Has labour become a competition?

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

I wonder if it serves a few purposes.

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

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

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

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

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

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

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Anatomy of a C-section: they save lives, but would you choose one?

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Andrew … watched his partner endure two invasive births, one elective, the other life saving.

My partner’s first cesarean, whilst swift, was disorientating, cold and left my other half feeling cheated.

Lying on her back, she couldn’t see or feel anything, having been given a powerful anesthetic. I could see the staff – their expressions informing whether the operation was going to plan – the bleeping equipment, the blood splashing on the floor, the whitewashed walls. The cutting of the abdomen and subsequent extraction was done out of sight, behind a screen they never seem to bother with on television. Baby was brought into the world, fleetingly given to mum, then handed to me for carrying into the weighing room.

We were later told separation isn’t standard procedure, and that the medics must have felt there was an urgency with doing my partner back up, and didn’t want distractions. That night I had to leave the maternity ward by 8pm – visiting times are strict, with everyone apart from mother and child kicked out, no exceptions.

My partner was put in a bed in a crowded room, a blue curtain separating her from half a dozen other mums plus (wailing) newborns. Our daughter was placed in a white plastic cot adjacent to the bed. Having been sliced open and stitched back together again just hours before, reaching over the short distance to pick our daughter up was difficult, if not impossible, that first night. When she moved, the pain was intense, despite being given a cocktail of drugs. She had to press the buzzer to get a midwife to help every time she wanted to lift her baby up to comfort or attempt to feed her. The first time the [midwife] was more than willing, by the fifth time there was resentment.

In the morning, having had not a minute of sleep – she’d been awake for more than 72 hours by now – my partner was unable to properly tend to her baby or to attempt a shower. She described feeling like the contents of her abdomen were going to fall out onto the floor if she moved. With my help – I’d arrived at 9am, the beginning of visiting hours – she managed to wash. The staff were economic with sympathy for her inability to move around.

Once home after some three days, the difficulties arising from an invasive birth continued to dog my partner’s joy of being a new parent. Doing virtually any normal daily task was difficult, doing everything that our newborn daughter required was impossible. How would someone cope alone? About a week after the birth, mum and baby took their first, tentative trip out. Every step felt alien, she described, the feeling that the stitches were going to come undone at any time persisting. We later attributed this stroll to the nasty infection that settled in my partner’s cut. Although treated, the infection set recovery back, and heightened anxieties.

It was not the physical difficulties that most blighted those post-birth days however. It was the psychological impact of not having had the birth she’d wanted. She felt cheated, having originally wanted a home, or at the very least, natural, delivery. Prior to the birth, owing to the anticipated size (over 11lbs) of our baby one consultant had insisted only a C-section would do. Another consultant had said she could ‘try natural’. The decision was effectively made by the stark warning that if my partner ‘went natural’ and the baby became stuck – ‘very likely’ according to consultant one – they may have to dislocate her shoulder in order to try and bring her out. Afterwards, opinion was that ‘natural’ would have been fine, especially as our daughter weighed in at a much more reasonable (if large) 10lbs. Although acknowledging all medics involved were acting in her best interests, my partner remained deflated – this was not the exhilarating, empowering birth she had wanted, and definitely not what was ‘sold’ in the baby magazines.

She therefore had high hopes for a natural birth second time around. But during a routine early scan she was diagnosed with the potentially dangerous condition placenta previa where the uterus becomes blocked by the placenta.

Although in some cases diagnosed women go on to deliver naturally, as my partner’s due date approached it became apparent this wasn’t an option.

Without intervention … this condition is quite simply a death sentence for mother and child. The operation this time around made the first look like a walk in the park. Surrounded by up to twenty medics – doctors, consultants, anesthetists, nurses and support staff – the initial extraction went smoothly. However, minutes after delivery the surgeons couldn’t get the bleeding to stop. This is always a risk with placenta previa. For the next three hours at least – time moved in slow motion – we watched (from behind a screen) as the medics worked through the full spectrum of options available to them to stem the bleeding.

First the clotting drugs, then the ‘figure of eight’ stitch, then something called the ‘bakri balloon’, a little-known ‘last resort’ that quite literally saw a balloon type device directly inserted into my partners’ womb to bring extra pressure to bear on the uterus.

The latter worked. But she’d lost so much blood she needed a transfusion – urgently. Several hours after the birth, she was lying in intensive care … Needless to say, the birth she’d wanted hadn’t involved major surgery.

But the operation, the C-section, performed by brilliant, dedicated surgeons, had not only saved our son’s life, it had saved hers. The ability of modern medicine to deliver babies via C-sections is nothing sort of a miracle. But would you choose one?

This can be the reality of caesareans: if they are performed for life-saving reasons, they will inevitably involve a degree of risk. If there was no risk, there would be no need for the caesarean. A caesarean performed without risk factors is generally safe – safer than it has ever been and as safe as it can be – but not as safe as a vaginal birth.

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Hospital says No to cesarean

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A NORTH Coast mum who has been told she can’t deliver her baby by cesarean feels [that the] Hospital is prioritising policy over people.

Sylvia … said she was told by an obstetrician at the hospital she could only have a C-section … in an emergency.

“I just had tears streaming down my face – I couldn’t believe it,” …”I feel so powerless and betrayed by the medical system that my choice has been taken away.”

Ms Leveridge, who is 28 weeks pregnant, wants to avoid the 20-hour labour she experienced before undergoing an emergency cesarean to deliver her first child.

Her first baby was a whopping 4.240kg and Ms Leveridge understands this baby will be just as big.

… under the Towards Normal Birth policy, the state is aiming to reduce the cesarean rate to 20% before 2015.

Ms Leveridge said she was advised the hospital has to reduce the number of cesareans it performs in line with the policy.

… there are risks associated with cesarean section operations … the rights of the both babies and mothers have to be balanced out.

“It’s not just the mum’s choice. It’s also the baby’s choice as to how the delivery transpires. This is something that is often lost in the debate about how babies should be delivered,” …

“My problem is I have big babies and I just feel like I’m on the same treadmill,” Ms Leveridge said.

As I see it, there are four issues here:
1. Fear
2. A previous “big” baby
3. A woman’s sense of control over how she will deliver her baby, aka woman-centered care
4. Safety for mother and baby, and the health practitioner’s duty to recommend the safest course of action

Fear
It is not unusual that this woman would feel so fearful of her upcoming birth: her only experience of labour and birth had been an horrendous 20-hour labour with untold interventions delivered in a model of care that provided limited continuity, and ultimately leading to an emergency caesarean. In my practice, women have only one midwife for the whole pregnancy – baby experience. This model of care has been demonstrated to reduce women’s fear, and also promote normal birth. Around 90% women who birth with me experience a normal birth.

A previous “big” baby
A “big” baby is not necessarily a concern, and nor is it necessarily associated with a caesarean. The important factor here is whether the baby was always destined to be a larger baby that is able to fit through an ample pelvis, or whether the baby was abnormally large perhaps because of poor maternal diet or poorly-controlled gestational diabetes. Many “large” babies are born normally: these are often babies who have been nurtured with good nutrition in a woman whose pelvis is amply able to accommodate a larger baby. The labour and birth is often rapid and the baby is born healthily and safely. The same cannot be said of babies who are abnormally large because of high circulating glucose in the mother’s blood. In my practice, much time is spent with women talking about nutrition; why it is important; motivational tools to remain healthy and fit in pregnancy; and finally assisting them with a healthy eating plan that is flexible and is based on their own unique tastes and needs. The average birth weight is around 3.4Kg.

A woman’s sense of control over how she will deliver her baby, aka woman-centered care

We know from studies that a request for a caesarean is based mostly on a woman’s fear of labour. The woman in this article was quite justified in her fear: her only personal knowledge of birth was an awful labour culminating in a caesarean, and she sees herself staring down that same barrel, since she again feels that she has a big baby. I often find that women will make an initial request, for example for a hospital birth or an epidural, and through their pregnancy care experience, they grow massively in terms of their confidence, knowledge and trust, such that they are saying later in pregnancy, “Actually, maybe I can do this without an epidural. Maybe if I can labour and birth in the water, that will help and I won’t need an epidural.” Or, “I know I’ve been wanting a hospital birth all along, but I’m curious about homebirth and if all’s well, I think I might like to stay home in labour.” The power of continuity of care – where every woman has only one midwife as her midwifery care provider – is often understated in the literature.

Safety for mother and baby, and the health practitioner’s duty to recommend the safest course of action

I’ve sometimes been heard to say that as midwives, we really only have one job, and that is safety. Women engage midwives for their care because they understand that midwives have a unique skill-set that includes knowledge, experience, judgment and compassion. If women possessed this skill-set, they would have no need for midwives. It is the health practitioner’s role to recommend the safest course of action, which in this case is a VBAC. The woman is so caught up in fear from a traumatic previous experience that rationally, she is probably not even able to take any of this in. The woman should be supported, not necessarily to birth vaginally or abdominally, but just supported. Nothing more, nothing less. After working one-on-one with her private midwife, towards the end of her pregnancy, and with a healthily-grown baby, she just might see things differently and agree that a VBAC is the safest course of action for her and also for her baby. To thrust this (VBAC) upon a woman who is driven by an unresolved and justified fear state is unreasonable and shows a lack of compassion. Yes, a VBAC is probably the safest for mother and baby. But fear (and the absence of fear: confidence, calmness, surrender) is the most important driver of birth. Until we work to eliminate fear and instill confidence, we will have high caesarean rates, whether these are chosen by women or recommended by health practitioners.

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Women need a year to recover from childbirth

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New mothers may be told that they will be back to ‘normal’ within six weeks of giving birth, but a new study has found that most women take much longer to recover.

… it takes a year to recover from childbirth

… The psychological effects can also take much longer to recover from.

… hospital wards can have a negative impact on women’s ability to recoup and celebrate the birth of their child because of the constant stream of visitors and the unfamiliar rules and regulations.

Helping new mothers adapt to having a baby in the home has also changed a lot over the years.

In the past women were shown how to perform tasks such as baby bathing and were only discharged from hospital when they were ready.

Now women can go home as soon as six hours after childbirth and many feel they are just ‘left to get on with it’.

Dr Wray said: ‘The research shows that more realistic and woman-friendly postnatal services are needed.

‘Women feel that it takes much longer than six weeks to recover and they should be supported beyond the current six to eight weeks after birth.

‘However, government funding cuts and a national shortage of midwives means that postnatal services will only face further challenges. The midwifery profession must raise the status of postnatal care as any further erosion can only be bad for women and their children.’ …

Private midwifery provides women with 6 weeks of comprehensive postnatal care.

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Natural Twin Birth

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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Rates of C-sections and postpartum posttraumatic stress disorder on the rise

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The birth of Helen Dunn’s first son didn’t go nearly as smoothly as she had envisioned. Induced two weeks early because of concerns about the baby’s health, the Vancouver clinical counsellor endured 17 hours of painful contractions before her baby went into distress … She had an emergency caesarean section, the whole experience proving to be a traumatic one with terrible, lasting effects.

“I immediately felt disconnected from him when they showed him to me,” … “I didn’t recognize him. I wasn’t attached to him; in fact, I had an aversion to him. I wanted them to take him away, which is hard to admit. After that it was very difficult for me, it was a long process of panic attacks, which I’ve never experienced before, and full-blown agoraphobia.

“I didn’t want to tell people how I felt; I felt a tremendous amount of shame about how I felt toward my child, the difficulty I was having bonding with him,” she adds. “I was diagnosed with postpartum depression, but I had no idea about postpartum posttraumatic stress disorder.”

Looking back now, she can see that those panic attacks were among the condition’s telltale signs … PTSD after childbirth is characterized by two key elements: experiencing or witnessing an event involving actual or threatened danger to oneself or others and a response of intense fear, helplessness, or horror. Symptoms include obsessive thoughts about the birth; feelings of numbness, detachment, or panic; disturbing memories of the birth experience; nightmares; flashbacks; and sadness, fearfulness, anxiety, or irritability.

… the reported prevalence of postpartum PTSD ranges from 1.5 percent to 6 percent …

Dunn was even more struck by the effects of her traumatic birth following the delivery of her second son six years later. She laboured for 17 hours again, but this time delivered vaginally with the assistance of a midwife in hospital and went home soon after.

“I didn’t have any problems,” Dunn says. “He immediately looked familiar to me — he looked like my sister — I felt bonded to him, attached to him.” The stark differences between her two childbirth experiences prompted her to explore other women’s feelings of attachment to their newborns among those who delivered via emergency C-section as well as vaginally in her Master’s thesis. Now she wants to raise awareness among health professionals and the public alike of two pressing issues: postpartum PTSD—in particular signs, early intervention, and effects on maternal-infant attachment—and the high rates of C-sections in this country.

Although C-sections clearly play a vital role in maternal health and can be life-saving, about 26 percent of deliveries in Canada take place this way, which is nearly double the rate recommended by the World Health Organization.

Then there is the way postpartum PTSD is so widely misunderstood and overlooked, in Dunn’s view.

“When I did reach out for help, people would say, ‘You’ve got a healthy baby; what do you have to complain about?’ or ‘This was so long ago; why is it still bothering you?’

… “When someone says, ‘I don’t want to see my child… I really wish someone would have said to me at that point, ‘Can we help you?’ When I told a nurse I was feeling strange, having panic attacks, she said it was because of the medication. Even one gesture of support or kindness from somebody on the front lines can go a long way to help a woman gain a sense of control of what’s happening to her. I think it could have been handled a lot better in my case. I think I would have benefitted from more support had there been more knowledge around it.”

Maternal-health expert Michael Klein … says that … women who have emergency C-sections without adequate support or communication from their caregivers suffer from posttraumatic stress disorder far more frequently than those who don’t.

“What we know about the psychological experiences of women is that women who have a sudden, unexpected, emergency caesarean section without any chance to really adapt to it are the most likely to suffer psychological distress,” … “Posttraumatic stress disorder is much, much, much neglected.”

… Klein emphasizes that the primary determinant of whether a woman will suffer PTSD after child birth is not the mode of delivery. Rather, it’s how she’s cared for. In other words, the condition can occur in women who have vaginal births, deliveries that require forceps, midwife-assisted labours, and in other situations. The crucial factor throughout is how her care team responds to her needs.

Other factors come into play as well, such as prior psychological and psychiatric disorders and the woman’s prepregnancy mental state.

… “We know that women never forget their childbirth experiences,” … “They can be transformative in a positive way or transformative in a negative way. Talk to any 50- or 60-year old woman and she can tell you every minute of their childbirth experience.” …

Continuity of care – that is, being cared for by one person who is trusted and liked throughout the pregnancy, birth and postnatal period – is vital for minimising the chance of PTSD. Continuity models include private obstetric care, where a woman has all of her pregnancy care with one obstetrician and that same obstetrician is on-call for her birth. Continuity models also include private midwifery care where a woman has the same midwife for all of her pregnancy, birth and postnatal care. Obstetric care can be accessed through eligible midwives who have collaborative arrangements with obstetricians.

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Charging women for non-medical caesareans?

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The health minister has said that women in Northern Ireland who choose to have a Caesarean for non-medical reasons may have to pay for the operation.

Edwin Poots is launching a consultation on a review of maternity services.

Women at low risk will be encouraged to consider having their baby in a midwife-led unit or at home, if appropriate.

Around 30% of deliveries are by Caesarean section – the highest level in the UK and Ireland.

… giving birth was a natural process and superb assistance was available to help women through the delivery.

“It costs several thousand pounds more for a Caesarean section so there are savings to be made,” …

“… what we want to encourage, is more people to give birth naturally because it has better outcomes for the mother and the baby.

… “We want to ensure that people take the natural choice where they can and to have that back up where they need Caesarean section to take place.”

… At present, women who elect to go private to have a Caesarean on non-medical grounds pay for their pre and post-natal care.

But the cost of the delivery is met by the health service.

… women will be encouraged to have their baby in a midwife led unit

“If you want to go down that route, if you want to pay for it, it is totally up to yourself, but I don’t feel that we the public in Northern Ireland should be paying additional money for people to have the choice.”

The minister said he expected to see a “considerable” number of midwifery units being established.

“A lot of them would be set up in association with the main maternity unit, so they would be on the same site as existing hospitals,” …

“Women would be giving birth totally with the midwives but there would be a fallback position of having an obstetrician nearby if things do not work out.”

Breedagh Hughes from the Royal College of Midwives said the focus was on trying to “normalise” child birth.

… “One of the things we hope will come out in the review will be asking trusts to look at … the reasons for the Caesarean sections and to focus on trying to prevent women from having that first Caesarean section, which very often leads to the old adage – ‘once a section always a section’.”

She said a “fear” of child birth stopped many women from choosing a natural birth.

“When one in every three women gives birth by Caesarean section, you lose that critical mass of people who know what it is like to give birth normally, and women are losing confidence in their own body’s ability to give birth,” she said.

Ms Hughes also welcomed proposals to shift the focus to midwife led care.

“I think if women are given the opportunity to get to know and trust their midwife and to trust their own bodies, we’re more likely to see women saying, ‘OK, this is what nature intended me for and this is what I’m going to do’,” …

Visit my website to explore birthing services

Post-traumatic Stress Disorder and Birth

Research has suggested that up to 9% women meet the diagnostic criteria for post-traumatic stress disorder after birth, and that 18% women scored above the cutoff score, indicating that they were experiencing a degree of post-traumatic stress symptoms.

Amongst variables that were found to be associated with PTSD were lack of support, unplanned pregnancy, pressure to have an induction and epidural analgesia, planned cesarean and consulting with a clinician about mental well-being since birth.

PTSD is an important issue in birth, and one that is attracting more and more attention. It’s time for health services, midwives and obstetricians to become more aware of their practices and treatment of pregnant and birthing women, and for communities to consider how they can best support new mothers.

With almost one in ten women experiencing their birth as traumatic, we also have to wonder if things have really progressed in birth. Pain relief came in in the 1800s with the intention of reducing the trauma associated with a long and painful birth, however in this study, epidural use in labour was associated with PTSD.

The lack of caesareans in years gone by were an important contributor of traumatic births as women endured days of labour only to give birth to a stillborn baby. Nowadays we have ready access (perhaps too ready) to operating theatres and caesareans, yet caesareans are suggested as being associated with PTSD.

I believe that the heart of the issue is a woman feeling supported in the decisions she makes, being able to trust her care providers and ultimately birthing safely. Continuity of care is known to have the lowest rates of PTSD and birth trauma, specifically because women are cared for by one midwife and obstetrician who know the woman, her wishes, fears and hopes, and together they can develop a care plan that places the woman at the centre of her care.

Visit my website for information on birth debriefing, homebirth and hospital birth.

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.

Midwives can help traumatised new mums

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About a third of women are traumatised by childbirth …

But counselling by midwives can ease their distress.

… Debra Creedy surveyed 1038 pregnant Australians with no previous history of mental illness.

About 30 per cent described childbirth as “horrific” or “terrifying” after they gave birth.

“They feared for their life or that of their baby,” …

Untreated trauma could lead to anxiety or postnatal depression … or fear of giving birth again.

“Unless these sort of emotions are dealt with in a productive way they can have lasting effects on women.”

“We found midwives are very well placed to support the emotional needs of women because they understand childbirth,” …

“They can talk with the woman about what happened and why that procedure may have been necessary and to normalise a woman’s responses.” …

It’s often unspoken, but it’s real and it matters. It’s great that good quality research is being done into this sensitive and almost-taboo topic so that women are able to access help when they feel they need it. My practice has supported many women who have described their birth as traumatic. The most common feature isn’t a drug-free birth, a caesarean, an epidural or so on – it’s about not being listened to and respected, not experiencing care from one midwife who is known to the woman in advance of labour – and whom the woman likes and trusts – and feeling a sense of loss of control over what is happening in labour. Of course, labour is all about losing control. But control in the sense of birth trauma is very much about the feeling that decisions have been taken away and feeling that you don’t have a voice – either because of exhaustion, confusion, fear or a lack of understanding. These feelings can overwhelm a woman’s coping mechanisms in labour and this is when birth can be perceived as traumatic.

I see birth trauma in women who have experienced the “cascade of intervention” that culminates in a forceps birth or a caesarean, as much as I see it in women who experienced a natural and drug-free birth that was not their intention. It’s not so much about “what” happens in labour, as much as it is about being prepared for what might reasonably happen, and supported by a known, liked and trusted care provider if things don’t go to plan.

Posttraumatic Stress Disorder in New Mothers

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Prevalence [of] … posttraumatic stress disorder after childbirth ranges from 1.7 to 9 percent …

…The following variables were significantly related to elevated posttraumatic stress symptoms levels: low partner support, elevated postpartum depressive symptoms, more physical problems since birth, and less health-promoting behaviors. In addition, eight variables significantly differentiated women who had elevated posttraumatic stress symptom levels from those who did not: no private health insurance, unplanned pregnancy, pressure to have an induction and epidural analgesia, planned cesarean birth, not breastfeeding as long as wanted, not exclusively breastfeeding at 1 month, and consulting with a clinician about mental well-being since birth …

… the high percentage of mothers who screened positive for meeting all the DSM-IV criteria for a posttraumatic stress disorder diagnosis is a sobering statistic …

Time to do something positive about this statistic! Continuity of care and carer is unlikely to result in PTSD. A written birth plan that is agreed by the woman and her health care provider antenatally, and then honoured during the labour and birth, are also key to avoiding PTSD. Another important factor is asking women questions early in their pregnancy so that women who might be at an increased risk of PTSD are able to access help during the pregnancy to avoid issues later on.

Case study: ‘My C-section was a horrific experience’

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HAVING a Caesarean was so traumatic for new mum Pamela Anderson, she had to have counselling after the birth of her son Archie, now nine months.

… “It was the most horrific experience of my life,” …

After 22 hours in labour, hospital staff became concerned when her baby moved into the wrong position for a natural birth.

However, Mrs Anderson is convinced it might not have been necessary.

She said: “It seems to be the case that they don’t give you enough time. After 20 hours they just say ‘that’s enough’ …

She had to have two blood transfusions and had problems later as a result of the surgery.

She said: “Nine months on and still I feel the physical effect of it as well as the emotional side …

The sorts of things that may lead a woman to perceive her birth experience as traumatic are things such as impersonal care, not having a say in decisions that are made, lack of continuity of care, care by strangers, and a lack of care, respect or kindness in labour.

“Do it yourself” births prompt alarm

MEDICARE NOW AVAILABLE FOR MIDWIFERY CARE THROUGH THIS SERVICE!
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A growing number of women are choosing to give birth without the assistance of doctors or midwives, provoked by dissatisfaction with modern obstetric care, fear of unnecessary medical intervention and a desire to reclaim birth as a private, natural act.

It’s a choice the professionals say is fraught with peril. They fear the fledgling “freebirth” movement may undo gains in mother-infant mortality. The women, however, believe unassisted childbirth is emotionally and physically the safest option for themselves and their babies.

Some 33%, or 8708 out of 26 667 homebirths in the United States in 2007 were not attended by a physician or midwife … Two-thirds of those deliveries attended by someone other than a physician or midwife … were reported as “planned” …

Canada lacks similar statistics, but a cursory search online turns up a surfeit of websites, forums … dedicated to freebirth …

It’s a difficult trend to track with any certainty … because advocates of unassisted childbirth aim to avoid interaction with the medical system wherever possible.

While some women forgo prenatal care entirely, others orchestrate a “planned oops” or “accidental” unassisted birth to avoid confrontation with health care providers and the law.

Many are already mothers, wary after a bad experience with a doctor or midwife.

“My first son’s hospital birth left something to be desired … the doctor I had was terrible. When I became pregnant a second time, I sought out a midwife and while one of the women in the practice was great, the other really talked down to my husband and I … ” … “I was probably seven months pregnant when I decided I didn’t want [that midwife] at my birth. I didn’t want it to be a guessing game.”

Others fear being coerced into medical procedures they’re not comfortable with.

“There are some people who can go into the birthing room and put their foot down, but I know when I go into a doctor’s office for an appointment, I get overwhelmed, let alone in a case where they’re saying your baby might die,” … “I think it’s easier to trust yourself if there’s not another voice there. Having that other set of interests involved makes me uncomfortable.”

Doctors and midwives bring their own timelines and expectations about how a delivery should proceed, and will err on the side of intervening in birth to protect themselves against litigation … “I can see the position they’re in, because if you don’t deliver a perfect baby there’s a chance you’ll get sued, and there’s this idea that if you’ve transferred someone to the hospital or done a C-section then you’ve done everything you could.”

… primary C-section rates ranged from a high of 23% of deliveries in Newfoundland and Labrador to a low of 14% in Manitoba.

With up to 15% of all births involving potentially fatal complications, however, “the evidence is overwhelmingly in favour of giving birth with a skilled attendant present,” …

Proponents of unassisted childbirth say it’s all a matter of perspective. They prefer to view birth as a “spiritual, sexual experience, not an inherently dangerous medical event,” says Shanley. “I trust the same intelligence that knows how to grow the baby from an egg and a sperm into a human being also knows how to complete the process.”

Unnecessary intervention in birth is more often the cause of complications than a remedy, she adds. “People counting, measuring and managing birth into this controlled, manipulated act, it’s no wonder women’s bodies shutdown — the way anybody’s would if someone kept interrupting them while they were trying to have sex, go to the bathroom or go to sleep.”

Intervention should be the last resort, not a given … ” … one of the nurses asked why we didn’t go to the hospital and my husband looked her in the eye and said: ‘Because it wasn’t an emergency.’”

The couple prepared for complications by reading books for first responders on how to deliver babies in emergency situations.

Others look for such information online.

“I had to assess what my personal risks were,” says Rundle. “I’m a healthy young woman, so when people say that 15% of the time there’s a complication, are they talking about women who have different medical histories than I have?”

Some women, like Shanley, prefer to put complete faith in their bodies and refer to complications as “variations of normal.”

“There are going to be babies who die during an unassisted birth who may not have if there had been intervention, but there are also going to be babies who die because of interventions,” she explains. “There’s no way to ensure a successful birth every time. Sometimes a baby dies and that’s just the way it is.”

It’s not a stance Shanley takes lightly, having lost a child to a congenital heart defect following an unassisted delivery, and been told by a coroner that the baby would have died even if she had gone to the hospital.

It’s a difficult stance to counter, says Canadian Association of Midwives president Anne Wilson. “You can’t say to a mum that 60% of all unassisted births result in complications where the baby dies because that kind of statistic doesn’t exist. A lot of complications in childbirth are predictable and occur over time, but a few happen without warning, such as severe hemorrhage. And if a woman doesn’t have prenatal care, doesn’t report the birth to the hospital, there’s no way to know.”

… “Unassisted childbirth is unsafe — period,” … “The people advocating this as a mainstream option for women are tragically uninformed.”

Midwives, however, are more “fuzzy” on the issue, says Wilson. The association has yet to take an official stance for fear of alienating women wary of intervention. “If someone came to us who was considering an unassisted birth we would want to keep that person engaged, build a relationship of trust and if they ended up going ahead with it, at least you’re someone they can call if they get half way through a delivery and change their mind.”

Failing that, “some prenatal care is better than none,” she adds.

The debate raises ethical questions of “autonomy versus beneficence” for midwives, Wilson says. “By the nature of what we do, we tend to look after people who don’t want interventions. It would come down to individual choice in terms of how comfortable you are as a practitioner taking that person into your care.”

For Shanley, however, unassisted childbirth is more a question of reproductive rights. “It’s your body, your birth and your baby, so you should have the right to give birth however you want.”

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

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

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

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

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

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

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

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

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

Other maternity units … report similar trends.

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

Your body, your choice

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

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

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

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

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

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

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

Wong’s experience isn’t unique.

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

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

Birth trends

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

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

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

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

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

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

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

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

Medical interventions

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

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

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

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

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

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

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

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

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

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

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

The big ‘C’

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

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

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

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

Disturbed birth

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Take control

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

Too scared to push: big rise reported in birth trauma

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The NHS is responding to a surge in cases of birth trauma by setting up specialist support services to reduce the rising demand for a caesarean delivery from those who, after a bad experience, are scared to undergo labour again.

Midwives say increasing numbers of women are so badly affected by their first experience of birth that they are postponing for years, or abandoning, plans to have any more children.

… At Liverpool Women’s hospital, for example, the number of mothers who have asked for an elective caesarean with their forthcoming child, because they suffered trauma the last time, has risen 40%.

“Tocophobia [fear of childbirth] is a distressing psychological disorder that is growing at an alarming rate,” said Simon Mehigan, a consultant midwife at the hospital. Most of the women with birth trauma he works with “are so fearful about giving birth for the second or third time that they are making themselves unwell”. Typically, this fear is a result of experiences during the first pregnancy or delivery and can often be traced back to a lack of information or explanation about what was happening, he added.

… In January Stepping Hill will launch a specialist birth trauma support clinic run by a consultant midwife, Debbie Garrod. “Last year I saw 21 women who were troubled by something that happened during their birth, usually a first birth. Before 2009 it was a handful. This year so far I’ve seen 48 women,” said Garrod.

Many other hospitals across the country are also introducing similar counselling services run by specially trained midwives to help women work through their fears and discuss the pros and cons of natural and surgical births. The apparent growth of tocophobia has prompted fresh debate over the variable quality of NHS maternity care as well as prompting some to claim that it is due to women being less prepared than previous generations to endure pain during childbirth.

Ah, I see, it’s the woman’s fault again?

Dr Tracey Johnstone, a consultant in foetal maternal medicine at Birmingham Women’s hospital, said a more confessional culture, soap operas’ portrayal of birth as painful and dramatic, and women’s reluctance to withstand labour pain lie behind the increase.

“Women are more frightened of labour and delivery now. Among women there almost seems to be a competition about who has suffered the most during childbirth, talking about 18-hour labours and the like, and that scares other women before they have their babies,” …

“A lot of women are less tolerant of pain now. They should realise that childbirth is painful,” she said. The greater medicalisation of birth – with more women having pain relief, or a caesarean or being induced – is also making women unsatisfied …

But Cathy Warwick, general secretary of the Royal College of Midwives, said: “There is a worry that, with the increasing birthrate, there are just not enough midwives. If women don’t have support throughout their labours, then they are more likely to feel they have been let down and left alone, and had too little information and explanation, so are more likely to end up feeling traumatised.”

Cathy has hit the nail on the head: the availability of a supportive midwife, preferably a midwife known and liked by the woman.

She added that the NHS would need another 3,000 midwives in order to help women properly during labour.

More and more women are contacting the Birth Trauma Association by email or Facebook or through its helpline. … “Some women have a quite horrific experience of childbirth and often feel they weren’t listened to because they had a baby who was well. Given the lack of care it’s no wonder 30% find it traumatic.”

… “We’re looking into why some births become complicated and traumatic. That could be because the foetus became distressed due to lack of oxygen, or because the baby couldn’t be delivered because the uterus seemed to run out of energy, or women not always having the support they need during long labours,” said Wray.

“It’s vital for the NHS to understand why so many new mothers are left traumatised because this affects so many women, their future fertility and their psychological wellbeing.”

Angela Almond suffered birth trauma after having … her first child …

It was only by getting extra support from a specialist NHS midwife that she felt able, six weeks ago, to have her second child, Scarlett, naturally.

The 32-year-old music teacher and husband Stuart, 31, a marketing manager, live in Liverpool.

“It was a difficult birth with Amelie. I was having a checkup four weeks before she was due when they unexpectedly told me that I was in the early stages of labour and that they were going to admit me there and then and induce me.

And here we read of an intervention that, on the face of it, was completely unnecessary. Whatever was wrong with waiting for labour to take its course? The story of trauma follows:

“The main trauma for me was all the intervention: being induced, having my waters broken for me and being examined all the time. And I found being in such an unfamiliar clinical atmosphere frightening and intimidating.

“I was in for three days and three nights altogether, which didn’t help. That was partly because my labour didn’t progress well because I didn’t dilate enough. In the end they had to use both forceps and a ventouse suction cup to get Amelie out, which was frightening and stressing.

“There was a high turnover of midwives, who were always rushing around looking after patients. Things were going on but staff were too busy to explain what they were doing and why.

“I didn’t know what was happening or going to happen, and I didn’t like that lack of control.

“I was also left alone a lot of the time and didn’t feel supported or reassured.

“I found that first birth experience so frightening and so bad that it was putting me off having a second child. I wanted more children but was put off by the thought of going through another labour like that.

“When I got pregnant again I knew I needed some support. I was frightened at the prospect of nine months of worrying about the labour, and didn’t want that to stop me enjoying the pregnancy.

“Labour is a frightening prospect to the bravest of people. After becoming pregnant I thought I might ask for a caesarean section, to help avoid what happened first time round. But luckily soon after that I was referred to Simon Mehigan, a midwife at Liverpool Women’s Hospital who helps women who have had a traumatic labour. He was absolutely brilliant. He supported me throughout my pregnancy and labour. He guided me and reassured me. Eventually I felt confident enough to have a home birth – Simon’s idea – which he attended.

“The fact that it was at home empowered me and I felt safer and more supported than if I’d had Scarlett in hospital.”

Melissa Maimann, Essential Birth Consulting 0400 418 448

Childbirth and post-traumatic stress

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It’s more often associated with survivors of torture or war, but post-traumatic stress disorder (PTSD) can also affect women who have had an unexpectedly difficult childbirth.

Reliable figures are hard to come by as the condition often goes undiagnosed, but studies suggest up to a third of women find labour traumatic, with as many as 6 per cent of new mothers going on to develop symptoms of PTSD.

Symptoms of PTSD in the postnatal period are often confused with post-natal depression. But PTSD is different in that the focus is on the traumatic birth itself, with sufferers typically experiencing flashbacks and seeking to avoid anything that will remind them of the trauma.

“If it’s PTSD, they usually get the classic things such as flashbacks and the fear, a feeling of powerlessness and loss of control,” says obstetrician Ted Weaver, the president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Affected women often feel they did not get the support they needed during a difficult labour, he says.

“A lot of it seems to be related to how a woman is cared for in labour: the support she receives, or the feeling of being ignored perhaps, the care from all the professionals and others, the environment, the calmness or otherwise around the birth…”

Most of which can be prevented by having continuity of midwifery care for pregnancy, labour and the postnatal period. Homebirth or hospital birth, the value of continutiy of midwifery care cannot be understated.

Triggers of future trauma symptoms will vary for individual women but might include an unexpected emergency caesarean, especially if ordered by an unfamiliar clinician, or a request for an epidural when a woman is “in great pain but is told she doesn’t ‘need’ one”.

Two groups of women seem to be at particularly high risk of developing PTSD if their labour does not go according to plan, according to Weaver.

Women who are very anxious and fearful beforehand are at greater risk, as are those who have very high expectations of themselves and of the way they want their labour to go.

For both groups, a key to preventing trauma symptoms is to establish a solid and trusting relationship with care providers before the birth, Weaver believes.

The more anxious women need to be reassured that they will be looked after and health care professionals then need to make sure they deliver on those promises during the actual labour.

The second group are often women who have a “really idealised view of what birth will be”, which leaves them at risk of trauma if things don’t work out the way they expect.

It is important for these women to have the “what if” conversations with caregivers before they go into labour so that they are prepared for the possibility that all might not go according to plan.

In my experience, these “what if” conversations take time – time in each consultation over a period of months. Hence, another good reason why continuity of midwifery care is perfect for women who are fearful of their birth experience. Women who have a “really idealised view of what birth will be” are also fearful in a way, because their idealised view protects them from gently exploring “what if”. This exploration can be done with a trusted midwife over the course of the pregnancy.

Having a trusted support person who understands their wishes present during the birth can help to prevent the feelings of abandonment, or of not being listened to, that are common in many women who later develop trauma symptoms, Weaver says.

For new mothers who develop PTSD, cognitive behaviour therapy has been shown to help, as have opportunities to “debrief” about the birth experience, but too many miss out because their condition is never diagnosed, Weaver says …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Natural childbirth: whose birth plan is it anyway?

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With the trend for ‘natural’ childbirth growing and a government setting targets for home births, are British women really free to choose how they’d like to go through labour, or must they bow to a new earth-mother ideology? …

Hannah Hancock was pregnant with her first child she was keen on the idea of a drug-free birth. But … when labour pains kicked in, ideals were abandoned. ‘It was a long labour. At first I was on an oxytocin drip, then on pethidine, and a few hours later when they asked me if I wanted an epidural I was shouting, “Give it to me now!”‘

This is a common occurrence in hospitals where women do not have continuity of care and women don’t have access to resources and preparation to help them through natural labour and birth.

Two years later Hancock gave birth at a London teaching hospital. There the experience was very different.

‘I knew I wanted an epidural but the midwife ignored me, saying, “Why do you want pain relief? You’re doing really well.” I was crying, saying, “I don’t want to do well!”‘ Hancock begged her to find the anaesthetist. ‘But she just stood outside the door not going anywhere.’

Another scenario that doesn’t generally happen with continuity of midwifery care and in particular private midwifery care. In these cases, the woman and midwife have formed a trusting and caring relationship so that the woman has been able – ahead of time – to let her midwife know her intentions for her birth and the midwife is then able to support her.

In the end Hancock gave birth to her daughter using just gas and air. ‘It didn’t help at all. I was panicking so much at the prospect of no pain relief I couldn’t relax and tore really badly. I couldn’t understand this patronising attitude … It really coloured my view of the birth. When Ines was laid in my arms it was a special, dreamy moment. The second time I was in such shock, I’d been in so much pain without anybody helping, I could barely look at the baby.’

Birth trauma happens after natural birth as well as after birth with intervention.

As any woman with children knows, the politics of childbirth are so highly charged they make infighting between Labour and the Tories look like a teddy bears’ picnic. On one side sit the medics, portrayed by their detractors as men in white coats intent on cutting women open so they can avoid litigation and clock off on the dot of six. On the other sit the midwives, scoffed at as strident feminists denying women modern analgesia in favour of whale-music CDs and back rubs. In the middle of these competing philosophies is a labouring mother, her wishes drowned out in the clamour of debate.

Maureen Treadwell of the Birth Trauma Association, which supports women who have had difficult births, says that far too often ideology takes precedence over individuals’ needs. ‘The consequences can be unbelievably cruel. The truth is that what suits some women can be distressing and wholly unacceptable to others. Some women are obsessed with a natural birth and are distraught if this doesn’t happen. But for others – say, a 40-year-old woman who has had three miscarriages – the priority may be having the safest birth possible with naturalness very low on the list.’

At the heart of much of the argument are the philosophies of Grantly Dick-Read, a British obstetrician who was convinced that much of labour pain came from society conditioning women to expect it. His 1942 classic Childbirth Without Fear expounded his belief that women educated to be free of fear and tension would experience birth as a ‘normal and natural defecation’. Pain relief, he said, was undesirable because it affected the baby and slowed down labour, frequently leading to interventions, such as the use of forceps or the ventouse vacuum pump, or emergency caesareans.

Dick-Read became the first president of the Natural Childbirth Trust, promoting better understanding of his system. This later became the National Childbirth Trust (NCT), whose antenatal classes are seen as a rite of passage for all middle-class couples …

While acknowledging that pain is subjective, Belinda Phipps, the NCT’s chief executive, defends such a stance. ‘A lot of women who feel they are denied an epidural are on the verge of starting to push the baby out and don’t actually need one any more … an experienced midwife will know she’s actually getting ready to push and persuade her to wait a few more minutes. She should reassure her that what she’s feeling is normal and let her know it won’t last much longer …

Others, however, are furious their wishes were ignored. ‘I talk to women who have been left screaming in agony because they were either not offered or were refused pain relief,’ Treadwell says. ‘Afterwards, they’ve needed psychological help, their relationships have been scarred, they’ve been afraid of getting pregnant again, they don’t bond with their babies.’ …

Fashions in giving birth are as variable as hemlines. Tina Cassidy, the author of Birth: A History, asserts, ‘The way we choose to give birth reflects the culture of the age. Whenever women feel their choices are being limited by political decisions, they push back and say, “We can do what we darn well want.”‘

In the early 20th century the church preached that suffering in childbirth was the curse of Eve and that to try to avoid pain was a sin. Outraged by such repression, the suffragette movement embraced the introduction of ‘twilight sleep’, a mixture of morphine and the amnesiac scopolamine injected during labour to made women forget the pain. Obstetricians initially expressed doubts about drugging women, but were rapidly shouted down. The result was that birth quickly became so medicalised that by the 1970s another generation of feminists were fighting for the right to experience childbirth awake.

‘In the 1980s, when women were in thrall to “having it all”, they embraced epidurals that rid them of pain while allowing them to be conscious,’ Cassidy says. ‘In the 1990s, when the focus was on technology and convenience, there was a vogue for elective caesareans.’

In today’s eco-conscious society, the pendulum has swung back towards nature. On Manhattan’s Upper East Side society women reputedly send out birth announcement cards embossed with the words natural childbirth in gold letters …

In Britain the number of home births has risen from a low of one per cent in the 1980s to nearly three per cent today, a trend that the government seems eager to assist …

The debate becomes even more heated when it comes to elective caesareans. The National Institute for Clinical Excellence (Nice), responsible for government guidelines, is pushing for a reduction in the caesarean rate from 23 per cent of all births to the World Health Organisation’s recommended ten to 15 per cent. In fact, while acknowledging that a caesarean is major surgery, some women prefer the idea of a planned operation to the unpredictability of a vaginal birth. When pregnant for the first time, Leigh East, 37, from West Yorkshire, was terrified at the prospect of natural childbirth, not least because so many of her friends’ attempts had ended in traumatic emergency caesareans.

‘At my antenatal class they acted out a caesarean, showing you how there would be 12 people in the room,’ she says. ‘This was portrayed as a negative thing, but for me it seemed like a no-brainer. Why would I not want everyone I could possibly need around me?’ Certain she wanted a caesarean, East had to battle to get one on the NHS. ‘Midwives judged and lectured me,’ she says. Eventually a consultant agreed to her request. ‘It was the most amazing, calm experience, and I knew I had made the right choice.’

East has since had another caesarean and set up a website, csections.org, giving ‘a balanced view of caesareans’. ‘Some people are very negative about it, but the site’s not saying planned C-sections are the best answer; it’s just being pro-choice, letting women know about a route that organisations like the NCT keep quiet about. So much emotion surrounds the birth of the baby that rationality goes out of the window, which I find very frustrating. Birth is the most physically exhausting thing that is ever going to happen to you, and who is anyone else to tell you how to do it?’

East’s sentiments are echoed by Julia Wilson, yet their attitudes could not be more opposed. Last year Wilson chose to give birth to her second child, Maddy, at home unassisted by even a midwife, a trend known as ‘freebirthing’.

‘Birth is a sacred process and nothing should interfere with it,’ she tells me from her home in Worthing, East Sussex. ‘I had a midwife for the home birth of my elder son, and her presence put me off. I believe that having a professional present poses more of a risk than being left alone, because they try to interfere when it’s completely unnecessary.’

When Wilson first mentioned her plan to friends and family, most were horrified. ‘At check-ups midwives were equally dismissive. They didn’t even support a home birth, because my low iron levels meant I might haemorrhage. But that was just nonsense. It was so empowering just believing in myself, rather than relying on other people telling you how to manage your body.’

Such a view makes Pat O’Brien, a spokesman for the Royal College of Obstetricians and Gynaecologists, shake his head. ‘In India and Africa thousands of women with potential complications give birth at home without support because they have no choice, and it ends in disaster. But in the West childbirth has become so safe that people have just about forgotten that there can be major problems. It’s been written out of people’s psyches.’ After all, the risk of dying in childbirth is one in 28,000 at Queen Charlotte’s hospital in west London, compared with one in seven in Niger.

It does seem extraordinary that an event that lasts at most a couple of days compared to the lifetime of actually bringing up a child can provoke so much controversy. Yet Belinda Phipps points out that nature probably has its reasons for this. ‘If we just dropped babies like eggs without noticing, what would that say about the responsibilities we’re taking on for the next 20 years? Birth marks you out as a mother and a carer for a very long time.’

Melissa Maimann, Essential Birth Consulting 0400 418 448

Delivering real choice after a Caesarean

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

Post traumatic stress disorder and birth

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It is supposed to be one of life’s most rewarding and wondrous experiences, and fortunately that is how most women describe childbirth.

But if the birth is difficult or distressing it can have a profoundly negative effect on the mother.

A Griffith University research team has found that 6 per cent of Australian women go on to develop debilitating post-traumatic stress disorders after giving birth.

One woman … almost died while giving birth to her son.

On top of that she says her doctor treated her inappropriately during the delivery, and a midwife agreed.

“As soon as I was up on the post-natal ward I was scared that I would see that registrar again …” she said.

That fear prompted Cathy to discharge herself from hospital. When she got home it quickly became clear something was wrong.

“I would have panic attacks for no reason, like, I was really anxious,” she said.

“I didn’t sleep very much. We had to pass the hospital on our way into town, so I rarely went into town because we couldn’t even drive past it.”

Cathy says at her lowest point she felt suicidal and after researching she realised she was suffering from post-traumatic stress disorder (PTSD).

“I did go and see a doctor. That doctor diagnosed post-natal depression, but I knew that it wasn’t post-natal depression. I knew that it was something else and I knew because everything was about the birth,” she said.

An associate professor of midwifery at Griffith University, Jenny Gamble, says her latest study shows about 6 per cent of women in Australia develop PTSD after childbirth.

“… 30 per cent of women report their birth as traumatic,” she said.

“It means that they feared for their life or their baby’s life, or that they, or their baby, would be seriously damaged or permanently injured.”

Professor Gamble says it is common for mothers with PTSD to be misdiagnosed with post-natal depression.

“If we’re not really addressing the key that sparked the distress, the key reason for the distress, then I think that can be a problem for women who’ve had a traumatic birth,” she said.

“Then they just keep blaming themselves about why they’re not better.”

… once PTSD is correctly diagnosed, targeted treatments are very effective.

“What we’re doing is we’re changing a sense of meaning for these women. We’re actually changing the way they look at the trauma and therefore the way they look at themselves,” he said.

… about 90 per cent of women no longer suffer PTSD after about 10-12 weeks of cognitive behaviour therapy …

A good article that exposes the trust about PTSD and childbirth. I am concerned that the focus is on the woman and not on the health services that cause the PTSD. When 30% women report their birth as being traumatic, a large focus needs to be on reforming the maternity service so that women are safe – and feel safe – to birth in clinical settings, or to ensure that they have ready access to homebirth services and midwifery care. Interestingly, birth trauma is very rare in home birth and amongst births attended by private midwives.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Politics of birth

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After five hours of active labour, Kate gave birth to her second, healthy baby boy. Holding him tenderly she is oblivious to the drama unfolding … She is hemorrhaging.

Her uterus has failed to contract after the birth causing massive blood loss … the registrar tugs at her umbilical cord in an attempt to remove her placenta. Unable to do so he proceeds manually. There is no explanation, sedation or consent as he plunges into her uterus.

Meanwhile a midwife has been instructed to ‘wring out’ her uterus by gripping her hands deep around Kate’s stomach. Kate is screaming in pain and her partner begs them to stop. Instead he is removed from the room and their baby is taken away … What happens next is hazy for Kate as she passes in and out of consciousness. But what is clear is since that day, four years ago, Kate has been managing posttraumatic stress. Unable to go back to hospital her following two births are at home with no medical practitioners present.

“I know it sounds reckless but … We just can’t fathom going in to the hospital because that previous experience had been so bad,” she says.

“… I felt an unassisted homebirth was safer for me than going back to hospital to let them do the things to me that they did that time.”

Kate is now planning her fifth pregnancy and wants an independent midwife to attend her birth at home. She has been advised to seek a collaborative agreement between her midwife and the Women’s and Children’s Hospital (WCH) as per new Federal laws governing homebirths.

Called the National Health (Collaborative arrangements for midwives) Determination 2010, they were passed by Federal Health Minister Nicola Roxon days before the election was called. They state that for an independent midwife to access Medicare and insurance they must have an obstetrician agree to care plans created for clients.

However when Kate contacted the WCH she was told that they “do not participate in collaborative agreements”. In a statement to The Adelaide Review the hospital says: “The public-funded Homebirth strategy from the Commonwealth is part of the broader National Maternity Services Plan which is yet to be endorsed by the Health Ministers of Australia.”

It reads like a straightforward strategy for insurance purposes, yet it has been met with confusion and anger. Firstly, insurance providers are yet to create a product that allows independent midwives indemnity while attending a homebirth.

The Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG) does not support homebirths and believes women who choose them are putting the birth experience above that of risk. RANZCOG President Dr Edward Weaver welcomes the new legislation and hopes it will curtail the number of high-risk cases that do birth at home.

He believes: “Virtually every obstetrician would have had an experience where he’s been called in to a situation where a woman has been brought in to hospital by an independent midwife and has had difficulties dealing with that situation.”

In 2008 there were 115 planned homebirths or 0.5 percent of births in South Australia. While 94 of those occurred at home, 21 women transferred to hospital for care before they could birth.

RANZCOG advocated for collaborative agreements in submissions to the Maternity Services Review, which informed the legislation. However they concede they cannot make their members adhere to them.

And here lies the problem: a midwife needs to have a collaborative agreement to remain in practice, but there is no requirement on an obstetrician to participate in an agreement. This threatens the ability of women to access midwifery care at all, and threatens the midwife’s ability to remain in practice. At a time when there is an acute shortage of midwives, these moves only mean that there’ll be fewer midwives left to care for pregnant and birthing women and new mothers and babies.

Australian College of Midwives Vice President Hannah Dahlen has found obstetricians will not enter into these agreements because they do not want to take responsibility for a midwives’ practice.

It should not be a case of an obstetrician needing to take responsibility for a midwife’s practice. Midwives are autonomous and regulated practitioners. We do not require an obstetrician to be responsible for our practice any more than an ENT specialist, cardiologist or orthopedic surgeon is responsible for a GP’s practice.

“If our most moderate and collaborative obstetricians are telling us that they are not going to be entering in to signed agreements,” she says. “Then we are potentially stymieing the reform that is going to be rolled out from November.”

Yet one of Dahlen’s greatest concerns is that the reforms go against the World Health Organisation (WHO) definition of a midwife. The WHO states a midwife promotes a natural birth, can detect complications and is able to carry out emergency procedures if required. Hannah is concerned these new laws will end up seeing “one practice of medicine veto and regulate another”.

Christine is an independent midwife with close to two decades of experience in the maternity sector. She has birthed hundreds of babies both within a hospital setting and independently. More than 20 women who want to birth at home have employed her until April 2011.

“I’m happy to work alongside a doctor when it is required but I do not agree, and no midwife will agree, that it is ok for them to sanction our practice,” she claims. If this does not get resolved she is adamant homebirths will go underground with women birthing with unregistered midwives.

… RANZCOG and the Australian Medical Association deem homebirth a high-risk proposition. Of the 202 perinatal deaths in 2008, one was in a homebirth setting. In June the State Coroner ruled to investigate the circumstances surrounding a baby who died at a homebirth in 2007. While this was widely reported in the media, the coronial inquest of an obstetrician who lost two babies to ventouse extraction at the same time was left unreported.

“If a baby does not make it into this world, and not every baby is going to, and it is a midwife’s domain, (they) are really crucified,” says Christine. “But for doctors to lose babies and make mistakes, it is a very different thing.

South Australian MP Frances Bedford is an advocate for a woman’s right to birth at home. She was unable to be interviewed for this article but said in a statement to The Adelaide Review: “(I) find it extraordinary that a woman choosing caesarean section without any medical need is apparently acceptable to the medical fraternity (with Australian taxpayers funding most of those costs) yet a woman choosing to maximise her chances of health and wellbeing through homebirth is discriminated against.”

As this debate continues in the medical fraternity, Kate remains sceptical she will have the birth she wants. Instead her partner has become versed in birth advocacy.

“We should be able to share everything we need with (a midwife) and same for the hospital,” she says. “Our partners should not have to go in there and be aggressive and advocate on our behalf.” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Who controls childbirth: women or doctors?

Visit my website to learn more about my services.

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

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

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

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

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

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

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

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

No answer.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

‘Love drug’ may help mums bond to babies

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

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It’s a shame the resesrchers in this study haven’t considered ways of boosting the natural form of this “love drug”: natural bitrh and breastfeeding are the most effective ways to promote this chemical and enhance bonding.

A hormone nasal spray may help mothers bond better with their babies.

A world-first trial by Sydney researchers involves giving mothers a synthetic version of the hormone oxytocin, often dubbed the ”love drug” or the ”cuddle chemical”. Past studies have shown mothers who are deficient in oxytocin are less sensitive to their babies’ cues than mothers with high levels of the hormone.

It’s interesting to take a look at the things that diminish the mother’s production of oxytocin: epidurals, infusions of syntocinon (the artificial form of oxytocin that’s given to women to induce or speed labour), caesareans and pain-relieving medications.

… University of NSW school of psychology have launched the Mothers Early Experiences of Parenting (MEEP) project, which will use oxytocin nasal spray in combination with infant massage and play sessions. They will then measure eye contact, affectionate touch and feelings of closeness and warmth to see if there is improvement in attachment between mother and child.

… although the role of oxytocin in childbirth and breastfeeding was well documented, scientists were increasingly interested in the hormone’s role in human social interaction. It is known to reduce fear, increase empathy and improve memory, especially of happy events.

Hence the research that points to increased rates of violence, suicide, anti-social personality disorders and the like in children who have experienced a raumatic entrance to this world.

”It allows us to recognise and feel connected to loved ones,” Professor Dadds said. ”So after eye contact, cuddling, even an orgasm, with a loved one, you get a big shot of oxytocin, which increases trust and connection.”

Professor Dadds said oxytocin delivered by nasal spray had very subtle effects but could be a powerful intervention when combined with psychological therapies. ”It’s a new age of psychology and medicine working together and magnifying the effects of each other,” he said.

I’d rather see psychology and midwifery working together: midwifery to promote and protect natural birth, and psychology to work with women to reduce the fear surrounding natural birth, to debrief women of their past traumatic birth experiences, and for supporting programs to be developed that enable women to feel safe and trusting again.

… between 10 and 20 per cent of mothers had post-natal depression, and at least a third of those women had trouble bonding with their babies. An impaired early bond is associated with adverse developmental outcomes for children.

And the major cause of PND and impaired bonding is a traumatic birth experience.

”There’s a huge body of research showing that the more securely attached you are by age three to five, the better your outcomes for mental health,” she said …

Melissa Maimann, Essential Birth Consulting 0400 418 448

FAQs

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

Birth trauma symptoms

The symptoms of birth trauma are many and varied. A common theme is that the trauma interferes with your enjoyment of daily life. The trauma issues may surface at different times, and then completely disappear.

Some women experience:

  • Flashbacks of the event and sudden, vivid memories. You will usually feel distressed, anxious or panicky when you’re exposed to things that remind you of the event
    Avoidance of anything that reminds you of the event. Some women never talk about their births or avoid hospitals. In contrast, other women talk about their birth trauma all the time; this is their way of expressing their extreme hurt, anger and fear.
    You may also experience emotions such as anger, irritability, and hyper-vigilance (feeling jumpy or on-guard all the time)
    Nightmares of the birth
    Physiological responses when you are exposed to events resembling the traumatic event, such as panic attacks, sweating and palpitations
    Numbed emotions
  • benefits of birthing by midwives over doctors

    The msin benefits of using a midwife are:

    Higher chance of natural birth
    Continuity of care: you have the same midwife for pregnancy, labour, birth and postnatal care. Even with a private obstetrician, you’ll be attended by midwives you have not met when you’re in labour and afterwards when you stay in the ward with your new baby. If you choose midwifery care, especially private midwifery care (no private health insurance needed), you have the same person looking after you the whole way through.

    do you need informed consent episiotomy

    Most definitely! The only time consent is not needed is in a genuine emergency. Since women are generally awake for their births, there is no reason why your midwife or doctor would not seek your permission before doing an episiotomy, even in an emergency situation. Remeber – you can always say no to an episiotomy.

    duty of care to an unborn child

    Midwives and obstetricians do owe a duty of care to the baby. Babies do nto have any rights until they are born alive and take their first breath. Once they do that, they are afforded the full rights of a person.

    no obstetrician for birth in private hospital

    Currently, it is not possible to birth in a private hospital without an obstetrician. However, you can have a private midwife and a private obstetrician at aprivate hospital.

    private birthing classes at home, Sydney

    Yes, this is possible. See here.

    will homebirth be legal after July, 2010?

    Absolutely! Homebirth has always been, and will always be, legal. The ability for midwives to practice in women’s homes is dependent on the midwife reporting every homebirth, letting women know that we are not insured for births at home, and also agreeing to abide by a quality and safety framework. This is all designed to give the public greater confidence in private midwifery services and to increase safety for women and babies.

    Birth providers who support vbac in sydney

    The best way of achieving a VBAC in Sydney is to contract a private midwife to provide your care. Private midwives have roughly a 90% VBA success rate.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Midwives want to meet Roxon to avoid home-birth ban

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

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    A sensationalist title as home birth is not about to be banned but here goes:

    ABI WHITEHAIR is only nine days old but she’s already saved taxpayers thousands of dollars.

    She was delivered at home after her mother, Leah, rejected advice to have a caesarean section … because her first baby … had been born that way …

    A surgical birth – about 30,000 are performed in NSW each year – would have cost the public hospital system about $8000.

    If she had been admitted to a neonatal special care unit, like 70 per cent of babies born by caesarean, including her big brother, it would have cost another $900 a day.

    But her entry to the world, in a Dee Why lounge room, cost taxpayers nothing …

    [Midwives] are calling for another urgent meeting with the Health Minister, Nicola Roxon, before the new rules come into effect in July.

    More than one in three babies in NSW is born by caesarean section but only one in seven subsequent babies are born vaginally due to the risk of uterine rupture.

    The risk is very small: less than one in 200. Most studies on uterine rupture include dehiscenses, which are not complete ruptures, have no symptoms and do not cause any problems for mother or baby.

    About 95,000 babies were born in NSW in 2008, but only 258 were born vaginally in public hospitals after a previous caesarean …

    It is well-known that VBAC is far more successful – around 90% – with private midwifery care. Otherwise the chance of a siccessful VBAC can be as low as 3%.

    … women who had undergone traumatic births, with extensive intervention, were eager to avoid a repeat performance but were often left with little choice.

    ”Keeping away from obstetric intervention by having a home birth is the best chance they have of achieving a normal vaginal birth,” …

    Up to 70 per cent of home births were by women who had previously delivered by caesarean and there was a growing band who would deliver at home alone if home births were outlawed.

    … Ms Whitehair, who had longed for a natural birth, spent months researching a home delivery. Abi’s birth, attended by two private midwives, cost her almost $5000 but was ”beautiful and textbook”.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    FAQs

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

    informed consent and childbirth

    Every woman who is competent to consent, has the right to refuse any or all professional care. Informed consent must be obtained prior to any procedure being performed.

    how to minimise labour intervention in a hospital?

    The best way to minimise intervention in a hospital is to be as well informed as you can possible be about all things related to pregnancy, labour, birth, breastfeeding and babies. Read widely, attend independent childbirth education classes and consider employing a private midwife to be with you throughout your labour. She can help you to decide if the proposed interventions are necessary in your situation, she can support you emotionally, mentally and physically and she can aso help to ensure that your birth plan is respected without a fuss.

    Do any independent midwives in Sydney offer prenatal care for women who are planning to freebirth?

    Yes! This service enables women to access antenatal care from a midwife without the midwife attending the birth. Postnatal care is available if needed.

    Do you think there are advantages to continuous monitoring for low-risk women

    In a word, no. Intermittent auscultation is the method of choice. Continuous monitoring will increase the chance of a caesarean with no benefit to the mother or baby.

    How much is a private midwife

    Prices range from $3000 – $6000. Melissa Maimann offers for her clients to pay by the hour, making the service one of the cheapest.

    What is a good caesarean rate?

    The World Health Organisation recommends that no more than 15% births need to be caesareans. The WHO argues that when caesarean rates exceed 15%, the risks to the mother and baby increase on the whole. You’ll be hard-pressed to find a hospital with a caesarean rate of less than 15%, but birth centres and private midwives have caresarean rates of less than 10-15%.

    What is the best hospital in sydney for delivering babies?

    It all depends what sort of birth experience you’re after! If you’re wanting a natural birth, home birth will be the best option. If you want a natural birth in a hospital setting, the best options would be birth centre or private midwifery care for a planned hospital birth. If you’re wanting to have intervention in your birth, a hospital birth would be best. If you choose an obstetrician, you’re far more likely to have a caesarean, episiotomy, epidural, forceps or vacuum. Choosing your care provider is the single most important decision you will make in birthing.

    Is there a birth centre at westmead hospital?

    No, there isn’t. If you’re after a natural birth, the best choice would be a home birth.

    C section or natural delivery midwife?

    Midwves cannot perform caesareans. If a caesarean was needed, the midwife would call a doctor in to perform it. Most caesareans that are performed are unnecessary and increase the risks to the mother and baby. A natural birth is the safest way to birth, and midwives are qualified specialists in natural birth.

    giving birth after birth trauma

    Private midwifery care will be really important so that you can have the same midwife all the way through pregnancy, birth and postnatally. It’s also important to debrief your last experience and come to a place where you feel safe to birth again.

    high risk midwife sydney

    Midwives are not qualified to care for high risk pregnancies. We refer these women onto obstetricians. In most cases, one or two consultations is all that is needed with the obstetrician and the midwife continues the care of the woman.

    how many births proceed naturally

    What a great question! It all depends what care provider you choose and where you have your baby. You see, if you choose a private midwife and birth at home, you have about a 95% chance of having a vaginal birth. If you birth in a private hospital, you have about a 33% chace of having an unassisted vaginal birth. In some hospitals, the caesarean rate is more than the vaginal birth rate! Sad but true.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Caesarean births risk mums’ lives

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

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    A study of more than 100,000 births showed mums-to-be who had a caesarean section when there was no medical need were 2.7 times more likely to have complications than those who gave birth naturally.

    … mothers should only have a C-section for medical reasons, according to the authors of the World Health Organisation study.

    Women who chose a caesarean over a natural birth were 10 times more likely to be admitted to intensive care and suffer severe bleeding.

    … “I do get women who ask for a C-section, often because they’ve got a pathological fear of childbirth, fears of pelvic floor problems in later life or have been sexually abused earlier in life, so they choose to have a C-section to avoid any genital tract trauma which would remind them of what’s happened.”

    Dr Kliman said Epworth Freemasons had about 20 mother-requested caesareans out of 3500 deliveries a year.

    “I tell them it is not necessarily an easy way out,” he said.

    “They have risk of haemorrhage, infection and more discomfort after the procedure.”

    Vice-president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Michael Permezel, said …”If a woman said, ‘I want a C-section’ and had no understanding of the risks, I think most doctors may decline the request,” Prof Permezel said.

    “If she’s having her first baby later in life and perhaps planning to have one more, then the pros and cons are pretty even, but if it’s a younger woman planning a relatively large family then certainly the recommendation would be for a vaginal birth if possible because of the risks associated with each subsequent pregnancy …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Emotional Impact of Cesareans

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    Every 30 seconds in the US, a cesarean is performed.This overuse of cesarean surgery puts moms and babies at risk—not just physically, but emotionally … A cesarean can reach far beneath the bogus smile on mom‘s face. It can scar her heart, as well as her uterus.

    A baby girl is born. She grows and begins menstruating. She becomes sexually active and becomes pregnant. She births her baby. She breastfeeds her baby. This is life—normal and natural, yet exciting and important. In the continuum of life, pregnancy, birth and the postpartum period are milestone events. These experiences profoundly affect women, babies, fathers and families …

    When a woman gives birth, she has to reach down inside herself and give more than she thought she had … There is a moment when every woman thinks, “I can‘t do this.” If she is lucky, she has a midwife … to whisper in her ear, “You are doing it.” As she does it, she becomes someone new: a mother. If the birthing process is skipped or occurs in a hostile situation, or if the interventions become overwhelming, she becomes a different mother than she would have been if she had only had a supportive, midwifery model of care.

    … A woman‘s confidence and ability to give birth and to care for her baby are enhanced or diminished by every person who gives her care and by the environment in which she gives birth.

    To control and actively manage a woman‘s labor and delivery, modern obstetrical practice relies on conformity. A woman is “subject” to rules, restrictions and protocols … Physicians and the hospital staff have authority—there is an unbalance of power … I say: You can only consent to that which you are capable of refusing. If you can‘t refuse the test, the drug, the procedure or the surgery, then you did not consent to it. This is coercion and it leads to disempowerment of women …

    Many women who have cesareans suffer in silence because society expects them to “just be happy about their baby.” …

    … Research has shown that when we stray from evidence-based maternity care, we have a high degree of obstetric intervention that is associated with acute trauma symptoms … how a woman perceives the event, not the event itself, plays a vitally important role in whether she has trauma symptoms.

    Women report experiences that fall into the following categories:

    * A sense of loss: birth didn‘t turn out like expected, loss of the experience of participating in the birth experience, not being there when the baby enters the world
    * Interrupted relationship with baby: feelings of detachment from her baby
    * Altered identity: sense of failure, feminine identity altered; lowered confidence in her body
    * Intimations of mortality: surgery gives “rise to fears about mortality”
    * Feelings of violation: from surgery where the body boundaries are violated, feeling “mutilated” or “butchered”
    * Anger at caregivers: particularly regarding “what was perceived to be an unnecessary cesarean, lack of involvement in medical decisions, feeling unsupported by hospital staff before, during and after the cesarean”
    * Dissociation: feeling that the surgery was taking place on someone else or from a distance
    * Humiliation: being scolded
    * Helplessness: not being able to take care of herself or her baby
    * Posttraumatic Stress Disorder symptoms: anxiety, trouble sleeping, panic attacks

    Let‘s consider that a moment. What if we went to a wedding today and while waving the couple off in the limo, we see it get hit by a truck before it turns the corner. If the bride were to spend her honeymoon in the hospital, no one would tell her, “Well, at least you have a healthy husband.” …

    … Some women have such a traumatic experience, they close themselves off to the possibility of more children. They never consider the idea that it doesn‘t have to happen that way …

    … Women who have had cesareans have higher rates of voluntary … infertility … This is often due to their determination that the trauma, whether physical or emotional, was too much to repeat.

    Men are in a unique place during labor. They have been asked to be the support person and the labor coach. Now they are asked to be the protector. While historically men have taken the role of protector, I submit that the labor room is not the place men want to be trying to protect their wives.

    Is it fair to expect this of partners? How are partners to be effective protectors / advocates when it is their partner and baby going through the experience? Is it fair to expect this role on anyoen who does not have the qualifications and experience to advocate?

    Husbands of women who had had cesareans responded … mainly with fear and anger … “The pall that the experience placed over our entire relationship was stronger than a death in the family, because we both feel that we should have been able to do better. She has an alibi and can say she did all she could. I have no such explanation.”

    Another husband expressed … he was “ashamed that I let them hurt my wife as I stood by.”

    What is a husband protecting his wife from? We trust our obstetricians to provide care that is safe and effective for women and their babies. Yet, in the US, the norm in maternity care that is provided is technology-intensive and not consistent with the best available research.

    This is the norm in Australia too.

    Healthy women often are given … interventions that could have been avoided. In the hospital, some procedures or interventions are done freely and routinely, whether or not the mother or baby has shown a clear need. These interventions are disruptive, uncomfortable, can cause serious side effects and often lead to the use of other procedures …

    … Birth has become extremely interventive and this includes everything from the seemingly minor … to the most invasive—the cesarean. It has become so interventive that it takes something away from what the experience should be. As a result, many women find themselves grieving.

    … Partners witnessing birth trauma are also at risk of developing depression, caused by feelings of helplessness during the traumatic event. Men are more likely to express their feelings of depression through anger and abusive behavior. Truman stated, “The cesarean completely destroyed my faith in the medical community … ”

    … Tim stated: “I‘m mad and bitter—disillusioned. That likely won‘t change with time. Recovery is not a term I would use. I‘m not recovering. I have learned a lesson.”

    How the couple process their experience can determine whether the marriage survives. Chris said, “… It put us at the brink of divorce. I didn‘t understand fully what happened and my wife thought I didn‘t care.”

    The cesarean may be difficult for the father. A husband may have seen his wife rushed to the OR. He saw her uterus taken out of her body. He was worried about her. He may not have words to describe the experience, but he needs to process it.

    When I broached the subject of intimacy after cesareans to husbands, some asserted, “Everything‘s fine there, thank you.”

    Others report having to work hard to restore intimacy to their marriages: “It took more than a year for intimacy to start returning. More than a year.”

    One husband, when asked, snorted, “Hah, are we seriously going there? Personally, it has left ’intimacy‘ out in the dark. She is embarrassed about her scar and she thinks it makes her less sexy. I guess it‘s more of an emotional hardship for her and she just doesn‘t feel sexy anymore.”

    The cesarean recovery has an impact on the couple‘s ability to resume intimate relationships. The immediate problem is healing of the incision and recovery from the surgery itself. There also is long-term impact that is rarely noted by the medical community. Some women report a loss of feeling around the scar. Others are hypersensitive to any touch or pressure in the scar area—which may be psychological as well as physical. They report pain and discomfort.

    Intimacy is an emotional connection. After a cesarean a number of things may interfere with this connection. The husband may have been frightened by the sight and sounds of—or the scenario that lead to—the cesarean. He may be hesitant to resume relations, worrying that he might hurt her. What if she gets pregnant again? He certainly doesn‘t want to do that again. His wife might feel the same way. She has to focus on her own recovery, which takes away from what she can give to their relationship.

    … Stephanie‘s cesarean changed her husband‘s view of the medical community. He said, “… To know that people we trust with our lives and the lives of our children are so careless and insensitive about our lives and the little ones they savagely bring into this world.”

    The veil has been removed—even doctors no longer believe in the Hippocratic Oath. They cite liability as the main reason they do many things, including unnecessary surgeries and banning VBACs. Since they are more concerned with money than with the health and safety of women and babies, we must now claim the right to have full and complete information about the risks and benefits of, and alternatives to, every test, drug, procedure and surgery. We must claim the right to make medical decisions for ourselves and in behalf of our babies.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    The real safety issues in maternity care

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    Maternity care provides a classic example of the pitfalls of a specialist-driven model of practice in health care. It results in more expensive and interventionist care, rather than a community-based approach which could also help ensure a more equitable distribution of services. It has led us to talk about obstetrics, which implies a focus on a particular professional group, rather than maternity care, which implies a broader focus on the woman’s and baby’s needs, both before and well after the birth.

    Professor Lesley Barclay … is a leading proponent of the need to reorient maternity care around the needs of women and babies …

    “When women talk about what matters to them when it comes to childbirth, the issue they repeatedly mention is safety.

    But their understanding of safety around childbirth is often quite different to how health systems and many professionals define it.

    For women, a safe childbirth is not only about what occurs at the time of the birth. It also refers to longer-term issues, such as their social and emotional wellbeing in the weeks and month after the birth.

    When women talk about safety, they are also thinking about the increased rates of depression and anxiety that manifest after operative birth or the consequences of wound infection on general health.

    The Australian health system often makes it difficult for women to make wise choices around birth …

    For example, evidence shows for most women most of the time birth does not need to take place in hospital. Some women will only feel safe however, whether this is evidence-based or not, with specialist medical services and technology.

    The term “maternity care” … incorporates their social and emotional needs. It puts them – rather than the professional or the service …

    Evidence shows maternity care can be provided by both midwives and obstetricians in public and private sector hospitals and can be safely provided at home.

    … evidence also shows that safety from morbidity is less likely for Australia’s healthiest and wealthiest women cared for by private obstetricians in private hospitals. More recent epidemiological evidence shows as volumes of operative birth increases, deaths of mothers and infants are also increased by overuse of the very operation that was developed to save lives.

    So where does choice fit in this repertoire of terms, locations, professionals, services and outcomes?

    Safe birth should be the goal of choices offered to women and decisions taken by those who provide care for them.

    Unfortunately, the choices some professionals offer or accept are self or income centered and ignore evidence. As a consequence of gender-located power historically, and a rapid increase in the numbers of more technically oriented professionals in recent decades, health services and costs do not reflect women’s needs or evidence.

    The most important example of this is allowing caesarean birth to be a choice rather than only using this as the lifesaving emergency procedure it is.

    … caesarean birth is rapidly becoming a life threatening procedure itself because of excessive use … maternal death reviews and coroner’s reports now show the risks attached to using a major surgical procedure as a routine mode of birth.

    Maternal mortality is between two and seven times higher for surgical than vaginal birth …

    … The physical, social and emotional morbidity attached to women who experience this mode of birth is not recognised therefore ignored within acute care hospitals but is evident in their homes and the community.

    Research has identified that physical morbidity associated with CS is five to ten times higher than for women birthing vaginally. No less importantly there are also psychosocial consequences of surgical birth with women less satisfied, more concerned about the baby’s condition and fearful. Women delivering by CS report feeling less in control than women who have birthed vaginally.

    Research also shows rates of post natal depression significantly different between women who birthed vaginally and the group of women who delivered either by planned or unplanned CS … Women who birth by CS evaluate their babies less favourably, are less likely to breastfeed and/or feed for a shorter duration.

    Paradoxically, the choice to have a normal, safe, confidence affirming birth that is low cost and relieves pressure on hospitals is only available to a small minority of women.

    This is not possible for Australia’s most vulnerable women and families, who, the evidence suggests, would benefit most. How many rural or remote living Aboriginal women can opt for a home birth attended by a skilful midwife?

    … 1 in 10 remote living Aboriginal women in one large community avoid hospital services or skilled professionals because of the unacceptable risks to them of being evacuated from their community …

    Other Australian women with more options are also taking this route, fed up with what they see as biased, self-interested advice and unacceptable risks of our current system.

    To have real choices, one needs options and good information on which to base decisions. Better resourced women … can chase evidence themselves, or question doctors, hospitals and midwives …

    … there are some ultimate arbiters beyond opinion. One of these is the impartial review of evidence provided by such as the Cochrane data base.

    I saw to my great delight a writer (male and medically qualified) who also a Member of Parliament, recently quoting this source in a newspaper. His message, while aimed at indemnifying home birth midwives, was that home birth is safe.

    … home birth is indeed safer at times than hospital birth when planned and supported by good hospital care for rare emergencies.

    I wish the current president of the AMA, an erstwhile obstetrician, would be similarly correct with his claims that certainly are not recognisable as fact to those familiar with the evidence.

    Choices for women are difficult when all they receive is highly partial and ill-informed opinion. Choices around birth are important or women will opt out of a system that does not meet their needs.

    …. Should it be a matter of choice though for women to give birth via major abdominal surgery? Should we permit choice that means their babies avoid the process of vaginal birth that prepares them to live and breathe? Should it be women’s or obstetrician’s choice that health pays or heavily subsidises the avoidable costs of unnecessary operations that prevent other necessary surgery being performed and add to waiting lists? I think not.

    We need to recognise that operative birth is the option to use only when the risks associated with the alternative are unacceptable. This is not a matter of choice.”

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Don’t tell women how to give birth

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

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    How a woman gives birth provokes strong views, with impassioned arguments for normal births, and for Caesareans.

    But … the most important thing is for women to be able to choose.

    The use of technology in birth – such as the development of epidurals for pain relief and Caesarean sections – has long been a cauldron into which divisive and conflicting issues and opinions have been poured.

    … Women can be left deeply scarred by a birth which may have been physically safe but has ignored the emotional aspect of it

    When the … NICE was considering guidance on giving birth in the NHS, the large number of midwives who sent in comments were only too aware of how the home birth option was once again nearly lost.

    They had to challenge the appropriateness and interpretation of the evidence being considered on the safety of place of birth.

    There is a fundamental question needing to be asked here: why do some doctors and midwives devalue the choice of home birth, despite the lack of evidence against it?

    … what women want at all times, is good and unbiased information from the health professionals caring for them, so that they can make the appropriate choice about how technology can help them.

    One high-profile obstetrician recently relating the birth experience to the advances in agriculture, transport and energy production reminded us alarmingly of the language previously used in the “active management of labour”, when women’s bodies were viewed as machines that were frequently “inefficient” and in need of acceleration.

    It has seemed that the health professionals that care for women today had largely moved on from this strange and controlling discourse, and it’s disappointing this may not be the case.

    The bottom line here is that what women want is to be able to make a real choice, for the health service to offer them that choice, and for that choice to be based on having all the information needed to make an informed decision …

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Offspring’s Behavior Influenced By Trauma Experienced By The Mother Even Before Pregnancy

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

    Juat an interesting article I came across ….

    Article

    new study in rats at the University of Haifa reveals that tauma experienced by a mother even before pregnancy will influence her offspring’s behavior.

    The findings show that trauma from a mother’s past, which does not directly impact her pregnancy, will affect her offspring’s emotional and social behavior. We should consider whether such effects occur in humans too,” stated Prof. Micah Leshem who carried out the study.

    A mother who experienced trauma prior to becoming pregnant affects the emotional and social behavior of her offspring …

    The effects of trauma that a mother experienced in the course of pregnancy are known from earlier research, but until now the influence of adversity before conception has not been examined …

    The researchers chose to investigate rats, as social mammals with cerebral activity that is similar in many ways to that of humans. The present study examined three groups of rats: one group was put through a series of stress-inducing activities two weeks before mating, allowing the female time to recover before becoming pregnant; the second group was similarly treated over the course of a week immediately prior to mating; and the third, control group, were not given any form of stress. When the rats’ offspring reached maturity (at 60 days), the researchers examined their emotional behavior – anxiety and depression – and social behavior.

    The main finding revealed that trauma experienced by the females prior to conception had varied effects on the offspring … these effects varied between groups and between male and female offspring; but their behavior was without doubt different from that of the rats from the control group.

    All the offspring of stressed mothers showed reduced social contact compared with that of the control mothers’ offspring: these rats spent less time with one another and interacted less. In other tests, there were important sex differences. The female rats displayed more symptoms of anxiety, while the males exhibited less anxiety. Finally, those rats whose mothers became pregnant immediately after being stressed were hyperactive, indicating that how long before pregnancy adversity is experienced, is also important. “Everyone knows that smoking harms the fetus and therefore a mother must not smoke during pregnancy. The findings of the present study show that adversity from a mother’s past, even well before her pregnancy, does affect her offspring, even when they are adult. We should be prepared for analogous effects in humans: for example, in children born to mothers who may have been exposed to war well before becoming pregnant,” Prof. Leshem concluded.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    Postpartum Depression Is Top Priority For New ACOG President

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

    Link to article

    Today Gerald F. Joseph Jr, MD, of Louisiana, became the 60th president of The American College of Obstetricians and Gynecologists (ACOG)… . During his inaugural speech at ACOG’s Annual Clinical Meeting, Dr. Joseph announced that postpartum depression is the theme of his presidential initiative.

    “While in an ideal world, the newly delivered mother is at the peak of her reproductive health, with a beautiful child and, ideally, a supportive, loving family, this unfortunately is not always the case,” said Dr. Joseph. “Studies show that this is a most vulnerable time for our patients, especially those prone to depression or those with a history of depression.” Complicating matters is that the new mother often can’t bring herself to admit to any problems or negative emotions due to societal pressures, he said. Instead of asking for help, she may feel guilty for not being ‘grateful’ or a ‘good’ mother.

    Dr. Joseph explained that the ‘baby blues,’ which affect as many as 80% of new mothers, usually start early after delivery and spontaneously resolve within a very short period of time. “But what happens when these negative feelings don’t resolve and true major depression becomes a part of the process?” he asked. “This can be devastating for the mother, the child, the partner, the family, and the ob-gyn who is caring for her.”

    There are three areas in particular that need to be addressed, according to Dr. Joseph. “First, we need to determine the true prevalence and incidence of postpartum depression,” he said. … postpartum depression is estimated to range anywhere from five percent to more than 25 percent … we need to develop evidence-based guidelines for ACOG members to screen for postpartum depression.”

    It would be great if there was some sot of acknowledgement of the role that pregnancy- and birth-related interventions have on the incidence of PND. It would also be great to see a study looking specifically at women with PND, to establish what sort of birth experience the woman had, and who her primary care provider was (midwife or obstetrician). It’s not hard to see that when women are told, overtly or covertly, that their bodies don’t work and that they need intervention to start labour, keep it going, or bring it to an end, that they take this learning away to motherhood, and approach motherhood with the same sense of failure.

    Rates of PND are lower with midwifery care and with home births. Birth debriefing may help women who are experiencing PND.

    Melissa Maimann, Essential Birth Consulting 0400 418 448

    The Benefits of Using a Midwife During Childbirth

    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. It will either be a doctor or a midwife, and in some circumstances, it will be both. Women may choose birth centre, homebirth or hospital midwifery care to benefit from primary midwifery care.

    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 generally 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, birth centre, 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 birth trauma
    - 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

    Visit my website to learn more about my services.

    Mother and baby are doing well

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

    Link to article

    The article commences with the story of Rachel, who plans a midwife-attended home birth. Her waters break three weeks after her due date, and after 2 days, there is evidence of meconium in the amniotic fluid. The article goes on to say that two days later, she has a fever and is transferred to hospital, not in labour. Hospital induces labour and the baby has an infection, and has sadly died. The woman bleeds and requires resuscitation, a hysterectomy and two weeks in an intensive care unit.

    I cannot vouch for the accuracy of the reporting. We know reporters say what they want to say and sensationalise stories. However, there are a few points I’d like to make, assuming the article is true. There are several risk factors here: 43 weeks (1 week “overdue”, since normal pregnancy lasts until 42 weeks), prolonged rupture membranes, and mecomium-stained liquor (amniotic fluid). Should this woman have birthed her baby at home? Maybe not. Homebirth is the domain of low-risk, healthy birth. What we need is a system whereby the midwife can transfer that woman into hospital and remain her primary care provider. I think blame needs to be laid fairly and squarely with a system that does not recognise the full scope of midwifery practice and that does not welcome privately-practicing midwives in the hospital system. It seems to me that much information has been left out of the story above. We do not know if the midwife has taken the woman into hospital already; perhaps the hospital has discharged her saying all was well. We do not know the point at which the midwife was made aware that the woman’s waters had broken; maybe the midwife was not aware of the situation until after the baby passed meconium. Maybe the midwife had taken the woman for scans after 42 weeks to ensure that the baby was well. My point is, we will never know the full details. We read what the media wants us to read, and this story has heped blacken the name of home birth in this country. What it lacks are the details to support what happened.

    ‘It is not possible to know exactly what information Rachel was given regarding the possible benefits and risks of planned home birth which led to her decision to choose this option, but it is likely she was told that planned home birth with a qualified midwife is as safe as hospital birth, and decreases the likelihood of medical intervention, which harms women and babies.’

    Women who choose homebirth research information as if it were an obsession. Yes, planned, midwife-attended homebirth is safe for low risk women. To say otherwise would be a lie. What we need to communicate very clearly is that when freebirths and high-risk homebirths are added to the equation, the risk profile of homebirth changes significantly.

    What happened to Rachel and her baby was a terrible, avoidable tragedy and certainly, the majority of home birth midwives would not have advised Rachel to stay at home as long as she did.

    Thank goodness they said it! Homebirth midwives are very risk-adverse.

    … it is important to them to feel they can have as ‘natural and active’ a birth as possible when receiving care from mainstream maternity services.

    No, it is not important for them to merely “feel” they can have a natural birth in the system, it is important that they actually get a natural birth in the system! With some hospitals having caesarean rates of over 46% (NSW stats, 2006), it’s no wonder women don’t quite trust that they can have a “natural” birth in the system. Whatever natural means these days.

    “It is always sad when any baby dies perinatally, but it is even more concerning when it happens to a woman having a home birth, because mothers attempting a home birth should only be those considered to be at low risk of poor pregnancy outcome.”

    At least one of the deaths that the article refers to was a freebirth. The important factor that was not present there was a midwife. The emphasis on low risk homebirth also needs to be made. Trouble is, many women are attracted to homebirth because of the deficiencies in the hospital system. So they are attracted to homebirth to:
    - Have continuity of care and build a trusting relationship with their midwife. Not midwives, midwife. 1.
    - Give birth in familiar surroundings, not an institution.
    - Have choice and control because that was taken away from them in hospital.
    - Be pregnant and give birth in a relaxed setting that is not dominated by clocks, a delivery bed, drugs, strangers who can come in at any time and shift changes.
    - Have care as and when they need it – not have to attend noisy, uncomfortable and impersonal hospital clinics, where they wait for an hour or two and are seen for 5 minutes by a midwife or doctor they have not met before; where they leave with unanswered questions and have no idea what this diabetes test is for that they’re told they have to have (or their baby may die).

    What system is this that we’re putting women through? And during pregnancy and birth? These are natural and healthful experiences, not medical conditions. Home birth services are a stark contrast!

    It is very disappointing that women can feel completely disenfranchised from any sort of hospital care, and feel that the only way their needs can be meet is to attempt birth at home.

    Yes, it is disappointing, isn’t it. hospital birth with a private midwife is a great way around this issue.

    RANZCOG considers that there is no place for the ‘independent’ practitioner, working in isolation and having no link with any other health professional or hospital,

    No “independent” midwife works in isolation! All IMs collaborate with hospitals, consulting and referring when necessary. We work in our full scope of practice and we are autonomous care providers, as is supported by WHO, FIGO and ACMI.

    The four deaths referred to above indicate why RANZCOG is opposed to ‘independent’ practitioners.

    Even though at least one of them was not professionally attended?

    Melissa Maimann, Essential Birth Consulting.

    More press about Home births and Freebirths

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

    Unfortunately, the media does not distinguish between homebirth and freebirth …. I really wish they would!

    A home birth is not a safe birth

    Reports this week of the death during childbirth of the baby of a leading home birth advocate at her inner-western Sydney home come just as the Government is considering a review of maternity services … The most ardent of lobby groups is Joyous Birth, whose convener, Janet Fraser, 40, tragically lost her baby after several days of labour at her Croydon Park home, which ended on March 27, when an ambulance was called. The NSW Coroner’s Office yesterday confirmed it had received a report of the baby’s death.

    … as one of the most extreme proponents of home births, Joyous Birth has been influential in persuading pregnant women to shun medical intervention in childbirth. It describes as “birth rape” doctor intervention that saves the lives of mothers and babies …

    Birthrape is not simply medical intervention: it is intervention that has not been consented to. You know, episiotomies that are performed without permission, vaginal examinations without permission – that sort of thing. Just as you would not accept these actions from a stranger if you walked down the street, so you do not need to accept this from care providers in labour. So you can understand:

    Despite the disasters, Joyous Birth continues to promote 2009 as “Birth Trauma Awareness” year, urging members to write … “Birth rape on demand, a surgeon’s right to choose”; “Did your rapist wear a mask and gown? Mine did”; “Episiotomy is genital mutilation”; “Fingers, forceps, hands, ventouse, baby – which one belongs in a vagina?”; “My body, my birth, my choice”.

    Women seduced by the “empowering” idea that only a woman knows how to deliver her child forget, as Pesce said yesterday, that “100 years ago … women died from complications of childbirth, and [so did] babies”.

    The cases [stillbirths] are mainly from the Blue Mountains area, and two stillbirths occurred at the hands of “doulas” – women paid to help women give birth, often former midwives.

    Doulas are mostly not former midwives. They are birth support people who have usually done a short course in birth support. But they are not former midwives!

    Again, it is very important to distinguish freebirths – birth at home that is not assisted by a midwife – from midwife-assisted homebirth. The latter has deen demonstrated to be safe, for low-risk, healthy women. The former – there is no research to suggest it is safe, nor would it be ethical to do such research. So we will never know.

    A midwife is a professional. When you have a midwife at your birth, you’re employing their knowledge, skill, judgment and experience. This is not present in a freebirth. It’s very easy to read a lot and think you know a lot. How does a a labouring couple accurately assess the situation when their experience might be less than 5 or 10 births, one of thich is their own? Midwives study for 3 years and attend many many births – complicated and normal. And their education needs to be this way: most complications are not common, so you need to see many births to come across those complications.

    Having a midwife at your home birth who has the experience to resolve a shoulder dystocia, safely administer an injection of syntocinon, resus a baby and so on, is essential for a healthy outcome. I believe midwives have a vital role in all births.

    Melissa Maimann, Essential Birth Consulting.

    PND More Prevalent In Mothers Of Multiple Births

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

    Link to article

    Mothers of multiple births have a 43 percent increased odds of having moderate to severe postnatal depression symptoms nine months after giving birth compared to mothers of single-born children, according to new research. 19 percent of mothers of multiple births had moderate to severe depressive symptoms nine months after delivery, compared to 16 percent among mothers of singleton pregnancies. Women who had a history of hospitalisation due to mental health problems or a history of alcohol or drug abuse also had significantly increased odds.

    The question needs to be asked – does a multiple birth cause PND, is it about the social support offered to women who are at home with twins or triplets, or is it about the way the birth is managed?

    It is well-known that a lot of PND is mis-diagnosed, and that these women are really experiencing birth trauma - a normal reaction to abnormal events and situations that have been beyong the woman’s control. Perhaps it is a combination of factors. Either way, the study does lead to the notion that women who are having multiple births need more support before, during and after birth. I would be interested to know if the woman in the study received continuity of midwifery care, which is known to positively impact a woman’s experience of birth and new motherhood.

    Melissa Maimann, Essential Birth Consulting.

    Birth Trauma

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

    Visit my website to learn more about my services.

    October 13, 2008

    birth traumabirth trauma

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

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

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

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

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

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

    • Nightmares of the birth

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

    • Numbed emotions

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

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

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

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

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

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

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

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

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

    Read books or articles on birth trauma.

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

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

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

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

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

    Visit my website to learn more about my services.

    Home deliveries

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

    Link to article

    John Elder
    March 22, 2009

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Melissa Maimann, Essential Birth Consulting.

    Memory of Labor Pain Influenced by a Woman’s Childbirth Experience

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

    By Megan Rauscher
    NEW YORK (Reuters Health) Mar 11 – Research shows that for about half of women who give birth, memories of the intensity of labor pain decline over time. However, for some women, their recollection of pain does not seem to diminish and for a minority, their memory of pain increases with time.

    The study also shows that the memory of childbirth pain is influenced by a woman’s overall satisfaction with her labor experience.
    ….
    Women who reported labor as a positive experience 2 months after childbirth had the lowest pain scores, and their memory of the intensity of pain had declined by 1 year and 5 years after giving birth.
    “Memory of labor pain declined during the observation period but not in women with a negative overall experience of childbirth,” the team notes in the March issue of BJOG ….

    Roughly 60% of women reported positive experiences and less than 10% had negative experiences. For women who said that their childbirth experience was negative or very negative, on average, their assessment of labor pain did not change after 5 years.

    “A woman’s long-term memory of pain is associated with her satisfaction with childbirth overall,” Dr. Waldenstrm said, summing up. “The more positive the experience, the more women forget how painful labour was …”

    The researchers also found that women who had epidural analgesia remembered pain as more intense than women who did not have an epidural …

    - I was not surprised to read that women who have epidurals rate their labour as more painful. Generally, those women may have had an expectation of having pain relief, or of having a pain-free birth. Hence, any pain would have been experienced negatively, and perhaps also they would not have had good birth preparation. I find that women who are well-prepared for labour and birth, have positive experiences and rate their satisfaction with labour very highly.

    It is well-known that continuity of care from a known midwife is key to a positive labour experience.

    Melissa Maimann, Essential Birth Consulting.

    Quality of Life After Normal Birth and Caesarean.

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

    Comparing the quality of life in women after normal delivery and cesarean section.

    A study suggests that vaginal delivery might lead to a better postnatal quality of life than cesarean delivery, especially with regards to physical health. Significant differences were found for vitality, mental health and physical functioning … The findings indicate that in the short term, vaginal delivery might be preventive of postnatal depression.

    I’m not surprised by these findings. Caesarean is major surgery; having a major operation and then having to care for a new baby must be a very stressful experience. Other research has shoen that operative births are more likely to leave a woman traumatised following her birth. Continuity of midwifery care is known to reduce the need for caesarean.

    Melissa Maimann, Essential Birth Consulting.