No room at hospital for ‘high-risk’ pregnancies

Posted on April 24, 2009 by Melissa Maimann

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

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PREGNANT women were being turned away from Bowral
Hospital because the maternity ward doesn’t treat high-risk pregnancies, a mother of six has claimed.

The News understands there is only one permanent obstetrician currently on staff after two had left during the past six months.

Several women claim they were told they couldn’t deliver at Bowral because they were considered high-risk and not because of inadequate resources.

… the hospital no longer delivers babies for women who have had caesareans.

Mother of six Kellie Bennett said she was forced to have her first home birth in February after her obstetrician … left the hospital late last year.

… A GP told Mrs Bennett a few days later she couldn’t deliver her baby at Bowral because the hospital had a no-vaginal birth after caesarean policy.

She was told she would have to attend Campbelltown Hospital, but should be prepared to travel to Liverpool Hospital as Campbelltown had issues with their own numbers and may not be able to accommodate her.

Mrs Bennett’s fifth child was delivered via caesarean in July 2007 with no complications.

Worried about where she would deliver her most recent child, Mrs Bennett arranged to meet Bowral’s temporary obstetrician at the time … to discuss a plan of action … She was unsatisfied with the response.

That was the last time Mrs Bennett attended Bowral Hospital.

Bowral Hospital general manager Denis Thomas denied there was a policy of rejecting women with previous caesareans.

… He said Bowral was not equipped to deal with high-risk pregnancies and only catered for women with low risk and selected moderate risk pregnancies.

After obtaining her medical records before her home birth Mrs Bennett said she discovered abnormalities in her previous pregnancies.

She said her fourth child was delivered by caesarean because she was told it was in a difficult breech position but her records show the baby was in normal breech position for a natural birth.

…She added she was told she was at high-risk because of high blood pressure, but her records didn’t indicate that.

“I was upset at the time as I assumed they knew best,” she said. “Maybe women who are told they are at high-risk aren’t at high-risk at all.”

The Colo Vale resident wondered if women were being unnecessary induced and given caesarean births because of the lack of resources at the maternity ward.

…. The birth of her sixth child Matilda on February 27 went perfectly and she recommended home births to other expectant mothers.

… Mrs Bennett said more information on home births needed to be available to mothers if the hospital was unable to look after them.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Lessons from Labour

Posted on April 20, 2009 by Melissa Maimann

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

Link to article

Dr Hannah Dahlen wrote a great article on Unleashed. She is the Associate Professor of Midwifery at the University of Western Sydney. She has been a midwife for more than 20 years. Hannah is also the Secretary of the Australian College of Midwives, NSW Branch. She has researched women’s birth experiences at home and in hospital and published extensively in this area.

I have had the pleasure of Hannah’s company several times and I am impressed by her skill, commitment and dedication.

The front page of the Daily Telegraph ran the sensational headline recently ‘Four dead in home birthing’. The article went on to say that at least four babies had died ‘during homebirths in the past nine months’ and a further four babies had suffered brain damage. This was presented as ‘fact’ although it remains unconfirmed to date.

The facts we have from the latest Australian Institute of Health and Welfare (published in 2008), indicate that 708 women had planned homebirths in Australia in 2006 (0.3%) and there were no deaths reported amongst these births. In this same year 2730 babies died – most of them in Australian hospitals. While we must remain committed to trying to reduce these deaths, the reality is this rate has remained unchanged for nearly 15 years, despite a doubling in the caesarean section rate.

What has been missed in this debate is the difference between a planned home birth for a woman with a low risk pregnancy attended by a competent midwife who is well networked into mainstream services (supported by evidence as safe), and a birth at home where there is no professional care or where the woman has risk factors in her pregnancy (supported by evidence as less safe).

To put some balance into this argument the following issues need to be considered.

Firstly, the intervention rates during childbirth have sky-rocketed over the past ten years in Australia, leaving many women traumatised and fearful. A first time mother in Australia now has a greater chance of having surgical intervention during her birth than of not having it. Miranda Devine’s mocking disregard for the emotional trauma that stems from this reality was evident in her article ‘A home birth is not a safe birth’.

Secondly, options of care for childbearing women remain limited with around three per cent of women able to access continuity of midwifery care.

Thirdly, around 130 maternity units have shut down in Australia over the past 10 years, many of these in rural and remote Australia, leaving women with little option but to travel great distances from family and community to give birth. The rising incidence of ‘roadside births,’ is the unintended consequence of such actions.

Fourthly, privately practicing midwives have not been able to obtain affordable insurance since 2000, leading many to stop practicing, with the remaining midwives practicing uninsured and without visiting rights to hospitals. Midwives cannot even order routine blood tests or ultrasounds and often find it difficult to obtain the results for the women they care for, causing delays in appropriate management.

Fifthly, there are very few financial rebates women can access for midwifery care, and they pay between $3000-5000 dollars for this service. Some women clearly cannot afford it.

The ramifications of these issues are: more traumatised women due to interventions during birth; fewer options of care – especially continuity of midwifery care; fewer experienced, networked midwives available to attend women privately; and no access for women to a hospital birth under a private midwife. The result has been increasing numbers of unattended births and more women with high-risk pregnancies seeking midwifery care at home.

The rise in the numbers of unattended births is ironically being seen in two countries – Australia and the USA – both with the highest intervention rates in birth and limited access to continuity of midwifery care.

The answer to all this is not to demonise women but to stop and consider our responsibility as a society to mothers and babies. It is time we made our maternity care system accountable and really listened to what women are telling us. Over 400 submissions from women to the government, as part of the National Maternity Review should not be dismissed as irrelevant, as Miranda Devine seemed determined to do. It is time to make birth safe, physically, emotionally, culturally and spiritually.

Never before in history have women been able to reap the benefits of safe and satisfying birth like we can now. We need to give women access to choice and continuity of care, where midwives and doctors are willing and able to work together respectfully. We need to begin to reconstruct our maternity system with women, their babies and families at the centre – not the health professionals and their inevitable turf wars.

In the United Kingdom they have made an effort to do just this, with a joint statement on home births produced by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives. In this joint statement they say, “The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.”

In Scotland they are now urging mothers to give birth at home. In the Netherlands where 30 per cent of babies are born at home, and the caesarean section rate is more than half ours (14 per cent versus 31 per cent), both private insurance companies and government health funds cover only midwives or general practitioners and home birth; or short stay hospital births (anything more women pay for), for low-risk pregnancies.

Financial support for care from an obstetrician is only available to women with high-risk pregnancies. For women with low-risk pregnancies in the Netherlands, outcomes of planned home births are as good or better than the outcomes of hospital births. The often misquoted Bastian study of homebirth in Australia between 1985 and 1990 showed, “while homebirth for low risk women can compare favourably with hospital birth, high risk home birth is inadvisable and experimental.”

The Bastian study provided what we call low-level evidence – the study design was retrospective (looking back at what had been done), it included births by non-registered and registered midwives and it used a number of methods to collect the data (eg searching newsletters for death notices). The one study you will never hear the medical profession quote is the USA home birth study. This was a prospective study (gathering data as it happens) looking at 5418 low risk women who planned a home birth with midwives in the USA and Canada in the year 2000. There was no difference between the numbers of babies dying at home or in hospital, but the intervention rates were significantly lower amongst homebirth women.

The largest study done to date in the world was published this month and showed that out of more than 500,000 births in the Netherlands there was no difference in outcomes for babies of planned homebirths and babies of planned hospital births. What all this research indicates is homebirth is safe for low risk women under the care of competent, networked midwives who work in collaboration with mainstream maternity services.

Recent media has revealed the hazard of ignoring this evidence.

Whatever your beliefs about home birth, the facts are this – never in history, and in no country on earth, has homebirth ever been eradicated. There are two potential responses to this fact. One, we put in place supportive, safe, collaborative systems of care that respect a woman’s right to choose her place of birth and care provider, like they have in the UK and the Netherlands, or two, we bury our heads in the sand and hope it will all go away.

This last choice is the one we have made to date in Australia and it is clearly not working. It’s time to take the proverbial ‘log’ out of our own eye and seriously consider where we have let women down in the maternity system we currently make available to them, before we try to pick the ‘spec’ out of our sister’s and criticise the choices some may make.

Perhaps then we will all see more clearly, and hopefully respond more wisely.

I think what really needs to be addressed is the hospital system that currently delivers the majority of maternity services. We can enable independent midwifery practice, open birth centres – even freestanding birth centres – but until we address the real issue – the medically-dominated and un-woman-centered care that is present in most hospitals, we will not move forward.

Melissa Maimann, Essential Birth Consulting 0400 418 448

A hospital is not a natural environment for a natural event

Posted on April 18, 2009 by Melissa Maimann

Visit my website to learn more about my services.

Link to article

This week a study – the largest of its kind – was published in … an International Journal of Obstetrics and Gynaecology. It showed that giving birth at home was “as safe” as giving birth in a hospital.

Periodically, we get studies like these. They come, they make a bit of a splash and then they go again. What they’re saying however is so fundamental that we can’t ignore it. Because a woman’s experience of labour can shape her entire life, even the relationship she then forms with her child.

I’d go further than these studies and say that giving birth at home, these days, is safer than being in a hospital. A woman in labour needs to be confident and relaxed. Fear is the enemy of labour progressing because it causes the woman’s body to release adrenalin which inhibits oxytocin – the hormone needed to make the uterus contract.

A pregnant woman needs to build a relationship with her midwife so that she feels confident and the midwife can anticipate problems before they actually occur. Despite popular scare-mongering, a woman or her baby don’t just die without warning in labour. There are signs that something is amiss, and these signs can be missed in a busy hospital.

All of this is difficult to achieve in a hospital where you’re in a strange place, with people you may have only just met coming and going (“how are you getting on?”) and with the almost constant threat of induction (which ironically is when they administer artificial oxytocin – having inhibited the natural stuff – to speed things along) if your labour doesn’t conform to their timetables.

In The Father’s Home Birth Handbook (a quite brilliant book, as dads are often more fearful than women of homebirths), it asks which would you prefer? Having sex at home, all low lights and candles; or in a hospital with bright lights, and where everyone is monitoring your every move. A hospital is not a natural environment for a natural event.

Eight weeks ago I gave birth to my second child. She was born at home. I had no drugs. Easy for you, you may be thinking: you were obviously low risk, brave and had a high pain threshold. I was none of those things. I was 42, my previous labour had ended in an emergency C-section and I’d spent five years grappling The Fear. But, crucially, since I’d last given birth, I’d been a lay representative in a major maternity hospital (so I had also seen the wonderful things hospitals could do) and spent four and a half years as co-founder of a parenting board. I learned that the majority of problems with childbirth weren’t solved by hospitals, but introduced by them.

When I hear a woman say, “If it wasn’t for the hospital little Johnny would be dead” and trace the story back, nine times out of 10 you see little Johnny would never have got into distress if his mother hadn’t been in a hospital in the first place.

Home birthsaren’t for everyone. But then, neither are hospital births, which also carry risks. We’re in a unique position now in that we have more medical knowledge than ever before and most of us are near a hospital in case we need to transfer. Yet women are still told of all the risks of a home birth, and none of the benefits. The latter far outweigh the former.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Repeat C-sections Rise By Over That 40 Percent In One Decade, USA

Posted on April 17, 2009 by Melissa Maimann

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

Link to article

The percentage of pregnant women undergoing a repeat Cesarean section … jumped from 65 percent to 90 percent between 1997 and 2006 … Nearly one-third of the 4.3 million childbirths in 2006 were delivered via C-section, compared with one-fifth in 1997.

… although C-sections account for 31 percent of all deliveries, they account for 45 percent of all costs associated with delivery.

C-sections account for 34 percent of all deliveries by women who are privately insured but only 25 percent of deliveries by women who are uninsured.

This is similar to the situation in Australia where we have escalating primary caesarean rates and diminishing VBAC rates. Hopefully the changes proposed in the Maternity Services Review will help midwives to become primary care providers to women – this will help to reduce the caesarean rate. If homebirth midwives are able to access insurance and hence register, this will also help lower the CS rates.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Birth in NSW Today

Posted on April 13, 2009 by Melissa Maimann

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

In the past ten years or so, a lot has changed Australia-wide when it comes to birth. Focusing solely on NSW, the latest (2006) report paints a grim picture of birth in this State.

Since 1996, the caesarean rate has increased a whopping 64%. The caesarean rate was a mere 16% in 1990, rising to 17.6% in 1996. It is now 29%.

In 1999, 22.5% women had a VBAC. By 2006, this figure was down to 12.7%, with some hospitals having VBAC rates of a mere 2%.

In 1996, 23.1% women had an epidural or a spinal. In 2006, this figure was 43.5%.

In 1996, 70.7% women had a normal vaginal birth. This figure fell to 60.4% in 2006. Some private hospitals have normal birth rates of 32%. It makes you wonder what is “normal” in those hospitals. That hospital in particular has a caesarean rate of 45.3%. Maybe we need to re-define normal birth. In contrast, another hospital has a normal birth rate (as in, a normal vaginal birth) of 93.4%. It makes you wonder what is possible, given the right information, support and care provider.

Publicly-funded women had the following outcomes in 2006:

Normal birth: 67.1%
Assisted vaginal birth: 8.2%
Caesarean: 24.3%

Privately-insured women had the following outcomes in 2006:

Normal birth: 48.9%, 37% lower than publicly-funded women
Assisted vaginal birth: 14.5%, 77% higher than publicly-funded women
Caesarean: 36.4%, 50% higher than publicly-funded women

In 1999, 0.6% babies were stillborn, and 0.3% babies died shortly after birth. In 2006, 0.6% babies were stillborn, and 0.3% babies died shortly after birth. Those figures remain unchanged, despite our ever-increasing rates of intervention. The perinatal death rate per 1,000 births remained stable between 2002 and 2006: 2002 recorded 8.7 deaths per 1,000 births; 2006 reported 8.8 deaths per 1,000 births. No babies died in home births in 2006. The most common cause of neonatal death was extreme prematurity. Between 1990 and 1996, the perinatal mortality rate decreased from 10.4 to 8.9 per 1,000.

Looking now at maternal mortality (indirect and direct causes), in 1990, this figure was 11.6 per 100,000. The figure came down to 9.0 per 100,000. Because these numbers are so small, when we look at the stats for individual years, we see that the rate fluctuates from 4.7 to 11.6 per 100,000. Maternal mortaility is generally analysed in trienniums to try to even out these differences. The average maternal mortality between 1990 and 2005 is 8.1 per 100,000.

Looking now to home birth statistics, we see the following results:

Transfer rates range from 43% to 22%, depending on the criteria for home birth. The transfer rate is 12% – 20% for privately-practicing midwives. You need to remember that this figure includes women who transfer in pregnancy – eg for high blood pressure, placenta praevia etc. Most transfers were not in labour. Many of the women who transferred achieved a vaginal birth in hospital.
Normal birth rates range from 82% 94%
Assisted vaginal birth rates range from 3% to 4%
Caesarean rates range from 5% to 14%
VBAC rates range from 65% to 85%
Episiotomy rates range from 2% to 4%
Stillbirth + Neonatal death rates range from nil to 2.3 per 1,000, and one study even found a death rate of 9 per 1,000.

Midwifery care has several advantages

Less likely to be hospitalised during pregnancy
Less likely to have an epidural
Less likely to have an episiotomy
Less likely to have an assisted vaginal birth
More likely to have a natural labour and birth
More likely to feel in control during labour and birth
Higher breastfeeding rates
More likely to report a high level of satisfaction with the care and the outcome
You will have autonomy
You will have choice and control over what happens to you and your baby
You will be a partner in your care

So …. where will you have your baby? Who will you choose to be your care provider? Be sure to employ a private midwife if you choose to have your baby in hospital.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Caesarean rates rise as mothers get older

Posted on April 12, 2009 by Melissa Maimann

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

Link to article

MORE than one in five babies in NSW are born to mothers aged over 35, and almost one in three are delivered by caesarean section, latest figures reveal. NSW Health authorities say women are ignoring warnings about the increased risk of pregnancy complications and birth defects as women age.

This may be for good reason. Risk does not equate with eventuality. If it did, we’d all live in hospitals just in case. Another approach is to argue that since some complications are more likely in women over 35 or 40 or whatever age, let’s take the path of prevention, and put our energies into preventing what may go wrong and enjoying the healthful state of pregnancy. Doctors are always available if needed; let’s call on them when we need them, not because we might need them.

For the first time, fewer than half of all babies born in private hospitals had been delivered by normal vaginal birth.

This is a disgrace! In some private hospitals, around 1 in 3 first-time women will birth their baby without forceps, vacuum or caesarean. The article goes on to say:

Women with private health insurance had higher elective caesarean rates (25.4 per cent) than the overall rate of 17 per cent.
The Mater at North Sydney and Kareena Private Hospital in Sutherland Shire had rates of 32 per cent.

The data will fuel the debate between maternity experts who say childbirth has become overly “medicalised” and those who advocate the right of the mother to choose how, when and where to have a baby.

Is it any wonder women are turning to midwives for their care in an attempt to avoid becoming yet another caesarean statistic?

… Over 10 years, surgical births had risen by more than 60 per cent, from 17.6 per cent to 28.8 per cent of all births. Normal vaginal births had fallen from more than 70 per cent to 60.4 per cent in the same period.

And what is the Govt doing about this? Homebirth midwives have caesarean rates of well under 10% – many around 5%. It’s amazing how well nature works, when you let it.

Dr Nicholl said the increased level of medical intervention could not be explained by older mothers alone. He said many first-time mothers who have their labour induced do not progress well and go on to need forceps or vacuum delivery, or caesarean section.

At least there’s some acknowledgement of the way the medical model has messed up natural birth and its outcomes. The vast majority of first time mothers do not require induction. Women who start labour spontaneously usually labour very well, and if pain relief consists of use of water in labour and positioning, you’ll find epidurals and forceps / vacuum are not needed so often.

“There is a level of fear attached to childbirth, and women who have had a caesarean section are fearful of trying to have a vaginal birth the next time.”

I’d be fearful too if I knew that my VBAC was going to be managed with admission as soon as labour started, continuous monitoring, labouring in bed, an IV “just in case”, a recommendation of an epidural, vaginal examinations every 2-3 hours, and a caesarean if I didn’t dilate at the required rate. Not to mention the fear of friends and family and the scare-mongering of some of the medical profession. Again, private midwives achieve a VBAC success rate of 80%+. Why is that you need to have a private midwife in order to have a VBAC? NSW’s rate of VBAC was 12.7%, down from 17% in 2002. Some NSW hospitals have rates as low as 2 or 3%. This is in our private hospital system, where we are supposedly supported in our birthing choices. So long as we are choosing caesarean, induction, epidural. It seems natural birth doesn’t exist in the private health system.

To turn now to this article, we can see how it happens that women end up with “necessary” caesareans in the private health system:

FOR Anita Catilano, 43, the choice of a caesarean … was driven by health concerns and age … She said she did not feel that she had missed out by having assisted deliveries for Alexandra, 9, and Nicholas, 11 weeks. “I have a history of high blood pressure and the doctor said to me that I had more risk giving birth naturally. When the doctor explained some of the risks it outweighed the complications associated with a caesarean.”
She said her second pregnancy was a surprise at her age and she did not think twice about another caesarean. “It was a clear-cut decision and I felt very confident … It was based purely on a medical decision. It was safer for me and my baby.”

What a shame this woman, along with so many others, was mis-informed about her options. How can major surgery ever be seen to be a positive thing, in the absense of any obvious complications? Maybe I ought to get an electric wheelchair and start using it now, just in case I need one when I’m 80. Oh, and while I’m at it, a heart bypass would be a good thing too. You just never know when you’re going to have a heart attack, after all.

Melissa Maimann, Essential Birth Consulting.

Why Birth at Home?

Posted on April 1, 2009 by Melissa Maimann

Visit my website to learn more about my services.

Homebirth provides a familiar and safe environment for birthing. This helps to keep stress hormones low, and positive birth hormones high, and can therefore make the birth easier and less painful.

Women choose a homebirth because they believe in their body’s ability to birth, wish to involve their partner and other children more, or prefer to reduce the chance of intervention in their labour. And becuase let’s face it: pregnancy and birth are normal, healthy and natural experiences. We don’t go to hospital to experience other normal, healthy and natural bodily experiences such as food digestion, urination, menstruation, defecation …. we trust that our bodies work, and that these processes work too.

Women choose homebirth to:
Experience fewer complications in labour
Reduce the need for interventions
Use less pain medication
Lower their chances of a caesarean from about 35% to around 5%
Remain in comfortable and familiar surroundings
Have a baby who has fewer problems after the birth
Increase their success with breastfeeding
Avoid time limits being imposed on labour and birth
Experience antenatal and postnatal visits in their home
Improve bonding with their baby
Provide a gentle birth for their baby
Involve other siblings and family
Have choice and control
Reduce birth trauma
Receive care from the same midwife right the way through
Benefit from having more choices available
Benefit from sound education and birth preparation
Have a great birth!

Visit my website to learn more about my services.

Hospital Birth with your own Private Midwife!

Posted on April 1, 2009 by Melissa Maimann

Visit my website to learn more about my services.

Many women prefer to birth their babies in hospital, but they want to have the same midwife all the way through their pregnancy, birth and post-birth period. It’s about building trust, having a familiar face and being understood and supported.

There are a range of options. Some women see the hospital midwives or their own doctor for care, and see me for pregnancy, birth and postnatal support.

Other women have some or even all of their antenatal, labour and postnatal care with me, and we birth in hospital. You’ll find this service very flexible – no more waiting in hospital clinics for 30 – 60 mins: I can come to you when it suits you and we can take our time addressing the things that matter to you.

I support you in your decisions, whatever birth you’re planning. We explore what birth means to you and discuss your goals for pregnancy and birth, focussing on what’s important to you, what you need, and looking at ways of making the birth as positive and healthy as possible.

I know that no two women are the same, so services are tailored and individualised to your needs and budget.

The service ….

As a midwife, I can provide clinical care, birth support, information, advice and emotional support as you journey through your pregnancy and birth. I meet with you several times in your pregnancy so we can learn about each other, and so you can more feel comfortable with me. I help you formulate a birth plan and de-brief previous birth experiences. Your consultations may be instead of, or in addition to, your hospital or doctor appointments. Some women have all of their antenatal care with me.

When your labour starts, I come to your home and stay with you until you’re ready to go to hospital. I will stay with you in hospital, supporting you through your labour and advocating for you, until your baby is safely born. You leave the hospital when you feel ready and we continue your care at home, for up to 6 weeks.

I will facilitate communication with midwifery and medical caregivers to ensure that you have the information necessary to make informed decisions during labour and birth. Childbirth education is provided. After your baby is born, I can meet with you to discuss your birth and review your medical records, if requested.

What are the Advantages of Midwifery Birth Support?
Many women ask me how they can benefit from having a midwife provide birth support when they have family, friends, doulas or hospital staff to support them. Family and friends love and care for you, and this emotional attachment can prevent them from seeing situations objectively. Also, they may not be aware of the full range of options that are open to you. Some family and friends also feel reluctant to advocate for you.

Hospital staff are often busy caring for other women in labour: a hospital-employed midwife often cares for 2 labouring women at any given time, while also answering phones, performing administrative roles and so on. So if good birth support and advocacy are what you’re after, your best options are to employ a doula or a midwife. “What’s the difference?”, I hear you ask. Read on to find out ….

An independent / private midwife can provide all the services that a doula can provide. In addition, you benefit from:
- being professionally cared for by a registered health professional who is recognised by legislation
- being cared for by someone who is educated to university level
- being cared for by somoene who is educated in skills such as resuscitation
- higher chance of normal vaginal birth
- minimal intervention during birth
- professional advice and clinical care
- having some or all of your antenatal and postnatal care with your midwife
- lowest chance of caesarean
- lowest chance of episiotomy
- midwives can advise on VBAC options
- lower requirement for pain relief
- higher breastfeeding rates
- lower rates of pregnancy admissions to hospital
- access to midwife means you can change to home birth at any time and have that mifwife as your primary care provider
- midwives can monitor your baby in pregnancy and labour
- midwives can monitor your health in pregnancy and labour
- midwives can liaise with other health professionals if needed

Visit my website to learn more about my services.

Tips for a Successful VBAC

Posted on March 31, 2009 by Melissa Maimann

As published on the Essential Baby website

Author: Melissa Maimann www.essentialbirthconsulting.com.au

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

February 9, 2009

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

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

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

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

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

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

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

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

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

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

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

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

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

Visit my website to learn more about my services.

Fetal Monitoring in VBAC Labour

Posted on March 31, 2009 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting.

Birth by surgery: The skyrocketing cesarean rate

Posted on March 30, 2009 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

….

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

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

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

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

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

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

…

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

…

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting.

Birth Trauma

Posted on March 29, 2009 by Melissa Maimann

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

Visit my website to learn more about my services.

October 13, 2008

birth trauma

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

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

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

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

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

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

• Nightmares of the birth

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

• Numbed emotions

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

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

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

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

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

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

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

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

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

Read books or articles on birth trauma.

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

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

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

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

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

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Birthing your Baby at Home

Posted on March 28, 2009 by Melissa Maimann

As published on the Essential Baby website

Visit my website to learn more about my services.

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

Author: Melissa Maimann

October 27, 2008

Essential Baby member Alinta homebirthed baby Mason on 9 September, 2008

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Home deliveries

Posted on March 23, 2009 by Melissa Maimann

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

Link to article

John Elder
March 22, 2009

JANET Fraser is in labour. Her plan is to drop the baby on the loungeroom floor, or wherever feels good at the time. Has she called the hospital to let them know what’s happening? “When you go on a skiing trip, do you call the hospital to say, ‘I’m coming down the mountain, can you set aside a spot for me in the emergency room?’ I don’t think so,” says Fraser, whose breathing sounds strained.

This is pretty much where we end the conversation that started with me calling Fraser and asking if it was true that her organisation, Joyous Birth, was advocating that women go it alone giving birth at home, with no midwife …

“Free-birthing, plenty of women do it,” she says. In fact, Fraser is doing it right now. “I prefer to be an autonomous care-provider,” she says.

By the time she tells me the birth of her third child is “impending”, Fraser has already talked intensely about the likelihood that home births attended by midwives will be illegal from July next year, when the national registration scheme for health professionals kicks in …

She has also talked about how the Joyous Birth group, of which she is national convener, wasn’t encouraging women to free-birth as a means of flouting the law, but to run their pregnancies and birthing in the manner they desire.

“If that happens to be free-birth, then you go for it … We don’t advocate hospital-based birth or being beholden to all sorts of authority figures,” she says.

Janet Fraser’s son, 5, was planned as a home birth, but came into the world via an emergency caesarean after Fraser was transferred to hospital. Her daughter, 2, was born at home …

Fraser is 40. She hasn’t seen a doctor or any health professional since becoming pregnant this time. No ultrasound, no genetic testing, no internal examinations, no stethoscope. [Internal examinations do not form part of the routine care of pregnant women.] Does she have any feeling for how long the labour will go? “I could do this for days. My daughter’s birth was 50-something hours. You just do it — it’s just birth, a normal physiological process.”

At the time of publication, Ms Fraser’s labour was continuing to progress slowly.

[A very small proportion of Australian choose to birth at home].

The home-birth crowd has always been loud, but if they are more strident of late it’s possibly because they are feeling left behind in an evolving birth scene, where hospital midwives are increasingly required to train for emergency situations, including home-birth complications.

St George [Hospital] is one of a number of hospitals in NSW trialling home-birth programs where two midwives are required to attend a birth, and the home births need to be sanctioned according to a set of low-risk protocols [that do not see the majority of women as low risk, and therefore the woman cannot access that services. Women are not "cleared" for home birth until 36 weeks when they have a compulsory swab to determine if they have group B strep, which may or may not be present when they do into labour, perhaps some 4 - 5 weeks later]. Independent midwives generally work alone, with a more lenient policy on risk. For example, independent midwives will home-birth twins, breech presentations and … VBACs.

The status of midwives is the key to where birthing is headed. The Maternity Services Review has recommended an expanded role for them. One option on the table would see their services covered by a Medicare rebate for the first time. However, this would not be extended to independent midwives attending home births.

There is growing enthusiasm for the case that continuous care by a midwife through the prenatal, birth and post-natal stages tends to result in happier and healthier outcomes for a pregnant woman. And that if the midwife role was expanded … then a significant portion of … hospital resources could be freed up, and the nation’s health bill somewhat reduced. [Not to mention the outcomes for women and babies would be greatly improved].

Within this context, home birth might sit more comfortably in the public mind as a viable option.

Justine Caines, secretary of Homebirth Australia, [says]: … “It’s only the home-birth mothers who have experienced one-to-one midwifery who advocate for change … The vast majority aren’t passionate about their experience basically because … The system basically treats them as someone to shuffle through. The whole passion around home birth is about the experience of one-to-one midwifery care.”

Caines sees midwives as the great hope of the overburdened health system. “We fund private obstetrics to hundreds of millions of dollars through Medicare … fees for services that don’t relate to case load. Most of it is a waste of money,” she says.

“(Federal Health Minister) Nicola Roxon could offer a $5000 birth package that would cover continuous care for each pregnancy … as opposed to women engaging in private obstetric care spending $20,000 believing they have the best care money can buy.

“I have a midwife come to my home every day for the first seven to 10 days. The most expensive is $4000 for the entire package … and no health fund covers it. People could get better, cheaper care.”

Barbara Vernon, chief executive of the Australian College of Midwives, says this message gets lost in media sensationalism sparked by organisations such as Joyous Birth and a small number of midwives who don’t make risk minimisation their primary focus, whereas most midwives working privately — and there are only 50 registered with the college, possibly 100 throughout the country — are “very risk-averse”.

“Midwives have the skills and equipment for the safe care of a mother and baby in a home-birth situation, and they recognise quickly when something’s going wrong.

“What fails to compete with the sensationalism is … the evidence showing that a trust relationship between a woman and a midwife, established from early in the pregnancy, means that the woman in labour is feeling safe and less anxious. It’s a better experience.”

Vernon says the flow-on effects of continuous midwife care include shorter labours, a reduced need for drugs and pain relief, reduced admissions to neonatal intensive care, reduced vulnerability to post-natal depression and improved rates of breastfeeding to 12 months of age.

“Even if she has a caesarean, the woman is not traumatised by the process … “It’s the women who get run over by the system that feel most vulnerable after that experience. They can’t understand why all of that happened.”

… is a hospital-governed home-birth system the answer to mainstreaming home birth? Free-birther Janet Fraser says: “It would be a disaster if hospitals ran home birth. Hospitals are dangerous.”

Justine Caine says: “Not until obstetric care is kept in check. The problem with most of (the trial schemes) is that women and midwives are not able to make decisions. Hospital midwives are handmaidens of the doctors. Obstetricians call the shots and much of the exclusion criteria is not based on evidence.”

Veteran private midwife Robyn Thompson, who has spent 30 years assisting home births, says: “It wouldn’t be a disaster. I’m welcoming whatever it takes that makes it good for women.”

Thompson says the average transfer rate over those 30 years had been about 17 per cent … “You anticipate what’s happening…”
…..
Barbara Vernon says: “RANZCOG has a position statement where home births are not endorsed. But some women are going to always birth at home.” [And therefore the approach needs to be one of harm-minimisation, not making home brith illegal by denying midwives access to professional indemnity insurance, and therefore registration].

- I guess the real question is – who owns birth? Midwives? Obstetricians? Maybe it’s time for women to claim birth.
……
Home-birth advocates insist that doctors only have a role to play when a birth becomes problematic. They say doctor intervention has led to skyrocketing induction, epidural and caesarean rates, issues that were at the heart of the Maternity Services Review. [And this is true. Midwives do not intervene in these ways. We cannot perform caesareans, we do not authorise inductions and we cannot insert epidurals. These are in the medical domain.]

In April 2007, Melbourne lawyer Ann Catchlove was told by her obstetrician that she needed a caesarean with her first child because her pelvis was not big enough. “He said, ‘You can keep going if you want but we’ll still be here at 3am’,” she says … The doctor told Catchlove that her future babies would have to be delivered by caesarean. Research on the internet convinced her otherwise. “I found the original caesarean probably wasn’t necessary.”

She also found research that indicated vaginal birth after caesarean was a reasonable option. She started thinking about a birth centre “but none of them would accept me”.

Last November she gave birth to a son at home. “… once I’d made the decision, and met the midwives, I never had any doubts. There’s an idea of hippies burning incense in the background, which is wrong. They were very focused on safety … the birth itself was very smooth and relaxed, other than the pain. I felt very safe and in control.”

Obstetrician Pieter Mourik warns ominously that graveyards are full of “failed home births”. He has called Janet Fraser’s Joyous Birth group “a bunch of nutters” and Fraser herself “a fool”. When told Fraser was free-birthing at home, Mourik was quieter than usual, less on the soapbox.

Fraser had said she didn’t expect anything to happen for another couple of days; that nothing bad happened quickly in a labour and that there would be time to get to hospital if things went wrong.

Mourik paused. “She told me (during a debate) she’d had a caesarean. That’s how a uterus is most likely to rupture. If that happens, there won’t be time … Well, I wish her well.”

Melissa Maimann, Essential Birth Consulting.

Evidence Increases For Risks In Cesarean Surgery As National Rate Continues To Rise, USA

Posted on March 20, 2009 by Melissa Maimann

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

Link to article

As research continues to mount for the risks of cesarean surgery, the CDC released new, staggering statistics today reporting that 31.8% of women endure birth by cesarean in the United States (2007). [This is no different to the stats in Australia as of 2006. No doubt our caesarean rate is higher now]. This announcement comes after the release of significant findings from the New England Journal of Medicine reinforcing that birth by cesarean surgery before 39 weeks of pregnancy causes increased complications in newborns.

Despite the latest advances in medical technology, health care providers cannot determine a baby’s due date with 100% accuracy. [Babies can come anywhere between 37 and 42 weeks and still be considered term. So if a baby was not destined to come into this world until 42 weeks, and a caesarean was performed at say 38 weeks, that baby would be 4 weeks premature]. Therefore, cesarean surgeries scheduled before a woman’s estimated due date could result in a baby born as early as 36 weeks to a few days before the baby is actually due. During the last few weeks of pregnancy, a baby’s lungs mature and a protective layer of fat forms, both of which are vital developments for a healthy baby … Without time during labor to prepare the baby to breathe, lungs cells may not be ready. Thus, babies born by cesarean surgery, even when they are full-term, need to go to an intensive care unit more frequently than babies who were born vaginally to get help breathing.

Research … [suggests] that cesarean surgery performed prior to 39 weeks of pregnancy increases poor outcomes in babies. Of the babies in the NEJM study born before 39 weeks, more than 26% had complications, including the need to be on a ventilator, respiratory distress syndrome, low blood sugar and severe infection (sepsis).

“Overuse of cesarean surgery complicates the otherwise natural process of birth,” says Lamaze Institute Chair Debra Bingham, LCCE, MS, RN, DrPH, “Allowing the natural process to occur not only reduces risks for mothers in this and future pregnancies, but also reduces health risks for her baby.”

Spontaneous labor is almost always the best indication for a baby’s physical readiness for life outside of the womb. As one of the key steps to a healthy birth, Lamaze International recommends that women let labor begin on its own. … When a birth outcome is good, mother and baby can bond and start breastfeeding immediately after birth-both of which provide the best start for a baby’s growth and development.

Lamaze International President Pam Spry, PhD, CNM, FACNM, LCCE says, “Maternity care in the United States is at a crossroads. The most commonly used practices don’t align with the best evidence for a healthy birth.” …

Cesarean surgery … also carries risks for women, such as blood loss, clotting, infection and severe pain, and poses future risks, such as infertility and complications during future pregnancies such as stillbirth and placenta problems like percreta and accreta, which can lead to excessive bleeding, bladder injury, hysterectomy and maternal death …

Two of the most important decisions a woman can make are where she gives birth and who she chooses as her care provider.

Melissa Maimann, Essential Birth Consulting.

The Trouble With Repeat Cesareans

Posted on March 18, 2009 by Melissa Maimann

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

Link to article

By Pamela Paul
Thursday, Feb. 19, 2009
To avoid another C-section, Barton has to drive 100 miles to deliver in Los Angeles.
For many pregnant women in America, it is easier today to walk into a hospital and request major abdominal surgery than it is to give birth as nature intended. (It’s often the same in Australia, unless you have a private midwife or doula with you) Jessica Barton knows this all too well … her first child ended up being delivered by cesarean section, she can’t find an obstetrician in her county who will let her even try to push this go-round. And she could locate only one doctor in nearby Ventura County who allows the option of vaginal birth after cesarean (VBAC). But what if he’s not on call the day she goes into labor? … in order to give birth the old-fashioned way, Barton is planning to go to UCLA Medical Center in Los Angeles.

Much ado has been made recently of women who choose to have cesareans, but little attention has been paid to the vast number of moms who are forced to have them. More than 9 out of 10 births following a C-section are now surgical deliveries … the International Cesarean Awareness Network (ICAN) … found that 28% of [hospitals] don’t allow VBACs … ICAN’s latest findings note that another 21% of hospitals have what it calls “de facto bans,” i.e., the hospitals have no official policies against VBAC, but no obstetricians will perform them …

Why the VBAC-lash? … The risk of uterine rupture during VBAC is real–and can be fatal to both mom and baby–but rupture occurs in just 0.7% of cases … only 1 in 2,000 babies die or suffer brain damage as a result of oxygen deprivation.

After 1980 … more women began having VBACs. By 1996, they accounted for 28% of births among C-section veterans, and in 2000, the Federal Government issued [a] … report proposing a target VBAC rate of 37%. Yet as of 2006, only about 8% of births were VBACs, and the numbers continue to fall–even though 73% of women who go this route successfully deliver [vaginally].

So what happened? In 1999, after several high-profile cases in which women undergoing VBAC ruptured their uterus, the American College of Obstetricians and Gynecologists (ACOG) changed its guidelines from stipulating that surgeons and anesthesiologists should be “readily available” during a VBAC to “immediately available.” …

Some doctors, however, argue that any facility ill equipped for VBACs shouldn’t do labor and delivery at all …

Part of the answer has to do with malpractice insurance. Following a few major lawsuits stemming from VBAC cases, many insurers started jacking up the price of malpractice coverage for ob-gyns who perform such births … 26% [of OBs] said they had given up on VBACs because insurance was unaffordable or unavailable; 33% said they had dropped VBACs out of fear of litigation …

Of course, the alternative to a VBAC isn’t risk-free either. With each repeat cesarean, a mother’s risk of heavy bleeding, infection and infertility, among other complications, goes up. Perhaps most alarming, repeat C-sections increase a woman’s chances of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth. The rate of placenta accreta–in which the placenta attaches abnormally to the uterine wall–has increased thirtyfold in the past 30 years …

… while many obstetricians say fewer patients are requesting VBACs, others counter that the medical profession has been too discouraging of them … 57% of C-section veterans who gave birth in 2005 were interested in a VBAC but were denied the option of having one.

… “the pendulum has swung too far the other way,” So how to reverse the trend? For one thing, patients and doctors need to be as aware of the risks of multiple cesareans as they are of those of VBACs. [Concern arises that perhaps doctors will forget how to do VBACs.]

- Well, fortunately, you “do” a VBAC the same way you “do” a natural birth. By supporting the natural processes that women’s bodies are designed to perform. In this country, VBAC rates are between 10% and 16%. In some private hospitals, the rates are as low as 1%. In homebirth, the rates of VBAC are at least 80%. And it is a numbers game, so put yourself where the numbers are stacked with you, not against you. Plan a home birth for your VBAC, or employ a private midwife for a hospital birth.

Melissa Maimann, Essential Birth Consulting.

Hospitals curb caesarean births

Posted on March 7, 2009 by Melissa Maimann

For further information, contact Melissa at Essential Birth Consulting

Link to article

The Sunday Times
February 15, 2009

Hospitals curb caesarean birthsSarah-Kate Templeton, Health Editor

NHS trusts have … barred women from routinely having elective caesareans because they cost too much. The procedure, which costs twice as much as a natural birth, will be rationed … so that it is only available to women with specific medical conditions.

Some top obstetricians condemn the decision, arguing that, while it will curb the fashion for choosing caesareans to reduce the pain of childbirth, it will also penalise those who opt for them on the grounds that they are safer for the mother.

Caesareans have been placed on the same lists for rationing by the NHS trusts in Greater Manchester as infertility treatment, cosmetic surgery and acupuncture.

The lists, called Effective Use of Resources Policies, state that planned caesarean sections should only routinely be offered to women in particular categories. They include women who have previously already had at least two caesareans.

About 23% of deliveries in Britain are by caesarean section, and, of these, more than half are emergency operations.

The CS rate quoted is 23%. If only our National CS rate could be that low! In 2006, Australia’s CS rate was 31%, up from 28% in 2005. Maybe it’s 35% now? I was interested to read that VBAC is not an indication for elective repeat CS, but VBA2C is. Sounds sensible! I’d like to see something similar here in Australia. It’s a shame that here, a woman has a greater right to a caesarean, than a homebirth. We all know which option is safer, cheaper and more satisfying for mothers and babies. It also begs the question – how many women would opt for an elective caesarean if they had access to continuity of midwifery care?

Melissa Maimann, Essential Birth Consulting.

Midwives in the UK Help Women Who Have Previously had a Caesarean Section to Choose a Normal Birth for their Next Baby

Posted on February 18, 2009 by Melissa Maimann

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

Midwives At Southampton, England, Helping Women Who Have Previously Had A Caesarean Section To Choose A Normal Birth For Their Next Baby17 Feb 2009

Nationally, the number of c-sections has dramatically increased over the last decade. This has led the NHS Institute for Innovation and Improvement to develop a toolkit to help midwives reduce these numbers.

… there has been a 4 per cent reduction in the number of c-sections [since this toolkit was implemented.]

One of the initiatives is to introduce midwife-led care for women having vaginal birth following a previous caesarean.

The consultant midwife … who helped set up the project said, “We try not to medicalise the event, so from the beginning the mother will see a midwife, rather than a doctor. They will have a risk assessment to make sure they are suitable for midwife-led care and VBAC, and we fully explain the risks and benefits so they can make an informed choice.”

After a normal birth, recovery tends to be quicker and the mother is up and about sooner. This means there is less risk of deep vein thrombosis (DVT), and breast-feeding also tends to get off to a more successful start.

What a fantastic initiative! It would be great if it could be implemented as a routine here in Australia.

Melissa Maimann, Essential Birth Consulting.

NHS Institute for Innovation and Improvement

Private Midwifery in Sydney

The blog of Melissa Maimann: a Medicare-eligible midwife in Sydney.

Category Archives: VBAC

No room at hospital for ‘high-risk’ pregnancies

Lessons from Labour

A hospital is not a natural environment for a natural event

Repeat C-sections Rise By Over That 40 Percent In One Decade, USA

Birth in NSW Today

Caesarean rates rise as mothers get older

Why Birth at Home?

Hospital Birth with your own Private Midwife!

Tips for a Successful VBAC

Fetal Monitoring in VBAC Labour

Birth by surgery: The skyrocketing cesarean rate

Birth Trauma

Birthing your Baby at Home

Home deliveries

Evidence Increases For Risks In Cesarean Surgery As National Rate Continues To Rise, USA

The Trouble With Repeat Cesareans

Hospitals curb caesarean births

Midwives in the UK Help Women Who Have Previously had a Caesarean Section to Choose a Normal Birth for their Next Baby

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