Tag Archives: Babies

Risk assessment in pregnancy and birth

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Risk assessment has been around for a long time in maternity care and has become more widely spoken about as midwifery-led services have expanded. Risk assessment is a way of identifying potential problems and minimising risks to the woman and baby. Some form of risk assessment is used in almost every profession and although the actual risk assessment process is not perfect, it’s the best tool we have at present. Risk assessment is used on OH&S, education, food service, health, media, emergency services, law and so on.

In maternity, risk assessment is an incredibly useful tool. The benefit of risk assessment is that it is based on science and evidence. We can state with certainty the risks of certain complications such as pre-eclampsia and this is helpful when preparing women for what to expect and things to be on the look-out for. In this way, risk assessment actually lowers the risk to the woman because she can become more involved in her care and more alert for signs that mean she needs to get help.

The downside of risk assessment is that it does tend to categorise women according to a tick-box system. Although the risk might be there, it might not necessarily eventuate for the woman sitting with us.

How can risk assessment be useful?

Risk assessment can be an incredibly useful tool for both women and midwives in helping to plan care that will meet the woman’s needs safely. Midwives are primary care providers and are responsible for proving care to healthy, low-risk women and babies throughout pregnancy, birth and the postnatal period. So a risk assessment tool helps the midwife and woman to know when a consultation or referral is needed.

Risk assessments can also highlight potential problems that would benefit from early organisation and planning before labour. This might include reviewing the birth plan, reviewing place of birth, engaging other health professionals and putting in place supports so that the woman can cope well after the baby is born.

Risk assessment can also be useful for discussing homebirth with women and their partners. Some women are perfectly suited to homebirth: they’re healthy, their pregnancy is going well and they’re wanting a natural birth. In this case, risk assessment can be used to explain to the woman that she’s safer at home.

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Negative Blood Groups

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Everyone has a blood group, or a blood type. The groups are O, A, B and AB. As well as this, a person may or may not contain a protein in their blood called Rhesus factor. A person who has the Rhesus factor is called “Rhesus positive” and a person who does not have this factor is called “Rhesus negative”. So people may be (for example) O positive, A negative, AB positive and so on. About 85% people are Rhesus positive. That is, they contain the Rhesus factor in their blood, so their blood group would be one of the positive ones.

The other 15% of people do not have this factor in their blood. A pregnant woman’s blood group and Rhesus factor are determined by a blood test as part of the tests that are done when a woman first discovers she is pregnant.

If a pregnant woman has a negative blood group and her partner has a positive blood group, there is a chance that the baby will also have a positive blood group. Should any of the baby’s blood get into the mother’s system, her body will make antibodies to the baby’s Rhesus factor. This doesn’t cause any problems in the current pregnancy, but the next time the woman falls pregnant, the antibodies can affect the baby. The baby can be born prematurely, miscarriage is more likely, the baby may be born anaemic and the baby is more likely to experience jaundice.

Fortunately, there is something that can be done to prevent this all from happening!

Women who are a negative blood group will be offered two injections of Anti-D in pregnancy. This prevents any antibodies from forming. After the baby is born, the baby’s blood group will be determined from blood that is in the cord, and if the baby’s blood group is found to be positive, the mother will be given another dose of Anti-D.

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Planning a homebirth vs having a homebirth

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Is it just semantics? “I’m having a homebirth” versus, “I’m planning a homebirth”? I often wonder why more women don’t plan homebirths. Planning a homebirth doesn’t rule out hospital as an option if it’s needed or desired. Planning a homebirth keeps all options open and allows women to make the decision about place of birth towards the end of the pregnancy or even in labour.

Sometimes I’m concerned when I hear, “I’m having a homebirth”. The same way I’m concerned if I hear, “I’m having an epidural / induction / waterbirth” or whatever. Yes, these are our plans, but we never really know what’s going to happen until the time.

There is a transfer rate associated with homebirth and this reflects safe practice and respect for women’s decisions. Bearing that in mind, it’s wiser to say, “I’m planning a homebirth” rather than, “I’m having a homebirth”.

Also, consider the reactions from family and friends when they hear these words. When we “plan” a homebirth, friends and family are put at ease. Plans can change if they need to. The common response, “Homebirth?!?! Isn’t that … dangerous??” is no longer needed because plans can change if risks emerge. Sometimes when people hear, “I’m having a homebirth”, they don’t understand that if hospital is needed, we go. The common questions like, “what if you need a caesarean?” “what if you need an epidural?” are valid when we frame it as “having” a homebirth because these interventions are not available at home. But when homebirth is “planned”, those questions are no longer necessary: plans can change.

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The Benefits of Using a Midwife During Childbirth

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In Australia, all babies are born with the help of a midwife. This is true whether you’re giving birth in hospital, birth centre, at home or in an operating theatre. The question is really – what are the benefits to having a midwife as your primary care provider?

So, what is a primary care provider?
A primary care provider is someone who is responsible for your pregnancy and birth care. They may also been seen as the coordinator of your care or “go-to” person. It may either be a doctor or a midwife. Your primary care provider should know all about you and your pregnancy, attend your birth and know all about your baby. Without a primary care provider, your care will be fragmented and it’s entirely possible that some important aspects of your care will be overlooked or forgotten.

Primary medical care is provided by private obstetricians or through doctor’s clinics in public hospitals.

What are the benefits of having a midwife as your primary care provider?
Midwives have a firm belief in pregnancy and birth as natural processes that women can do. In other words, they believe that a woman’s body is perfectly designed for pregnancy and birth. They look for what’s right in the pregnancy and birth, while always being mindful of risks. Midwives help to keep pregnancy and birth normal by focussing on nutrition, lifestyle, health and well being. We that with health in general, healthy people are less likely to get heart disease, diabetes and so on. Well, it’s the same in pregnancy and birth: healthy women and babies are less likely to get sick. So midwives focus on health and well being, while always being alert for situations that need more attention.

Midwives use a holistic, or biopsychosocial model of care. What this means is that you’re not just a pregnancy or a birth to a midwife. You’re a woman, mother, friend, wife, partner, employer / employee and so on. Your midwife will seek information about your life, your family, your interests and so on, as well as your health and medical history. She will take all of this information into account when making recommendations and giving advice.

Midwives are less likely to use disruptive technologies that may lead to further intervention and complications. They’re less likely to induce labour, perform an episiotomy, perform vaginal examinations, break your waters and so on. So your labour is allowed to progress naturally. When you work with your body, it will work with you. When you interfere with your bodily processes, your body will not work as well. This is especially the case in birth where there’s a strong reliance on hormones to initiate labour and keep it going.

Women are usually very satisfied with midwifery care. They feel supported, emotionally, from seeing a midwife. They feel they can trust their midwife and that their wishes are respected. Women feel more comfortable to write a birth plan and discuss their hopes and preferences for their pregnancy and labour when they see a midwife.

So, what does this mean for birth and babies?
Well, there are lots of positives! When you have a midwife as your primary care provider, you can expect:
- choice of birth place (hospital or home)
- a lower rate of caesarean
- a lower rate of episiotomy
- you’re less likely to be induced
- you’re less likely to need pain medication in labour
- you’re less likely to have your waters broken
- you will be listened to and respected
- your birth plan will be respected
- you will be able to build trust with the midwife who will help you in birth
- you will be less likely to have an assisted birth (eg forceps)
- you will have a lower chance of getting postnatal depression
- you will be less likely to have a traumatic birth
- you will be more likely to bond well with your baby
- your baby will be more likely to breastfeed successfully
- you will most likely view your labour as being very positive

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Vitamin K

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

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

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

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

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

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

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

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

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

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

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

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

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What to pack for your hospital bag

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It can be really helpful to have a hospital bag packed by about 36 weeks, just so that it is ready to go to hospital when you are. Women planning a homebirth will also pack a hospital bag just in case a transfer is needed in labour.

For the most part, women stay in hospital up to 48 hours after birth. This means that you really don’t need to bring very much in the way of changes of clothes. So – what to bring?

Clothes for labour

Hospitals provide gowns, but many women prefer to wear their own clothes, or even no clothes. The best clothes to wear in labour are loose, baggy t-shirts, a dressing gown (if you are cold), tracksuit pants and so on. Nothing tight or restrictive, and nothing you can’t take off quickly if you want to. It’s also a good idea to wear old clothes, not your best new outfit. Bring a couple of pairs of underpants for labour.

Toiletries

Tooth brush, tooth paste, shampoo, conditioner, moisturiser, deoderant etc – whatever you normally use. You’ll also need 2 packets of maternity pads. Ie, not panty liners or thin menstrual pads, but heavy-duty maternity pads.

Underwear

Breastfeeding bras, lots of dark-coloured, loose underpants.

Clothes for the hospital stay

Again, whatever feels comfortable. Nighties, singlets, buttoned tops, loose clothes, tracksuit pants etc. You’re best to pack lightly, as anything that’s needed can easily be brought in from home by a relative or friend. Slippers, shoes etc – whatever you normally walk comfortably in. After you have a baby, your feet often swell a bit, so loose shoes are the key. Hospitals can often be cold places, so give some thought to layers of clothes so that you can layer up or down as you need.

Things for labour

Food and drinks, massage oil, aromatherapy, homeopathics, herbal medicines, pillows, photos / visualisation aids, CDs / iPod, anything that makes you feel ‘at home’.

For baby

Babies are small … and therefore easy to pack for! The hospital will supply baby clothes while you’re in hospital. Some hospitals provide nappies; others don’t. Best to check with your hospital. In geberal, you’ll need two outfits to take your baby home in. Why two? babies are notorious for pooing and weeing through outfits and this way you can have a change of clothes if you need them. You’ll need singlets, mittens (if chosen), nappy wipes and nappies. In winter or cooler weather, you’ll also need a beanie.

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Tummy time for babies?

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Tummy time is often recommended for babies, but what is it and why do we recommend it?

Tummy time simply means allowing your baby some play time on his/her tummy while you are there to watch over your baby. During waking hours, it helps a baby’s muscle development and eventual hand-eye coordination, as well as enhancing head and neck control. Developing head control is important for babies as it helps your baby to visually explore their environment. Once a baby can see things, s/he is more likely to start to reach for them and this helps in their exploration of their world.

Tummy time also helps the development of a baby’s skull bones. Due to the risk of SIDS, all parents are strongly encouraged to sleep their babies on their backs, but consequently there are a lot of babies with flat heads and even hair loss on the part of the head that the baby sleeps on. Tummy time can help with both of these concerns.

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Babies Born At 37-38 Weeks More Likely To Have Health Problems

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… babies born just a few weeks premature have worse health outcomes than babies born at full term …

… both babies born at 32-36 weeks … and 37-38 weeks (early term) required hospitalization in the first few months compared to those born at full term (39-41 weeks). In addition, the risk of wheezing and asthma was increased among babies born between 33 and 36 weeks compared to babies born at full term.

The researchers found a strong association between increasing risk of poor health outcomes and decreasing gestation, and that the greatest contribution to disease at age 3 and 5 was being born moderate/ later preterm or early term.

… mothers of early preterm babies were less likely to breast feed for 4+ months compared to women who gave birth after 37 weeks, and were more likely to smoke …

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Cesarean Delivery May Not Be More Protective For Small, Premature Newborns

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…delivery by cesarean section may not be protective compared to vaginal deliveries for babies who are small for their gestational age … born more than six weeks before their due date.

“We found that infants delivered vaginally were not at a significantly increased risk for any neonatal complications. In fact, infants delivered by cesarean had significantly higher odds of breathing problems after birth,” … “This indicates that cesarean isn’t superior to vaginal deliveries for this high risk population.”…

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Inducing Labor Better for Big Babies

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The study below has made a compelling argument for induction for babies who are thought to be large for their gestational age. The first thing to ascertain before deciding on a course of action, is that the baby is truly larger than expected. All methods of judging a baby’s size in the uterus are prone to error, for example ultrasound has a 15% margin of error. Therefore we need to take this into account when we are advising women of the safest options. Many inductions (and even caesareans) are performed for “big” babies, only to have the induction go pear-shaped and lead to a caesarean … for a 3.5Kg baby. On the other hand, an earlier induction for a genuinely large baby may well prevent a caesarean, forceps birth, perineal trauma (tears, episiotomy) and so on.

Large-for-date babies are more likely to experience neonatal trauma if nature is allowed to take its course than if labor is induced …

Among fetuses estimated sonographically to be above the 95th percentile for weight, adverse events such as shoulder dystocia were three times less likely if labor was induced …

Induction of labor also was associated with a greater likelihood of spontaneous vaginal delivery …

Previous observational studies have suggested that induction of labor may lower birth weight and decrease the chance for neonatal injury such as shoulder dystocia, brachial plexus injury, and death.

However, studies also found increased rates of cesarean section with induction, and the reliability of fetal weight estimation has been questioned.

… 817 women … were assigned to be induced within three days of enrollment or to expectant management.

They averaged 37 weeks gestation, and fetal weight was estimated at an average of 3,700 grams.

The difference between the groups was approximately nine days additional gestation in the expectant management group along with a 287-g (10 oz.) higher birth weight.

In the expectant management group, 6.6% of neonates experienced shoulder dystocia, compared with 2.2% in the induced group …

Also significant was the difference in vaginal deliveries, which occurred in 58.7% of the induced births and 51.7% of expectant births.

Cesarean section was needed in 28% of the induction group and 31.7% of the expectant group.

Secondary outcomes — including clavicular fracture and brachial plexus injury — were similar between the two groups.

There were no serious or permanent brachial plexus injuries or deaths.

… The study demonstrated that prevention of macrosomia at birth can lead to safe birth outcomes …

The other aspect that has not been mentioned in this study is the importance of caring for women and providing advice that will help them to grow a baby who is appropriate for their pelvis, to maximise the chance of a normal birth. This is an essential aspect of the care that I provide to women.

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After baby arrives: midwifery care

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The focus of midwifery care is often “the birth”, however, the biggest “chunk” of midwifery care is pregnancy care, and then postnatal care. The birth – special, important and transforming as it is – is only one day (or night) in a ten-month professional relationship. I wanted to share some insights in postnatal midwifery care, as an often-neglected but important aspect of the care of a woman and her family.

Once a baby is born, new parents can be thrown into an enormous sense of responsibility, combined with a very steep learning curve. A midwife helps the mother and family make this transition to parenthood. A midwife is there to help with breastfeeding, teach practical baby care and also to provide the necessary checks of mum and baby to ensure that the normal recovery process is underway.

I provide my clients with extensive postnatal care because I know it can be a challenging time for a new family. I visit at home or in hospital every day for the first week. After that time, families can choose to see me in my private rooms or I visit them in their home. There are two visits in the second week, and then week 3, 4 and finally discharge at week 6.

We do all sorts of things: I attend the baby’s newborn screening test (Blood spot test), I check the mother and baby to ensure that they are both recovering, we talk about breastfeeding and ensure that the baby is feeding well, we monitor the baby’s output to be sure that the baby is getting sufficient milk for his/her needs, I attend the Vitamin K drops for families who choose to give their babies Vitamin K drops, and we do lots of education about postnatal care, postnatal depression, what to expect with a new baby in the first few weeks, expressing milk, safe sleeping, adjusting to parenthood and so on.

Over time, I have increased the care that I provide to my clients and the feedback from my clients has been that the current visiting schedule has enabled them to feel confident, safe and secure with their new baby. Much of this stems from the extensive preparation that my clients do in their pregnancy, and that most have a drug-free, natural birth. This seems to help with the baby’s adaptation to newborn life.

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Caesarean babies face more infections

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Some caesareans are genuinely necessary for the safety of mother or baby, so I wouldn’t like for this article to offend readers who may have had a caesarean that they feel was necessary for one reason or another. However, necessary or not, this article is reporting on the fact that babies who are born by caesarean tend to experience more infections than babies who were born vaginally. This adds to the other known risks of caesareans such as an increase in the rate of asthma, respiratory infections and diabetes.

BABIES born by caesarean are much more likely to be admitted to hospital with gastrointestinal disease or chest infections in their first year of life than those born naturally … The babies were 22 per cent to 26 per cent more likely to be hospitalised with gastrointestinal disease and about 12 per cent more likely to be admitted with bronchiolitis, a type of chest infection …

… children born by caesarean could miss out on picking up important gut bacteria that children born naturally get during the birth.

“We take all these yoghurts and things to get the right bacteria in our guts but the baby travelling through the birth canal is going to get the right sorts of bacteria,” …

… there could also be a link between caesareans and breastfeeding problems.

… women who gave birth by caesarean were 70 per cent more likely to be diagnosed with a complication affecting breastfeeding.

And the babies of the women with breastfeeding problems were then 30 per cent more likely to be hospitalised with gastrointestinal problems.

… Earlier Australian research had found the link between bronchiolitis and caesareans existed with only planned caesareans, suggesting labour itself could activate the mothers’ immune system …

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Eating Fish While Pregnant is Good for Baby’s Brain Development

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… infants of mothers who consumed more fish during pregnancy achieved higher scores in verbal intelligence and fine motor skill testing, as well as having a higher pro-social behavior …

Fish oil is the primary source of Omega-3 fatty acids and contains docosahexaenoic acid (DHA), the main component of brain cell membranes … “it contributes to the normal development of the brain and eye of the fetus and breastfed infants” …

Eating fish is good, but it’s also important to eat the right type of fish, as some fish is higher in mercury. As a guide, the smaller the fish, the better in terms of the fish having the lowest possible mercury content. Salmon and other types of fatty fish are also better for baby’s brain development than white fish. That’s not to say that white fish is not good for you and your baby – it’s very healthy – just that fatty fish is better in terms of baby’s brain development. Canned fish is also fine; the fish doesn’t need to be fresh. Enjoy it in a salad, on a sandwich, grilled with veges or in a stew. We can enjoy winter foods given all this winter weather we’re having!

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“I’ve been told my baby is big”

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and my care provider wants to induce me / schedule a caesarean.

An interesting dilemma. What to do? A recent article has found that ultrasound diagnosis of fetal macrosomia (a big baby) at term is inaccurate in the majority of cases, and this inaccuracy may be contributing to unnecessary caesarean sections.

In an observational cohort study of 235 pregnancies at term in which ultrasound measurements led to a diagnosis of fetal macrosomia, only about a third of the infants were actually macrosomic at birth. Additionally, these pregnancies with ultrasound-diagnosed fetal macrosomia were more than twice as likely as all pregnancies in the population to end in cesarean delivery

Surprisingly, the accuracy of ultrasound in assessing fetal weight is similar to that found with simple clinical palpation (feeling the size of the baby through the woman’s abdomen)

The [average] percentage error of the estimated fetal weight was 8.6% overall. Viewed another way, 44% of the weights were off by more than 10%, and 7% were off by more than 20%.

The mode of delivery was cesarean section in 66% of the pregnancies, compared with just 29% of all pregnancies in Calgary during the same period. “So it’s [more than] double, the percentage who are getting C-sections, on what is [an inaccurate weight]

It’s a difficult situation for the care provider when considering what to say to a pregnant woman. Tell any woman her baby might be “big” and she’ll rightly be scared. And this fear can impact the birth and lead to interventions. Conversely, is it ok to say, “Your baby is the perfect size for your pelvis and you’ll birth your baby beautifully”? What if it doesn’t quite work out this way for this woman?

I like to let women know that size isn’t everything. We all know this! The position of the baby is also really important as is the strength of the contractions, a woman’s morale and motivation, her support team, and the decisions she’ll make with her care provider.

A woman can have a “small” posterior baby that results in a long labour … or a “large” but well positioned baby that results in a smooth and easy labour. I’ve known many women to have a caesarean with their first baby – women will say, “He didn’t fit. It was a long labour and I only got to 4cm and he was only 3.4Kg” and they go on to have a 4kg baby next time in a four hour labour with no tears.

My feeling is that it is ok to let a woman know that her baby feels like it might be larger than expected so that the woman can proactively plan for her labour with things like upright positions in labour, positions that open the pelvis and positions that help her to relax. It’s always important to be truthful as this builds trust. It’s also really important to talk about the position of the baby as I often find that a baby’s position in labour is more important than its size. It’s not about creating fear and disappointment by suggesting, “Your baby is h.u.g.e … you’ll need a caesarean for sure. In fact, why don’t we book it in now and you can save yourself hours of labour only to end up with a caesarean?” But rather to explain that the baby feels larger than expected, that babies grow at different rates and that size is not the only important factor. And then work with her to help her to understand positions and strategies that will help her through her labour. In my own practice, only 4% women having their first babies have a caesarean, compared with 25% as the National average for first-time mums. I wonder how many caesareans can be avoided by providing continuity of care for women through pregnancy, birth and the new parenting experience?

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Natural Twin Birth

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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How do Midwives Work?

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It’s a common question I am asked! When people ask me what I do, I tell them I am a midwife. The next question is usually, “Oh, so you’re a nurse?”. “Not quite”, I reply, “a midwife – I care for women though pregnancy and birth and with their new baby.” Then they really look puzzled. “That’s not what an obstetrician does?” “An obstetrician is a doctor who specialises in caring for women with complicated pregnancies and births. A midwife specialises in caring for women who are having healthy pregnancies and births.” By that stage they’re well and truly confused and I start to wonder what we need to do to promote midwifery as a care option for all women.

The term midwife means ‘with woman’. Midwives work in partnership with women through pregnancy, birth and the postnatal period. Midwives can provide care to women from the time that the woman discovers she is pregnant, right up until her baby is 6 weeks old. In fact, women who experience a normal, healthy pregnancy and birth may not see a doctor at all! Eligible midwives are able to order all the necessary tests and scans during pregnancy and may refer directly to an obstetrician if their services are necessary.

Midwives provide education, support, advice and information, as well as doing all the routine checks of mother and baby.

Midwives advocate measures throughout pregnancy and birth that promote normal birth: that is a birth without interventions. Midwives and are experienced in such things as water birth, active birth, and so on.

Midwives are also specially educated to know if anything is out of the ordinary, and they can get help from obstetricians. In pregnancy, midwives see women at intervals so that any issues that may present can be dealt with before they cause any major issues.

Women who are cared for by one midwife from pregnancy through to birth have better outcomes in terms of safety, lower rates of intervention and satisfaction with their experience. Midwives too prefer to work in this way, getting to know each family individually.

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Heart test that saved baby

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This test is very simple to perform – any midwife could administer this; it takes very little time, is non-invasive and causes no pain for the baby. It is not (yet) routine in Australian hospitals, although some are performing it.

… Baby Charlie is the apple of his mother’s eye. A little more than three months ago he was born, seemingly healthy …

“We were packed ready to go literally on our way out the door” …

But Charlie still needed two newborn screens. One, the heel prick is mandatory. The baby’s heel is poked, drawing a spot of blood. The sample is then tested to detect rare genetic disorders. The other newborn test is voluntary.

… It’s called pulse-oximetry. There’s no pain, no poke, just a reading of the oxygen level in a baby’s blood. If a newborn baby’s reading is above 90, it signals a healthy heart. When Charlie got his test, at first no one believed the oxygen levels.

“… they just kept registering in the 60s. I remember at that point looking at my husband and thinking, there’s something wrong,” Lindsay said.

The test had picked up a life-threatening defect in Charlie’s heart … “It tells us there could be a problem. And the number one problem we’re looking for is congenital heart disease,” …

The babies are given the pulse-oximetry test at a day old. It’s a crucial window of time before a baby would show heart defect symptoms, such as breathing or feeding trouble, or blue skin.

“My big passion comes from babies that do not have this test that show up in our emergency room or clinic, very sick or very ill with serious heart disease that could have could have been detected earlier,” said Dr. Park.

After his pulse-oximetry test baby Charlie was rushed the Neonatal Intensive Care Unit … at just six days old Charlie had open heart surgery.

… parents of newborns can ask for the test if a hospital doesn’t routinely offer it.

… undetected heart defects are the number one cause of infant death from birth defects.

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Treatment Halves Preterm Birth Rate

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The risk of preterm birth and neonatal mortality and morbidity declined significantly in asymptomatic women with a … short cervix treated with vaginal progesterone …

The treatment was associated with a 40% to 50% reduction in the risk of preterm birth, a 43% reduction in total neonatal morbidity and mortality, and a 45% reduction in the frequency of low birth weight.

… “Our analysis provides compelling evidence that vaginal progesterone prevents preterm birth and reduces neonatal morbidity and mortality in women with a short cervix,” …

“Importantly, progesterone reduced early preterm birth. These immature babies are at the greatest risk for complications, death, and long-term disability. Progesterone also decreased a fraction of late preterm births, which are the most common preterm deliveries.”

… Progesterone has a key role in maintenance of pregnancy …

“Vaginal progesterone was associated with a significant reduction in the risk of preterm birth <33 weeks of gestation in both women with a single gestation and no previous preterm birth, as well as in women with a single gestation and at least one previous spontaneous preterm birth before 37 weeks of gestation," ...

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Delayed Cord Clamping

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Delayed cord clamping refers to the practice of clamping the umbilical cord after it has stopped pulsating. The usual hospital practice is to clamp and cut the cord straight away, however new wisdom (practiced for many years by private midwives) challenged the usual practice.

Soon after a baby is born, the umbilical cord is clamped. But just how long those minutes should be, in between birth and clamping, is the subject of some controversy.

New research from Sweden shows that a delay in clamping the cord, by just a few minutes, results in improved iron levels for babies … iron is crucial for healthy development of the brain and central nervous system.

… For the babies whose clamping was delayed, there were fewer instances of anemia two days after birth. By four months of age they showed a 45 percent higher mean ferritin concentration … and a lower prevalence of iron deficiency than the babies who had been clamped early.

In the early clamping group, researchers noted that the degree of iron deficiency was moderate, rather than mild. All infants, from both groups, had similar weights and lengths as well as similar levels of hemoglobin.

Delayed cord clamping permits additional blood, including iron, to reach the neonate. The controversy comes in, however, because … later clamping can have a potential for … maternal hemorrhage …

In the event of excessive bleeding, the cord could be clamped and cut and Syntocinon administered to stem the bleeding. Delayed cord clamping is my usual practice. I do not generally cut or clamp the cord until after the placenta has been born.

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‘Illegal’ midwives: Is Australia destined for the same?

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An article from Canada explains their midwifery system which includes unregistered midwives.

Ann (not her real name) operates outside the regulated profession, living life on the edge, exposed to a constant threat of legal action should births under her watch go wrong.

She knows five other unregistered midwives working in Montreal’s so-called “parallel network.” They typically help women who are unable to secure legal midwife services to have their babies at home or in a birthing centre, and who reject the official alternative of giving birth in a hospital

There is no shortage of demand for their services. With just 140 registered midwives able to practise across the entire province, the parallel network fills a yawning gap in the market. Much of the birthing industry – obstetricians, gynecologists and some registered midwives – would consider its covert practitioners to be charlatans. But, to women determined to choose how, where and with whom they give birth, they are valued allies.

Take Teprine Baldo, who had her eldest child, now 2 years old, at home with the help of what she calls a “midwife recognized by the community. I prefer the term. It’s more respectful. People tend to talk about illegal midwives the way they used to talk about witches,” she says.

There has been one prosecution over the years. In 2006, Diane Boutin was forced to transfer a woman in her care to … Hospital after complications set in mid-labour. Following an emergency Caesarean, the gynecologist on duty filed a complaint with the provincial order of midwives … which went on to successfully pursue Boutin for illegal practice under Quebec’s professional code, a felony carrying a fine of up to $6,000.

In the days before the profession began its slow march toward legalization in the 1990s, all midwives were renegades operating outside the system, some entirely self-taught, others holding foreign qualifications unrecognized by the province. But, times have changed and as the now-regulated profession wages a PR battle for public acceptance, pushing against residual resistance from an often skeptical medical establishment, it cannot be seen to condone illegal practice.

parents are likely to be the biggest losers when things go wrong, should newborns be left damaged as a direct result of negligence or malpractice.

It’s a hugely sensitive issue. Sinclair Harris, a registered midwife at Pointe Claire birthing centre, is sympathetic with her unregistered counterparts. But, she says, “You need an understanding of pathology, of the things that can go wrong, if you are to be available for the mainstream public.”

Women like Baldo are incredulous that they are still being denied that choice, outraged that the black market midwives helping the most determined to exercise basic rights over their bodies risk prosecution.

“It’s like we’re being told we can’t birth properly,” she says. “I’m not against hospitals. My issue is that there’s often no alternative.”

At 32 weeks, she dropped out of the system, switching to an unregistered midwife

Seeking closure after a traumatic first birth in hospital, Caroline Gauthier gave birth to her second child at home with an unregistered midwife.

She was living in British Columbia, pregnant with her first child, when her dream of an intervention-free home birth went awry. Transferred to hospital by her registered midwife after her cervix was slow to dilate, she was administered hormones to speed up labour.

“I was like Jabba the Hutt, hooked up to the monitor,” she says. Staff forgot to turn on the oxygen supply to her mask, leaving her flailing about for help. When her baby finally arrived after a traumatic final push, she was barely able to touch his foot before he was whisked away.

Pregnant with her second child in Quebec, she immediately set about trying to secure a midwife at the Du Boisé birthing centre in the Laurentians. However, her place was contingent on her delivering at the birthing centre.

But Gauthier had already set her heart on giving birth at home. At 32 weeks, she dropped out of the system, switching to an unregistered midwife. Again, her labour was long, but she sat out the hours in the bath and in bed. “This time, I had a midwife who didn’t have a system to please,” she says.

After three days of labour, the baby’s head popped out while she was on her way to the bath. “In less than two minutes, the whole body was out,” she says. He didn’t immediately cry, “but nobody made a circus out of it.”

Vindicated by her second experience, she is now a fierce advocate of women’s right to give birth as they choose. “I was given the time my baby needed,” she says. “My neighbours tell me I was so brave delivering at home. My reaction is: ‘My God, you’re brave giving birth in hospital. You’re putting yourself at their mercy. You don’t know what you’re getting yourself into.’ ”

The midwife: With no insurance, every new client is a gamble

On D-day, Ann arrives on the scene with a case containing oxygen supplies, a heart monitor, synthetic oxytocin, herbal remedies, suture material and local anesthetic for stitches.

She has been practising midwifery in the parallel network for more than 10 years. Clients find their way to her by word of mouth. She has a busy schedule year round, attending to three or four clients a month.

Clients are generally women who have been unable to find a registered midwife …

Occasionally she has transferred cases to hospital …

With no insurance, every new client is a gamble. “My insurance is the trust I develop with the parents. I trust people who have the deep belief that it’s best for the birth of the baby. Nobody can be sure of the end result.”

There is a contract, though she is clearly ill at ease with cold legal realities. “It’s about ensuring the parents understand what they’re getting into,” she says. “But, sometimes I forget to get people to sign. We’re on another level. It’s not about business.”

She describes herself as a self-taught midwife eschewing a system where midwives are “too stressed, too watched.” …

The four-year university program didn’t appeal to her. “I thought it was too focused on pathology. There was no alternative medicine. No spirituality,” she says. “It’s as if only one kind of intelligence is allowed. Forget emotional intelligence.”

Midwifery was legalized in Quebec in 1999, following a five-year pilot project. Home births with the assistance of registered midwives have only been allowed since 2005.

In a 2007 Statistics Canada report, 71 per cent of women who had delivered with a registered midwife rated the experience as “very positive,” compared with 53 per cent of women who had delivered in a hospital.

According to research … midwife-assisted home births are associated with lower rates of obstetric interventions and adverse outcomes. Newborns born at home were also less likely to require resuscitation or oxygen therapy.

Australia is heading for a similar situation, brought about by a few factors: the recent position statement on homebirth which effectively prevents midwives from attending high risk births at home, the lack of visiting rights to enable most midwives to birth in hospital with their clients, dissatisfaction with current hospital-based maternity services that are seen by women to be impersonal and highly interventionist, and a differing view of things such as risk and responsibility. Although some midwives are making the choice to unregister and continue to attend births, they do face the same issues that are explained in the article.

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Smoking’s effect on unborn babies revealed

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Unborn babies exposed to nicotine have a higher risk of high blood pressure and heart disease growing up.

… researchers now know why the nicotine exposure – including from patches and gum – has the effect:

… the addictive substance causes the formation of potentially damaging chemicals, known as reactive oxygen species, in the blood vessel walls of the foetus.

… nicotine patches and gum, commonly used by people trying to kick their smoking habit, could have the same effect.

… the study proved the long-term harm nicotine caused to children from a young age or as a foetus.

… “Both babies whose mothers smoke while pregnant and babies who are exposed to second-hand smoke after birth are more likely to die from sudden infant death syndrome (SIDS) than babies who are not exposed to cigarette smoke.”

She said babies whose mothers smoke while pregnant or who are exposed to second-hand smoke after birth also have weaker lungs than unexposed babies, which increases the risk of many health problems later in life.

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“I’ve been told my baby is big”

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and my care provider wants to induce me / schedule a caesarean.

An interesting dilemma. What to do? A recent article has found that ultrasound diagnosis of fetal macrosomia (a big baby) at term is inaccurate in the majority of cases, and this inaccuracy may be contributing to unnecessary caesarean sections.

In an observational cohort study of 235 pregnancies at term in which ultrasound measurements led to a diagnosis of fetal macrosomia, only about a third of the infants were actually macrosomic at birth. Additionally, these pregnancies with ultrasound-diagnosed fetal macrosomia were more than twice as likely as all pregnancies in the population to end in cesarean delivery

Surprisingly, the accuracy of ultrasound in assessing fetal weight is similar to that found with simple clinical palpation (feeling the size of the baby through the woman’s abdomen)

The [average] percentage error of the estimated fetal weight was 8.6% overall. Viewed another way, 44% of the weights were off by more than 10%, and 7% were off by more than 20%.

The mode of delivery was cesarean section in 66% of the pregnancies, compared with just 29% of all pregnancies in Calgary during the same period. “So it’s [more than] double, the percentage who are getting C-sections, on what is [an inaccurate weight]

It’s a difficult situation for the care provider when considering what to say to a pregnant woman. Tell any woman her baby might be “big” and she’ll rightly be scared. And this fear can impact the birth and lead to interventions. Conversely, is it ok to say, “Your baby is the perfect size for your pelvis and you’ll birth your baby beautifully”? What if it doesn’t quite work out this way for this woman?

I like to let women know that size isn’t everything. We all know this! The position of the baby is also really important as is the strength of the contractions, a woman’s morale and motivation, her support team, and the decisions she’ll make with her care provider.

A woman can have a “small” posterior baby that results in a long labour … or a “large” but well positioned baby that results in a smooth and easy labour. I’ve known many women to have a caesarean with their first baby – women will say, “He didn’t fit. It was a long labour and I only got to 4cm and he was only 3.4Kg” and they go on to have a 4kg baby next time in a four hour labour with no tears.

My feeling is that it is ok to let a woman know that her baby feels like it might be larger than expected so that the woman can proactively plan for her labour with things like upright positions in labour, positions that open the pelvis and positions that help her to relax. It’s always important to be truthful as this builds trust. It’s also really important to talk about the position of the baby as I often find that a baby’s position in labour is more important than its size. It’s not about creating fear and disappointment by suggesting, “Your baby is h.u.g.e … you’ll need a caesarean for sure. In fact, why don’t we book it in now and you can save yourself hours of labour only to end up with a caesarean?” But rather to explain that the baby feels larger than expected, that babies grow at different rates and that size is not the only important factor. And then work with her to help her to understand positions and strategies that will help her through her labour. In my own practice, only 4% women having their first babies have a caesarean, compared with 25% as the National average for first-time mums. I wonder how many caesareans can be avoided by providing continuity of care for women through pregnancy, birth and the new parenting experience.

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Dutch abandon home birth

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A recent article informs us that:

RISK OF DEATH INDUCES DUTCH WOMEN TO ABANDON HOME BIRTHS

It goes on to say that in the last 10 years, the percentage of Dutch women who are giving birth in hospitals has risen from 37% to 75%. They state that reasons for this include:

  • concern at the disproportionally high baby death rate in home birth
  • the rising popularity of epidurals, a pain relief option in labour which is only available in hospitals.

    • The Dutch system of home births has been promoted as one which other countries should emulate, including New Zealand. However, last year a large study found that the perinatal death rate was greater in low risk women who were cared for by midwives than in higher risk women who were cared for by obstetricians. The researchers concluded that the Dutch system of risk selection is not as effective as was once thought.

    I have read the study that has been referred to above. The study concludes that:

    The main finding of this study is that the Dutch obstetric system that is based on risk selection and obstetric care at two levels may not be as effective as was once thought. The Dutch obstetric system itself possibly contributes to the high perinatal mortality compared with most European countries. We found that delivery-related perinatal death was significantly higher among low risk pregnancies in midwife supervised primary care than among high risk pregnancies in obstetrician supervised secondary care.

    The Dutch system relies on a risk assessment. Women are either in primary care or secondary care. Women who are in primary care have midwifery care and they have the option of home birth or hospital birth. The Netherlands currently has a 22% homebirth rate. Women with risk-associated pregnancies have obstetric (secondary) care and give birth in hospital. They might have issues such as high blood pressure, diabetes, twins, a previous caesarean and so on. Overall, 49.5% women remain in primary care at the start oaf labour, and 35% women remain in primary care throughout labour and birth. 65% women either start their pregnancy in secondary care or are transferred to secondary care at some stage in their pregnancy or labour. It is a system that has worked well for many years.

    However, the study has found that the intrapartum (labour and birth) death rate among term babies without congenital malformations (birth defects) was as follows:

  • For babies who started labour in primary (midwifery) care: 0.96/1000
  • For babies who started labour in secondary (obstetric) care: 0.24/1000
  • For births that took place in primary care: 0.91/1000
  • For births that took place in secondary care: 0.45/1000
  • For births that were referred from primary care to secondary care in labour: 1.09/1000

    • Babies of women who were referred from a midwife to an obstetrician during labour had a 3.66 times higher risk of delivery-related perinatal death than did infants of women who started labour supervised by an obstetrician.

    The study concludes that:

    The obstetric care system in the Netherlands may contribute to the high perinatal mortality

    and:

    the Dutch system of risk selection in relation to perinatal death at term is not as effective as was once thought.

    I suggest that there is another major issue involved that has been ignored in the above suggestion. In the Netherlands, midwives book 105 women per year. You read that correctly. While in Australia, midwives care for around 20-40 women per year, in the Netherlands it’s a huge caseload of 105 women per year. Therefore it is impossible for the midwife to personally attend every labour for the duration. Instead, there is a system in place where the women are cared for by a Kraamverzorgenden who stays with the woman during labour and for the first week after the baby is born. This person does not perform any midwifery care but provides support to the woman. The midwife pops in and out every two or four hours to examine the woman and perhaps listen to the baby’s heart beat – I say “perhaps” because there is no official guideline in The Netherlands that this ought to be attended at any specified interval. Hence the midwives check the baby’s heart beat as and when they choose. Acknowledging that the midwife does not sit with each women in labour, it’s plausible that the baby’s heart beat would only be checked every two or four hours. The standard of care for the UK and Australia is that the baby’s heart beat should be checked every 15 minutes in labour and after every contraction in the second stage of labour when the baby is being born. This is identified in the article:

    Of major concern is the fact that the highest mortality was among the infants of women who were referred from primary care to secondary care during labour because of an apparent complication. Hypothetically, this high mortality could have several causes … diagnosis in primary care can be delayed because the midwife is not always present during the first stage of labour and fetal heart beats are often checked only every two to four hours.

    I am interested in why this fundamental issue has not been addressed; rather, a complete review of a system that is in place in other countries – successfully – has been called for?

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    Hospital Transfers

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    Visit my website to explore home birth, hospital birth and Medicare-funded private midwifery care.

    There have been some articles in the press in the past few days about women being transferred from one hospital – the one they were booked to give birth in – to a different hospital. See here and here.

    Of course the women and families concerned are, well … concerned. Any time a woman’s birth plans are disrupted without notice, the situation can be stressful.

    In one situation, a woman was transferred from Campbelltown Hospital in Sydney to John Hunter Hospital in Newcastle. She was in threatened premature labour with twins. The ambulance trip took three hours. This journey happened because there were no neonatal beds available in Sydney to care for these twins.

    On the surface, this seems appalling … a woman transferred by road, for three hours, carrying twins, with the possibility of delivering them in the ambulance! However, looking beneath the surface, the detail reveals that the care provided was appropriate. According to the media reports, the woman was only 26 weeks pregnant. This is called “extreme prematurity”. In cases of premature babies, we have a task of matching their care needs to the right hospitals. We have hospitals of different levels. Some are only equipped to care for term babies, being those born after 37 weeks, while others can care for babies born after 34 weeks. And very few – only 8 across NSW and ACT- can care for babies as young as these twins were.

    Caring for babies as young as these ones requires immense resources.

    Intensive care baby

    Intensive care baby

    A specialised neonatal cot, sophisticated monitoring equipment, syringe drivers, 24/7 access to pathology and radiology, a neonatologist (this is a paediatrician who specialises in the care of newborn babies) and dedicated NICU nurses. These are specialised nurses who have completed additional graduate certificates and have extensive clinical experience. In smaller hospitals, the requirement of having these skilled and competent practitioners – as well as the purchasing and maintenance of equipment that is seldom used – would represent a significant cost inefficiency. The vast majority of babies are born at term, with a mere 0.7% babies born at – or prior to – 26 weeks.

    The Health Minister, Jillian Skinner, advised that there were more than enough beds to cater for the State – and this is true. On average. Averages work well most of the time, but sometimes we need more beds than we have available, and this is when babies are transferred to another hospital. Sometimes this is as simple as transferring from say Canterbury Hospital to the near-by Royal Prince Alfred Hospital. Other times, rarely, babies are transferred further away, and even interstate. And other times – though this never reaches the news – there are very few babies in our neonatal intensive care units …. and the full complement of staff has very few babies to care for. Neonatal beds lie idle. This is never newsworthy but according to the law of averages, it happens as often as babies are transferred to another hospital.

    Some have argued that the woman should have been able to birth her babies at Campbelltown and then move the mother and babies to another hospital. This situation is what we call an ex-utero transfer, where babies are transferred after they have been born. unfortunately this is always worse for the babies for a couple of reasons: first, the birthing hospital may not have the facilities, staff, equipment and expertise to care for the babies, and second, when the specialised team arrives to transfer the babies, this complex transfer takes hours just to set-up in the hospital because the babies need to be switched over to the helicopter equipment and stabilised before they can be moved. Having been involved in these situations, I know it can take hours and this is all time that the fragile and delicate babies are being disturbed. So for many reasons (more than I have listed here), it is far better to do an in-utero transfer – that is, transferring babies while they are still inside their mothers.

    In this woman’s case, her babies remained safe inside and were not born.

    In another case, a woman was transferred in labour from a low-risk birth unit to a unit that handled higher-risk births when it became apparent that she had risk factors associated with her labour. This was a good call. A risk was anticipated that could not be dealt with at the local hospital, and the woman was safely moved to a unit that had the resources to provide safe care to her. This is no different to a woman moving from the birth centre to the delivery suite, or from a planned homebirth to hospital at any stage of the pregnancy or birth.

    What’s important is that the care that is provided is safe, and part of providing safe care is recognising the limitations of a service and having a good back-up plan or transfer plan. NSW has a specialised network that communicates well to advise all hospitals of which ones have available NICU beds. In this way, a midwife or doctor can quickly arrange a transfer. Likewise, a smaller hospital will be buddied with a nearby larger hospital with formal transfer plans and agreed indications for transfer, so that if a woman presents with something that is higher risk than what the smaller hospital can safely care for, the smaller hospital will have a plan in place to communicate with the larger hospital and to arrange a safe transfer.

    Study links smoking during pregnancy to birth defects

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    SMOKING in pregnancy increases the risk of many congenital defects, including cleft palate and club foot, according to the first systematic review of the literature, spanning 50 years.

    … Smoking in pregnancy was associated with increased risk of cleft palate (28%), club foot (28%), craniostenosis (33%), hernia (40%) and gastroschisis (50%), with more modest increases in risk for heart and musculoskeletal defects.

    Maternity Reforms: Good news for expanded birthing options

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    Visit my website to explore home birth, hospital birth and Medicare-funded private midwifery care.

    Maternity reforms came into effect in November 2010 which gave women access to Medicare benefits for private midwifery care for the very first time. In addition, eligible midwives were to be able to order relevant tests and ultrasounds through Medicare. Medicare benefits are available to clients of eligible midwives for pregnancy and postnatal care, however there is no benefit for birth care at home.

    So, 6-odd months on, how are things looking for maternity care and what possibilities await us?

    Well, for a start, we had around 200 private midwives in Australia. 6-odd months into the reforms and we have at least 30-40 eligible midwives. Some of those 200 midwives have ceased private practice, leaving about 100 in private practice. So 30-40 eligible midwives represents a 30%-40% update of the maternity reforms by the current private practice workforce in just 6 months. That is phenomenal. As well as this, private practice has become a more attractive option to employed midwives now that private practice is medicare-funded and indemnified. So in months and years to come, we will have more midwives in private practice, and less in the hospital employed system. This is not a concern as the hospitals would not need their own staff: women will bring their midwife with them to the hospital when they come in to birth their babies. From the hospitals’ perspective, this is excellent news: they may benefit from significant cost savings in terms of recruitment, retention, staff education, pay-roll, rostering, management and so on.

    What about for women? Well, it is well-known that women benefit from exclusive one-to-one midwifery care through pregnancy, labour, birth and the postnatal period. When women are cared for exclusively by one midwife, we know that they experience lower rates of interventions without compromising safety, and they experience higher rates of satisfaction with their birth and new parenting experience. When women choose a Eligible midwife, they can access significant medicare benefits that do reduce the cost by quite a lot. Depending on the number of pregnancy and postnatal consultations a woman has, the benefits range from say $1,000 – $2,500.

    However, in order for eligible midwives to provide medicare-rebatable services, midwifery care needs to be delivered within a collaborative arrangement. And this does open the possibility for private midwives and private obstetricians to work together in collaborative practice. The huge benefit to the woman is that she has midwifery care right the way through, from early pregnancy to 6 weeks after her baby arrives, with the reassurance of having a known obstetrician who is available is needed. Women meet the obstetrician twice in pregnancy, and the obstetrician is available for labour and birth if his care is needed, and in this way, women can benefit from the ultimate in continuity of carer. This model of care is now available for the very first time in Australia history, and we are very pleased to be able to offer it to women. So far it is a very popular option! More to come.

    Mom-to-be says her hopes were destroyed by midwife

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    A … mother says things went tragically wrong when she used a midwife …

    … after her baby died, she was surprised to learn, there are different kinds of midwives …

    … Muhsin lost her daughter Alia before she even gave birth …

    … when she was 7 months pregnant, she felt like her OB/GYN office was a bit impersonal, so she did some research online …

    “I walk in this place, very serene, very organized. They have a wall full of babies’ pictures,” …

    Muhsin says the midwife who handled her care was also the director … [the midwife's] resume on her website seemed impressive.

    “She sold me a very good story, and I believed her,” said Muhsin.

    … her original obstetrician had diagnosed her with gestational diabetes. But Muhsin says [the midwife] convinced her that she didn’t really have the condition, which can jeopardize the life of a baby if it’s not properly treated.

    Muhsin and her husband got worried when she went nearly 4 weeks past her due date. Muhsin says the midwife kept reassuring her that everything was fine – but it wasn’t.

    “I just feel really sick and I told her, I don’t feel contractions anymore, nothing. She told me, it’s okay, you stay home,” …

    … “She said, okay, now you have to go to the hospital, because I don’t know what’s going on. We went in; they asked my husband, what is her due date? And they start running.”
    Hospital records indicate both mother and baby had a severe infection …

    “The baby had no heartbeat,” …

    … Direct Entry [Midwives] … are not required to have any formal training – in fact they can be self-taught.

    “They’re operating on their own without any oversight by the legislature, without any oversight … ”

    … the baby could have been saved if the midwife had transferred Muhsin’s care to a doctor before she went nearly 4 weeks past her due date.

    … “Gestational diabetes can be very risky to the baby,” …

    … “There’s a great increased risk from 39 weeks onward of in utero fetal distress, and even fetal demise,” …

    … [The midwife] denies that she waited nearly 4 weeks after Muhsin’s due date to advise her to go to the hospital. She also says that she’s still working as a midwife …

    “We want to be licensed because we want to make sure there’s a standard of care. That consumers are protected,” said Kate Mazzara.

    Kate Mazzara is a Certified Professional Midwife … she’s trying to get Lansing to pass a law to license midwives … a licensing board would then be able to hear complaints, and take action against midwives if problems arise.

    “I want to make sure that these moms and babies are birthing in a safe way, and the midwifery model of care has been shown to be an extremely safe option for families, but there should be that safety mechanism to which midwives can be held accountable,” …

    … the sad stories are rare … home births are a beautiful, natural experience … the number of home births has jumped 20% in recent years …

    Part of this article deals with the fact that in the US, there are different types of midwives, from certified nurse midwives who have degrees, work collaboratively with obstetricians, and have visiting rights, through to certified professional midwives and finally direct entry midwives. In Australia, we have registered midwives who are all accountable to the same high standard of care. As well as registered midwives, we also have eligible midwives who have satisfied an additional registration standard that entitles them to access a medicare provider number, and in the future, visiting rights. The next article deals with another aspect: that of choosing a midwife:

    How to Choose a Good Home Birth Midwife

    If you’re looking into home birth, probably the most important thing is finding a good midwife. Your midwife will be the one who cares for you, watches over you, and makes any decisions if something unexpected or difficult happens in your pregnancy. It is imperative to get a midwife who is well-trained and experienced and whom you trust and feel comfortable with.

    How do you know if you’ve found a good midwife?

    Feel free to ask anything else that makes you feel comfortable. In my experience, midwives are usually very cautious and ready to refer patients to the hospital or an OB at the first sign that something isn’t right. The should be very conscious of the limits of their training, so that if any situation crops up that they feel uncomfortable about handling, they are prepared to rule you out as a home birth candidate. This doesn’t happen too often, but it’s very important to know that if you are one of the “riskier” cases, your midwife will tell you so and refer you. Any midwife who says that she never transfers or refers women because “all women can do this!” should be avoided!

    Go with your instincts, too. If you feel comfortable with the midwife and she’s answered your questions sufficiently, then choose her. If not, keep looking …

    Choosing The Best Midwife and Why is choosing a care provider one of the most important pregnancy decisions you will make? are also helpful posts. Ultimately, registered health practitioners are responsible for practicing their profession safely. But as a consumer of a service, it is up to you to make sure that the person you have engaged for your care, is legally and professionally able to care for you (ie, registered). Don’t be afraid to check the AHPRA register of practitioners if you would like to check the registration status of your health practitioner.

    Doctors admit C-section error in tragic baby’s botched birth

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    TWO consultants have admitted to the parents of a baby deprived of oxygen at birth they should have performed a caesarean section earlier.

    Baby Senan Michael Christopher Dodd was born at Mount Carmel Hospital, Dublin, on March 28, 2008.

    There was a delay in performing the emergency birth procedure and the baby boy suffered severe brain damage due to oxygen deprivation …

    He died … on March 30, 2008.

    Two consultants obstetricians … acknowledged … the caesarean section should have been performed earlier.

    Dr Rafferty said he contributed to the delay in delivering the baby and expressed his “profound apologies” to the baby’s parents …

    [The] Midwife … told the court she called Dr Rafferty to review Roberta … due to lack of progress of labour, following an hour of active pushing.

    The doctor said he gave the parents the option of a caesarean section or of an epidural with syntocinon …

    Syntocinon and an epidural were administered.

    But the doctor failed to look back at the trace of the foetal heartbeat, which indicated a slow heart rate at 2.45pm and another slow rate after pushing began.

    … He told the inquest he should have, “been more direct and said a C-section was the way to go”.

    He agreed with counsel for the family, Bruce Antoniotti, that he did not tell the Dodds there was foetal distress because he failed to perceive it, as he failed to look back far enough on the trace.

    The baby’s heart rate was monitored intermittently …

    This is the standard of care for women in normal labour with a healthy pregnancy and baby.

    Dr Valerie Donnelly, who took over from Dr Rafferty, reviewed Mrs Dodd around 6.20pm after a prolonged period of slow foetal heart rate.

    Dr Donnelly proceeded as planned and recommenced the syntocinon although it had been turned off by the midwife, who was preparing for a C-section.

    “I regret I did not deliver the baby by C-section at that point. I believe my delay in making the decision to deliver him by caesarean section has contributed to his death,” …

    Special delivery brings relief

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    PRUE Corlette travelled up to five hours a day to Liverpool Hospital from Rose Bay.

    … The twins were born nine weeks premature at Liverpool Hospital … not at The Royal Hospital for Women as she intended.

    When Ms Corlette went into early labour, there was no room in the Randwick hospital where her midwife and obstetrician were.

    Their 15 high-care cots in the neonatal intensive care unit were all occupied but there were ones available at Liverpool, Canberra and Newcastle hospitals — the closest one Liverpool, 45 kilometres away.

    “My midwife and obstetrician (from the Royal Hospital for Women) couldn’t come with me,” …

    … “I had built up a good rapport with my obstetrician … We had similar philosophies of birth.

    “When I got to Liverpool, the birth philosophy was quite different. They wouldn’t even give me a hot water bottle.”

    Theodore arrived first, then Hugo was born through an emergency caesarean section.

    “I had a succession of different doctors see me,” …

    “To be going into premature labour and to not have a consultant is terrible.

    “My second baby got into some kind of distress. I heard people screaming ‘code red’ but no one explained to me what was happening.”

    Ms Corlette was discharged after three days but the twins remained at Liverpool Hospital’s neonatal intensive care unit for another 10 days.

    Having undergone a caesarean she was not allowed to drive so she had to make the long trip from her home on public transport.

    “The staff in the neonatal unit were very helpful but the maternity ward not so good. It was very busy and overcrowded,” …

    The babies were transferred to the Royal Hospital for Women when cots became available.

    … “Liverpool Hospital has a well-staffed and resourced 12-bed Neonatal Intensive Care Unit (NICU), which is one of a number of NICUs in NSW that provide specialised care for premature and very sick babies from across the state,” …

    … neonatal intensive care beds are networked to ensure that whenever an expectant mother gives birth, she and her baby have access to the specialist care required. “This may result in the transfer from one hospital to another due to the level of care required or bed availability.”

    If I were Prue, I’d be thankful that care was available for my babies, that I did not have to be flown to Canberra (or further – say to Perth), and that we live in a country that provides such a high standard of care to mothers and babies. She did not get the care she had planned from the midwife and obstetrician that she had chosen and this was not expected, but thankfully a transfer was possible to a hospital that could provide the necessary care. Had her babies been born at RHW, they could not have received the care they needed as there were no cots available in the NICU, and presumably no staff available to care for the babies.

    For some women, a transfer will be needed. This could be because the hospital doesn’t have the facilities to care for the baby – such as a private hospital or a small public hospital – or because the larger public hospital’s NICU is full. It’s not possible to staff every unit with NICU-qualified staff 24/7 and obtain and maintain the very specialised equipment that is needed so seldom. Hence, these specialised services are provided in a few centres. In Sydney, we are proud to have 6 hospitals with NICU facilities. These hospitals provide a high standard of care to preterm babies, as measured by international standards. We are lucky to live in a country where our babies can be cared for so well.

    New anti-smoking campaign targets pregnant women

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    PREGNANT women who smoke are the target of a new advertising campaign that warns their habit increases the risk of birth defects and sudden infant death syndrome.

    In a hard-hitting campaign to be launched today, expectant mums will be warned: “When you smoke she gets less oxygen.”

    It warns premature birth, ectopic pregnancy, low birth weight and cleft palates are among the risks women expose their unborn children to if they do not quit.

    … 40 per cent of teenage mums in Australia smoke, and 15 per cent of all women smoke while pregnant …

    Mums back home visits by midwives

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    NEW mums in Bundaberg can now get follow-up care after giving birth, thanks to a State Government program that aims to make life easier through midwives making post-natal visits to the home.

    First-time Bundaberg mum Natasha Toovey said visits from Bundaberg Hospital midwife Ann McLennan during the past two weeks since giving birth to son Aiden on May 1 had helped her settle into the role of being a new mum.

    … “… visits have supported me with breastfeeding, bathing and settling techniques for my little boy.

    “Ann also checks to ensure that I’m doing well both physically and mentally.”

    … “My own mum was amazed at the services of the midwives. She said that when I was born there was nothing like this available,” she said.

    … Health Minister Geoff Wilson said more than 60% of new mums had received a home visit from a midwife and more than 600 local families had accessed the Bundaberg centre in the past six months.

    “We’re continuing to deliver on the commitment we made in 2008 – that by 2012, all new mums will receive follow-up care after giving birth,” Mr Wilson said.

    “Our children are the future of Queensland and we want to ensure every child gets the best possible start in life.

    “That’s why the government is investing in innovative new programs so that parents can access the help and support they need closer to home.”

    Obesity in pregnancy hinders women’s ability to fight infection

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    Pregnant women who are obese are less able to fight infections than lean women, which could affect their baby’s health after birth and later in life …

    … Obesity in pregnancy has been associated with an increase in infections such as chorioamnionitis …

    … obese women had fewer CD8+ (cytotoxic T) cells and natural killer cells, which help fight infection, compared to lean women. In addition, obese pregnant women’s ability to produce cells to fight infection was impaired. …

    Another reason why it is really valuable to book a preconception appointment with an obstetrician or midwife so ensure that you can be in the healthiest state possible before becoming pregnant.

    Pioneering Collaborative Private Maternity Care: Continuity, woman-centered, personalised, safe.

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    Our brand new model of care – launched for the first time in Australia – has recently welcomed its third baby. So far, three families have benefited from a collaborative model of private maternity care that enables women to have care with a private midwife (with Medicare funding) and also develop a trusting and nurturing relationship with a Specialist Obstetrician who is available for the pregnancy, labour and birth. Our service has so far supported an empowered birth after caesarean, a waterbirth and a natural birth. All within a hospital setting, with all the support available that is occasionally needed.

    We’ve received some really positive feedback:

    “The collaborative model seemed unique to me. To have a private midwife and our own birth experience but in a hospital with an obstetrician who was known to us as back-up in case of unexpected complications, allowed us to feel totally comfortable and confident for our first baby.”
    “I felt entirely supported and encouraged.”
    “A highly personalised level of care was offered which makes you feel listened to and allows time for lots of questions.”
    “I liked the fact that we got time to develop a relationship and feel comfortable together, allowing us a better birth experience. Postnatally, it was nice to have the same person continuing my care. It was highly personalised.”

    Our model sees women booking with me for their care. Women who are interested in having collaborative maternity care meet with the obstetrician early in their pregnancy and again between 32 and 36 weeks. Women see the obstetrician more often if additional visits with him are needed. Otherwise, I am in frequent communication with him and we work together to provide safe, evidence-based, woman-centered care to our pregnant women. This allows women to build a sense of connection, trust and continuity.

    We support natural birth, active birth, physiological birth positions, physiological third stage, water birth, VBAC, twin births, breech births … and so on. Women are really well prepared for natural birth with an emphasis on informed decision making and woman-centered care. Childbirth education is included, as well as access to a lending library of books and DVDs.

    Birth care is provided initially at home and then we move to hospital where I provide full midwifery care. The birth is attended by myself and the Obstetrician if needed / desired. It’s an intimate, calm, peaceful experience and facilitates a gentle and safe birth.

    After we have welcomed the baby and birthed the placenta, women generally stay in hospital for 4 – 24 hours before returning home. Of course, if there are any issues women are welcome to stay longer, but generally I find that women feel more comfortable in their own homes, in their own beds. I visit at home every day for a week and continue care for 6 weeks. Since women book into hospital as a private patient, they are almost assured a private room with an en-suite.

    I’m really excited about this model of care because it meets the needs of women so perfectly:

  • Women having their first babies, maybe feeling unsure of what to expect
  • Women who previously experienced dis-continuous care from care providers who were unknown to them
  • Women who are planning a natural birth but perhaps with a more challenging pregnancy
  • Women who want a home birth / birth centre birth but with a known obstetrician available if needed
  • Women who really desire a sense of control over their birthing experience

    • This is a new way of working for both midwives and obstetricians and is a really supportive and nurturing way to practice. There is a huge potential for professional growth and learning. The most positive element, however, is the radiant smiles on the faces of the women who have birthed with us and the babies who have received a safe and gentle start to life.

    Babies’ Developing Brains Fed By Placenta, Not Mom

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    Researchers have found evidence that the placenta plays an important role in fetal brain development during the early stages of pregnancy.

    Experiments in mice show that during a key period, the placenta becomes a source of the chemical serotonin, which helps determine the wiring of key circuits in the brain.

    The finding … could help explain what leads to brain disorders such as autism and schizophrenia. And it shows that the placenta does a lot more than simply transport nutrients from a mother to her unborn baby.

    … The placenta itself is the source of a specific signal at a very particular period in development which is influencing the brain of the new child. And that influence is likely to be long lasting.

    … “The forebrain has the circuits that we know are disrupted in autism and schizophrenia, and bipolar disorder, and in anxiety and depression,” …

    … in mice, the placenta was making serotonin. What’s more, the placenta only produced serotonin during a specific period of early fetal development. Then it stopped.

    And when the team looked at the human placenta, they found it also had the potential to make serotonin.

    … “the placenta itself is the source of a specific signal at a very particular period in development which is influencing the brain of the new child,” …

    Half of world’s stillbirths ‘preventable’

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    More than two million babies are stillborn each year worldwide and about half could be saved if their mothers had better medical care …

    While the vast majority of stillbirths happen in the developing world, the rates in countries including Britain, France and the US have not dropped … as rising obesity levels among pregnant women increase the risk.

    Experts say providing better obstetric care, treating conditions like syphilis, high blood pressure and diabetes in mothers, among other strategies, could save more than one million infants every year.

    … In developing countries, most stillbirths are caused by delivery complications, maternal infections in pregnancy, foetal growth problems and congenital abnormalities.

    In developed countries, the reasons are often unclear why stillbirths occur, and surveillance and autopsy data are patchy.

    Risk factors for women include being over 35 years of age, carrying excess weight, smoking, alcohol or drug abuse, teenage pregnancy and multiple pregnancies, belonging to an ethnic minority group and social deprivation …

    NZ stillbirth rate 10 times higher than cot deaths

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    … New Zealand’s stillbirth rate is 10 times higher than the number of cot deaths.

    … about half could be saved if mothers had better access to medical care.

    Heather Clarke has a son and two daughters, but Danielle will never get to meet her big sister Stephanie – at a routine check up at 33 three weeks, Ms Clarke got the news every expectant mother dreads.

    “I knew something was wrong. Everything was taking far too long, nobody was saying anything, and then my midwife just put her hand on my shoulder and said, ‘I’m so sorry honey, your baby has died.’

    “I can’t describe how I felt. Our whole world just fell away.”

    … stillbirth rates in developed countries are frighteningly high. In New Zealand alone, at least one baby is stillborn every day, six out of every 1000 births, and in a third of all cases, the cause is unknown.

    There are some risk factors – women aged 35-plus are more vulnerable, as are those who smoke or drink.

    Researchers are particularly worried about rising obesity levels.

    … early antenatal care, would be a step forward in prevention.

    Study connects SIDS risk with infant formula

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    An opioid-like element of cow’s milk that is commonly found in infant formulas may be linked to sudden infant death syndrome …

    Polish researchers … reported that 12 formula-fed infants who had experienced ”near-miss SIDS” episodes where they temporarily stopped breathing had triple the number of peptides … compared to 20 healthy formula-fed babies who had not experienced breathing difficulties.

    The 12 children who had experienced life-threatening breathing problems also had low levels of an enzyme … known to deactivate or modify BCM-7.

    … BCM-7, a product of cow’s milk, is known to have opioid-like effects, meaning any penetration of an infant’s immature central nervous system could inhibit the child’s respiratory system.

    The researchers concluded that the two factors in the 12 vulnerable infants suggested a link between BCM-7 and apnoea (temporary suspension of breathing).

    Australian doctors warned that the study was not sophisticated or big enough to draw conclusions and said parents did not need to act on the study.

    … more research was required, but the research suggested that more of the peptide was getting into the brainstems of the ”near-miss” babies because they had less of the DPPIV enzyme to break it down.

    Dr Seton said the study reinforced the fact that breastfed infants were known to have about half the risk of SIDS compared to formula-fed babies.

    … exposure to cigarette smoke [posed] the greatest risk factor now that most parents knew babies should sleep on their backs …

    New limits for older mothers

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    MEDICARE NOW AVAILABLE FOR MIDWIFERY CARE THROUGH THIS SERVICE!
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    DOCTORS should induce older mums by 40 weeks or risk stillbirths, findings from the country’s biggest study into perinatal deaths has revealed.

    … the current policy of inducing labour at 41 weeks for all pregnant women needs to be reviewed for mothers aged 40 or older.

    … pregnant women aged 40 or older faced much higher risk of stillbirths once they reached their due date compared to younger mothers.

    … the general policy in hospitals was to induce birth at 41 weeks, with the risk of stillbirth 2.2 times higher for all mothers past their due dates. But the prognosis was more dire for older mothers, with the risk sharply rising from 38 weeks.

    … One of the key findings was that babies who died in stillbirth tended to move less in the final trimester, despite the widely held belief that babies slowed their movements towards the end of pregnancy.

    “People often get told that the baby slows down,” … “We found that … for people who have a healthy pregnancy outcome – it seems to be much more common that for the last few weeks prior to the interview, the baby movements become stronger.”

    … viral infections were not as significant as previously thought because they appeared to be just as common in healthy births.

    Urinary tract infections were more common in the mothers who lost a baby …

    ‘Kangaroo care’ enhances mother-baby bond

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    … “kangaroo mother care” … The idea was that a mother’s body temperature could take the place of the incubator – just like a mother kangaroo nurtures her baby in her pouch – while enhancing mother-to-baby bonding.

    Holding the baby skin to skin in an upright or near-upright position around the clock also would encourage successful breast-feeding and allow early discharge of stable babies regardless of weight or gestational age.

    Magee began promoting the practise in 1997 in the neonatal intensive care unit. It expanded in the last few years … Dads can do kangaroo care, too.

    … kangaroo care of low-birthweight infants reduced severe illness, infection and breast-feeding problems; improved mother-baby bonding and perhaps even saved lives …

    … “The surprising benefits of kangaroo care for the infant include warmth, stability of heartbeat and breathing, increased time spent in the deep-sleep and quiet-alert states, decreased crying, increased weight gain, and increased breast-feeding. These benefits are apparent even when kangaroo care occurs for only a few minutes each day,” the academy says on its website.

    … Casper credited kangaroo care with a baby’s “better weight gain; better sleep time – sleep helps brain development; they grow better; it helps with mother’s anxiety and postpartum depression”, she said, adding: “It evens out their breathing, (helps) skin maturation; and declining rates of infection.”

    She said studies have shown kangaroo care will decrease the length of their hospital stay, so it’s a potential cost-saving measure.

    … breast-feeding is more likely to be exclusive and of longer duration; even bottle-fed babies stabilise more quickly in terms of body temperature, heart rate and breathing.

    … “It can be used months later and have an impact on mother, baby, dad,” she said. “Continuing skin to skin through the first year there is a benefit: babies have better self-esteem, a sense of trust.”

    To find out more about the services I offer, please visit my website.

    Passive Smoking Linked To Lower Birth Weight And Stillbirth

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    Exposure to passive smoking is associated with lower birth weight, infection and stillbirth …

    … Undiluted side stream smoke contains many harmful chemicals and in greater concentration than cigarette smoke inhaled through a filter.

    … adverse outcomes were seen more frequently in women exposed to passive smoking including smaller head circumference, lower birth rate, increased rates of stillbirths and preterm birth less than 37 and 34 weeks of gestation.

    Women exposed to passive smoking were more than twice as likely to have a stillbirth …

    … women exposed to passive smoking were twice as likely to have babies with bacterial sepsis. In the exposed group, 1.08% had sepsis compared to 0.51% in the non exposed group …

    To find out more about the services I offer, please visit my website or call me on 0400 418 448.

    Baby dies after mum waits five hours for a room

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    THE Health Department is investigating whether the tragic death of a baby at a … hospital could have been averted.

    It is alleged the expectant mum … was forced to wait in an emergency department after her waters broke, only to be told five hours later when she finally got a room that her baby had died inside her …

    … She got to the emergency department … and doctors asked that she be put in a room and monitored, as is the practice with women who have gone into labour.

    However there were none available and she was told to wait in the emergency room while experiencing contractions.

    She remembers her baby was still kicking and seemingly fine.

    Five hours later when a room became available, an ultrasound was taken and it was discovered that the baby had died.

    Ms Otoreno had to be induced to give birth to her baby …

    A tragic outcome for this woman and baby. One-to-one midwifery care can avert situations such as these. It is unfortunate that there is such a shortage of midwives that it is not possible to staff labour rooms with one-to-one midwifery care, as is the gold standard of care, however women who choose a privately practicing midwife can be assured that they will have a midwife by their side.

    To find out more about the services I offer, please visit my website or call me on 0400 418 448.

    Social before Birth: Twins First Interact with Each Other as Fetuses

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    Every mother knows that newborns are social creatures just hours after birth. They prefer to look at faces over objects, and they even imitate facial expressions. Now a study sug­gests that the propensity for social interactions exists in the womb. Twins begin interacting as early as the 14th week of gestation.

    … By the 18th week they spent more time contacting their partners than themselves or the walls of the uterus. Almost 30 percent of their movements were directed toward their prenatal companions. These movements, such as stroking the head or back, lasted longer and were more accurate than self-directed actions, such as touching their own eyes or mouth.

    … Contact between them appeared to be planned—not an accidental outcome of spatial proximity …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Scientific study shows the voice of moms activate a baby’s brain and learning

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    … the voice of a mother … robustly [activates] the language processing centers of the brain in the newborn. In other words … the voice of mothers is unique and babies inherently recognize their mother’s voice possibly even inside the womb …

    It has been well documented that newborn babies do have some innate language capacities. Moreover, infants may not only learn to specifically recognize their mother’s voice but also show adult-like responses in the brain to human voice at 7 but not 4 months of age. However, scientists are only just beginning to understand what the cognitive capacities of newborn babies are and the mechanisms by which babies learn and vocalize language … future studies are imperative to determine whether there are any deficiencies seen in babies in which mothers spend less than the average or ideal time talking to their newborn babies …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Women choosing midwives

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    When Lisa Unger was pregnant … she saw a gynecologist for medical care. Then she made the switch.

    … “I decided I wanted a midwife, I was pregnant, it was not an illness, I didn’t need a doctor. I was going with a midwife who could empower and coach me through the natural function of my body. I wanted to do it in the hospital, I wasn’t comfortable with a home birth … ”

    … “The term ‘midwife’ means ‘being with women’. We support them, empower them. We tell them how wonderful they’re doing. ”

    The midwife and mom-to-be establish a bond, since midwives are able to spend more time connecting with their patients over time …

    Visit my website to learn more about my services.

    Unnecessary C-Sections on the Rise

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    Australia’s caesarean rate was 31.1% in 2008.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Your body, your choice

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

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

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

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

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

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

    Wong’s experience isn’t unique.

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

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

    Birth trends

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

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

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

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

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

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

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

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

    Medical interventions

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

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

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

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

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

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

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

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

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

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

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

    The big ‘C’

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

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

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

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

    Disturbed birth

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Take control

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

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

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

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

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

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

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

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Umbilical cord to be kept intact for 3 min to avoid harm the child

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    Mother and child are connected in so many ways but the most literal connection is through the umbilical cord nine months prior to the birth of the child … In a recent study it is seen that if this umbilical cord is cut too soon after the birth then it could actually harm the child.

    … if umbilical cords are clamped away too quickly after birth then the child may suffer from anaemia or blood related physical troubles … at least three minutes should be given so that maximum blood is transferred to the child and blood related problems can be avoided in the child.

    The World Health Organization along with the International Federation of Gynaecology and Obstetrics advised doctors to give time to the born child and to refrain from clamping away the cord before 3 minutes. A British Journal on the other hand commented against the practice of waiting and said that quickly cord cutting has become order of the day so much so that “delaying clamping is generally considered a new or unproved intervention.”

    This age old practice of cutting the cord as soon as the child is born should be changed keeping the latest facts in mind for the betterment of the child. Even Hutchen is of the opinion that “’Lack of awareness of current evidence, pragmatism, and conflicting guidelines are all preventing change. To prevent further injury to babies we would be better to rush to change.”

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Use Of DHA Fish Oil Capsules Does Not Decrease Postpartum Depression In Mothers Or Improve Cognitive Or Language Development Of Offspring

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    In contrast to the findings of some studies and the recommendations that pregnant women increase their intake of fish oil via dietary docosahexaenoic acid (DHA) because of the possible benefits, a randomized trial that included more than 2,000 women finds that use of DHA supplements did not result in lower levels of postpartum depression in mothers or improved cognitive and language development in their offspring during early childhood …

    … “Despite the paucity of evidence, recommendations exist to increase intake of DHA in pregnancy, and the nutritional supplement industry successfully markets prenatal supplements with DHA to optimize brain function of mother and infant. Before DHA supplementation in pregnancy becomes widespread, it is important to know not only if there are benefits, but also of any risks for either the mother or child,” the authors state.

    “Current recommendations suggest that pregnant women increase their dietary DHA to improve their health outcomes as well as those of their children. Such recommendations are increasingly being adopted with women taking prenatal supplements with DHA,” the authors write. “However, the results of [this trial] do not support routine DHA supplementation for pregnant women to reduce depressive symptoms or to improve cognitive or language outcomes in early childhood.” …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Increased forceps training ‘could cut caesarean births’

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

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

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

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

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Mums’ obesity may have role in baby deaths

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    Nearly half of all newborn babies that die are born to overweight or obese mothers, prompting concerns that increasing obesity rates could spark a rise in the number of baby deaths.

    … At least 49 per cent of the mothers of stillborn babies and 45 per cent of mothers of babies who died in the first weeks of life were overweight or obese, and the report said research was “increasingly linking obesity with poor pregnancy outcomes” …

    Melissa Maimann, Essential Birth Consulting 0400 418 448