to birth in hospital with a private midwife, or at home.

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Recognising preterm labour

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Preterm (or premature) labour refers to labour that starts before 37 weeks of pregnancy. Signs of labour before the 37 weeks of pregnancy may be more subtle than the signs that might occur later in pregnancy, after 37 weeks.

Many women will appreciate that babies need to “cook” until they’re full term, that is, 37-42 weeks of pregnancy. Babies who are born before 37 weeks of pregnancy tend to experience more health issues than term babies, and it is for this reason that midwives and obstetricians would like to know as soon as possible if you think you might be in preterm labour.

Preterm labour might not necessarily be “painful”. And you generally don’t need to dilate to 10 centimeters before the baby can be born, as the baby is smaller and can pass through a prtially-dilated cervix. For this reason, a preterm labour will often be shorter than a term labour.

Some tips:
Be aware of contractions. They can feel as if like your abdomen is tightening like a fist every 10 minutes or less, rather than anything sharp or painful.

Pay attention to back pain. A dull ache in the lower back can be a sign of labour, whether it is constant or it comes and goes at intervals. Likewise, you might also experience pain or a dull ache down the inside of legs.

You also may feel more pressure or fullness in your pelvic area, as if your baby is pushing down.

Regular cramps that feel like period pain or gas pains — aren’t a normal discomfort of pregnancy.

Don’t wait for your waters to break. Even with full-term births, only about one in four women will experience the stereotypical gush of water before labour begins. TV is not real! In most cases, your waters will not break until your baby is just about to be born.

Stay in tune with your baby. A decrease in typical fetal movements after 28 weeks may also need attention.

Err on the side of caution. Your midwife or obstetrician would much rather check you numerous times unnecessarily, than risk you birthing a preterm baby unassisted. Often times, a woman in preterm labour will “niggle” for a while, before labour kicks into gear. Once it does, it is often very short. Call your doctor or midwife with concerns and follow their advice. If symptoms worsen or return, call again.

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Has labour become a competition?

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Sitting at mother’s groups, listening and observing, a general theme emerges when mothers speak of their recent births: competition. Who had the most traumatic birth? Who had the longest labour? And I came to wonder what purpose this competition serves.

I wonder if it serves a few purposes.

It reinforces birth as a scary, dangerous, even deadly experience that really must occur in hospital. “Thank god I was in hospital. My baby would have died if I had been at home!”

It validates the experience of the woman who had the most traumatic labour. The woman who wins the most-traumatic-birth-competition feels good, as any winner would do. Why would she want to give up this good feeling? After-all, she’s been traumatised by the birth and it feels good to finally have a group of women say, “wow, that was really bad!” rather than, “at least you have a healthy baby”. This reinforcement relieves the woman of her quest to find out what went wrong, and more importantly why, in attempt to avoid the same situation from occurring next time. Hence, “I’ll just go for a ceasar next time” if often heard and the other mothers agree that yes, since this woman’s birth was the most traumatic of all the births in the group, this woman is certainly justified in “going for a caesar” next time.

Other themes that emerge are an avoidance of self-responsibility, empowerment, ownership and belief in birth as a process that a woman’s body can do, if let to labour as nature intends. The most-traumatic-birth-competition rarely centres on the woman’s individual choices and decisions. It focuses on what was done to her and what was out of her control. Have we lost the ability to have the courage of our convictions, to trust our instincts, to believe in ourselves, that we hand over responsibility for our births to a stranger / professional? Often times, the mother who has had the most traumatic birth will have handed over the most responsibility for her birth. This protects the mother from any guilt: one the one hand, it was her care provider’s fault if things didn’t go to plan, and on the other hand, thank goodness she had her careprovider to sort things out and rescue her and her baby from the birth. Either way, the woman bears no responsibility for the outcome that was less-than-desirable.

The mother who had the most natural birth often doesn’t speak. She’s in the minority after all. No-one wants to hear about her amazing home waterbirth. And indeed, if she dares to speak of her positive, empowering experience, she is met with disapproval for daring to speak while Mrs Jones is re-living her nightmare to the group. The natural birth mother is labeled “odd” for ever pursuing a natural birth, and even odder for actually achieving it. She best not speak or her views will only isolate her from the group, and motherhood can be isolating enough. So now the situation is that the competition exists entirely of traumatised mothers, all seeking to be awarded the prize for having had the biggest tear, longest labour, greatest number of interventions and biggest baby. Each wants to feel that although the circumstances were not ideal, there was nothing they could have done to avert such outcomes, that they were mere victims in the unpredictable process of birth. They went to a top private hospital with the best obstetrician in Sydney (funny that they’re all “the best”) and that’s where their responsibility ends.

It’s hard to do the self-reflection and question decisions you made. Maybe you’ll learn that other decisions would have led to better outcomes and this starts the painful cycle of regret for something that cannot be changed. However, it’s ok to honour that journey and know that at the time, we made the best decisions we could have made, but now that we know differently, we will choose differently.

When this happens, maybe the competition will be on different terms. I live for the day when the competition is for the most satisfying, safe and empowering birth experience with the woman coming away with her dignity intact and feeling respected and cared for throughout her experience. It’s totally possible!

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Preparing for a natural birth and going with the flow

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In society today, there is a great focus on pain in labour birth, with the assumption that women cannot handle the pain of labour and that women need medical assistance in the form of an epidural or drugs to get through. Many women go to hospital saying, “Well, I’d like a natural birth, but I’ll go with the flow”.

Even with today’s technology, birth comes with pain most of the time. Even for those women who are sure they want an epidural, they will still feel some pain as epidurals are given once labour is established, after 4cm dilation. There is usually pain / discomfort to get to that point.

And once women get to 4cm, the last 6 are usually much faster and easier to get through. That’s because our bodies are designed to release natural pain relief that helps with the later stages of labour.

The best thing is to learn techniques for managing the sensations of labour, to feel well prepared for labour and birth.

When preparing for a natural birth, most women feel better informed – and therefore relaxed – if they have read a lot about labour and birth. Women who are well-informed about the process of birth, the options available to them and what they can expect, are generally more accepting of the sensations of labour. They are not fearful because they know what to expect and what might happen next.

It’s a great idea to read other women’s birth stories – positive and negative – to give a balanced view of what happens, what is possible and what you might like for your own labour.

Independent childbirth education is excellent for teaching women in an unbiased way about all the options available to them.

Calmbirth is another fantastic tool for assisting with natural birth.

It’s essential to be surrounded with positive messages about birth. Try to limit contact with people who are skeptical and judgmental of your plans for a natural birth. Don’t let people discourage you or tell you birth horror stories. If you expect it to be terrible, it will be.

Think about what you want your birth to be like. Make a birth plan, detailing what you’d like for your labour, birth and postnatal period. Show it to your midwife or doctor and get their agreement to help you achieve that birth that’s right for you.

Of course, birth plans are always flexible and we understand that sometimes they need to be modified and that’s ok. A birth plan is just that – a plan. It’s not set in concrete and women can change it at any stage.

Watch DVDs on natural birth. See, hear, read and talk about natural birth. Focus on becoming the healthiest person you can be with great nutrition and a firm exercise program. Women who are physically fit and well-nourished often have easier labours.

Finally, your choice of care provider is also worth considering. Do you know the midwife who will be caring for you in labour? Would you like to know the midwife who’ll be caring for you? Women who are well supported in continuity of carer programs such as private midwifery care are far more likely to rate their labour and birth experience as being positive and satisfying.

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Decision-making: Heart and Head

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Through my practice, I have a lot of women coming to me who are experiencing conflict with regards to the choices they have made for their pregnancy and birth. Typically, they find (sometimes quite late in their pregnancy) that perhaps the choice they made right back at the start of their pregnancy, no longer works for the, or the choice that they made was perhaps not as well informed as they thought it was. Some women find it hard to take the attitude of interviewing potential care providers before pregnancy (or very early in pregnancy) and then choosing the midwife or obstetrician who is best able to meet their needs. The end result can often be a woman who chooses an obstetrician with the goal of a natural birth, only to discover that their doctor will only “deliver” their baby if they’re on their back in bed with an epidural in place. Or that induction is performed by 40 weeks, or that all women have their waters broken and all first time Mums have an episiotomy or so on. And sometimes, the more reading a woman does, the more she realises that this is not what she wants.

I often ask the question, “What was it that made you decide on this particular care provider?”

And the responses are generally very interesting.

• My GP referred me
• My mother / sister / friend / neighbour used this midwife and she said she’s wonderful
• Well, when I got pregnant I went to my GP. She asked me if I have private health insurance and I said yes, so she wrote a referral to Dr XX.

I ask these women if they considered any other options. “What options?” comes the response.

I’m amazed that with the marvels of modern technology, internet etc, women don’t know they have other options. We have options with all sorts of things in life, and we don’t shy away from discovering them either! It seems to be to be an interesting handing-over of responsibility when it comes to pregnancy and birth, and I’m curious why it happens with pregnancy and birth, but not in other aspects of life. Do we buy a particular computer – that can’t meet our needs – because it was recommended and we didn’t know there were other computers on the market? Do we buy a large house when we need a small house because it was recommended by the real estate agent?

In most other situations where choices are involved, people will engage in a process of assessing options.

We might list all the possible options and then assess each option across a range of qualities.

We ask questions.

We consider what it is that we really want, and then match it to what’s available, seeking the most compatible choice.

But sadly, this does not happen with pregnancy and birth. Perhaps it should?

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Responsibility in birth: Who owns it?

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Who is really responsible for intervention that happens in our births? Is it us or our health professionals? Or is it both?

In this blog post, I’m referring to situations where unnecessary intervention has taken place. Of course there’s a place for intervention in some labours and this post does not address interventions that are truly necessary. However that’s defined!

Some women argue that birth – and what happens in birth – is their responsibility and they take charge of all decisions and also take responsibility for the outcome of those decisions – good or bad. Women in this category would never dream of blaming their care provider for a bad outcome because the decision was theirs alone and they made a fully informed decision that they were comfortable with. When things go well, they attribute that great outcome to their good preparation and decision making.

Other women will outsource decision making to a health professional such as a midwife or a doctor. “They’re the experts”. In life, we outsource all sorts of decisions, so it’s not surprising that women may choose to do this for pregnancy and birth.

When things go according to plan – a woman has the birth she was hoping for, the baby is healthy, breastfeeding goes really well – there’s no issue at all. When things don’t go as planned, issues of responsibility (and sometimes blame) come up.

Over the years, I’ve sat back and observed women’s reactions when things don’t go well.

I think there are two parts to things not going well. One is the woman’s responsibility for her decisions and the other is the health professional’s conduct.

I’ve observed that when things don’t go to plan, very few women take responsibility for the choices they made that might have led them down a path that they never planned to walk. Eg women who might really want a natural birth who choose a hospital with a very high caesarean, episiotomy, epidural and induction rate. “It won’t happen to me” and then it does.

Some go right back to the same care provider and place of birth – it’s what they know and what they’re comfortable with – even though the outcome is not what they really want. Should they complain about their [caesarean / epidural / induction / forceps / episiotomy] and say they’re not responsible: their care provider is? I think not – choosing the right care provider and place of birth is each woman’s responsibility. If the hospital / health professional has a 50% caesarean rate – yep, that applies to you too.

Some people argue that women can never take full responsibility for their births because the information that’s relevant to them is hidden, disguised, not available until it’s too late and so on. In these cases, some argue that the woman could not have possibly got the information that would have assisted them to make a choice for their birth that is more aligned to what they’re trying to achieve. But if this is the case, how do we account for women who do magically find information, make decisions that are compatible with their needs, and experience the birth they had wanted? What sets these women apart from other women? Determination? A strong sense of self-efficacy? Confidence? Having options?

Information is all around us. We can talk to care providers, hospital midwives, friends / family, google relevant articles and information, talk to private midwives and obstetricians and so on … there’s lots of information out there, even in rural / remote areas, thanks to the WWW. In NSW, hospital statistics are publicly available. Is there any excuse for not knowing your hospital’s caesarean rate if you live in NSW?

When we buy a car, we know we have many choices. Not just the make of the car, also auto / manual, number of doors, convenience features, comfort features, safety features and so on. If we only go to Toyota and buy a car that’s not suited to our needs – and this becomes apparent a couple of weeks later – is this Toyota’s fault? Maybe, but only if Toyota falsely advertised the car’s features. We’re responsible for the choices we make. Likewise, if we choose hospital X without exploring other hospitals, or settle on Dr Y or Midwife Z without interviewing others who might be better suited to our needs – is it the doctor’s / hospital’s / midwife’s fault if the birth has more intervention than the woman had hoped for?

In all industries, it is the responsibility of the consumer to first work out what they want, and next to set about finding a service / product that meets their needs. Is birth any different? It is true that we cannot control birth, but if we want a drug-free birth and we know from the outset that our care provider only attends epiduralised births, is this a compatible choice?

Now, the other side of this whole argument is the issue of conduct. While I firmly believe – and know – that information is out there, freely available, and that women are most definitely responsible for choosing the right care provider and place of birth for their needs, I also appreciate that health professionals are responsible for their conduct.

Negligence says that a health professional owes a duty of care to the patient, the duty of care is breached, the patient suffered harm, and the harm is a reasonably foreseeable consequence of the breach of duty of care.

If this happens, then of course the health professional is to blame and the patient ought to raise this as an issue so that it can be addressed either legally or within the profession. Drug errors, incorrect surgical technique, performing the wrong operation, failing to gain consent, working while under the influence of drugs or alcohol – these are all serious issues that ought to be reported.

So, in summing up, I think that responsibility for birth is a complex issue. While women are most certainly responsible for choosing the right care provider and place of birth (amongst other decisions), health professionals are responsible for how they practice their profession.

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How is a hospital midwife different to a private midwife?

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This is a question I’m asked quite frequently so I’d like to take this opportunity to explain the difference.

Hospital midwives are employed by a hospital, either public or private. The majority of hospital midwives work shifts and there are generally 3 shifts in a day, so that each woman will go through 3 different midwives each day, in the provision of her care. Many hospital midwives do not work across the full scope of midwifery practice; instead, they work in one area only, such as postnatal. Because of this, it is unlikely that women would be afforded the opportunity to meet with the midwives who’ll be providing their care in labour and after their baby is born, first because the midwives work in shifts and it’s impossible to know who’ll be rostered on on the big day, and second because the midwives in postnatal, for example, would not work in the antenatal clinics which is where women go for their pregnancy care. The other implication is that antenatal midwives – who do not work with breastfeeding mothers – are not best placed to provide breastfeeding preparation and advice in pregnancy; likewise, delivery suite midwives would also not be best placed to advise about early pregnancy tests.

Another important factor is that hospital-employed midwives are bound by hospital policies. It’s a condition of employment. So that when something props up and the woman wants impartial information or alternative suggestions to explore, the hospital-employed midwife is not able to provide this.

Private midwives run their own businesses and are self-employed. They book their own clients and arrange their work life and hours to meet the needs of their clients. They follow their clients through from pregnancy, birth and afterwards with their new baby, generally for 6 weeks. Private midwives do not work in shifts; we are on call 24/7 for the families in our care. This means that the same midwife is accessible at all times, either by phone or in person.

Families choose their private midwife, whereas there’s no option to choose hospital midwives: you have whoever is rostered on when you’re there. Choice is an important factor of maternity care, and is a driving factor in the success of private obstetric practices where women can interview several obstetricians before choosing the one that best meets their needs.

Private midwives are not bound by hospital policies. We do follow the guidelines of our professional bodies such as the Australian College of Midwives, as well as researched and widely-accepted clinical practice guidelines, as well as legal requirements, but when it comes to exploring all options, private midwifery is the way to go. A common example might be a breech baby. Hospital policy may be to offer to turn the baby manually (ECV) so that it is head down. If this is not successful, caesarean will be encouraged. These options are also given by private midwives, as well as the natural alternatives to turning breech babies, and if the baby decides to remain breech, there is the option of vaginal breech birth and the woman will be able to approach this knowing that she has a skilled professional by her side, on her side.

Women will generally approach private midwives for the one-to-one flexible care that we provide; they want to get to know the midwife who’ll be there on the special day (or night) when their new family member arrives. It’s only natural to want to know that person who’ll be with you during the most life-changing, amazing and special moments of your life.

Generally, satisfaction with private midwifery care is very high, whether the woman birthed at home or in hospital.

Women are generally very satisfied with their care because they have far more control over what does and does not happen to them. Women have greater access to resources that helps them to feel confident with their abilities to birth naturally and fully aware of all options so that they can choose the best one for their needs.

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Twin Birth

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I had a difficult delivery with my first baby, including posterior presentation, premature rupture of membranes, meconium staining, stalled labour, 18 hours of Syntocinon, a largely ineffectual epidural, a 4 hour second stage, and forceps delivery. My daughter had severe respiratory distress and was in the NICU for several days. It was a very tough introduction to parenthood and left me quite traumatised, especially the separation from my daughter. My husband and I decided that we would try for a homebirth if we had another baby, in the hope that a calmer environment would assist the birth process. When I fell pregnant again, we found a lovely homebirth midwife.

I started to show really early. At 8 weeks I was in maternity wear. I thought it was just because it was a second pregnancy, but a 9 week ultrasound showed TWO BABIES. We were completely shocked as there are no twins in my family. Twins of course meant that a homebirth was out of the question.

There followed many long months of argument with various obstetricians about our birth choices. We wanted as little intervention as possible. A standard twin delivery involves syntocinon (which I was very afraid of, after the previous experience), continuous monitoring (which I had hated with my first birth, as I felt chained to the bed) and an epidural prior to the second stage, in case positioning/version or a c-section is necessary to deliver the second twin. In my first birth, the epidural meant I had no pushing urge and seriously compromised my ability to deliver my daughter, hence the very prolonged second stage, so I did not want an epidural this time around, although I was prepared for Synto to be administered between the twins if labour did not re-establish. The hospital also wanted both twins delivered on the bed, which I did not agree with as I had found pushing in that position impossible the first time around. Our views were very challenging to the obstetricians and some were quite aggressive about it, although I must say the head OB was more reasonable and was prepared to admit that my refusal to consent to an epidural would be a “complete contraindication” to giving me one! Throughout this stage our midwife was a pillar of strength and information. She gave us the courage of our convictions and more than once came to the hospital to talk with the obstetricians on our behalf. Even so, the hospital was very unhappy with our birth preferences. It was a stressful time, helped somewhat by a Calmbirth ® course.

In the end all our arguments ended up being moot. At 33 weeks, I started to feel an ominous itching all over. Tests showed elevated bile salts and poor liver function results. I had obstetric cholestasis. Our midwife and the hospital agreed: the babies would need to be delivered by 37 weeks. And I knew that that early, an induction would almost certainly involve Syntocinon.

This was really difficult for me to accept. I was terribly afraid of the drug, and knew that Synto would mean continuous monitoring and therefore limit my movement, which I also feared. However, I knew that my fear would make the delivery more difficult and the pain worse. At this point the hospital dropped the bombshell that despite all their delivery rooms having deep birthing baths, I would not be allowed to use those or the shower if I had to have Synto, as they believe this risks pump damage to the Synto pump. Essentially this meant I was walking into a labour that was likely to be more painful, with less pain relief options. It was going to be down to Calmbirth ® alone, if I wanted to avoid drugs (and I did!).

I did a lot of Calmbirth ® practice from then on. But the Calmbirth ® visualisation exercises presupposed a normal delivery without intervention, and I found it very upsetting to listen to them. I hit on the idea of doing my own visualisations, of a medicalised induction process. After a few of these I was able to work through some of my fears.

On the day of the induction, we kissed our daughter goodbye at 5am and met our midwife at the hospital. Preliminary checks showed a Bishop score of 5, very promising for 36 weeks. The hospital midwife applied prostaglandin gel and sent us out to freedom. We had a lovely breakfast. I started to have sporadic contractions but nothing serious. We returned to the hospital 6 hours later. My cervix had ripened to 2cm, and the very cheerful OB was able to break the waters for twin 1 (our second daughter) at 3.45pm. No meconium staining! I dared to ask the OB how she was presenting. ANTERIOR, WOOHOO! I was very pleased with that.

Contractions came rather more strongly after that point, but were still sporadic. The felt very “knifey”, and our midwife explained this was from the prostaglandin gel. We held off on the Synto as long as possible, but at 6.25pm the drip was put up and contractions started in earnest. Continuous monitoring was in place, but via telemetry so I could have moved. Ironically, though, I didn’t feel the need to. I went deep into calm breathing and spent most of the labour sitting beside the bed on a fit ball, sometimes circling my hips but more often just breathing to ride the contractions with my husband stroking my back. Unlike my first labour, I had no real idea of when the next contraction was coming, and ended up doing my calm breathing (in for 4, out for 6) solidly for hours. I wasn’t afraid of the contractions. I could really feel them doing their work, and little twin 1 moving firm and fast down. I was determined to “get out of the way” of labour and with each contraction focused on opening up and not clenching against the pain. Our midwife was convinced things were going quickly and asked us when we thought we would be having the babies. I told her anything before midnight was a sucker bet! She said 11pm.

At 8.30pm, about 2 hours after I started having regular contractions, the pain was starting to get BIG. The OB did a cervix check – I was 5cm. I was very disheartened by this, but our midwife told me that the first 5cm was the hardest, and the very encouraging OB tried to convince me that it wasn’t all about centimetres and that my cervix felt promisingly thin and stretchy. In hindsight, even in my first labour I dilated from 5 to 10cm in under an hour, so I should have known what was coming – but I didn’t!

Throughout this time I was not making any noise. The hospital’s midwife didn’t seem to think I was in established labour, and threatened to up the Synto dose to make the contractions “strong and regular”, even though they were already sufficient to dilate my cervix 3cm in under 2 hours. I managed to insist “no. more. Synto!” She reserved judgement, but it might have been the adrenaline kick I needed, as by 9.15pm I was having enormous contractions every 2-3 minutes. I could feel them as a giant swelling band of pain stretching around my whole belly and stretching lower. At this point I started vocalising “ah, ah, ah” throughout contractions, to help me ride the pain and stop me clenching down. I remember saying “if this isn’t transition, I’m in trouble!” I didn’t believe it could be transition, though – not so early, not when my first birth had taken almost 3 days. Our midwife said she thought we would have babies by 10pm, and I didn’t believe her.

I needed to get off the fit ball and change position, and asked if I could get on all fours, although the idea of moving seemed impossible to imagine. The hospital midwife set up a crash mat and a nice beanbag for me to lean on. I leaned forward and within one contraction of moving had started making some amazing noises. Unlike my “ah ah ahs” they were completely involuntary. And then I could feel twin 1 crowning. I did not believe it had happened so quickly, and cried out “what’s happening?” Everyone still makes fun of me for this. She was born in only a couple of pushes at 9.25pm, and our midwife had to tell the hospital midwife to put her gloves on to catch her. Our beautiful daughter, with a lovely round head, pink skin and a great big yell! There is a photo of me still on all fours, with a blissed-out grin. I could not believe how easy and quick it had been. I got to hold her straight away, but contractions started up again quite quickly, and she went to her daddy for some skin to skin time.

At this point the obstetricians arrived – a registrar and resident. I wanted to stay on the floor, but the registrar managed to persuade me up on the bed to check twin 2′s position, as we knew he was breech. Contractions started up again within minutes and were really agonising now, as I had lost my Calmbirth focus and as the position (twin 2′s spine to mine) had that sort of posterior feeling to it. But within seconds I was again feeling the inexorable urge to push. The OB flicked twin 2′s feet out as he was in a squatting position, the midwife and OB flexed twin 2′s head by pushing on my stomach and with a few mighty pushes he was out too, at 9.39pm. Our son! He was handed to me but unlike J, had a bit of trouble breathing, and spent some time in the special care nursery. He was back to us almost before we knew it. I must say he had a very breech-looking head, which looked like a mighty frown, but he’s ever so handsome and cheerful now.

J weighed in at 2.98kg (I was really ticked off she could not stretch to the extra 20gm), and P weighed 3.06kg, excellent weights for 36 weekers, let alone twins!

After twin 2 was out, I lost all patience for the pain – rather a pity as the Synto kept getting ramped up to deliver the placentas and then to deal with my uterus which did not want to shrink back down. I ended up with a Synto drip all night. I tell people this birth was meant to help me deal with my fear of Synto once and for all.

Both babies had beautiful breastfeeds within an hour or two of birth, which sadly was not an omen of things to come for twin 1, but it was lovely.

 

Anyway, that was our birth. Twins born without any pain relief (not even hot water) or really any intervention other than the induction drugs, with 4 hours of contractions total and only about 2 of those active labour. It wasn’t the birth I had wanted but it was a wonderful experience and very healing after my first daughter’s birth. I am so proud of myself, and look back on the birth with amazed gratitude all the time.

Visit my website to explore birthing services.

Is your care fragmented? Does it matter?

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If your computer slows, may have been advised to “defragment the disc,” which puts all parts of a file together in the same place on the drive, enabling it to run faster and more efficiently. In much the same way, your pregnancy, birth and postnatal care needs to be defragmented. For most people, care is extremely fragmented, creating errors, delaying care and increasing frustration.

Even for healthy women, the burden of keeping even two or three different midwives or doctors apprised of what you’re experiencing is typically on you. No one else is doing it. You will find you need to repeat yourself to several people, several times. “Oh, your file is too big. I haven’t had a moment to read it. What are your main concerns?” “Oh yes, there is note here from … hmmm …. I can’t read who wrote it. It says something about … oh, I can’t read that either. Do you know what that might have been about?” Such conversations are not uncommon when you’re dealing with the general hospital system.

You have to be the central communicator. Unfortunately, that role requires a fairly high level of knowledge about pregnancy and birth, and the ability to pry written information from one midwife or obstetrician so you can deliver it to another. You might be thinking this is not your role: you have a midwife or obstetrician so that they can coordinate your care, not you. And you’d be correct.

However, the more complicated your problems, the more fragmented your care will be. The average woman sees at least 30 care providers: midwives and obstetricians – from the first pregnancy visit until discharge from hospital with a baby.

What can you do?

Choose private care wherever possible. This can be a private midwife or a private obstetrician. Private midwifery delivers better continuity than does private obstetrics, because with a private midwife you will have that same person from your very first pregnancy visit until your baby is 6 weeks old, whereas with a private obstetrician, although they will provide all of your pregnancy care, you will have unfamiliar midwives in labour and shifts of midwives when you stay in hospital after your baby is born.

Be the hub of the wheel. Of everyone involved in your health care, you’re the one with the most at stake.

Visit my website to learn more about my services.

I’m meeting with a private midwife. What questions should I ask?

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Some of the suggested questions will be of major importance to you and others will not concern you at all. It is very important to be clear with your midwife about what is important to you and what sort of care you expect.

Contact and availability

What are your back-up plans?
How can I contact you if I need help or advice?
Are you likely to be away when my baby is due?

Experience

How long have you been registered as a midwife?
Where have you worked?

Qualifications

What qualifications do you hold?
Do you hold any professional memberships?

Professional Development

Can you describe the continuing professional development you have participated in over the past year?
Do you engage in peer review?

Safety

What arrangements for professional indemnity insurance do you have?
Do you maintain a register of the births that you have attended?
Do you currently have any cases against you?
Do you audit your practice? Are your stats in line with current safety standards?
Does your practice adhere to current professional guidelines for midwifery practice?

Fees

What costs are incurred in midwifery care? What is included in these costs? Can I claim the cost with my private health fund?
Can I claim your fees through Medicare?

Pregnancy

Where will my antenatal consultations take place?
How long are the antenatal consultations?
How many antenatal consultations am I likely to have?
What will happen if I need to see an obstetrician during my pregnancy or labour?
How can I access tests and ultrasounds?
Do you provide antenatal classes or should I make arrangements to attend private classes?

Birth

What hospital transfer arrangements do you recommend?
How do you monitor the well-being of my baby during labour?
Do you attend water births?
What percent of the time do you find it necessary to cut an episiotomy?
What would happen if I decided that I want an epidural?
What percentage of your clients have a cesarean section?
What sort of resuscitation equipment do you have?
Do you provide support through miscarriage or stillbirth?
Do you encourage your clients to write a birth plan?

Postnatal

What will happen if my baby needs to see a paediatrician?
How many postnatal consultations do you provide?

Visit my website to learn more about my services.

Why do midwives need to charge for their services?

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There are some common questions around fees that I often hear from women who enquire about private midwifery services. In general, the feeling is that private midwifery is very expensive. Some women want to barter, many want a discount or other reduction, some want to re-pay me after their baby bonus comes in (this payment is now made over 6 months after the baby is born) and many simply do not understand why they need to pay at all.

All of this baffles me.

Do we bartner for other goods and services at this stage of evolution? Can I pay my mortgage with eggs from my farm? Or maybe they’ll accept my car as payment? That ought to knock a few thousand off the mortgage, surely. Sadly, no, our society runs on money.

Do we ask for a discount at the dentist? Maybe the dentist can do only my top teeth and I’ll pay half price?

Midwifery is a kind and caring profession that is unlike any other. We go to family’s homes, often meeting their extended family and close friends. We form strong bonds with our clients that often last way beyond the official 6-week discharge. I have recently attended a birthday party for a very special person who came into this world just over a year ago. Her family is very dear to me, as are many of the families I work with. Midwifery is heart and soul. It’s a passion. If I didn’t need money to live, I would do it for free because there’s no other “job” in this world that brings me and the families I partner with, more pleasure and joy and satisfaction.

But …. I do need to live. And if I was employed, my boss could not expect me to work for free.

It saddens me to have a woman enquire about my service and then exclaim how expensive it is and hang up quickly. It saddens me to read posts on forums from people who are only wanting a student midwife or a trainee doula because they do not value their babies, births and themselves enough to engage a private midwife.

When women say, “It’s too expensive”, I hear, “I don’t prioritise and value myself enough to find the money to pay for this essential service”. We find money for cars, holidays, new computers, clothes, handbags …. but when people find that the going rate for private midwifery care is around $5000, they baulk at that amount. An average of $5000 over 42 weeks of care is $119 per week. That’s what the family pays. What does the midwife commit for this payment?

Well, I think there are two main aspects. One is lifestyle and the other is “business”.

Lifestyle first.
Being on call is a part of midwifery. I take calls from clients any day, any time. I’m ready, at their beck and call whenever they need me. For labour, because they’re concerned about something and need me to check things out, because they’re fearful or anxious, or becuase they’ve had their baby and are having difficulty feeding. It’s also about being on call for births – that’s of course a big part of being a private midwife. Babies come when they’re ready but most come between 37 and 42 weeks. What this means for the midwife is that for that entire 5 week period, she is on call for birth. Bit in reality, from the time she accepts a client’s booking, she commits to being available for that woman’s pregnancy, birth and new parenting time. No holidays, nothing planned that can’t be cancelled at short notice. No other employment. Simply being on call. When a midwife is on call, she lives, sleeps and showers with her phone. It’s always on. It’s on at the movies. It’s on at an expensive restaurant (sans alcohol because you can’t drink if you’re on call). It’s on during your best friend’s wedding. It’s on when you’re tired, it’s on at the supermarket. And it does ring. And when it does, the midwife drops what she is doing and attends her birthing client. Always. No weekends off. You must always have your car with you, packed with your birthing kit and oxygen and suction … because you just never know when the phone’s going to go off. And when you go, you don’t know how long you’re going to be gone for. A few hours? A day? 2 or 3 days? Hmmm. Better pack a change of clothes and toiletries.

Now if it was any other “job”, being on call would be a huge issue. But midwifery is a passion and so the 3am phone calls on a wet and cold winter’s morning are answered excitedly. Besides, it’s wonderful to be at births at sunrise. There’s something so special about welcoming a new baby at the start of a new day.

Now the other side to midwifery is … business.

Private midwives run their own businesses. It is our only source of income and we cannot take unlimited numbers of births each month or we’d miss some. That, of course, is not the aim. Therefore I limit my bookings to an average of 2 births per month. Like any business, there are expenses. These aren’t obvious to clients. But they’re there. The car, consulting rooms and insurance are the biggest expenses. It’s not unusual to do 30,000Km per year. Petrol is filled every week, sometimes twice a week. Then there’s midwifery equipment. There’s not a lot there really, and most items aren’t that expensive. Dopplers are probably the most expensive “tool” and they cost anywhere from $350 – over $1000. But there are other costs such oxygen and suction hire and sterilisation of instruments. Then there are other expenses related to holding a professional license. We are required to participate in at least 40 hours of continuing professional development (ongoing education) each year. We have fees associated with professional memberships, journal subscriptions, registration renewal and so on.

There are costs associated with running an office: stationery, printing, computer, fax machine, marketing aids such as brochures and business cards, exhibiting at expos, advertising and so on. Then there’s things like superannuation, annual leave and sick leave. If we don’t work, no money comes in so we need to plan for some time off for a holiday and also for the inevitable cold or flu that might strike once in a while.

Doctors, Energy Australia, Coles etc do not accept requests for discounts or payment 6-12 months after purchase (some shops do, but you can’t generally do this for fruit and veges and bills). If we can’t afford the services, we either need to make a more affordable choice or find the money to pay for the goods or services. We don’t ask the supplier or provider to compromise their position.

If women don’t pay their midwife, their midwife cannot afford to pay her bills or run her practice. Believe me, midwives do not live rich lives. Most do not drive Porsches, live in fancy houses and have expensive holidays. But we do need to live.

I have had clients who truly don’t have money, find the full fee, make payments on time and never question it. They know the value of their choice. I’d like to share with my readers some of the comments I have heard from my clients about fees:
“We received an exemplary standard of care, unavailable through any other service … we received a top quality service which was incredibly good value for money.”
“I believe this service is superior to any other available and really suited our needs”
“The service is very thorough and “on-call” whenever we needed it.”
“It’s not expensive when you look at the hours that go into it”

What are your views on private midwives requesting payment for their services?

Visit my website to learn more about my services.

Collaborative care: one year on. What are women saying?

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It has been over a year now since I starting providing care in collaboration with a private obstetrician, and just over a year since we had our first birth under this unique model of care. What do women have to say about the care that they have received?

I am extremely pleased with the service, which I believe allowed me to achieve my goal of a natural birth.

The collaborative model seemed unique to me. To have a private midwife and our own birth experience but in a hospital with obstetric back-up in case of unexpected complications, allowed us to feel totally comfortable and confident for our first baby.

We found your program very thorough. I felt extremely well prepared in every way.

We feel that if we had been dealing with unknown hospital staff, we would have felt much more anxious.

It would be hard to improve such good care

We were very happy with the continuity of care received by Melissa and Andrew which enabled us to have the birth we wanted. The prenatal care and education is what we valued the most as it enabled us to feel confident and prepared for labour and birth. Having Andrew involved gave us the confidence that if we required obstetric intervention at any stage that it would be available with someone who knew us and our birth plans.

Looking back on the night leaves me feeling elated, confident and proud about how the labour and birth turned out. I don’t believe I would have these positive feelings about the birth if we didn’t have Melissa and Andrew.

Having Melissa as my private midwife was one of the most valuable and most special experiences of my life. There is no way I could have achieved the same level of confidence in myself and the birth process without Melissa’s guidance and experience.

I was respected in my choices and decisions.

Visit my website to learn more about my services.

What is a Medicare-Eligible Midwife?

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In order to claim Medicare benefits from care with your midwife, you will need to ensure that your midwife is Medicare Eligible. A Medicare-Eligible Midwife meets certain advanced requirements:

  • Current general registration as a midwife in Australia with no restrictions on practice;
  • Midwifery experience that constitutes the equivalent of 3 years full time post initial registration as a midwife;
  • Current competence to provide pregnancy, labour, birth and postnatal care to women and babies;
  • Successful completion of an approved professional practice review program for midwives working across the continuum of midwifery care;
  • 40 hours per year of continuing professional development relating to the continuum of midwifery care (20 hours in addition to standard requirements);
  • Formal undertaking to complete an accredited and approved program of study to develop midwives’ knowledge and skills in prescribing within 18 months.

    • Essential Birth Consulting provides a high standard of care to women and babies and a Medicare Eligible private midwifery practice. Clients of Medicare-eligible midwives are able to claim Medicare benefits for midwifery services and are able to have their midwife order and interpret tests, and in the future, prescribe, supply and administer medications.

    Visit my website to learn more about my services.

    I’m pregnant and I have private health insurance. What are my options?

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    Great question! There are a few options available to you as a private patient, as well as all of the options that are available to public patients. Specifically, the private options are either a private midwife, or a private obstetrician.

    Private midwife
    To receive care from a private midwife and obtain Medicare benefits, your midwife will need to work with an obstetrician or a doctor who provides obstetric services. Some private midwives are able to provide labour and birth care in hospital settings, while others are only able to provide labour and birth care at home. All private midwives can provide pregnancy and postnatal care. Hospital options may include private or public hospitals; it’s best to ask your midwife which hospitals she attends births at.

    Private obstetrician
    Private obstetricians can provide pregnancy, birth and postnatal care, although birth care would also be provided by hospital midwives who may be unknown to you until birth. Private obstetricians deliver babies at public and private hospitals.

    Visit my website to explore birthing services.

    What are your practice statistics?

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    It is a question I am often asked, and rightly so. If a woman would like to have a natural birth, she ought to choose a care provider who has a high rate of natural birth.

    My birthing statistics are listed below.

    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 issues
    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): 87%
    Caesarean 6%
    Vacuum 3%
    Forceps 4%
    VBAC 86%
    Episiotomy 3%
    Intact perineum 63%
    6% women use an epidural for labour
    79% women use no medical forms of pain relief in labour
    10% women are induced

    Statistics for first babies:

    Normal birth (no forceps, vacuum or caesarean): 90%
    Caesarean 3%
    Vacuum 4%
    Forceps 3%

    Visit my website to learn more about my services.

    Choosing the right care provider

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    Choosing the right practitioner is a very personal decision and there is no right or wrong choice. Some women will make an initial choice of care provider and decide to change care providers during the pregnancy, while other women will make one choice in their first pregnancy and then a different choice in a subsequent pregnancy. What’s important is understanding all the options available so that you can feel confident to choose the best option for your needs.

    When you are considering a care provider, it’s also necessary to consider where you would like to give birth and to ensure that your care provider can attend you in your chosen setting. You might choose to birth your baby in a public hospital as a public or private patient, in a private hospital as a private patient, in a birth centre or at home. It can be helpful when trying to make a decision to write down a list of questions you may have and also consider what is important to you as you make your choices. For example:

    What do I want from my care?
    What type of practitioner would I feel most comfortable with?
    Do I want public or private care?

    These are questions only you can answer. Other questions are for your care providers, and it’s a good idea to interview a few care providers – midwives and obstetricians – before making a choice. Midwives and obstetricians will charge a fee for interviews and you are able to claim this through Medicare (your midwife will need to be eligible in order for you to claim a Medicare benefit). It is important during the interview that you ask all the questions that are on your mind, and to be aware of how you feel throughout the interview. Your care provider should inspire you with confidence, help you to feel at ease and comfortable, and the appointment should feel unhurried.

    Likewise, your care provider may like to “interview” you, and this is so that your care provider can be sure that s/he can meet your needs. Maternity care is provided in a partnership and so it’s important that both parties feel really comfortable with the other.

    There are many questions you might wish to ask your care provider; the best suggestion is to consider what is important to you and write a list of questions.

    Visit my website to learn more about my services.

    I’m pregnant. Who should I go to for care? A Midwife, an Obstetrician, or both?

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    Private Midwife:

  • Provides autonomous pregnancy, birth and postnatal care for women who are experiencing normal, healthy pregnancies
  • Provides care in consultation with an obstetrician when a woman’s pregnancy has risk factors (eg high blood pressure, prem labour, concern for baby’s growth, gestational diabetes etc)
  • Supports women to birth normally with a high rate of natural birth, even when there are complications
  • Supports and educates women with breastfeeding and baby care up until 6 weeks after your new baby arrives
  • Provides pregnancy, birth and postnatal care
  • Pregnancy appointments allow time for questions, education and discussion with appointments typically 60 minutes in duration
  • Women are highly likely to report satisfaction with their care and experience

    • Private Obstetrician:

  • Provides autonomous care for women regardless of risk factors
  • Receives referrals from midwives for women with risk-associated pregnancies or births
  • Always provides labour and birth care (including caesarean) in collaboration with a midwife
  • Obstetric care on average results in a high degree of intervention such as induction, epidural, caesarean and episiotomy
  • Provides brief in-hospital consultations after the baby is born, followed by a 6-week check
  • Pregnancy appointments are generally no more than 15 minutes in duration

    • Collaborative care: private midwife and private obstetrician

  • Receive autonomous pregnancy, birth and postnatal care from one midwife and one obstetrician regardless of risk factors
  • No transfer of care if risk factors emerge
  • Supports women to birth normally with a high rate of natural birth
  • Supports women to breastfeed
  • Provides pregnancy, birth and postnatal care
  • Pregnancy appointments allow time for questions, education and discussion with appointments typically 60 minutes in duration
  • Women are highly likely to report satisfaction with their care and experience
  • Provides autonomous care for women regardless of risk factors
  • Supports women to birth naturally, including with twins, a breech baby or a VBAC

    • Visit my website to learn more about my services.

    Communicating with your Midwife

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    We’d all agree that good communication is essential for an effective relationship with anyone, but especially for your relationship with your midwife.

    A good relationship with your midwife – one that is founded upon good communication – can lead to better care and a more satisfying experience of that care.

    Your relationship with your midwife is an important one that can last for many years if you birth several babies with the same midwife, as many women chyoose to do. It is a partnership with an emphasis on shared responsibility and active participation in care. You and your midwife work together with the shared goal of a healthy and satisfying experience for you and for your baby.

    Good communication means that you and your midwife work as a team.

    Good communication includes:

    listening to your midwife
    feeling listened to and understood
    mutual respect
    being honest
    asking questions
    following through on agreed plans

    Be honest with your midwife

    Your midwife cannot do her job if you aren’t forthcoming about the things that are concering you. Share your concerns, details of any new symptoms, how you are feeling and what has been happeing for you since your last visit to your midwife. If you have been unable to follow through on agreed plans, let your midwife know, as she would for you.

    If there is something that is scaring you, let your midwife know. She can reassure you and help you to feel more comfortable with what is happening.

    Write it down

    It’s a great idea to write down all the questions that you have before your appointment, so that you can be confident that nothing important will be missed. Between appointmnets, many questions will come to you, so write them down as they come to you and your midwife will welcome the opportunity to address them with you in your appointment.

    Likewise, it’s also a good tip to take some notes as your midwife speaks so that you can refer to this new information between appointments. An hour-long appointment can include lots of information, and it’s only natural that some things will not be remembered. Writing things down can help you to recall what was said.

    Ask questions

    Full understanding of what your midwife tells you is key to good communication, and it is your job to ensure that you have fully understood what your midwife has said to you, just as your midwife needs to be sure that she has fully understood you. So do ask questions if you are confused or unsure.

    It’s not “that important” and I don’t want to bother my midwife

    Some people are embarrassed, worried about bothering their midwife with questions or concerns, or feel that their concerns aren’t important enough to raise with their midwife. This is understandable, but try to keep in mind that this is what your midwife is there for: to ensure that all of your care needs are met. If you can’t let your midwife know something, she can’t be in a position to help you. Remember that you have engaged the care of your midwife so that you can feel confident, well cared for and safe.

    You need to feel listened to

    Do you feel that your midwife listens to you? This is a very important aspect of the quality of communication with your midwife. When you speak to your midwife, you should have her undivided attention and she should check with you that she has understood you correctly.

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    Pregnancy Testing

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    Many women will want to find out as soon as possible if they are pregnant, and so it’s a relief to know that you don’t need to see your midwife to find out if you are pregnant. Home pregnancy tests are very reliable – about 98% reliable, and can be done from as early as the time that your period is due. Other, newer test kits can actually be done before your preiod is due. Home pregnancy tests are urine tests that give you a positive or negative result. Your midwife can also perform this test, or s/he can send you for a blood test to confirm your pregnancy. You can obtain a home pregnact test kit from your local chemist or supermarket and test yourself in the privacy of your home.

    If you test fairly early – at or before the time that your preiod is due, it might be helpful to repeat the test in a few days if the first test is neative (not pregnant) and your period doesn’t start. Alternatively, you can make an appointment with a private midwife for testing.

    Another, very accurate method is a blood test, and many mdiwives will do a blood test to confirm a pregnancy. The blood test checks for hCG in your blood. This is a hormone that rises during the first few weeks of pregnancy.

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    Vitamin K

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    When I see my clients during pregnancy, one of the topics we always discuss is that of Vitamin K for the baby. I provide the standard pamphlet on Vitamin K, along with books and encourage my clients to read widely about Vitamin K, and then we talk through what they have learned and clear up any questions.

    Several years ago, there was concern that the Vitamin K injection might cause leukaemia. Consequently, some families opted not to give their babies Vitamin K at birth, and the rates of Vitamin K Deficiency Bleeding increased. Something needed to be done!

    Babies are naturally born with low levels of Vitamin K, and this is totally normal. However, it does predispose babies to a rare form of bleeding called Vitamin K Deficiency Bleeding, since Vitamin K is one of many elements that is needed for successful blood clotting. Without adequate levels of Vitamin K, babies may haemorrhage – this may be internal or external. The risk is not very high: about one in every ten thousand babies born. Or to put it another way, 100 babies out of every million that are born. Vitamin K drops at birth, day 4 and week four will reduce the risk of Vitamin K Deficiency Bleeding to 23 per million, while an injection will reduce it even further to one in a million. It sounds like a no-brainer to give all babies some form of Vitamin K at birth, whether drops or an injection.

    Not everyone agrees. One of the common arguments is that if all babies have low levels of Vitamin K, this is normal for them and who are we to go administering a medication / Vitamin to alter their natural state? This might be a valid argument, as we probably are improving on nature when we give babies Vitamin K. But let’s think about other areas of life. Do we withhold antibiotics if we are sick? Do we withhold Insulin from a person with diabetes? And do we withhold a wheelchair from an elderly person who cannot walk? In each of these cases, we are improving on nature. Is Vitamin K any different?

    The other arguments I often hear are mentioned here:
    1. Synthetic vitamins (including synthetic Vitamin K) should be avoided because synthetic vitamin A supposedly causes the type of birth defects that natural vitamin A prevents. This argument is far from logical. Should all medications be avoided because some are unsafe?

    2. The administration of Vitamin K is linked to childhood cancers and leukaemia: this used to be the case; the formulation was changed and there have been no reports of childhood cancers and leukaemia following the changed formulation.

    3. Emotive words such as “disturbing” and “more disturbing” are used to generate anxiety in the reader, while offering no solid evidence to back this “disturbance”. Vitamin K is fat soluble; this is true. The article suggests that little to no vitamin K shows up in urine or bile, but it does not let the reader know at what stage the urine and bile were tested for the presence of Vitamin K. Vitamin K, being fat soluble, will take some time to become evident in urine or bile. The authors imply that as Vitamin K is not showing up in urine or bile, it must therefore be accumulating in body tissues, causing untold harms. Of course. Never mind that this has never been proven, despite almost every baby receiving Vitamin K at birth. Readers should be “disturbed” by this mere suggestion, without proof. This is disturbing, indeed.

    4. The author cites the manufacturer’s insert which contains a warning about severe reactions following intravenous injection of Vitamin K. The average reader might be frightened to learn this, yet the author does not let readers know that Vitamin K is not given to babies intravenously: it is given into the muscle or by drops into the mouth.

    5. “If that isn’t enough to scare you, Midwifery Digest … September 1992 estimated that the chance of your child developing leukemia from the vitamin K shot is about one in 500! This means that the risk of developing leukemia from the vitamin K shot is much higher than the risk of bleeding on the brain which the vitamin K shot is supposed to prevent!” That would be very scary indeed, if only it were true. No academic article could cite 1992 research in a contemporary article, unless the article was about historical data. Since the formulation of Vitamin K was changed, there have been no reported cases of leukaemia, if the link ever existed.

    The authors go on to say, “Does any of this make any sense to you? It makes absolutely no sense to me. How could anyone say that this shot is safe and effective for newborns?”
    Quite easily: Vitamin K does reduce the chance of a baby developing Vitamin K Deficiency Bleeding from 100 / 1,000,000 down to 1 / 1,000,000. That certainly makes sense to the 99 / 1,000,000 families and babies who benefit from the injection.

    Next, the author recommends that pregnant women “eat lots of leafy greens in the weeks before your due date to make sure your blood is high in vitamin K”, and assumes that said Vitamin K *will* transfer to the baby. Two flaws in this argument. One: there is no quantifiable amount of leafy greens that need to be consumed to raise the mother’s Vitamin K levels to a high level, and no quantifiable level that the mother would need to raise her levels to – and maintain – in order to meet her baby’s needs. And two: we have no evidence that maternal Vitamin K transfers through breastmilk to the baby, and if it does, how much the baby would actually receive.

    The discussion on Vitamin K is always interesting, and people will “do their research”, which I always encourage. I only wish that the material out there on the WWW was accurate and balanced so that people could rely on the information.

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    Women hire own midwives after trauma of NHS births: what can we learn from this?

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    A UK article entitled, “Women hire own midwives after trauma of NHS births” suggests that London mothers are resorting to private midwives because they fear giving birth on the NHS. The NHS is the UK’s public health system. Unlike Australia, most of the health care in the UK is public, on the NHS. In Australia, about 30% women have a private obstetrician or a private midwife for their birth.

    According to the article, “Women are scared of not having enough time with a midwife in hospital …” “Women realise it’s not what they want and you don’t see the same midwife twice.”

    A Mother has said, “It was an [NHS] midwife I’d never seen before who wasn’t overly welcoming. It was all very painful, very rushed and not an experience I ever wanted to repeat. It was the best decision I ever made [going private].”

    “I’d definitely go down the independent route if I did it again. The NHS treated you as a number rather than as a person.”

    Is this the same as the Australian situation? I wonder. Very few women will birth with a private midwife and then turn to the public system, but many women will do the reverse: go public for baby #1 and turn to the private system – obstetric or mdiwifery – for their next baby.

    And what are these women saying about their decision?

    I am extremely pleased with the service, which I believe allowed me to achieve my goal of a natural birth. I have many girlfriends who also shared this goal at their first birth but without the support I had, they did not achieve it.

    I felt like lots of attention was given to my individual case.

    Looking back on the night leaves me feeling elated, confident and proud about how the labour and birth turned out.

    I felt validated and supported, never rushed.

    I appreciated knowing the responsibility was on me to make decisions regarding my pregnancy and birth, rather than having those decisions made for me. I never felt pressured to choose any particular options, and was supported in whatever I decided. All my concerns were taken into account, and the things that were of most concern to me were discussed at length, hence I felt a lot more prepared for the birth experience.

    I really appreciated having someone listen to what I want and support me through this process. It was by far my best birth!

    So – when you’re making your decision on where to birth your baby and with whom, consider your options thoroughly. Talk to other women who have had private obstetricians, public hospital care and also private mdiwifery care, and make the best decision for you and your baby.

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    Are modern births lasting two hours longer than in 1960s?

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    An article (http://www.sunjournal.com/news/maine/2012/04/03/moms-today-spend-two-more-hours-giving-birth-1960s/1176573) suggests that modern births last two hours longer than in 1960s. How can this be so? The process of birth hasn’t changed since the 1960s.

    This is really a conseqnce of the way we care for women in labour today, as opposed to the 1960s. What has changed? I think the main difference is the rate of epidurals, which were seldom used in the 1960s but are now a common element of modern-day childbirth.

    Epidurals are known to prolong labour, and often a woman who has received an epidural will also need to have her waters broken and a drip to speed the labour once the epidural thas taken effect.

    Another aspect is the increase in inductions: it is well-known that when women start their labour on thei own, the labour tends to be faster and less painful than when midwives and obstetricians use medication to start the labour.

    So the take-home message? Plan an active, drug-free birth, well-supported by your partner and midwife and you can expect an easier birth.

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    How will my labour start? Common myths.

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    There are some common misconceptions about how labour starts, and in particular, how you will know.

    The first is that babies arrive on their “due date”. The due date that you are given is not an actual predicted date that your baby will arrive: rather, it is an estimate of when your baby may arrive. Normal, term pregnancy lasts from 37 weeks until 42 weeks. This is a 5-week period. Other countries give women a “due period”: that is, a period of time in which the baby may arrive. Only about 3-4% of babies are born on their due date. In my private practice, I find that most babies arrive in the 38th, 39th or 40th week.

    Having a show
    Some women believe that once they have had a show, their baby will arrivw. There is some truth in this, as all babes will arrive eventually. However, a woman can have a show a couple of weeks before the baby comes. Having a show does not mean you are in labour, although a show can happen when you are in labour, particularly as your cervix approaches full dilation.

    Breaking your waters does not mean you are in labour or that your baby will be born imminently

    For some women, their waters break some time (many hours or even days) before the baby arrives, and even before labour starts. For most women, however, the waters break right at the end of the first stage of labour, as your cervis is almost fully dilated. Waters breaking is not related at all to labour starting; they are two separate processes that often occue together, but waters breaking is not a labour sign.

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    Back Pain in Pregnancy

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    Many women experience back pain at some point in their pregnancy: sometimes at the start, sometimes at the end … and for a few women, the back pain is there throughout their pregnancy.

    There are a number of things that can cause this pain, such as the pregnancy hormones that soften and relax the joints and ligaments, including those in the lower back and pelvis. The purpose of this is to make the pelvis more flexible to allow the baby to be born naturally. This is a common cause of back pain towards the end of pregnancy.

    Postural problems can be pre-existing, or can be caused by the growing uterus and baby. If a woman has a history of back pain, this can often mean that she will have problems throughout pregnancy. Chiropractic can help.

    Sometimes, towards the end of the pregnancy, the position of the baby can mean that certain nerves (such as the sciatic nerve) are compressed and this can cause various forms of pain such as shooting pain or a dull ache.

    There are a number of positive steps you can take to reduce or even eliminate back pain in pregnancy, and the one I have found to be most effecive is chiroptactic care. For short-term relief, Panadol and a hotpack may be helpful.

    Exercise is also very helpful as a longer-term measure. I recommend to my patients that they do a minimum of 30 minutes of exercise every day, or most days of the week.

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