Probe into mass Caesarean birth

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Inquiries were ordered … into allegations that gynaecologists … had conducted several Caesarean operations without waiting for the actual delivery date, so that the doctors could proceed on leave.

… patients [alleged] that 21 Caesarean operations were conducted in a span of two days, on Wednesday and Thursday, so that four gynaecologists could proceed on leave from Friday to Sunday.

… The Director of Health Services … has initiated a probe into the issue …

Link Found Between Mental Health Problems And A Fear Of Childbirth

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Women with a fear of childbirth have an increased risk of mental health problems than non-fearful women …

… 6-10% of all pregnant women suffer from a severe fear of childbirth … women with a fear of childbirth had significantly more mental health problems than non-fearful women. From the group of women with a fear of childbirth, 54% had received psychiatric care … compared to 33.6% of the control group.

… women with a fear of childbirth delivered significantly more often by elective caesarean section (35.6% vs. 8.4%). Furthermore, women with a fear of childbirth attempting a vaginal delivery were more likely to have an emergency caesarean section and use medical pain relief.

… All the women with a fear of childbirth were sent for consultation and received psychological support for their fear by trained midwives, psychologists and obstetricians.

The study excluded cases in which a potential serious perinatal complication could have influenced the maternal psychological wellbeing during pregnancy or after delivery, for example, giving birth to twins, preterm birth, perinatal deaths or women with placenta praevia.

… “Overall, the study found a surprising number of women of childbearing age who had mental health problems …

“Specific clinical guidelines on how to treat women fearing childbirth or demanding a caesarean section should be developed. Often the only sign of the fear of childbirth is the constant request for a caesarean section.” …

C-section puts children at food risk

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Caesareans are the safest they have ever been, and for some women and some babies, they are life-saving and very necessary. However, we do have a current caesarean rate of over 30% and this is deemed to be too high; ie, the rate cannot be justified by medical need and at this level, may cause more harm than good. If a caesarean is genuinely necessary, the risks reported below of food allergies would be well justified by the benefit of having the caesarean.

GIVING birth by caesarean section increases the risk of your child suffering from food allergies …

Pediatric allergy specialist Dr Peter Smith is urging expectant mothers to consider a vaginal delivery because of growing evidence a c-section can “significantly increase the risk of your child suffering from an allergy to cow’s milk”.

Admissions to hospital emergency departments for allergic reactions have increased by 500 per cent since 1990 in Australia.

… the massive rise in food allergies [is] likely to be attributed to several causes rather than one.

But symptomatic food allergy was found to occur more frequently in children born by c-section.

“… studies have shown a difference in the composition of the gastrointestinal flora of children with food allergies compared to those without,”

“When a child moves through the birth canal, they ingest bacteria and become naturally inoculated through a small mouthful of secretions.

“The oral ingestion of those healthy bugs is the first bacteria that comes into their system.”

Dr Smith said that first bacteria entering the body established “the population”.

Not only does Australia have one of the highest prevalence of allergic disorders in the developed world, but recent studies have demonstrated a doubling in some conditions such as allergic rhinitis (hay fever), eczema and potentially dangerous anaphylaxis.

… the next best thing to a “natural” birth was to follow birth with breast feeding.

“Breast milk contains lots of healthy bugs … to promote the growth of healthy bacteria and assist your child’s immune system in the first few week’s of life,” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Considering Evolution And C-Sections

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This being the occasion of Charles Darwin’s 202nd birthday, it seems as good a time as any to consider the evolutionary role of cesarean sections.

… the increasing numbers of C-sections have played a part in natural selection, particularly in mothers’ pelvic size and babies’ birth weight.

Not only does it account in part for babies’ higher birth weight … but it possibly could lead to larger brains and higher IQ …

… the first cesarean sections … were performed around 150 years ago …

Over time, medical advances made the operations safer and more common. In the developed world, mortality rates during childbirth have decreased dramatically because of C-sections …

The C-section liberated humans from the natural selection against mothers with smaller pelvises carrying larger fetuses. Because both mothers and their children survive delivery, they pass down their traits to next generations. As a result, birth weight has increased … birth weights between 1960 and 1997 have increased 1 to 2 percent.

… “The maternal pelvis can get smaller over time and fetal birth weight can get greater over time, because there is now nothing to limit these changes,” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Delivery Even a Bit Early May Mean Developmental Delays

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Bucking the notion that being born a few weeks early has no discernible impact on babies, a new study indicates that “late preterm” infants face more developmental delays than their full-term peers and those delays may affect their school performance.

… late preterm babies were 52 percent more likely than term infants to suffer severe delays and 43 percent more likely to experience milder limitations. In motor skills, the preterm toddlers faced 56 percent increased odds of severe delays and a 58 percent increased risk of milder ones.

… 5 percent to 40 percent of U.S. births are now early elective deliveries, meaning that births are induced preterm without a valid medical reason …

Noting that many of these at-risk infants receive little or no specialized developmental follow-up, Woythaler’s data included babies with at least 34 weeks’ gestation from wide economic and racial backgrounds who received complete assessments near the age of 2.

The brain of a baby at 34 weeks’ gestation weighs 35 percent less than it would at term …

Social factors and gender had the greatest impact on the children’s mental scores … with language spoken at home playing a key role … In contrast, gestational age was the most important contributor to physical delays.

… Researchers have found such infants are at higher risk for respiratory problems, worse academic performance and school suspension down the road.

“There’s a reason why normal gestation is 40 weeks,” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

After the first caesarean, a second one is much more likely

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TRACY HART had intended to have her first child … naturally. But when Ariane failed to move into the normal birth position, Mrs Hart was told that a caesarean was the safest option.

Second time around, Mrs Hart, 35, was eager to try again for a natural birth, but at 41 weeks and two days into her pregnancy, she still had not gone into labour. A caesarean was ordered – because doctors thought an induction might have been too hard on her scarred uterus – and four days ago son, Saxon was born …

… Mrs Hart said, ”I was mortified and cried, because I had mentally prepared myself for a natural birth. A lot of women who don’t have any problems giving birth don’t realise some women just don’t have a choice.”

Unfortunately Mrs Hart didn’t know that all women have a choice about how their baby enters the world. Some choices are safer than others; some are safer for the mother while others are safer for the baby; but whatever way you look at it, all women have a choice.

First-time mothers with no obvious health problems, and subsequent births like Mrs Hart’s where the first was by caesarean, are overwhelmingly the biggest contributors to the NSW epidemic of caesarean births, state data shows for the first time.

Twins, and babies in the breech or other difficult positions in the uterus, account for a much smaller proportion of the one in three babies now born by caesarean section …

During that time, the overall caesarean rate increased from 19 to 30 per cent of all births. But subsequent caesareans increased much faster, at an average 5.3 per cent a year during the study period.

Among first-time mothers, caesareans grew fastest – on average 6.8 per cent a year – among those who did not go into labour or whose labour was induced, suggesting a big rise in planned procedures. Among first births where the woman went into labour and later delivered surgically, the increase was only 3.5 per cent a year.

… the new data provided the first comprehensive state-wide picture of factors behind the surge in caesareans, which NSW Health has pledged to bring back to 20 per cent of all births by 2050. It suggested that concentrating on promoting normal birth among first-time mothers would have the biggest impact on reducing the overall rate …

I have always known that promoting normal birth – via private midwifery care – to all first time Mums, all women who have had a previous caesarean, and all women who have had a previously traumatic birth – would dramatically lower the cesarean rate.

The research … showed it was highly unlikely the increase in caesareans could be legitimately attributed to complications such as the older age and the increase in overweight mothers … because most of the rise had occurred in women with apparently few medical risks …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Induced labor may double the odds of C-section

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First-time mothers who have their labor induced may face a greater risk of needing a cesarean section than those who go into labor naturally …

… those who had their labor induced were twice as likely to ultimately need a C-section.

… 44 percent had their labor induced — and the researchers estimate that failed induction accounted for 20 percent of the C-sections performed.

The findings … firm up the link seen in past studies between labor induction and an increased risk of C-section. By definition, labor induction is performed before a woman’s body is ready for spontaneous labor, and in some cases there will be problems with labor progression that necessitate a C-section.

The connection is important because while cesarean section is a generally safe procedure, it requires a longer recovery time than vaginal birth, and does present certain risks, such as blood clots, infection at the incision site or in the lining of the uterus, and breathing problems in the baby.

Moreover, the rates of both labor induction and C-section have been on an upward trend in the U.S. since the 1990s. Labor inductions have risen from just under 10 percent of births in 1990 to 22 percent in 2006; and in 2007, C-sections were done in almost one-third of all births.

… There are circumstances in which labor induction may be advisable. There is good evidence, for example, that inducing labor benefits mom and baby when pregnancy goes beyond 41 weeks …

… when a mother has pregnancy-related high blood pressure or diabetes, or when the mother’s “water breaks” but labor does not spontaneously begin.

I’d like to add that none of these are absolute reasons for inducing labour. High blood pressure that is stable and has no other complicating factors, does not necessarily require an induction. The research supports induction sometime after 41 weeks and before 42 weeks, not not strictly at 41 weeks. Furthermore, ruptured membranes does not necessarily require induction although the risk of infection does increase the longer the waters are broken.

In general, elective labor induction refers to those done with no clear medical reason. It may be done for convenience, for example, or in cases where late pregnancy is causing significant physical discomfort or when a woman wants to ensure that her own doctor delivers the baby.

Of the labor inductions performed in this study, 40 percent were elective …

… the bottom line for pregnant women is that they should understand the reasons for and potential risks of all forms of delivery. “It’s really important to have a frank discussion with your doctor about all of your options for delivery,” she said.

And, it would seem it is also important for care providers to understand the reasons and potential risks of induction. Many articles blame women for the outcome, however in reality women often do what their trusted care provider suggests.

… women contemplating an elective labor induction should be aware of the relatively higher risk of C-section.

Shouldn’t all women be aware of the higher risk of c/s with a planned induction? This would help them to determine whether they wish to proceed down the induction route, or explore other alternatives such as expectant management and monitoring.

In an interview, she also pointed out that when first-time moms have a C- section, they often have repeat cesareans with any future pregnancies. So limiting the need for C-section in first-time pregnancies is particularly important.

… the rate of labor induction in this study — at 44 percent — was striking.

Even among the 4,600 women in the study considered “low risk” for needing a labor induction — because they were not post-term, were free of diabetes, high blood pressure and obesity, and the fetus was not overly large — 29 percent had their labor induced …

Among these low-risk women, one-quarter of those who had a labor induction ended up needing a C-section, versus 14 percent of those who had a natural labor.

… the current findings … underscore a widespread need … to try to cut rates of “inappropriate” labor induction. “Labor induction performed for no medical reason is an area for us to target,” …

… according to ACOG guidelines, elective inductions and elective C-sections should not be scheduled before the 39th week of pregnancy, in order to reduce the odds of complications associated with relatively earlier birth.

However … this guideline is “not followed rigorously.”

A study published last month, for example, found that as the U.S. national rate of labor induction rose between 1992 and 2003, so did the proportion of births occurring at the earlier end of full-term …

In 2003, the study found 30 percent of all full-term singleton births occurred during the 37th or 38th week, versus 19 percent in 1992. The researchers concluded that labor inductions performed before the 39th week were a “likely cause” of that trend.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Health chiefs encourage more home births over caesareans

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HEALTH chiefs are aiming to slash the number of mothers giving birth by caesarean section and encourage more home births in Poole and Bournemouth.

The area has the highest rates of births by caesarean section in the south west, including the worst emergency rates – two per cent higher than the next primary care trust.

In Bournemouth and Poole, 11 per cent of mothers choose to have their babies by C-section, compared to eight per cent in the three best performing primary care trusts in the region, and seven per cent in Southampton.

NHS Bournemouth and Poole is working with maternity services to try and normalise the local pattern of births.

A spokeswoman explained: “We are concerned with the increase in planned and unplanned caesarean section rates because these procedures can present more risk to mother and baby.

“Women who have had a normal birth can return home more quickly to their family and their recovery is quicker.

“With appropriate care and support the majority of healthy women can give birth with a minimum of medical procedures and most women prefer to avoid interventions, provided their baby is safe and they feel supported.”

A spokeswoman for Poole Hospital’s maternity unit, the centre for high risk births in East Dorset, said: “The majority of caesarean sections are undertaken only where there is a clear clinical reason to do so – for example, if babies become distressed during labour, or for the safe delivery of breech babies or twins.

“However, we are working closely with NHS Bournemouth and Poole to reduce the number we carry out.”

The trust plans to recruit more midwives and use experienced obstetricians to increase the number of breech babies born normally.

Extra ante-natal clinics will be introduced to help women have a normal birth after previously having a caesarean, and the hospital will stop providing caesarean sections by choice instead of medical need.”

The hospital already has birthing pools and has just launched an on-call service to support women who choose home births.

Melissa Maimann, Essential Birth Consulting 0400 418 448

As early elective births increase, so do health risks for mother and baby

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A dramatic increase in the number of U.S. women and physicians choosing an early childbirth comes with new health risks for mothers and newborns …

The average time a fetus spends in the womb has fallen seven days in the United States since 1992 …

Researchers see an “evolutionarily dramatic event” in the trend, and perinatal health experts see dangers. Shortening gestation could affect lung development and some fine-tuning of brain functions …

… Babies born too early often sleep longer than normal and have trouble learning how to breast-feed, causing dehydration and jaundice

“For every day and every week before 39 weeks, it’s an increasing risk to the baby,” …

… women are significantly more likely to experience C-sections at for-profit hospitals across the state. … the number of women in the state who die each year from causes directly related to childbirth had more than doubled since 1996.

The rise in deaths during childbirth indicates that obstetric health has deteriorated in many important ways …

… A normal pregnancy lasts 40 weeks, although researchers believe it probably is safe to induce delivery at a full 39 weeks. Women often naturally give birth earlier than this, and in some cases medical problems call for an early delivery. The problem comes when babies are forced out of the womb.

Of all births from 1990 to 2006, the number of babies born at 36 weeks increased by about 30 percent, and babies born at 37 and 38 weeks rose more than 40 percent, according to national statistics. There was a corresponding drop in the number of babies born in later weeks. Now, more babies are born at 39 weeks than at full term.

The data examined is considered fresh by academic standards and covers such a long period of time — 16 years — that experts say the trend is unmistakable

… Some early births are scheduled for the convenience of the mother or doctor …

… One mother, Michelle Van Norman, gave birth to her second child … 11 days early in 2006, with no need for urgency … Van Norman, a 31-year old mom living in Las Vegas, said her doctor didn’t seem worried about the date.

“There were no medical reasons for the delivery being early,” Van Norman said. “He told me the week he could do it and asked me to choose which day was best for us.”

None of those days was best for the baby. After his birth by C-section, one of Christian’s lungs collapsed. He spent three weeks in intensive care and 10 days on a ventilator with six tubes going into his chest.

“The whole experience was horrific,” Van Norman said. “It didn’t end with the birth, it continued for the first year of his life, and we still don’t know if the oxygen deprivation has had any affect on him.” When Van Norman’s surgeon cut the cord, Christian seemed robust. The doctor declined to comment about the case.

“The doctor came in the day after and asked where the baby was,” Van Norman said. “When I told him, he asked me if I was joking. “… I swore from that day on I would never put another baby through that kind of torture for any reason.”

In California, the state Department of Public Health, March of Dimes and California Maternal Quality Care Collaborative have released what its authors call “the Toolkit.” The authors note that deliveries at 37 and 38 weeks account for about 17.5 percent of total births in the United States

Babies born early through induction or C-section without a medical reason are nearly twice as likely to spend time in the neonatal intensive care unit … They also are more likely to contract infections and need breathing machines …

“We are finding out that the last weeks of pregnancy really do count” …

“At 35 weeks, the brain is only two-thirds of what it will weigh at 40 weeks.” Many organizations are responding with programs designed to eliminate early elective deliveries …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Childbirth deaths from spinal anesthesia rising

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The number of U.S. women who die from anesthesia complications during childbirth has fallen sharply in recent decades. But deaths specifically related to so-called regional anesthesia, which includes epidurals and spinal blocks, have crept upward since the mid-1990s …

… such deaths remain rare. But … the results point to an area where anesthesia can be made safer for women.

… Regional anesthesia is considered quite safe. But in rare cases, patients can have a severe allergic reaction to the anesthetic, or the drug can cause breathing or heart problems.

… researchers found that between 1979 and 2002, childbirth deaths related to any anesthesia complication dropped by 59 percent among U.S. women.

There were three such deaths for every million live births between 1979 and 1990, compared with just over one death per million births between 1991 and 2002 …

However, while deaths related to general anesthesia kept falling in the 1990s, those related to regional anesthesia rose slightly, from 2.5 deaths for every million C-sections between 1991 and 1996 to 3.8 per million between 1997 and 2002.

“I think the main thing is to get good prenatal care, and keep any medical conditions you have under control during pregnancy,” …

What about helping women to prepare and plan for a drug-free birth? This seems like the most logical step. In Australia, almost 50% women have an epidural in labour. If this figure was around 5% (for labour, not caesareans), this would make an enormous difference.

… Most of the women who died – 48 of the 56 — had undergone a C-section. In the rest of the cases, the type of delivery was not reported.

Deaths related to general anesthesia during C-section declined markedly over the decade. From 1991 to 1996, there were 17 such deaths per one million C-sections; that rate fell to 6.5 per million for the years 1997 to 2002.

In contrast, deaths related to regional anesthesia during C-section inched up.

The reasons for the increase are not known … the overall drop in anesthesia-related deaths since the 1970s is likely related to factors like safer drugs, better monitoring of women’s heart rates, blood pressure and oxygen while under anesthesia, and an improved understanding of how individuals can react to anesthesia.

But … the medical profession may have become too narrowly focused on preventing deaths related to general anesthesia, which typically is more risky.

Research in the 1970s and 80s … showed that pregnant women were 17 times more likely to die from general anesthesia than regional. And people reacted to that.

“A good part of our energy was tunnel-visioned toward general anesthesia,” … “Maybe we’ve let the pendulum swing a bit in the other direction.”

It is hard to study the potential reasons for the increase in deaths linked to regional anesthesia, precisely because they are so rare …

Melissa Maimann, Essential Birth Consulting 0400 418 44

Role of mom’s choice in C-section rise questioned

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Cesarean-section rates have been rising steadily in the developed world over the past 30 years, but a new analysis of data on nearly 20,000 women from around the globe suggests it’s not because women are asking for them.

Sixteen percent of women included in the research review said they would prefer cesarean section to vaginal delivery ..

This is the first meta-analysis that’s looked at women’s preferences …

A rise in the rate of cesarean deliveries … is frequently attributed to women’s requests for the procedure …

The researchers found, however, that considerably fewer women said they would prefer to have a C-section.

Overall, 15.6 percent of women included in the analysis said they would prefer C-section to vaginal delivery …

Among women who’d had a C-section in the past, 29 percent said they would prefer to have their next delivery via C-section, compared to 10 percent of women who hadn’t had a previous C-section delivery. Women who’d had several children were also more likely than those pregnant for the first time to prefer C-sections (17.5 percent versus 10 percent).

Given that the study looked at women’s preferences, rather than whether they actually asked for a C-section when the time came, the actual rates of cesarean deliveries resulting from maternal requests cannot be inferred from the data …

Nevertheless, they add, “although cesarean section on demand has been suggested as a relevant factor for the increasing cesarean section rates, it seems unlikely that this explains the high cesarean section rates in some countries and regions.” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Caesarean rate continues to rise

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The number of women undergoing a Caesarean section in Ireland is continuing to rise, while the number of those opting for home births is on the decline …

… 26.7% of total live births were delivered by Caesarean section. In 1990, this figure was 20.4%.

There were 158 home births attended by independent domiciliary midwives in 2008, compared to 186 in 2007.

… Meanwhile, the perinatal mortality(death) rate was 6.8 per 1,000 live births and stillbirths in 2008. This figure has fallen by 17.1% since 1999, when it was 8.2 per 1,000.

The perinatal mortality rate was highest for babies born to mothers aged 40 to 44 (11.3 per 1,000). The lowest perinatal mortality rate was for babies born to mothers aged 35-39 (5.8 per 1,000) …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Obstetrical anesthesia: new data on the risks

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Virtually all Los Angeles hospitals offer epidural anesthesia to patients in labor. It allows a remarkable degree of comfort from labor pains …; unfortunately, it is not without risk. In many cases, anesthesia is optional; however, it is a necessity for a cesarean delivery. A new study … reviewed 12 years of obstetrical anesthesia-related deaths … The authors reported 86 deaths that were associated with complications of anesthesia; these deaths represented 1.6% of total pregnancy-related deaths. Pregnancy-related mortality ratios for deaths related to anesthesia was 1.2 per million live births for 1991–2002, which was a decrease of 59% from 1979–1990. Deaths mostly occurred among younger women; however, the percentage of deaths among women aged 35–39 years of age increased significantly. The delivery method could not be determined in 14% of the cases; however, the remaining 86% were in women undergoing a cesarean delivery. Case-fatality rates for general anesthesia were 16.8 per million in 1991–1996 and 6.5 per million in 1997–2002; for regional (epidural or spinal) anesthesia, they were 2.5 per million in 1991–1996 and 3.8 per million in 1997–2002.

Overall, the leading causes of anesthesia-related pregnancy deaths for 1991–2002 were: intubation, … failure or induction (starting general anesthesia) problems (23%); respiratory failure (20%), and high spinal or epidural block (16%) … The causes varied by the type of obstetric anesthesia administered. About two-thirds of deaths associated with general anesthesia were caused by intubation failure or induction problems; however, for women whose deaths were associated with regional anesthesia during cesarean delivery, (26%) were caused by high spinal or epidural block, followed by respiratory failure (19%), and drug reaction.

The authors concluded:

* Anesthetic-related maternal mortality decreased nearly 60% when data from 1979–1990 were compared with data from 1991–2002.
* Although case-fatality rates for general anesthesia are decreasing, rates for regional anesthesia are rising.

Melissa Maimann, Essential Birth Consulting 0400 418 448

‘We know the reality of childbirth’

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A new report on NHS maternity care has revealed divisions between midwives and obstetricians. One of the disputes … is over the best way to give birth. While midwives, and the government, advocate natural birth, many female obstetricians opt for a caesarean when they have their own children. Do they know something we don’t?

… Sher, 38, chose an elective caesarean … because she decided it was the safest method … Sher makes decisions on delivery and surgery every day, and she understands the consequences more than most – she is a consultant obstetrician.

One London study … reported that 31% of female obstetricians would personally prefer a caesarean birth. In the US, the figure is almost 50%. Many female surgeons and GPs quietly take this option too – though, as one told me, “to admit as much is still massively un-PC”.

In April 2007, the then health secretary, Patricia Hewitt, launched her strategy for the future of maternity care. Maternity Matters trumpeted “choice”, promising better access to “normal” deliveries via home births and midwife units. Her plans chimed with recent guidelines from the National Institute for Clinical Excellence (Nice) drawn up to reduce caesareans – currently 23% of all births – by advising obstetricians against granting them without medical justification. The official disapproval of elective C-sections means Sher daren’t talk under her real name; Stephanie Sher is a pseudonym.

So while the government promotes “normal” deliveries to the public, its employees are privately planning caesareans. Why do so many obstetricians opt not to push? What do they know that we don’t?

It’s important to remember that it is the obstetrician’s and the surgeon’s task to remedy the rarer complications and consequences of childbirth. Unlike midwives, who oversee successful, normal births every day, doctors bear witness to the worst-case scenarios.

Inevitably this difference in experience manifests itself in an ongoing debate on how best to manage childbirth. Midwife groups advocate normal delivery and “natural” births while obstetricians tend to see medical intervention as a benefit rather than a bane. Yesterday, the healthcare commission published a report highlighting several key problems in Britain’s maternity services, one of which was an inherent tension between midwives and doctors on maternity wards. Caught up in the middle are the mothers.

Maternity experts across the board believe that a straightforward vaginal delivery is by far the best for both mother and baby. Most women agree: 63% of mothers see childbirth as a natural experience that should not be interfered with unless necessary. In “putting women at the centre of maternity provision”, the government’s strategy reflects the overwhelming consensus.

Nevertheless, among all the furore that surrounds the issue of childbirth, for Sher and her colleagues, one thing is clear: the government’s promotion of delivery “choice” is a promise rarely kept. “There is nothing wrong with hoping for a natural event,” Sher says, “and for everything to happen beautifully. But it just isn’t like that for a large proportion of women.”

Sher’s greatest fear was not the pain of spontaneous labour. It was the prospect of emergency intervention, if the birth went wrong. According to the most recent NHS maternity statistics made available (2005-6), just under half (47%) of expectant mothers have a regular, uncomplicated “normal” labour. The rest have interventions ranging from induction, to forceps, to an emergency caesarean. In other words, when a woman tries for a normal birth and the best, safest kind of delivery, she has only a 50% chance of achieving it. For a significant number of others, the birth will be more complex.

I wonder if those women had access to one-to-one midwifery care for their pregnancy, birth and postnatal care? When women are put through a system that sees women having a different midwife at every antenatal visit, shifts of midwives in delivery suite and then shifts of midwives in postnatal, it’s no wonder that most women do not experience a natural birth. bur when women are cared for by the same midwife right from the first visit to 6 weeks postnatal, the outcomes are very different. The ability to develop trust, rapport and understanding are paramount to experiencing natural birth.

With odds like this, it is not illogical to consider alternatives, particularly not if your line of work exposes you to the most extreme of cases. Many obstetricians find the second safest solution is a planned caesarean. The National Caesarean Section Audit (2001) revealed half of obstetricians think this is the safest delivery method for the baby – though not for the mother.

The surgical risks of a planned caesarean include haemorrhage, thrombosis and infection. Scarring on the uterus means the more caesareans you have, the more risky later pregnancies become. But Sher knew she only wanted two children and made the choice that suited her best – both were delivered by C-section. The baby’s safety was her primary motive – but not, she adds, the only one. “The other issue was the risk of pelvic floor damage. Again small, but to me, just not worth it.”

… Michelle Thornton, a colorectal surgeon, sees around 100 women a year suffering from faecal incontinence. “I’m seeing the end result of a traumatic birth,” she says. “Very few of my colleagues would opt for a vaginal delivery and, if any of them asked me, then it’s an elective C-section.”

What about planning for a natural vaginal birth and preparing well for an intact perineum and a short second stage? Private midwives are expert at working with women to achieve these aims. Most women who birth with private midwives do not need stitches and experience a healthy return to normal pelvic floor function.

… Not all experts agree that the risks of a surgical birth outweigh the benefit of protecting the pelvic floor. But calibrating clinical percentages is different from witnessing the lives of women with faecal incontinence, says Thornton. “It’s definitely altered the way I think about childbirth. The thought of being faecally incontinent – to have a life like my patients – I don’t think I’m strong enough.”

… Thornton has half a dozen women in their early 30s. They have “bonding issues with their babies . . . as well as young partners expecting to resume a normal sexual relationship. Two of the couples have split up because of the traumas.” She counsels patients both psychologically and physically. “Emotionally it is tough,” she says. “Having those patients with you when they get upset is tough.” When treatments fail, “it’s terrible, because the patient is absolutely gutted”. Her patients know a permanent colostomy is the only solution. Imparting this news always makes Thornton anxious. “It’s a terrible feeling. It’s like giving them a cancer diagnosis.”

When it comes to medical matters, we assume that knowledge is a good thing. Looking at the childbirth choices made by some female doctors, we might think their superior professional experience makes them right. But many admit their exposure to complications inevitably taints their personal choices. Is it really better to know what they know? Perhaps it’s not that most women don’t know enough – but that female doctors, and particularly obstetricians, know too much.

… If you’ve seen deliveries, she says, “you know the reality.” And “maybe that’s why doctors go and have caesareans – they know it is quite a risky time”.

Interesting, as many midwives opt for homebirths when they have their babies.

Consultant obstetrician Virginia Beckett also puts it plainly: “When I was 14 weeks pregnant I dealt with 12 stillbirths in one 24-hour shift. You can imagine that might skew your view of how to manage your labour.” (Beckett has had two caesareans, the first because her baby was breach, the second was elective). On that particular shift, her baby was too small for her to feel any movement. Emotionally drained and anxious, she scanned herself in the middle of the night. She needed to know her own baby was still alive.

Beckett has worked in obstetrics for more than 16 years, but dealing with stillbirths “doesn’t get any easier”. As the obstetrician, you “go in with the machine and with the patient’s eyes boring in to the side of your head, make the diagnosis and break the news”.

Every time it happens Beckett finds it “heartbreaking, sometimes I do cry actually, not in front of the patient. You feel terrible . . . But there’s nothing you can do.” In the middle of a busy shift there is no time to reflect. “You can’t spend half an hour coming down from every case,” Beckett says, “because there will be another one along in a minute.”

Complications include “abruptions, where the placenta separates and mum and baby can bleed to death. We see people having seizures with pre-eclampsia or eclampsia. We see people’s uteruses rupturing when they’ve had a caesarean section in the past. We see acute fetal distress. We see very complicated vaginal deliveries using instruments, at which various degrees of injury can be sustained . . . All life is here as they say.”

It is the obstetrician’s job to control the less palatable, natural, consequences of childbirth. And they are very good at it. The UK is one of the safest places in the world to have a baby. And of the 1,917 babies born each day in this country, just 11 will be stillborn. “We know that when we work effectively we’re able to make a difference and that’s why we keep doing the job. When it goes to plan, you feel very positive.”

And when things go badly? “You feel absolutely awful: drained and disempowered, really.” Choosing a caesarean, admits Beckett, is one way of redressing this because “you realise how out of control things can be sometimes” and ultimately, “how fragile life is”.

The medics making this choice are unlikely to find support among their colleagues in the midwife unit or even, in some cases, their employers. Current Nice guidelines discourage obstetricians from offering C-sections on “maternal request”. Instead, natural births top the government’s maternity “menu”, with home births promised alongside other “normal” delivery options by 2009.

Privately, however, many obstetricians believe women should be able to choose a caesarean, if they are aware of the risks. Consultant obstetrician Sara Paterson-Brown has publicly asserted a woman’s right to an informed choice because “mothers must live with the consequences”. Her hospital has not since suffered a stampede of women eager for the surgeon’s knife. “Women are counselled and fully informed and recommendations are made,” she says. “We don’t feel threatened by women expressing their choice.”

Paterson-Brown won’t tell me how her own children were delivered, but resolutely feels “the best way to have a baby is normally with no complications. The trouble is, you don’t know if that’s going to be you or not.”

The vast majority of women want a vaginal birth. Just 3% of women even ask for a caesarean without medical indication. Almost 25% will end up having one anyway – largely in emergency circumstances – and a substantial number find their “normal” delivery will go seriously off plan. “There is a lot of luck involved,” says Beckett, “and sometimes the luck isn’t there for you.” Doctors know this, lay women don’t; and when things go wrong, they blame themselves.

Luck? Is it “luck” if we get a uni degree? Is it “luck” if we pull off a dinner party? Is it luck if we get through a very busy week with everything achieved as planned? Or, is it good planning, good information, good support and confidence in our abilities? There is so much a woman can do to achieve a positive, natural birth: she can inform herself, plan for a great birth, increase confidence and engage supportive care providers. Without this, intervention is the most likely result because that is the world we live in today: a world that is fear-ridden and that seeks to control that which we do not fully understand. I believe that most pregnancy and childbirth “complications” are mediated emotionally and mentally. When women are supported, informed, confident, prepared and cared for by a care provider who supports natural birth, she is most likely to birth her baby naturally.

Dr Abigail Fry remembers one birth as a medical student which turned from “calm” to “completely crazy” when a cautious doctor intervened. It became a difficult forceps delivery. Afterwards she remembers “the registrar doing the woman’s stitches and saying: ‘Do you think this bit, you know, should go there?’ And I was like ‘I don’t know!’ It was a mess.” Unlike her obstetric colleagues, Fry chose a home birth.

… “I really enjoyed it.” …

A recent study also found a huge polarity between pregnant women’s expectations of birth and the reality. Expectant mothers need not be frightened by rare, unlikely risks, but they should be given realistic information about the pain and unpredictability of childbirth.

How is that not frightening women? “It’s going to hurt like nothing else … it’ll be excruciating. Oh, and by the way, birth is also unpredictable so don’t have any expectations because they’ll be shattered”. How about, “The sensations of birth can be managed in many ways such as with water, hot packs, movement, position changes (etc). Birth can be unpredictable and so it might be helpful to spend some time going through some of the more likely issues that can come up and to look at how they might be managed at the time.” The latter is far more empowering and less fear-provoking than the former.

Instead there exists a misguided, competitive birth culture; where “lucky” or natural “birthers” are praised for their success, while mothers who “succumb” to medical intervention openly admit they’ve “failed”. Elective caesarean births are so low on the league table they can barely be mentioned without fear of acrimony.

“Women need education,” says Linda Cardozo, a professor in urogynaecology, who blames the “brand of doing it naturally” for this competitive approach as well as the trend for the “madness” of home births. “Most are perfectly safe,” Cardozo admits, “but if something does go wrong you’re in the wrong place to deal with it.” Childbirth is a natural process, but she thinks we’ve forgotten it’s also “a natural process for far more mothers to be damaged and far more babies to die, and medical intervention is absolutely wonderful because it’s prevented that”.

But this does not make Cardozo an advocate of elective caesareans. She remembers colleagues choosing them 20 years ago, but personally felt differently. “You see bad experiences in all deliveries, not just vaginal,” she says, besides which, “I truly don’t believe the risk is worthwhile.

Caesarean section is an operation and all operations carry a complication rate.” So Cardozo did what most women in the UK do, and delivered her three children vaginally, in hospital. Two were twins, one delivered by forceps. “And I’m not incontinent – yet,” she says …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Too many moms get C-sections, says study

Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

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Unnecessary C-sections … could be costing the health-care system more than $6.2 million a year …

… 2,420 surgeries could be avoided if the province were able to lower the proportion of C-section births among first-time pregnancies to the rate achieved by nation-leading Manitoba.

Dr. R. Douglas Wilson … rejects the suggestion that Alberta physicians are performing C-sections that aren’t medically necessary. However, he says he and his colleague need to do a better job of avoiding the surgeries in cases where labour is induced.

“Half the mothers we induce end up having a C-section because they don’t end up in full labour,” Wilson said. “We need to get that rate down around 10 per cent.”

… If every province could achieve Manitoba’s success with vaginal births, the institute estimates that 16,200 procedures could be avoided and more than $36 million could be saved in hospital costs.

… C-section deliveries cost hospitals nearly $5,000, approximately $2,265 more than vaginal births …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Mothers ‘too scared to push for baby No2′ as demand for Caesareans increases

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Expectant mothers are increasingly demanding Caesarean sections for second babies because their first births were so traumatic, say midwives.

In some maternity units, the numbers wanting the procedure has doubled in the past year.

On top of that, many women were so distressed first time around that they are putting off, or even abandoning, plans to have more babies.

The experience is often unnecessarily stressful because maternity units can be overstretched.

Women are often left alone and scared before and after labour as midwives simply do not have the time to offer them the advice and reassurance they need.

This is where private midwifery care is so beneficial for women: the private midwife does not leave the woman’s side, acting as a doula / support person and midwife all at once.

The number of expectant mothers asking for a C-section at Liverpool Women’s Hospital, one of the largest female hospitals in Europe, has increased by 40 per cent in a year.

Other maternity units … report similar trends.

Birth trauma clinics, which support women after difficult labours, say they have seen a doubling in patients in the past 12 months. Cathy Warwick, of the Royal College of Midwives, said: ‘If a midwife is very busy, clearly she won’t have time between dealing with women in labour to give others emotional support and reassurance.’

Doctors and midwives increasingly offer C-sections if women are fearful of giving birth …

Midwives also say that increasing numbers of women are suffering from tocophobia, or a fear of childbirth.

Simon Mehigan, a consultant midwife at Liverpool Women’s Hospital, blamed a lack of information or explanation about what was happening in a first pregnancy …

This is a really great point: it is so important for a woman’s first pregnancy and birth experience to be positive as this experience will shape her subsequent pregnancy and birth experiences. It can be easy to “go with the flow” and do what you are told is best for you / your baby, however this approach – almost a passive approach – will lead to a 31% chance of having a caesarean and a majority of women having their first babies with a “go with the flow” attitude will come away disappointed with their experience. It’s important not to have firm, fixed beliefs about how a pregnancy and birth will go, because no-one has a crystal ball to know exactly how things will be on the day. But it is really essential to be well informed and well supported by a private midwife who believes in birth and a woman’s ability to birth her baby naturally.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Study Examines Complication Rates For Pregnancies After Age 44

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Women who become pregnant at age 45 or older have an elevated risk of several complications to their own health and that of their infants …

The older women were more likely to have health conditions during their pregnancies, with 17% experiencing gestational diabetes … Nine percent of the older group had high blood pressure while pregnant, compared with less than 3% of younger women. Older women had caesarean-section births at more than twice the overall rate and experienced placenta previa — a condition in which the placenta blocks the birth canal — at six times the overall rate.

Women who delivered at age 45 or older also had higher rates of early deliveries, more instances of fever and severe bleeding, longer hospital stays, and more trips to the intensive care unit when compared with younger mothers. In terms of the infants’ health, 4% of newborns born to older women had metabolic problems, such as low blood sugar, compared with less than 2% of those born to younger women …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Unnecessary C-Sections on the Rise

Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

Australia’s caesarean rate was 31.1% in 2008.

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Five years ago, Jill Arnold got some unwanted news at her obstetrician’s office. At 37 weeks pregnant, Arnold was told her baby was too big for her body to deliver naturally. Flipping open a calendar, the obstetrician asked when Arnold would like to schedule a cesarean section.

Fact: You cannot know that a baby is “too big” until you give labour a go.

Unconvinced she needed the surgery — the doctor “couldn’t provide any statistics or data” her baby was too large — Arnold delivered her 10-pound, 3-ounce (4.6 kilogram) baby the old-fashioned way. Since then, the now 36-year old … delivered another baby weighing 11 pounds, and now pens a blog called The Unnecesarean.

Women like Arnold, however, are becoming increasingly rare. Between 1996 and 2007, the number of C-sections performed in U.S. hospitals rose by more than 50 percent to an all-time high: Almost one in three pregnant women …

“The most concerning problem is the high rate in first-time mothers,” …

… The shift is toward a more streamlined labor and delivery, and profoundly affects mothers-to-be.

… this shift is not likely to reverse any time soon.

In 2009, 26-year old Ann Carter … labored for 14 hours. With her cervix dilated to only 6 centimeters … her doctor told her it was time for a C-section.

“I was devastated and scared,” Carter said, “I knew it was a possibility but I was hoping it wouldn’t happen.”

During the surgery, the doctor discovered the umbilical cord had wrapped around the baby’s neck, which explained why Carter’s labor had stalled. The C-section saved the baby boy’s life.

Um, actually, it is very common for the cord to be around the baby’s neck, and it rarely causes concerns.

“Most times the decision to perform a C-section is based on the physician’s judgment,” Zhang said, “but there are great variations in decision-making among physicians.”

… there are “few clear-cut indications” of when to do one.

… For example, the American Congress of Obstetricians and Gynecologists (ACOG) lists “failure to progress” during labor, as an indication that cesarean delivery is needed … When things slow down, there is an element of judgment involved where a physician determines whether to continue to wait, induce or perform a C-section … it can take hours to determine whether or not labor is progressing.

In Zhang’s study, however, he found that many patients weren’t given a sufficiently long time period to allow their labor to progress. In other words, doctors were calling it quits on waiting and opting for a C-section too soon — often before the patient’s cervix was dilated to 6 centimeters.

This was especially true in cases of induced labor … Almost half of the C-sections in these women occurred before they were 6 centimeters dilated …

Still, it is not clear whether inducing labor raises the risk of C-section, or whether other factors are involved that contribute to why women were induced in the first place …

… Another factor contributing to the record-high cesarean rates is a drastic decline in vaginal births after cesarean … 70 percent of women in his study who had previously undergone a cesarean delivery had C-sections with their subsequent pregnancies, without attempting vaginal delivery.

One reason for this is a fear of lawsuits. If a physician doesn’t perform a C-section, and something goes wrong with a patient who previously had a C-section, the law often does not protect the physician …

… the number of malpractice claims involving obstetric and gynecologic surgery are the second highest of all medical specialties. In 2009, the claims totaled over $133 million.

Fears of legal action also explain why at least 30 percent of all U.S. hospitals have official bans prohibiting VBACs …

The risks associated with a vaginal birth following a C-section have been somewhat exaggerated, however, Zhang said.

“Women and physicians may be concerned about uterine rupture, but the risk is less than 1 percent,” …

To help reduce rising cesarean rates, the American Congress of Obstetricians and Gynecologists announced less restrictive guidelines in July, stating that vaginal birth “has fewer complications than a repeat cesarean….restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against her will.” …

… some medical experts have suggested the rapid rise of C-sections in the last decade is also due in small part to mothers-to-be requesting them, not doctors. Still, data on “patient choice cesareans” is lacking, as statistics used as support of their frequency are often based on ambiguous procedural codes used on hospital discharge records.

In any case, women who opt for a C-section may not be getting adequate information about risks, and may fear they have no other option …

… To curb the rise, many advocate giving women more autonomy over their labor and delivery, and combining the strengths of modern medicine with the principles and practices of midwifery.

La Follette’s California office is an example of this more comprehensive approach: After participating in a larger practice for 12 years, she now works with two experienced midwives and another physician. Her practice has a successful VBAC rate of 75 percent.

“We take into account the expectations and ideas of the mom and balance that with medical guidance,” La Follette said.

As more women consider practices with midwives and home births — which can be dangerous if complications arise — much of the medical establishment has been digging in its heels. In 2008, the American Medical Association’s House of Delegates proposed a resolution to declare hospitals the only safe place for labor, and only midwives who work under the supervision of physicians as safe.

The Midwives Alliance of North America declared the resolution “seriously out-of-step with the ethical concept of patient autonomy in healthcare [that] distracts from other critical issues in maternity care.”

If there is any chance of lowering the rates of C-sections, professional organizations will need to review all the available evidence, Zhang said.

But any change won’t be easy. On the one hand, doctors need to include expectant moms in their own care; on the other, it sometimes seems that doctors who are worried about potential legal consequences can’t focus on a patient’s best interests.

“We’re fighting a cultural issue,” Scott said, that extends beyond C-sections.

She said, “We need to change the entire way we view birth and we have to be able to trust our caregivers. The alternative would be terrifying.”

Melissa Maimann, Essential Birth Consulting 0400 418 448

Your body, your choice

Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

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The transforming experience of childbirth is increasingly blotted by medical interventions. Are women making informed decisions?

LIKE most first-time mothers, Faye Wong … was incredibly excited when she got pregnant. She read baby books and magazines voraciously, signed up for ante-natal class … to prepare for baby’s arrival.

When she was 38 weeks pregnant, her obstetrician said the baby’s head had engaged and his size was quite big. The doctor suggested inducing her labour.

In the labour room, her “nightmare” began. The pain from the drug-induced contractions was a rude jolt to her system. Then she was jabbed and prodded with painkillers, IV tubes and the works.

“I was shocked, confused, and in absolute terror,” recalls Wong, 35. Finally, the induction failed and she had to be wheeled in for emergency caesarean. Thankfully, she delivered a healthy baby boy weighing 3.9kg. When she got home, she struggled with breastfeeding and suffered a severe bout of post-natal blues.

“I felt ‘cheated’ … ” Wong admits. Her son is now seven. “I was a newbie to the birthing process and was meek as a lamb led to the slaughter,” she adds. “If I’d known then what I know now, I probably would have been better prepared, stood my ground and not undergone early inducement.”
Though doctors play a role in giving women the necessary information about labour options, women and their partners need to take their share of responsibility too in making informed choices and decisions.

Wong’s experience isn’t unique.

“We see a fair amount of women who are unhappy about the outcome of their deliveries,” says Jennifer Hor of Jenlia Maternal Services. The UK-trained midwife has been running ante-natal classes and post-natal home visits for 17 years. “Some felt they had a C-section even though they didn’t want it. Or, some felt they didn’t get enough information from their doctors.”

So, are women less assertive when it comes to childbirth? Are they getting or finding the information necessary to make informed choices and decisions? And have we forgotten that childbirth, an age-old practice, is meant to be natural?

Birth trends

… the medicalisation of childbirth means what used to be a straightforward, natural process is now treated as a high-tech medical procedure.

Caesarean rates are on the rise in both developed and developing countries …

… “Women say they want to take ownership of their bodies, yet we have healthy, low-risk women who said they had a C-section for their first births because they listened to their doctors,” says Farouk, who also sub-specialises in reproductive medicine. And because of the risks from the first surgery, these women are requesting for repeat C-sections. “Ironically, women are pushing the trends that way.

“We are also seeing the use of more technology to manage pregnant mothers, for example using CTG (cardiotocography) … and ultrasound scans,” says Farouk. “It’s not all bad, but if you monitor too much, you might pick up something and wonder if you don’t take action, there might be consequences, hence the interventions.”

… Doctors come with their beliefs and agendas, based on experiences. Some underplay certain risks and amplify others. For instance, placental calcification … is not a major issue for some obstetricians if the woman is near term and foetal growth is normal. But for a different doctor, a few specks on the ultrasound scan is reason enough for labour induction.

“There can be grey areas in medical investigations. I tend to be more conservative with placental calcification and continue to monitor foetal health and growth parameters,” …

Also, fear of litigation is scaring obstetricians into defensive and often interventionist practices.

“An obstetrician is more likely to be subjected to litigation because a caesarean section was not performed or was perceived to have been performed too late …”

Medical interventions

Clearly, it’s not always true that C-sections or epidural blocks are being foisted on reluctant women. The fact is, some women don’t question their doctors, or they themselves are asking for interventions.

Labour induction, elective caesarean, epidural jabs, and routine episiotomy are some of the common medical interventions during childbirth.

Induction of labour … is usually done when the mother’s or baby’s health is at risk …

“For such cases, studies have shown that caesarean section rate has been unchanged or lower among the induced group as compared with expectant management of pregnancy … ”

“But induction of labour at 37 to 41 weeks on non-medical grounds is linked with an increased risk of caesarean section for … a woman who has never given birth and an increased risk of instrumental delivery,” …

No doubt, medical interventions can be a lifesaver for mothers and babies …

However, once the natural process of labour and birth has been disturbed, if there is no actual emergency, there is risk that the side effects of the treatment will trigger more intervention necessary to fix the problem. This sequence of events is called the “cascade of interventions”.

“Pitocin (Syntocinon), a synthetic form of the hormone oxytocin used to induce or speed up labour, often results in a rapid increase in the intensity and strength of the woman’s contractions. As a result, she may opt to use pain medications such as pethidine … or epidural anaesthetic. Babies sometimes don’t react favourably to the sudden increase in the intensity of the contractions, which may result in irregularities of the heartbeat. Thus in turn may necessitate delivery by caesarean,” …

“Many women who use epidural do not experience the urges to bear down which help them to birth their babies. Often, in this situation, the doctor will use forceps or vacuum to deliver the baby, which means he needs to do an episiotomy … Many women experience long-term perineal pain following episiotomy.”

A failed induction (when labour doesn’t started after the first cycle of treatment) can either require a rescheduled induction or emergency C-section.

“Women should received accurate information about the risks, benefits, and alternatives of induced labour and understand the possible side effects and interventions, ” …

The big ‘C’

Most women also come with the preconceived idea that C-sections are safer than vaginal delivery …

… “In fact, C-section, which is classed as a major surgical procedure, carries with it the risk of complications and shouldn’t be viewed as an alternative option to normal birth.”

… “Babies delivered by elective caesarean section at 37 to 39 weeks’ of pregnancy are at two to four times more likely to suffer from respiratory morbidity compared with babies delivered by vaginal delivery,” … WHO global maternal survey also finds that women who choose elective caesarean with no medical indication are at increased risk of maternal death and serious complications.

… Studies have linked depression and distress after birth, which affect up to one in five women, to forceps and caesarean births …

Disturbed birth

“You must be mad to give birth without an epidural!” A common reaction these days if you speak with women who have undergone labour. But as the WHO states, “epidural analgesia is one of the most striking examples of the medicalisation of normal birth, transforming a physiological event into a medical procedure.”

… in her book,Gentle birth, gentle mothering, internationally acclaimed birth expert Dr Sarah J. Buckley explains how epidurals or painkilling drugs and synthetic hormones (used during induction) interfere with some of the major hormones of labour and birth. The five major hormones: oxytocin (hormones of love); beta-endorphin (pleasure and transcendence); the catecholamines or CAs, epinephrine and norepinephrine (excitement); and prolactin (tender mothering) form a “cocktail of hormones that nature prescribes to aid birthing mothers of all mammalian species”.

During an undisturbed labour, these hormones rise in crescendo and peak around the time of birth or soon after for mother and baby, and subside over the following hours and days. “An optimal hormonal orchestration provides ease, pleasure, and safety during this time for mother and baby.” Interference with this process, by injecting drugs or synthetic hormones, will “disrupt the hormonal orchestration, making birth more difficult and painful, and potentially less safe”.

For example, epidurals lower the mother’s production of oxytocin or stop its normal rise during labour. Oxytocin causes a woman’s uterus to contract in labour. It peaks at birth and catalyses for the final powerful contractions of labour, and helps mother and baby to fall in love at first meeting.

Under stressful conditions, our body releases epinephrine and norepinephrine (CAs). Towards the end of an undisturbed labour, the mother experiences an adrenaline rush – the natural surge in these hormones gives her the energy to push her baby out, makes her excited and fully alert at first meeting with her baby.

But when a woman feels fearful or unsafe, her labour is inhibited by high CA levels. Epidurals reduce the release of the CAs, which may be helpful if the high levels are restricting her labour. However, a reduction in the final CA surge may make it difficult for the woman to push her baby out, thus increasing the risk of instrumental delivery (forceps and vacuum).

Epidural’s side effects include nausea, slowing of labour and drop in blood pressure, slowing of contractions, and headache.

35-year-old Laila Aziz of Kuala Lumpur was wheelchair-bound for four months after an epidural jab injured her nerves when she delivered her third child.

“I wish my O&G and the anaesthetist had explained in details the pros and cons of using an epidural,” says Laila, who suffered severe post-natal blues after childbirth. “I would at least reconsider whether to use the option at that time.”

… Childbirth educator and lactation consultant Christine Choong has been advocating natural childbirth for the past two decades.

“My main passion is how birthing practices affect breastfeeding. What happens when you’re in labour can have a long-term effect on your breastfeeding,” …

Research has shown that when you put a baby on his mother’s chest (skin-to-skin contact) immediately after he was born, the baby will crawl instinctively towards her breast.

“Quite often the baby won’t do that if you had used drugs during labour … because he will be drowsy the first two to three days,” … “If women use epidural, very often their babies are delivered by suction or forceps which can cause discomfort on baby’s head (a shock to the system) and baby initially will not be happy feeding on one side or the other.”

Whether a labour induction is done on medical grounds or not, the baby is – by definition – relatively immature and likely to have impaired ability to effectively coordinate sucking, swallowing, and breathing at breast …

“In a C-section delivery, very rarely the mother is given the baby straight away,” Christine adds. “Early stimulation or suckling is important to establish breastfeeding. Also a higher percentage of caesarean babies end up with respiratory problems, which results in separation of mom and baby.”

But we need to look at the whole picture – the impact on baby, feeding, and mother-baby relationship.

“It isn’t just feeding but also nurturing,” says Christine, a mother of three.

“When babies are nurtured and their needs are met, in the long term, they will become people who are secure, confident, and know how to form relationships with people.”

Take control

What do you do if your care provider says you or your baby is at risk and an intervention is necessary?

“Using evidence-based information, your doctor should explain the reason for any suggested interventions. He should also explain the benefits and risks of such procedures,” advises Choong. If you’re not sure or not too convinced by your doctor’s explanation, get a second opinion.”

“Empowerment with the correct knowledge and information is useful so women can ask the correct questions,” Chow adds. “And their fear of childbirth should be addressed by getting support and learning about the labour process and pain relief options.”

Ultimately, a woman’s satisfaction with her birth experience is related more to her involvement in decision-making than to the outcome, as Buckley emphasises. Though doctors play a role in giving women the necessary information, women and their partners need to take their share of responsibility too in making informed choices and decisions.

When Wong had her second child, she was more mentally and emotionally prepared.

“Although I ended up having another C-section (due to hypertension), I didn’t feel disappointed and helpless,” Wong says. “I felt as if I was a real mom this time around.”

As Buckley sums it up best, “birth is the beginning of life; the beginning of mothering and of fathering. We all deserve a good beginning.”

Melissa Maimann, Essential Birth Consulting 0400 418 448

Forceps babies ‘more likely to behave badly’ while those born by Caesareans ‘are calmer’

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Babies born with the help of forceps or a suction cup are more likely to have emotional problems …

… assisted delivery techniques produce high levels of stress hormones that may affect development.

… children born after a caesarean requested by their mother have fewer emotional and behavioural problems. In pre-school, they were found to be much less likely to suffer from anxiety, aggression and attention disorders.

… babies born with the aid of forceps were more likely to be aggressive as young children, but Caesarean babies were calmer

… Immediately after birth, umbilical cord blood cortisol levels have been found to be lowest in babies born by elective caesarean, followed by spontaneous birth. The highest levels are found in assisted deliveries where forceps or a suction cup is used because labour is prolonged and complications may have developed.

Previous studies have suggested these children experienced the highest levels of stress at birth.

… ‘Cortisol levels have been linked to childhood psychopathology, however, more studies are still needed to look at this in more detail,’ …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Moms find alternatives to hospitals that say no to natural births following C-sections

Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

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Nine months ago, Jennifer Saavedra was pregnant with her second child. After her first daughter was born by cesarean section 2½ years earlier, the Redding woman decided that she wanted to experience a natural birth at least once in her life.

But having her child at a local hospital is almost out of the question.

Redding’s only birthing center, Mercy Medical Center, all but refuses to perform a vaginal birth after a woman has had a previous C-section.

The hospital’s policy isn’t unique. Because of liability and patient-safety concerns, more and more hospitals around the country have chosen to stop the practice, which experts say is contributing to a national rise in cesarean rates.

That leaves local women like Saavedra, a 43-year-old former “figure competitor” — a type of body builder — with few options. They can either have the baby at home with a local midwife or travel several hours to a hospital in Sacramento or the San Francisco Bay area, where a doctor may elect to have a natural birth.

… recent changes to national care standards, hospital staffing levels and threats from lawsuits also factor into Mercy officials’ decision six years ago to stop performing VBACs.

De Soto said the risk of a complication during a VBAC actually is “very low,” Although traditionally around half of the women who try to have a VBAC at a hospital end up having a C-section anyway.

Fairly appalling statistics! At least 75% women who choose a VBAC can be successful, provided that the environment for labour and birth is conducive to natural birth, and provided that the woman’s chosen care provider is supportive of her intention to have a VBAC.

Fewer than 1 percent of healthy women who try a VBAC run the risk a “catastrophic event,” like tearing the scar tissue on their uterus from their first C-section …

The tear can quickly become a massive hemorrhage, which could lead to removal of the woman’s uterus. The sudden blood loss also could choke off oxygen to the unborn baby, sometimes fatally, he said.

De Soto said the hospital is unwilling to take that risk.

But … multiple C-sections come with their own risks, which are often downplayed by the medical establishment.

… multiple C-sections increase a woman’s risk of future uterine hemorrhaging and hysterectomies.

There’s also an added risk of other problems caused by building scar tissue that develops from multiple surgeries …

Women who have multiple C-sections have greater chances of having sexual problems, incontinence, bowel obstructions and infertility, she said.

“I’ve never once heard a doctor mention that to a patient,” she said.

‘Avoid the first one’

Although that is a really pertinent statement to make, it’s also an unfair comment. A woman having her first baby has no experience of labour and of the terrain that she will find herself in once she steps into hospital. She may not have considered homebirth, even though her chance of having a caeasrean would be far less than 10% had she chosen a homebirth with a midwife. Is it an unfair expectation that a woman having her first baby will know all that she needs to know and have the support that she needs to have, in order to avoid that first caesarean?

Peaceman said patient safety worries — as well as multimillion-dollar malpractice lawsuits — are very much on the minds of doctors. It’s the same in Redding.

… Saavedra said she planned her VBAC [and] … quickly decided that UC Davis would be impractical and expensive. The university hospital requires women to stay near the birth center for almost a month before the birth just in case the baby comes early, she said.

After doing her own research, she chose to have the birth at home with McNeill.

Sarah was born Sept. 27, a healthy 6 pounds, 9 ounces. McNeill gave Sarah her first bath in Saavedra’s bathroom sink.

Saavedra’s story is one shared by only about 20 Redding women each year.

McNeill, a registered nurse and licensed midwife, said she usually performs at least one VBAC every two months or so. Redding’s other midwife, Dena Burgess, said that she may do 10 a year.

The women who elect to have the procedure are a special breed, local midwives say.

McNeill said such women are usually health-conscious and informed. They’re also confident enough to question the medical establishment, and they’re passionate about their own health care decisions, Burgess said.

“When women have a VBAC, it’s like so — I hate the word “empowering”; I hate that word — but it changes them,” she said.

Renee Harris, 38, of Redding said she knows that feeling all too well.

The home-school mother of seven children has had two VBACs. She’s planning another VBAC when her newest baby is due next month.

She said she decided to go the home-birthing route after doctors in Colorado performed a C-section when she had twins.

“I felt like the decisions were made for me,” Harris said of that birth … “I’m not going in for major abdominal surgery if I just don’t need it,” she said.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Increased forceps training ‘could cut caesarean births’

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Additional training in difficult births could help [lower] caesarean section operations …

… extra training could reverse the trend for caesarean sections being used in cases where an instrumental delivery would have been more appropriate.

… emergency caesarean sections carry a risk of “severe obstetric morbidity”, while proper use of forceps can be much safer – and make vaginal birth easier in the future …

If an assisted birth is needed, forceps are more likely than a vacuum to result in a vaginal birth. The vacuum is more likely to slip off, sometimes several times, before a caesarean is called for, whereas the forces are far more likely to result in a vaginal birth. Having a caesarean for the first birth makes all future pregnancies and births labelled “high risk” and will dramatically lower a woman’s chance of ever having a vaginal birth. So it’s really important to maximise the possibility of a vaginal birth for the first baby. Following births are generally much quicker and easier!

Melissa Maimann, Essential Birth Consulting 0400 418 448

Fear of natural birth driving one in three mothers to caesareans

Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

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Many well-off mothers-to-be think natural childbirth is undignified and distasteful, and want a caesarean for comfort and safety …

But they’re not just too posh to push, they’re also petrified.

According to a survey of 210 women published in Midwifery journal, researchers found there was a “distrust of the body’s ability to undertake labour and safely birth a baby” – despite evidence that shows caesareans are more risky for both mother and baby.

One in three Australian women now has a caesarean, with research showing the escalation has been driven largely by the mother’s request.

International surveys show between 6 and 15 per cent of pregnant women would prefer to have a caesarean.

In the Midwifery article, researchers questioned 14 of the 210 women at length and found they were concerned about the the “loss of dignity” of childbirth, were “mortified” about giving birth and wanted a “perfectly shaped baby”.

The women, who were mostly upper-income professionals with private obstetricians, also wanted a “perfectly orchestrated birth” which was “comfortable” and had a “high level of support”.

Dr Guy Skinner, obstetrician at Epworth Freemasons, said some women asked for elective caesareans because of negative experiences, such as sexual assault, or through concern for their pelvic floor muscles.

… Dr Skinner said one-third of women were “talked out of it” and he did not support the provision of caesarean on demand.

… “If you dig down there’s usually a significant pathology, and you have to address that rather than just agree to a caesar,” she said.

Fear is a powerful motivator of birth decisions. Unfortunately, it’s not a useful motivator as we tend to attract that which we fear the most. A more useful approach is to gently explore the issues causing fear, engage the services of a private midwife who will provide continutiy of care for hospital birth or home birth, and be open to surrendering to birth. This can be done with thorough mental and emotional preparation for birth with a midwife, Calmbirth classes and good information on birth and its options.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Fewer caesareans with ‘midwife-centred care’

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The district health board responsible for the most births in Australasia is bucking the national trend – reporting low figures for caesarean section deliveries.

Unlike other DHBs in the Auckland region with statistics well above the national average of 24.3 per cent, Counties Manukau DHB reported caesarean delivery figures of 17.08 per cent of all births for 2009.

… “Our midwives are promoting natural, vaginal births wherever possible. It’s why we like to focus on more women giving birth in our community clinics.

“The women feel more at home there and the recovery after a natural delivery is much, much quicker than a C-section.”

… the figures reflected a lack of involvement in the conception and birthing process from fertility clinics or private obstetricians.

… “For us our core philosophy has always been midwife-driven, that’s not going to change.

“We feel satisfied we are only providing caesarean surgeries when there is an indication for them.”…

Melissa Maimann, Essential Birth Consulting 0400 418 448

C-sections have risk unknown to many women

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One in three … babies is born by C-section … But there’s a twist; that high C-section rate is leading to a very scary complication.

… Georgia Barraza was 29 weeks pregnant with her third child when something went wrong on a family fishing trip.

“I stood up because we had a bite on both lines and I just started bleeding,” Barraza said. “My husband starts walking me down the pier and every step it’s just blood, blood, blood.”

It’s called placenta previa, a dangerous complication where the placenta tears and bleeds.

“Everyone is telling you stay calm, stay calm, but I mean it’s my wife and that’s my daughter, and you really can’t stay calm,” her husband, Mario Hernandez, said.

And what happened to Barraza is happening to thousands of women. In 1980, one in 2,500 deliveries involved a placenta previa. In 2006, it was one in 210 deliveries.

Blame it on C-sections, say obstetricians. One in three births is by C-section, and doctors say that’s causing the increase in placenta previa.

“You can bleed to death in 5 to 10 minutes,” said Dr. Pamela Promecere, an OB/GYN at Children’s Memorial Hermann Hospital.

Women are being saved through emergency surgery, sometimes hysterectomy. But many pregnant women don’t realize they’re at risk.

“Your chance increases with the number of Cesarean sections,” Promecere said. “So if you really, really want a big family — four, five, six children — you may want to avoid your Cesarean sections from the beginning.” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

‘Impatience’ With Labor, Low VBAC Rates Tied To C-Section Increase, Study Finds

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The rising … caesarean section rate reflects several factors — including a tendency to opt for c-sections too soon into labor, an increase in labor inductions and fewer attempts at vaginal births among women who have had previous c-sections …

… The increases in c-section rates “have caused debate and concern” because surgical deliveries pose greater risks for women and their infants than vaginal deliveries … Women who have c-sections also have a higher risk for complications, such as placental abnormities and possible uterine rupture, in subsequent pregnancies …

… one-third of first-time mothers had had c-sections. The increased use of drugs to induce labor might be a factor in the c-section rate among this group … Women who had labor induced were twice as likely as women who went into labor on their own to have a c-section.

Among women who were induced and had c-sections, about half of the deliveries were performed before the cervix had dilated to six centimeters, “suggesting that clinical impatience may play a role,” …

Caesarean rates amongst private midwives are less than 10% and in many cases, around 5%. This can be attributed to women’s preference for a natural birth but also the role of the private midwife in protecting, promoting and supporting the natural processes of pregnancy and birth and the avoidance of drugs to stimulate labour unless they are genuinely necessary.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Too posh to push? Ask my doctor

Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

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Pregnant women in the private health system are not “too posh to push”, a new Queensland report has shown.

While significantly more mothers give birth by caesarean-section in private hospitals than in the public sector, it is not due to low pain thresholds.

Of course it’s not due to lower pain thresholds: caesareans hurt too!

Research … has revealed a dramatic difference in the way maternity care is provided in the two systems.

It found eight in 10 pregnant women in both sectors wanted a traditional delivery.

However figures provided by Queensland Health show almost half of all births in the state’s private hospitals are by caesarean, compared to 27.6 per cent in the public sector.

About 62 per cent of women who had a caesarean in a private hospital said they had been recommended by their health care provider, compared to 40 per cent in the public sector.

In addition, 60 per cent of private caesareans were scheduled ahead of labour, compared to 41 per cent in public hospitals.

Research fellow Dr Yvette Miller said the findings disproved the popular belief that women who could afford the private system did not want a vaginal birth.

“A lot of differences [between public and private births] have previously been attributed to women’s choices,” Dr Miller said.

“What’s clear from our data is that doesn’t seem to be the case.

“Eighty per cent of women want a vaginal birth and there’s absolutely no difference between women in private and public hospitals.”

Australian Medical Association Queensland president-elect Dr Richard Kidd said he believed the research showed private obstetricians were better at identifying when women required a caesarean.

How does he arrive at that conclusion? An ideal caesarean rate is 15%. The vast majority of caesareans are therefore unnecessary.

“Sixty per cent of the caesareans [in the public system] were not planned,”

And nor should they have been: a caesarean is a life-saving operation and as most “emergencies” occur in labour, this is the time that most caesareans will be performed.

… Dr. Miller said women needed to be better informed about the differences in maternity care in private and public hospitals.

Pregnancies and child birth in the private system were always looked after by an obstetrician, while in the public sector midwives handled care unless a risk was identified.

Dr Miller said obstetricians and midwives had vastly different approaches to maternity care. Obstetricians were more likely to use medical intervention, including caesareans, epidurals and induced labours.

“It’s not clear to most women when they become pregnant and start considering their options,” Dr Miller said.

“Private hospital care is not just better quality of the same care, it’s actually a different approach.”

Dr Miller said research now needed to focus on health care providers, including obstetricians, general practitioners and midwives, to understand why they took their different approaches.

… “They’re all very, very committed to providing the best care for their patients, they just have different ideas about what that looks like.”

… “What we’re starting to see more and more is that the differences between the private and public system has to do with things like hospital policy [and] risk litigation strategies,” she said.

… Queensland has the highest rate of caesarean-section births in Australia …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Fear of lawsuits? Judicial reforms would reduce cesarean deliveries

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The reasons for rising C-sections … are not as mysterious as may appear. Some of these reasons are due to medical science; some of them are societal.

Important strides in the past 40 years or so has led to the often-mistaken belief held by society that medical science … can deliver perfection. The holy grail of obstetrics is to deliver a “perfect” baby each and every time. Reality, however, reminds us of our humanity.

We can summarize the reasons for performing caesareans by their indications or lack thereof. In no particular order, we can list the so-called abnormal fetal heart rate patterns, other than head-first presenting fetal body part, more than one baby in the womb, failure to deliver or progress by a certain timeline, failed attempts to initiate labor, repeat caesareans, problems of the placenta causing maternal and/or fetal hemorrhage, maternal fever and infection, extreme prematurity, and, what I call, the Nike indication — “Just do it!”

Because of the above, nationwide, the caesarean rate … rose from 5 percent in 1970 to more than 30 percent in 2008 …

… the statistics are not reassuring. Despite 40 years of using Electronic Fetal Monitoring, we have more children born today with cerebral palsy and brain damage as a percentage of live births as we did in 1970. This is explained because we now know that watching an EFM strip cannot give us the information we need to prevent brain damage. EFM has been shown to be virtually useless as a screening tool … Yet, every hospital birth … is monitored electronically … Most babies that have cerebral palsy had normal EFM tracings …

How many caesareans are done in the name of defensive medicine? … the climbing caesarean rate is driven by doctors’ fears of litigation …

… Unfortunately, I don’t believe that the trend in this state will significantly change without significant structural judicial change, which, can only come about if the people want it …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Women With Diabetes Having More C-Sections And Fetal Complications: Study

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Nearly half of women with diabetes prior to pregnancy have a potentially-avoidable C-section and their babies are twice as likely to die as those born to women without diabetes …

… rates of diabetes in Ontario have doubled in the last 12 years. Nearly one in 10 Ontario adults has been diagnosed with diabetes, including more women than ever before.

As women develop type 2 diabetes (adult onset) during childbearing age, complications during pregnancy are becoming increasingly common ….

* 45 per cent of women with pre-gestational diabetes are having C-sections compared with 37 per cent of women with gestational diabetes and 27 percent of women without diabetes.

* Babies born to women with pre-pregnancy diabetes have twice as many fetal complications as those born to women without diabetes.

* The rate of stillbirth/in-hospital mortality in women with pre-pregnancy diabetes is twice the rate in women with diabetes (5.2 per 1,000 vs 2.5 per 1,000) than women without diabetes.

* Rates of major and minor congenital anomalies were 60 per cent higher among women with pre-pregnancy diabetes than women without diabetes.

* More than 50 per cent of people who don’t yet have diabetes have risk factors for the disease.

… “Infants born to women with diabetes are at much higher risk for serious complications – which can be prevented by controlling glucose and blood pressure levels at the time of conception and during pregnancy,” … “This reflects a need for more targeted pre-pregnancy counselling and better pregnancy care for this group of women.”

… most diabetes can be prevented … “We need to focus on preventing or reducing rates of diabetes among young women, one of the most vulnerable groups, and ensure that women who have diabetes get effective treatment,” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Delivering real choice after a Caesarean

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… LOUISE McCANN felt like a “freak” when her first baby was delivered by Caesarean section, after attempts over three days to induce her failed.

In the immediate aftermath, she was just glad Darragh had finally been born and they were both okay. “It is only down the line, when the initial elation wears off, you kind of think what went wrong?”

It was a question that came back to haunt her when she was pregnant again within a year. Everything had been fine the first time until she went overdue; she was 28 years of age and had had a straightforward pregnancy.

“I was a bit naive, it being my first baby, and I assumed that if I was being induced it was going to work.”

… “I found out later I wasn’t ready to be induced.”

On her second pregnancy she was determined to try for a VBAC … She found the consultant initially supportive but, at 38 weeks, he told her to prepare herself for another section.

She believed he was trying to scare her into it by overstating the risks of a VBAC. “He was throwing stats at me and I would have to come back and say, ‘I looked that up and it is not true’.”

McCann was resolute that there was no need for a section; she was healthy, there were no complications and she had not even gone full term at that stage.

… women who go into spontaneous labour after one previous section have about 80 per cent chance of vaginal delivery …

“When a woman has an unhappy experience with a first labour, she does not want to repeat the experience …

As the second pregnancy progresses, inevitably the memories flood back and they get extremely anxious. They are assured the same thing won’t happen.

… “Women who have had a normal birth and then a section can never understand why somebody would elect for a section,”

… “The majority of women who have had a section and then a normal birth say, ‘I am glad I did that’.”

… research in Scandinavian countries shows that if women are debriefed and counselled after an emergency section, they are more likely to opt for VBAC.

[Debriefing gives] you some closure on what happened and help you plan for the next pregnancy …

… “Women are not getting the information to make an informed decision as to what is the safest option in their case.”

Generally, VBAC is associated with a lower risk of complications, for both mother and baby, than a repeat section.

… To people who argue that all that matters is a healthy baby, not the method of delivery, she says that is exactly where VBAC comes in. “If that in the end is all that you care about, then VBAC is something you should seriously consider.”

… “Every woman’s circumstances are different,” he adds, “but the best way is to go into labour spontaneously.”

That is what Louise McCann was holding out for in her second pregnancy. The consultant scheduled her for a section at 12 days overdue – although she had no intention of going in – but she went into labour at home in Naas, Co Kildare the night before.

“Things had been progressing well at home, but when I arrived in the hospital everything stopped – I suppose it was nerves and fear.

“They were trying to push me for induction and telling me I had 12 hours and that was it …”

When her daughter … arrived, 12 and a half hours later, McCann was relieved that she was healthy and had been born without unnecessary surgery.

… Less than a year later she was pregnant again. Having had a VBAC, there was no pressure on her this time and she was allowed to opt for the midwifery scheme – something which had been ruled out when her history was just one section.

… Ruth Doggett was in labour for 12 hours with her twins before it was decided to deliver them by Caesarean section.

… The official reason given was “failure to progress” … However, she says, “if I was doing it again, having learned more about sections and things, I probably would have fought that more.”

When Iseult and Lachlan were 15 months old, Doggett became pregnant again. She wanted a home birth but was told that having had a section, she was considered too high risk – nor was she eligible for the midwifery scheme.

Although she had gone private for her twins, she did not want to be under the care of one consultant this time.

“Consultants are great but they all have their own opinions and, [by] not knowing them well enough, it is hard to tell will they really have the same values and beliefs that you have – especially when the day comes.”

She opted for semi-private care, where she was seeing midwives and registrars. “I found it fantastic. Every doctor had a different view of my situation, so it reaffirmed my belief that I had to trust my own instincts and my own bit of research of what was best for me and my baby. Then take all the information I was getting and make a decision for myself.”

She was very keen to try for a VBAC and medical staff were supportive, telling her she had a 70 per cent chance of having one.

However, she took issue with some of the hospital’s policies for VBACs, such as that she would be allowed only seven hours of active labour, after which she would need to have a section.

“I was really concerned about that – the possibility of being on a clock and saying I had seven hours to give birth, to me that was just crazy.”

She was told she would need continuous monitoring because of the risk of scar separation (which is less than 1 per cent when women go into spontaneous labour), but she wanted intermittent monitoring so she could be free to move. Also there was a policy for induction at 10 days overdue, but she wanted to be allowed to go 14 days over.

As it turned out, she went into labour at five days over, early one Thursday morning last April. She spent the day at home … “I wanted to get as close to delivery at home so I would not be on the clock.”

At 10pm she went into hospital to be checked. “I was 4cm [dilated] , the baby’s head was down …

Then Doggett was questioned about things she had specified in her birth plan – such as longer time limits and no continuous monitoring. A registrar explained all the risks and asked her, she says, was she prepared to be in labour 24 hours, to have her baby flat-lining at birth or to have cerebral palsy.

“It was an awful thing to be asked. I said, ‘I want what is happening to me in my labour to be dealt with; I don’t want to be dealt with on the basis of statistics. Obviously I want my baby to be healthy’.”

Although she was sent to the delivery ward, she remained at 4cm. “I actually love being in labour, I know that it is a strange thing to say. I don’t find it painful; it is just a cramp. It is quite an exciting time.”

But, conscious of the clock ticking, she was becoming stressed as she heard talk of another section. However, then she was told she was not in established labour and was being moved back to the labour ward where she should try to get some sleep.

On Friday, one registrar said if nothing was happening by 6pm she should have her waters broken. But then word came down from a consultant that, “if I did not want any interruptions or interventions and everything was progressing fine – slow but no distress – that there was no need to get involved”.

She was delighted with that news and was moved into the pre-natal ward. “It was fantastic; I could eat what I wanted and I was off the clock. I relaxed completely there.”

By 10pm she felt the contractions changing and by 1am needed her Tens machine. She was found to be 7cm dilated and moved to the delivery suite.

She agreed to her waters being broken when she was almost 10cm dilated. “Nothing happened for about 15 minutes then the second phase started and that was incredible.” One and a half hours later, at 6.50am on the Saturday morning, Caelan was born, weighing 9lb 9oz.

… “being able to deliver him myself was empowering and kind of healing in lots of ways.”

Melissa Maimann, Essential Birth Consulting 0400 418 448

Cesareans more likely for women at for-profit hospitals

Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

Another article from the States, but the situation is the same in Australia. Reviewing the latest 2007 birth statistics, the caesarean rate within the private health sector was 40% whereas the overall caesarean rate was 29%. Births attended by private midwives have a 5-8% caesarean rate.

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For-profit hospitals across the state are performing cesarean sections at higher rates than nonprofit hospitals …

… women were at least 17 percent more likely to have a cesarean section at a for-profit hospital than at a nonprofit or public hospital from 2005 to 2007. A surgical birth can bring in twice the revenue of a vaginal delivery.

In addition, some hospitals appear to be performing more C-sections for nonmedical reasons — including an individual doctor’s level of patience and the staffing schedules in maternity wards …

… mothers with low-risk pregnancies had a 10 percent chance of giving birth by C-section at the public Santa Clara Valley Medical Center, … whereas low-risk pregnancies at the for-profit Los Angeles Community Hospital ended in a surgical birth nearly half of the time.

The numbers provide ammunition to those who have long suspected that unnecessary C-sections are performed to help pad the bottom line.

“This data is compelling and strongly suggests, as many childbirth advocates currently suspect, that there may be a provable connection between profit and the cesarean rate,” …

This was the first independent analysis of C-section rates at the 253 hospitals reporting birth statistics to state health authorities. The data focuses on low-risk pregnancies where cesareans are more likely to be unnecessary — excluding deliveries by older mothers, women with certain medical conditions and women with previous C-sections.

… For some, a C-section can have devastating consequences.

Heather Kirwan said her doctor at the for-profit … [hospital] urged her to have a C-section, warning that the baby was too big …

“She ended up being a 5-pound, 12-ounce baby,” … and who now believes she could have delivered vaginally.

There is a 15% margin of error on a third trimester ultrasound. They are, in fact, not designed to guesstimate the size of the baby as they are frequently inaccurate. In my practice, I find my hands are my best tool for judging the size of a baby.

When Kirwan got pregnant again, doctors discovered the embryo was developing outside the uterus — a life-threatening condition called an ectopic pregnancy which is more likely to occur after a C-section. The embryo was removed along with one of Kirwan’s ovaries and fallopian tubes. She has been unable to conceive since.

This is a valid point, and one that is often not mentioned: fertility diminishes for a variary of reasons after a caesarean has been performed.

… one important factor has always loomed over the debate about the rise in C-sections: the bottom line. In California, hospitals can increase their revenues by 82 percent on average by performing a C-section instead of a vaginal birth …

California Watch examined the births least likely to require C-sections, those in which mothers without prior C-sections carry a single fetus — positioned head down — at full term, and found that, after adjusting for the age of the mothers, the average weighted C-section rate for nonprofit hospitals was 16 percent, and for-profit hospitals had a rate of 19 percent.

That may seem like a small percentage gap to the casual observer, but medical experts consider it significant. It means women are 17 percent more likely to have a C-section if they give birth at a for-profit hospital.

“That’s a decent-sized difference,” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Shake-up of NHS ‘incentives’ in drive to curb caesareans

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Plans to reduce the number of caesarean deliveries and give women greater access to home births are being considered by ministers.

They want to remove incentives that see hospitals paid extra for surgical births, with or without complications.

The payments mean that one in four babies is delivered by caesarean section – almost double the World Health Organisation’s recommended rate.

… Ministers say they do not want to ‘demonise’ C-sections or discourage doctors from performing them when clinically necessary.

But they believe that equalising NHS payments for all kinds of birth, including those at home, could help bring down the number of surgical procedures …

The Royal College of Midwives has expressed concern over the fact that the proportion of caesarean births is 15 per cent in some parts of the country while hitting 33 per cent in others …

If only this could happen in Australia The UK College of Midwives and Collegs of Obs and Gynaes has a joint position statement on homebirth, providing support to homebirth in low-risk, midwife-attended births at home. We have no such statement in Australia and the Colleges remain opposed on the issue of homebirth. RANZCOG is outwardly unsupportive of homebirth and the Australian College of Midwives has no public position statement of support for homebirth, however they do support homebirth.

Australia’s caesarean rates vary less widely than those quoted in this study. We have a few small obstetric units with “low” caesarean rats of <25%, but it's not until you get to homebirth, midwife-led units and birth centres that you start to find low caesarean rates, under 15%. For the most part, our caesarean rates are shockingly high at ~30%+.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Why has the USA’s cesarean section rate climbed so high?

Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

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A government-sponsored study of 230,000 births between 2002 and 2007 found that the C-section delivery rate was 30.5%.

• Among women who ended up with an unplanned C-section, failure for labour to progress was cited in nearly half the cases.
• Fetal distress or non-reassuring fetal testing was listed as a reason for more than a quarter of unplanned C-sections.
• Nearly half of all planned C-sections were scheduled because the woman had had a previous C-section.

Regarding failure to progress, the accepted rate of progress is deemed to be 1cm/hour. First baby or fifth baby, this is the rate that your labour is expected to progress at. This is despite that fact that first time labours do take longer than second and subsequent labours. There is research to support 0.5cm/hour as an acceptable rate of progress but this is largely ignored. I wonder what the caesarean rate for FTP would be if 0.5cm/hour was used instead of 1cm/hour?

So what happens to the woman whose labour doesn’t progress at 1cm/hour? Well, in the first instance, her waters are broken. This is done with the aim of speeding the labour. Generally, a vaginal examination will be performed 2 hours afterwards and if the woman has not progressed another 2cm in this time, a syntocinon infusion is commenced. This is part of a package, however, and the package includes continuous monitoring. Continuous monitoring is needed because the syntocinon drip causes unnaturally stronger, longer and more frequent contractions that can stress the baby.

Which leads to the next cause of caesareans, according to the article: fetal distress or non-reassuring fetal status. This accounts for around 25% unplanned caesareans.

And finally, about 50% planned caesareans occur as a result of a previous caesarean.

Are you joining the dots yet? That initial diagnosis of “failure to progress” often leads to augmenting the labour. If the augmentation is not successful – or if the baby becomes distressed in the process – the woman is taken down the corridor for a caesarean. Having had that first caesarean, there’s a good chance all her subsequent babies will be born in this way.

What can be done to avid this? There are a few keys:
- continuity of midwifery care from pregnancy right through to 6 weeks after your baby is born
- planning to birth at home
- Ensuring that you have good support in labour from a loved one.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Women pushed into caesareans

Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

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… c-sections now account for one third of all births, and … a big reason for this increase is the over-use of labor induction.

•Almost half of women wanting vaginal births were induced.
•Women who were induced were twice as likely to have a cesarean birth as moms whose labor starts spontaneously.
•Of the c-sections done after induction, half were performed before the cervix had dilated to six centimeters, “suggesting that clinical impatience may play a role.”
•A third of first time mothers had c-sections.
•C-sections upon maternal request (those done for non-medical reasons) account for only 9% of c-sections.
•Attempts at VBAC are less likely to result in vaginal birth than previously thought. Few women are offered the option of VBAC.

… what can you do about all this if you are pregnant and want a vaginal birth? Here are a few ideas:

- Talk to your care provider … about his or her rates of induction, c-section and episiotomy …
- Educate yourself about labor induction …
- Stay home in early labor …

- Choose a midwife if you’re opting for a natural birth
- See an experienced independent childbirth educator for childbirth education classes
- Ask questions
- Read, read, read

Melissa Maimann, Essential Birth Consulting 0400 418 448

Health Risks To Infants Outweigh Convenience Of Elective Deliveries

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Medical experts point to a disturbing trend of expectant mothers who are choosing to deliver their babies for non-medical reasons before 39 weeks of pregnancy. Research published in the July 2010 issue of Obstetrics & Gynecology reveals just how prevalent elective deliveries are in the U.S. In that study of 7,804 women giving birth for the first time, labor was induced in 43.6 percent of the women, and 39.9 percent of those were elective inductions.

A startling number of first-time mothers – 92 percent — believe it’s safe to deliver a baby before 39 weeks, according to a recent UnitedHealthcare survey of 650 insured, first-time mothers …

… “Unfortunately, many expectant mothers are not aware of the risks associated with early elective C-sections and induced labor. Expectant mothers may believe that at 36 weeks they have completed their nine months of pregnancy, but Mother Nature’s formula for healthy babies is actually 40 weeks,” Dr. Groat says.

… babies born electively by C-section at 37 weeks were twice as likely to have health problems, usually respiratory in nature, than babies born at 39 weeks or later. Infants delivered preterm are at an increased risk of developing chronic lung disease, cerebral palsy, learning disabilities and behavioral problems.

“The results of recent studies stress the importance of educating expectant mothers on the risks associated with elective deliveries prior to 39 weeks. These early-term births can result in the newborn’s admission to the Neonatal Intensive Care Unit, which increases the baby’s hospital stay and health risks,” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Test could predict which mothers will need Caesareans

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A test which could stop women labouring for hours in the hope of a “normal” birth only to end up with a Caesarean section has been developed in Sweden.

Researchers have established that when high levels of lactic acid are measured in the amniotic fluid, it is unlikely the mother will deliver vaginally.

Measuring this acid could help decide whether to end a difficult labour and opt for a Caesarean earlier.

The test is being rolled out in a number of European hospitals.

Prolonged labours which end up in a Caesarean section are seen by many as the worst of all worlds.

In the UK, despite the mantra “too posh to push” more than half of Caesareans are emergency rather than elective procedures, in which the mother frequently undergoes a long and painful labour before an urgent operation is deemed necessary to protect the health of both her and her baby.

… the uterus produces lactic acid as other muscles do when they work hard, but that when it reaches a certain level the substance starts to inhibit contractions.

… The hormone oxytocin is usually administered in cases of slow labours to stimulate the uterus into contracting, but not all labouring women respond to it.

… the test should help doctors establish which women may go on to deliver vaginally, as low levels of lactic acid suggest the uterus could still produce the contractions needed to push out the baby.

“But a high level of lactic acid in the amniotic fluid indicates that the uterus is exhausted. To stimulate this kind of labour with an oxytocin infusion would be like asking a marathon runner to run an extra 10,000 metres after he or she has passed the finish line.”

He says the system of testing, which has already started in hospitals in Sweden, Norway and Belgium, should reduce the number of Caesareans for women who may not need them and accelerate them for those that do to “avoid the risk of complications from a long birth and limit unnecessary suffering” …

What is not considered here is the option to rest a tired woman – and then let nature re-commence the labour when the mother and baby are well-rested. There is no questioning of the idea that once labour commences, it must accelerate and lead to the birth of the baby and placenta within a certain time frame. For many reasons, some women will pause in their labours. It might be that they’re tired, hungry, bub isn’t in an optimal position, or a uterus that has worked hard and needs a rest. Resting, re-fuelling and waiting for nature to take its course – provided all is well with the baby – is a reasonable approach to a labour that is progressing slowly. I doubt that this test will reduce caesarean rates; rather I fear it will increase the caesarean rates.

Melissa Maimann, Essential Birth Consulting 0400 418 448

New Thinking on C-section Antibiotics

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In order to minimize the risk of infection in mothers, women giving birth to babies by caesarean section should routinely receive antibiotics an hour before the surgery, according to a new recommendation issued Monday by a national doctor group.

Currently, women who undergo caesareans often receive antibiotics as a precaution against infection to the abdomen and uterus—but usually only after the delivery, when the umbilical cord is clamped, because of concern for the baby’s safety.

Some pediatricians worry that antibiotics administered to the mother will reach the newborn and suppress the baby’s blood bacterial count, potentially masking a serious infection in the baby unrelated to the caesarean section.

The American Congress of Obstetricians and Gynecologists examined several large, recent studies that administered antibiotics to mothers before and after caesarean deliveries. The group concluded there was no evidence of greater risk to the babies when mothers received antibiotics before surgery. Yet there was an increased benefit for the mothers in receiving the antibiotics before surgery.

… Some 8% to 10% of women who have a scheduled caesarean will acquire an infection, as will about 30% of women who have a caesarean delivery after labor has begun, because of greater exposure of the inside of the uterus to bacteria from the vagina …

In newborns, the prevalence rates for sepsis … is estimated at less than 1% of live births.

While the maternal antibiotic appears to neither help nor hinder a newborn’s chances of getting sepsis, doctors have worried that in babies who have the bacterial infection, antibiotics administered to the mother before the c-section will suppress bacteria in the babies’ blood test, resulting in a failure to detect the sepsis infection.

Some doctors, however, question whether the existing research adequately addresses the question of harm to the baby.

Concerns about masking babies’ infections are largely theoretical … While the antibiotic does cross over from the mother to the baby through the placenta, and while it could mask the blood culture, there are usually other clinical signs that a baby is sick …

But while such a change in practice could make caesarean deliveries safer, it “comes nowhere close to eliminating all the risks of a c-section,” … vaginal delivery is still the safest for mom and baby.”

Melissa Maimann, Essential Birth Consulting 0400 418 448

Too Many C-Sections: Docs Rethink Induced Labor

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The rise in cesarean-section deliveries in recent years has been characterized by some as a key indication of the overmedicalization of childbirth. While the procedure undoubtedly saves lives and leads to better health outcomes for mothers and infants who face problems during pregnancy and labor, many experts say the procedure is being performed too often, and in many cases for nonmedical reasons, putting healthy women and babies at undue risk of complications of major surgery.

The rate of C-sections has reached more than 31% in the U.S., a historical high …

The rate of caesareans is the same in Australia. Our Government is making moves to cut this rate.

The reasons for the increase are many and have been widely discussed: the rising rate of multiple births, more obesity in pregnant women, the older age of women giving birth. In fact, C-sections have become so common that many women may have an inflated sense of safety about them. “For the most part, moms and babies go through the process healthy and come out healthy, so maybe there’s this sense that we’re invincible,” …

But C-section carries all the attendant risks of major surgery; and data show that compared with vaginal birth, cesarean delivery increases the odds that a mother will end up back in the hospital after birth with complications …

Now obstetrics experts are actively seeking ways to drive down the number of C-sections … the ACOG issued new guidelines recommending that hospitals allow most mothers who desire vaginal birth after cesarean … to attempt a trial of labor, including … mothers who are carrying twins or have had two prior C-sections. Despite studies showing VBAC to be safe for most women — ACOG data suggests that 60% to 80% of women who attempt VBAC will succeed — many hospitals have urged women to undergo a repeat cesarean over the past decade, largely to avoid medical risks and malpractice suits.

Another factor contributing to high C-section rates is the increase in induced labor, especially between 37 weeks and 38 weeks … The use of labor induction in the U.S. has risen from less than 10% of deliveries to more than 22%, between 1990 and 2006 … research suggests that induced labor results in C-sections more often than natural labor … those whose labor was induced were twice as likely to have a C-section delivery as those who experienced spontaneous labor.

… previous studies had come to the same conclusion. In her study of … mothers delivering before 41 weeks’ gestation … 44% of women had their labor induced.

… after 41 weeks’ gestation, at which point it is standard policy to induce labor, it may lower the risk of medical complications for mother and baby — including the risk of stillbirth — and even decrease the likelihood of C-section delivery, but those same effects are not seen in women who induce labor before the 41-week mark.

… Among the women whose labor was induced in Ehrenthal’s study, nearly 40% of cases were categorized as elective. In other words, there was no pressing medical indication for induction. Extrapolating from the study findings, Ehrenthal suggests reducing the use of elective labor induction could lower the national C-section rate by as much as 20%.

Several hospitals have already begun reducing medically unnecessary induction as a way to lower the rate of cesareans …

… under the new policy the overall induction rate dropped 33% and the rate of elective inductions fell by roughly the same amount … the total number of C-sections among first-time mothers who underwent elective induction dropped 60% …

If a relatively simple policy shift based on medical evidence can successfully cut the rate of induced labor and C-sections at a single hospital, experts say similar changes applied broadly may help lower the rate of C-sections on a national level.

But as with the new guidelines regarding VBACs, decisions about labor induction and other issues surrounding childbirth must be shared by women. Patients should be informed and included in the decisionmaking process, Ehrenthal says. “Unlike the decision to do an emergency C-section where there’s no time to talk, usually there is time to have a discussion about induction,” she says.

Melissa Maimann, Essential Birth Consulting 0400 418 448

New guidelines say vaginal birth OK after c-section

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Even if they aren’t staffed to handle emergency cesarean sections, hospitals should respect a woman’s informed choice to have a vaginal birth after cesarean (VBAC), new guidelines say.

VBAC is known to increase the risk that the scar left in the womb from a previous cesarean will tear during labor, leading to massive bleeding that can threaten the baby’s life. That has led to previous guidelines urging caution for women who have had cesarean sections.

But recent research shows so-called uterine rupture occurs in less than one percent of women who opt for vaginal birth, and that between 60 and 80 percent of VBACs are completed successfully.

While the new guidelines from the American College of Obstetricians and Gynecologists (ACOG) still say a full surgical team should be present in case an emergency cesarean is required, they now put a bigger emphasis on the woman’s decision.

“Respect for patient autonomy supports that patients should be allowed to accept increased levels of risk; however, patients should be clearly informed of such potential increase in risk and management alternatives,” they say.

“For most women with a previous cesarean delivery, a trial of labor is a safe and appropriate option,” …

… Even women who’ve had two prior cesareans might be good candidates for vaginal birth …

… Today, about nine in 10 pregnant women … end up with a repeat cesarean if they’ve already had one. By comparison about a third of all women who give birth have cesareans.

“… the cesarean rates are going up too fast,” … “There is no good evidence that newborns are better off now than they were 20 years ago.”…

Melissa Maimann, Essential Birth Consulting 0400 418 448

C-sections: getting the balance right

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THE FIRST successful Caesarean section (CS) recorded in Ireland was performed in 1738 by Mary Donally, a midwife, on a farmer’s wife who had been in labour for 12 days. She resutured the uterus and skin, and dressed the wound with the white of an egg. Within four weeks … the woman had recovered and was able to walk a mile. The survival of the mother after Caesarean section, however, was unusual. In 1884, a review of 134 operations reported a maternal mortality of 56 per cent …

… between 1932 and 1946, … only 2,273 (1.4 per cent) Caesareans were performed and 61 (3 per cent) of these were associated with maternal death.

By the end of the 20th century Caesarean births had become much safer for the mother. In 1985, the World Health Organisation concluded: “There is no justification for any region to have CS rates higher than 10-15 per cent”. Yet, in the generation since remarkable differences in global, regional, national and hospital CS rates have evolved. In underdeveloped countries, particularly African, CS rates remain around 2-3 per cent, in part because there is often no obstetrician available to do the operation.

Maternal mortality rates in these countries remain stubbornly high due to the lack of resources. In a report from 119 countries between 1991 and 2003, only 3.4 per cent of high-income countries had a CS rate of less than 10 per cent compared with 76.3 per cent of low-income countries. The maternal mortality rate per 100,000 live births was 630 deaths in the low-income countries compared with 54 in the high- income countries.

The risk of maternal death per million births has been estimated at 17-20 for a vaginal delivery, 59 for an elective CS and 182 for an emergency CS. Mortality risks of CS are low, but they are dependant on the healthcare setting and are higher in resource-poor countries.

Rising CS rates increase foetal risks. Elective Caesarean births increase the risk of transient tachypnoea of the newborn and respiratory disease syndrome …

In developed countries, however, Caesarean birth has become so safe that rates have soared as women and their obstetricians strive to avoid the perceived risks and traumas of vaginal birth …

Similar increases have been reported in other developed countries and there is no evidence that CS rates have reached a plateau.

In many developing countries, Caesarean section rates are too low, resulting in preventable adverse outcomes for mothers and their babies. In developed countries, there are growing concerns that CS rates are too high, particularly in circumstances where there is little medical justification for the operation.

A Caesarean delivery in the current pregnancy also has long-term implications … it increases the need for either emergency or elective Caesareans for future babies. It increases the future risk of catastrophic obstetric complications such as uterine rupture or peripartum hysterectomy …

Another concern about the rising CS rates is the impact on healthcare budgets with resources becoming more limited in the face of the economic recession … costs for Caesarean delivery were twice those for spontaneous vaginal delivery … for each 1 per cent reduction in the CS rate in England, the health services would save £8.8 million annually. Avoiding a first Caesarean delivery will also reduce economic costs in the longer term by decreasing repeat Caesareans.

The main reasons for the rise in CS rates in developed countries are the safety of the procedure and the perceived risks of labour. It has been fuelled by the carpe diem mentality of modern life where women and their doctors focus on the short-term outcomes of the current pregnancy without considering the long-term consequences for a woman’s health. This short-termism is more likely in circumstances where a woman is planning to have a small family.

Policymakers … have suggested target CS rates, for example … a CS rate of 20 per cent. However, such targets, including the WHO target, may be unrealistic. The optimum CS depends on local healthcare resources and service quality, and not on national or international recommendations. There is also a danger that, in attempting to meet hospital targets a Caesarean is not done in individual cases when it should have been done. This may have serious adverse consequences clinically and subsequent high financial costs medically and legally.

Optimising CS rates … needs to start with improvements in data collection and analysis to identify why Caesarean sections are done, and whether the results in some hospitals are outside an acceptable norm …

Any financial analysis also needs to consider the medico-legal costs of poor quality care. The CS rates cannot be considered in isolation, not just from the quality of clinical practices but also from the resources and organisation that underpin service delivery …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Who controls childbirth: women or doctors?

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That I am pregnant again is an act of either incredible optimism or mind-blowing amnesia. As the sonogram technician squirts jelly over my abdomen for my 20-week checkup, I think it’s the latter. Watching this baby, who the tech tells me is a boy, I am not caught up in visions of his future; I’m caught up in visions of mine. All of a sudden, I know with a certainty I haven’t allowed myself to confront before: Somehow, I am going to have to deliver this baby.
Obviously, you say. But my first birth was traumatic, and although my son and I emerged fine, I lost a year seeking treatment for post-traumatic stress disorder and all the depression, fear and anger it brings. I imitated mothers who seemed normal to me, cooing and tickling my son. In truth, I was a zombie, obsessing about how I had ever let what happened happen.

What happened is this: In my 39th week, I am induced because of high blood pressure. At the hospital, I am given Pitocin, a synthetic form of the labor-inducing hormone oxytocin, and Cervidil, a vaginal insert used to dilate the cervix. Within two hours, my contractions are one minute apart. I had lasted as long as I could without an epidural because I had read that they sometimes slow dilation. That’s the last thing I need: I’m at a pathetic 2 centimeters. My doctor comes up with a solution for the pain: a syringe full of a narcotic called Stadol.

“I have a history of anxiety,” I tell the nurse who has brought in the syringe, as I always warn any medical professional who wants to give me drugs. “Is this drug OK for me?” “It sure is,” she says.

It is not. Within 10 seconds, I begin hallucinating. For five hours, I hallucinate that I’m on a swing that’s soaring too high, that houses are flying at my face. My husband has fallen asleep on the cot next to me, and I’m convinced that if awakened, he will turn into a monster — literally. I’m aware this notion is irrational, that these images are hallucinations. But they are terrifying. I buzz the nurse. “Sometimes that happens,” she says …

By noon the next day, 24 hours after I had arrived, I am only 3 centimeters dilated. The new nurse, a nice lady, tells me the induction isn’t working. “Your blood pressure isn’t even high anymore,” she says. “Tell the doctor you want to go home.”

When my OB comes in, I say, “I’d like to stop this induction, if that’s possible. I’m worn out. I hallucinated all night … I just don’t think this is working out.”

“OK,” he says. “Let me examine you. If you’re still not dilating, we’ll talk about going home.”

My previous dilation exams had been quick and painless, if not entirely pleasant. This one takes a long time. Suddenly, it hurts. “What are you doing?” I scream. “Why does it hurt?”

No answer.

“He’s not examining me,” I scream at my husband. “He’s doing something!” My husband grips my hand, frozen, unsure.

I scream to the nurse, the nice one who had suggested I go home. “What is he doing?” She doesn’t answer me, either. I writhe under the doctor’s grasp. The pain is excruciating.

The first sound I hear is the doctor’s directive to the nurse, in a low voice: “Get me the hook.”

I know the hook is for breaking my water, to speed my delivery by force. I scream, “Get off of me!” He looks up at me, as if annoyed that the specimen is talking. I imagine him thinking of the cadavers he worked on in medical school, how they didn’t scream, how they let him do whatever he wanted.

“You’re not going anywhere,” he says. He breaks my water and leaves. The nurse never looks me in the eye again.

Eleven more futile hours of labor later, I am exhausted and terrified when the doctor comes in and claps his hands together. “Time for a C-section,” he says. I consider not signing the consent form, ripping off these tubes and monitors, and running. But the epidural I’d finally gotten won’t allow me to stand up.

It’s nearly midnight when I hear a cry. My first emotion is surprise; I had almost forgotten I was there to have a baby.

I was desperate to find someone who could tell me what had happened to me was normal. To say, “You hallucinated? Oh, me, too.” Or “My doctor broke my water when I wasn’t looking. Isn’t that the worst?” Nothing …

Now, I’d never loved my doctor … I’d found him patronizing — “Normal!” he’d shout at me, when I asked a question — I thought his assuredness might be a good antidote to my anxiousness. It seemed to work, until it didn’t.

… I also didn’t have a birth plan … Sure, I had a plan for the birth: Have a baby using whatever breathing method I’d learned in the hospital’s birth-preparedness class, maybe get an epidural. But I didn’t have the piece of paper that so many of my friends have brought to the hospital with them … in my opinion, the very act of creating such a contract was to ignore what labor is: something unpredictable that you are in no way qualified to dictate.

… people who hear my story ask … Did I consider a home birth? A midwife instead of an obstetrician? … The answer is no. I am not holistically minded. My philosophy was simple: Everyone I know has been born. It can’t be that complicated.

The women who ask me about my preparations for my first son’s birth — who imply with these questions that I could have prevented what happened to me if I’d been more diligent — are part of an informal movement of women who are trying to “take back” their birth — take it back from the hospital, the insurers and anyone else who thinks he can call the shots.

But hospitals aren’t so interested in giving women back their birth … stipulations dealing with labor and delivery (“I want only one medical professional in the room at a time”) garner barely a glance. University OB/GYN in Provo, Utah, even has a sign that reads, “…we will not participate in: a ‘Birth Contract’, a Doulah [sic] Assisted, or a Bradley Method delivery. For those patients who are interested in such methods, please notify the nurse so we may arrange transfer of your care.”

… This question of whether I could have prevented my trauma has lingered in my mind since that day; now that I am pregnant again, it has become deafening. I have a chance to do it all over. Would I benefit from thinking more holistically? Should I bother taking back my birth?

During my pregnancies, friends gave me two books; their spines are still barely cracked. The first is called “Ina May’s Guide to Childbirth.” … The other book is “Your Best Birth” by Ricki Lake and Abby Epstein; it’s an offshoot of their 2008 documentary, “The Business of Being Born.” Their urgent message is that women who want to deliver vaginally can do so if no one intervenes. Instead, doctors and hospitals are doing all they can to “help” the laboring woman along … and failing. Inductions like mine, epidurals given early in labor, continuous fetal-heart monitoring — all of them have been associated with a higher risk for cesarean section. The result is an epidemic — 32 percent of U.S. births were C-sections at last count, the highest rate in our history. Individual surgeries may be medically necessary, but as a matter of public health, the best outcomes for mothers and babies come with a rate of no more than 15 percent, according to the World Health Organization.

Sam … was five months pregnant when watching “The Business of Being Born” convinced her that hospitals could be dangerous and a home birth would be more meaningful. She and her husband found a midwife … and spent the rest of the pregnancy preparing.

After 24 hours of labor, Sam’s contractions were two or three minutes apart, yet when her midwife examined her, she was only 3 centimeters dilated. The midwife gently told her that she was nowhere close to delivering, despite her contractions, exhaustion and pain. Sam asked to be taken to the hospital.

The change of scenery did her good. “At that point, I had been in labor for 40 hours,” she says. “I entered the relaxed zone. The epidural took the edge off … It was a sacred space.”

After her son’s delivery, Sam passed out, having lost 50 percent of her blood volume in a postpartum hemorrhage. Needless to say, she was relieved that she was in a place where blood transfusions were readily available … she believes she will want midwife care at a hospital next time.

… Bialik’s first birth didn’t go the way she wanted. After three days of labor at home, she stalled at 9 centimeters, one short of the goal. Her midwife suggested they go to the hospital, where after a natural childbirth, Bialik’s son spent four days in the neonatal intensive-care unit. “My son was born with a low temperature and low blood sugar, which isn’t unusual in light of the fact that I had gestational diabetes,” she explains. “I understand doctors need to err on the side of caution, but there was nothing wrong with my child. All of our plans for bed sharing, nursing on demand, bathing him — gone.”

The experience was scarring. “I felt a sense of failure that I had to call my parents from the hospital,” Bialik continues. “Yes, I know vaginal birth in the hospital is the next best thing to a home birth.” …

I point out that natural childbirth in the hospital — her “failure” — was my best-case scenario. But I also understand when she says, “Everyone is allowed her own sense of loss.” She realized her vision when her second son was born at home.

The second time around
I don’t consider myself a candidate for a home birth. The risk of uterine rupture from an attempt at vaginal birth after cesarean (VBAC) makes it unthinkable … I’m also not really interested in a home birth … But I’m also not interested in another C-section …

So I’d like to attempt a VBAC, but I know that it doesn’t always succeed. I have a new doctor — the 10th I interviewed following my son’s birth — at a new hospital, and he has agreed to help me try. But my primary goal is more modest: not to be retraumatized. Even now, my heart pounds at the sight of hospital receiving blankets, the antiseptic smell of the maternity ward.

The common thread in Bialik’s and Sam’s stories that impressed me was how supported and safe they felt with their midwife …

In an e-mail Bialik sends after our meeting, she goes back to my idea that some women weren’t meant to have babies the holistic way. “There are those among us who believe that if the baby can’t survive a home labor, it is OK for it to pass peacefully,” she writes. “I do not subscribe to this, but I know that some feel that … if a baby cannot make it through birth, it is not favored evolutionarily.”

I think about my appendectomy, back in 2003. Had I not made it to the hospital in time, I would be dead. What would it be like to refuse medical intervention? I’d call my family, say my good-byes. “I’m sorry,” I’d say. “But I’m not evolutionarily favored. It’s time for me to go.”

This attitude, that everything was better back when there were no doctors, seems strange to me. C-sections, although certainly done too often, can save lives. Orthodox Jews still say the same prayer after childbirth that those who have been in near-death experiences say — and with good reason. A birth that leaves mother and child healthy may be commonplace, but it’s also a miracle every time.

As the weeks pass and my belly grows, I can’t stop thinking about Sam. Her pregnancy was a sacred time, and she had truly looked forward to labor. Is that what I should try for — a meaningful birth, as well as an untraumatic one? At what point had people like Sam and me learned to feel entitled to a meaningful birth?

“I think that birth should be a beautiful experience,” says obstetrician Kimberly D. Gregory, M.D. She’s the vice chair of women’s health care quality and performance improvement at Cedars-Sinai Medical Center in L.A. “It should be exactly the way you want it, and doctors should intervene only to preserve the health or life of you or your baby.”

Naturally, one would assume that Dr. Gregory advocates birth plans. When I ask her this, she laughs. “We always say, ‘If you show up with a birth plan, just get the C-section room ready,’” she says. “You get everything on that list that you don’t want. It’s like a self-fulfilling prophecy.” Dr. Gregory led an unpublished study that compared women who took traditional hospital birth classes with those who employed Bradley-like training and a birth plan. The birth-plan group trended toward a higher C-section rate and more interventions. “There’s a certain personality type that tends to be more anxious. Maybe the anxiety hormones themselves put them at risk,” Dr. Gregory theorizes. “It seems that being open and honest and choosing the right doctor is probably a better option than writing everything down. Walking in with this list appears to set up an antagonistic relationship.” …

… In the past three weeks, I’ve had the same dream. I’m in a field (I believe at Ina May Gaskin’s Farm), and women in braids are dancing around me as my baby is born, painlessly, joyously. As I reach down, I notice my C-section scar is gone.

I wake up upset. Am I truly under the impression, subconscious though it may be, that taking back this birth will undo the damage of the last one?

“I don’t understand this phrase ‘take back your birth,’” nurse-midwife Pam England, creator of “Birthing From Within,” … tells me. “Who took it? What would a woman tell herself it meant about her if she failed to meet the criteria she made up for ‘taking back’ her birth? I am concerned that this phrase, meant to generate action and a feeling of empowerment, may actually be generated by or feeding the victim part of her.”

England is right: Having a childbirth that I deem successful this time will not change what I haven’t overcome from the first. I try to find a way to make what my doctor and nurses did to me OK, but my mind rebels. I feel loss — no, theft — of an opportunity for me to have a baby the way so many other women do: a carefree pregnancy, a labor that could still go any way.

Maybe I’m not so different from the women I spoke with, after all. Bialik had a successful natural childbirth but felt like a failure because it was in the hospital. Women who had a C-section also used words like failure. Perhaps part of the problem is that our generation of women is so ambitious, so driven, that we don’t know how to do anything without quantifying it as a success or failure.

According to Dr. Gregory, women are now requesting a C-section for their first birth, even without indication. “A lot of people are uncomfortable with the unknown,” she says. Plenty of people are wary of C-sections by choice, from holistic moms to obstetricians. But isn’t this, too, taking back your birth? Refusing to be out of control seems to me the epitome of taking it back. You don’t have to have an unattended birth in the woods to be considered a real woman.

Deciding that you can’t control the uncontrollable — and committing to that decision when you are, in fact, out of control — is also taking back your birth. It’s what your grandmothers did. It’s what their grandmothers did.

With this, I realize that I have already taken back my birth, but not as part of any movement. I have stopped judging women who take extra precautions as defensive and started to understand that everyone has to find her way.

I don’t know how this story ends. I’m still not convinced my body was made to deliver vaginally. But here’s what I do know: I will insist on kindness. I will insist on care. And I hope I will be open to being treated kindly. It’s harder than it seems.

I have another hope, too. I hope there will be a moment when … I will look down at my baby — whether he is handed to me on my belly or from behind a curtain as my body is sewn shut — and I will remember what I’ve known from the beginning, when I looked down at that plus sign and we were alone together for the first time. Before these questions wrapped around my neck, choking me for answers. I will know that I am his mother and he is my son. And maybe, in that moment, I will be ready to say that the only success and failure is the outcome of the birth, that we are healthy …

I’m concerned that birth is defined in terms of success and failure, and that after this author’s journey, she has determined that health is the only important factor. In this day and age, it is entirely possible to have a safe VBAC – a safe birth experience as well as a satisfying one. The vast majority of women who choose VBAC will be successful provided that they choose the right care provider.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Focus on waterbirth

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NSW’s runaway caesarean birth rate is set to be reined in by one-third under an ambitious five-year plan to normalise the process of giving birth and reduce unnecessary intervention in public hospitals.

The proportion of surgical births should be reduced to 20 per cent by 2015, from 30 per cent now, and first-time mothers would be attended by the same midwife throughout labour.

The option of labouring in water, although not necessarily water birth, would be offered universally under the mandatory policy.

It’s a wonderful idea to introduce policies around use of water in labour, but not necessarily waterbirth. Most units don’t permit labouring in water, either due to lack of baths / pools or because the policies do not support it. Waterbirth challenges some doctors and even some midwives; promoting the use of water in labour is a fantastic starting point and from that, let’s hope waterbirth becomes more of a standard option in delivery suites. This move also complements the re-intruduction of private midwives back into hospital delivery suites with visiting rights.

The policy, the first of its type in Australia, is modelled on a 2005 British one credited with starting to reverse that country’s escalating caesarean rate.

The Minister for Health, Carmel Tebbutt, said the directive was ”designed to support women to have a birth that is as free as possible from invasive medical intervention, while also recognising that labour occurs across a wide spectrum … The safety of mother and child are, of course, paramount.”

The president of the Australian College of Midwives, Hannah Dahlen, said: ”For the last 15 to 20 years [birth interventions] have just gone up and up and up. At some point we have to start coming down again. The policy says, ‘Let’s stop, let’s regroup and try to get a balance.’ ”

She emphasised it would remain ”the safest option for some women to have a caesarean section, and women should not feel lesser because they had to have an intervention”.

Only about 13 per cent of women now achieved a vaginal birth after a caesarean, while up to 80 per cent could do so if properly supported. The NSW targets specify a 30 per cent rate by 2012 and 50 per cent by 2015.

”It all depends on how women are supported and how the facility as a whole supports it,” said Associate Professor Dahlen, a member of the committee that drew up the plan.

It always interests mt that VBAC rates vary so much. 80-90% with private midwives and as low as 1% with private obstetricians. Yes, it’s defintely about the level of support that a woman receives.

Ted Weaver, the president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, applauded the NSW policy to have a single midwife attend first-time mothers, but said this would require a shake-up of workplace rules.

Dr Weaver said the appropriate caesarean rate was about 25 per cent of all births, because the current generation of women represented ”an older population, a fatter population, and a lot of first-time mothers”, Factors which raised their risk.

Michael Chapman, professor of obstetrics and gynaecology at St George Hospital, said the policy would require more senior doctors, who had the expertise to continue with a vaginal birth when manageable complications arose …

Melissa Maimann, Essential Birth Consulting 0400 418 448

World Health Organisation drops its caesarean rate figure

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The World Health Organization … had previously advised that no more than 10 to 15% of babies be delivered by section …But now the WHO states that “there is no empirical evidence for an optimum percentage” and stresses that “what matters most is that all women who need Caesarean sections receive them”.

Yet in the NHS, doctors, hospitals and midwives have been under pressure to persuade women to give birth naturally. So should there be less pressure on women to avoid surgical intervention?

… Janet Fyle, from the Royal College of Midwives, said she believed the WHO’s original target was right, although nobody had kept to it.

“If a woman has a normal birth her outcomes and her chances of recovery are much better than someone who has gone through a major operation like a Caesarean.”

The surgical procedure means that both mothers and babies face slight risks, although often these risks are outweighed by the problems of proceeding with a natural birth.

Experts point to an increased risk of respiratory problems for the baby, higher risk of bleeding for the mother and a longer stay in hospital to recover as reasons why natural births are the preferred option.

… Professor James Walker, consultant obstetrician at St James’s University Hospital in Leeds and spokesman for the Royal College of Obstetricians and Gynaecologists, says targets are not helpful for Caesareans.

“If you set a target then people focus on that target. What we should be doing is giving optimal care to the mother. That way we minimise the reasons for a section.

“Having a Caesarean section is a reasonable option, but it’s about the appropriate treatment for the appropriate people,” he said.

Health professionals are regularly heard to say that giving birth is an unpredictable business. The key issue for many is having the right professionals around who understand pregnancy and birth so that women can be helped through their labour experience.

‘Normal birth’

In situations where a woman experiences complications in labour, says Maggie Blott, consultant obstetrician at University College Hospital in London, a Caesarean should be carried out for the right reasons.

“My job is not to perform Caesareans, it’s to prevent them happening.

“To help this process decision-making must be correct at a senior level and consultants should be available on labour wards all the time to advise,” she said.

The RCM’s Janet Fyle said: “There are many reasons to deliver babies by planned or emergency Caesarean, but we should be doing all we can to support women to have a normal birth, where possible.”

Having a good mix of staff on the labour wards, including senior midwives and consultants, is seen as key to keeping Caesarean rates down …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Induction of labour can lead to caesareans

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A new study … looked at 7,804 pregnant women giving birth for the first time and found that 43.6 percent of them had their labor induced … [Women having an induction] regardless of the reason were 2.6 times more likely to have a C-section, meaning 20 percent of them were linked to inducing labor. In 1990, 9.5 percent of women in the United States had their labor induced. Sixteen years later, that number jumped to 22.5 percent. Currently, 32 percent of babies born in the United States are delivered by C-section, an all-time high. Women who deliver by C-section the first time are more likely to have a C-section in subsequent deliveries, so the goal is to prevent C-sections the first time around.

There’s a place for all interventions in labour and birth. Mostly, they’re over-used. However, sometimes intervention is life-saving. Some good reasons for an induction might be high blood pressure or a baby who is not growing well inside. However, reasons such as suspected big baby or wanting to schedule birth for convenience might be re-thought in light of this research that confirms previous research on the topic.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Risk for babies born one week early: Serious health problems more likely

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Babies born only a week early are at higher risk of a host of serious health problems from autism to deafness …

A study of hundreds of thousands of British schoolchildren found that those born at 39 weeks are more likely to need extra help in the classroom than those delivered after a full 40 weeks in the womb.

… With most planned caesareans carried out at 39 weeks, the finding raises concerns that women who have the operation for non-medical reasons could unwittingly be endangering the health and prospects of their children.

… Almost 18,000 had been classed as having special educational needs. The term covers learning disabilities such as attention deficit hyperactivity disorder, autism and dyslexia, and physical problems such as deafness and poor vision.

The risk was highest in those who spent the shortest time in the womb. For instance, babies born at between 24 and 27 weeks were almost seven times more likely to need help at school than those delivered at 40 weeks. But even being born just a few weeks early made a difference …

Those born at 37 weeks were 36 per cent more likely to have learning difficulties, while for those born at 38 weeks the figure stood at 19 per cent.

Babies born at 39 weeks … were 9 per cent more likely to have special needs …

… These findings … suggest that deliveries should ideally wait until 40 weeks of gestation … ‘However the cause of early birth may contribute to the risk, for example, a baby who’s already sick may need to be delivered early to give it a chance of survival …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Caesareans take toll on babies

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Babies born by caesarean section are more vulnerable to asthma, allergies and infection because they miss out on receiving their mothers’ good bacteria during birth.

… This bacteria … [colonises] the intestine …

“This can have long-term health implications, as the development of a good intestinal ecosystem is necessary for health and immunity to allergies, from childhood right through to adulthood.”

… emergency caesareans, performed after labour had already begun, meant babies did receive some of the beneficial bacteria, particularly if the waters had broken.

However, elective caesareans … gave babies no chance to pick up any of the good bacteria.

… Australian College of Midwives vice-president Hannah Dahlen said babies born vaginally also had the advantage of hormonal surges during labour that made them more wide-eyed and able to connect with their mothers. Both mother and baby experienced a surge in catecholamines, the fight-or-flight hormone, during labour, making babies more alert at birth.

… white blood cells in babies born by caesarean were different to those of babies born vaginally, potentially altering the way their bodies responded to attacks on their immune systems for the rest of their lives.

The studies could explain dramatic increases in rates of diabetes, testicular cancer, leukaemia and asthma among babies born surgically, said Associate Professor Dahlen.

”In labour, the baby has a gradual escalation in its stress response and then a gradual decline. Research has shown that this could prime our bodies to respond to stress in a certain way,” she said.

”With a c-section, there is a … dramatic stress response. It could be setting that child up to always over-respond to stress.”

… previous studies … found babies born surgically had a 20 per cent increased risk of developing diabetes …
Melissa Maimann, Essential Birth Consulting 0400 418 448

Obesity Leading To More Caesareans

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Obesity increases the risk of needing to deliver a baby by Cesarean section. That in turn leads added risks from major surgery, potential for serious complications, and additional recovery time …

… obesity can interfere with a woman’s ability to get pregnant …“Obese patients have no good options,” … they are at increased risk of complications from a C-section, such as clotting in the legs associated with a pulmonary embolism, and increased risk of wound breakdown.

“Obesity decreases fertility and increases the chance of losing the baby, of hypertension and pre-eclampsia, which kills a lot of women around the world,” … because fertility drops with rising obesity, many women seek help in conceiving from fertility treatments, which increases the chance of having multiples (twins and triplets) and therefore increases the chance of having a C-section.

Obesity is a risk factor in C-sections independent of other factors, but it goes hand in hand with other serious complications, like diabetes and cardiovascular disease …

Ideally, women will attend preconception care where issues such as lifestyle, stress, nutrition, exercise and health can be addressed prior to becoming pregnant.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Canadian Researchers Suggest Review Of Current Guidelines On C-Sections

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A recent study showing that the rate of cesarean sections performed at hospitals across … Canada, varied between less than 15% and more than 27% — with only 2% requested by the women — prompted researchers to recommend “revising the current guidelines” on when it is appropriate to perform a c-section … Difficult labor was found to be the most prevalent cause for a c-section …

It will be interesting to read what the new guidelines say. Certainly, some factors promote vaginal birth such as staying at home for as long as possible in labour, planning a homebirth, receiving midwifery care, being well prepared – emotionally, mentally and physically – for birth, reading widely about pregnancy and birth to be well-informed and more comfortable with the process and having the continued support of a midwife who is experienced in supporting women through natural birth.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Doctor preferences may explain high C-section rates

Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

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The number of Cesarean sections performed at hospitals across British Columbia is highly variable, Canadian researchers have found.

Even when accounting for differences in women’s preferences and conditions that could complicate vaginal delivery, C-section rates varied from less than 15 percent to more than 27 percent of all births.

“Thus, our results illustrate what we believe to be ‘unwarranted variation,’” … noting that mothers requested C-sections in only 2 percent of the cases.

… earlier studies have found marked variation in the United States as well. Both Canadian and US experts agree that the current Cesarean rate — in the US, one-third of all births — is too high …

We have a similar situation in Australia where caesarean rates vary widely between public and private hospitals and midwifery-led services and obstetric-led services. Our National caesarean rate is also around 1 in 3.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Among the more than 100,000 deliveries that they analyzed, the most common reason for C-section was difficult labor, which accounted for one-third of the surgeries, and was also highly variable between different areas.

As a result, the researchers write, “we suggest that revising the current guidelines regarding the management of (difficult labor) may be a good starting point on the road to decreasing unwarranted variation in cesarean delivery and assisted vaginal delivery rates.”