Caesarean

… “Usually I start off by telling people my C-section started even before I got to the hospital …

… Sharp Mary Birch Hospital for Women and Newborns had the highest rate of cesarean section deliveries in San Diego County in 2009. The California average was 29.8 per 100 births; at Sharp Mary Birch, the rate was 37.7.

… At 40 weeks … Cooper-Schultz’s water broke, though she was not in labor. In a birthing class … they told her, we have to get the baby out within 24 hours. So she and her husband went to the hospital right away.

“They pretty much wanted to put me on Pitocin the minute I walked in the door because I wasn’t having regular contractions,” …

… women believe their C-section deliveries at Mary Birch were the result of convenience for the doctors, fear of litigation, and/or lack of staff training in nonmedicated childbirth options.

… It is common for hospitals to use Pitocin if a woman has not gone into active labor within 24 hours after her water has broken to avoid the risk of infection. But the staff at Mary Birch wanted to give Cooper-Schultz Pitocin within the first two hours.

Cooper-Schultz refused the Pitocin at first. She wanted to get things going naturally … At the 12-hour mark, her cervix had dilated to four centimeters. She says she now understands that this “is a good natural labor progression for a first-time mom.”

But it wasn’t fast enough for the staff at Mary Birch. Cooper-Schultz … allowed them to give her the Pitocin that she says they’d been pushing since she’d arrived.

… “They weren’t honest with me. They didn’t say, ‘If you get the Pitocin, you’re probably going to need an epidural.’”

… Cooper-Schultz withstood the pain of Pitocin contractions for eight hours before she finally gave in and got an epidural … The epidural worked on only her left half.

At one point, the doctor came in to check on her and alerted the nurses that she was going home to take her kids to school. Sometime later, she returned with wet hair, checked Cooper-Schultz, found her at nine centimeters, and told her to try pushing.

“I pushed, and [the baby’s] heart rate went down … she said she’s worried about it. She said, ‘He’s not in distress, but he’s a little bit stressed.’”

The doctor told Cooper-Schultz it would go one of three ways. In the first scenario, Cooper-Schultz would push for 20 or so minutes and the baby would come out. In the second, she could push for 20 or so minutes, the baby would not come out, and they’d have to do an emergency cesarean section. Or, the doctor said, they could do a cesarean section right now.

Cooper-Schultz chose the cesarean. …
∗ ∗ ∗

Helen … welcomes me into her North Park apartment shortly after the dinner hour on a Tuesday evening in mid-September. She tells me she’s an unlikely candidate for natural childbirth.

“I’m like Woody Allen,” she says. “I am a New Yorker who likes living in the city, who likes creature comforts. And for somebody like me to be embracing [natural childbirth] is humongous.”

… Dover’s story is similar to Cooper-Schultz’s in that it begins with a desire to give birth naturally … and ends in what she considers an unnecessary C-section. One difference is that when Dover started out, she did know she might have to fight for what she wanted … She stayed home and labored for 10 to 12 hours before she went to the hospital, avoiding “the clock” for as long as she could.

When she arrived, armed with her research and her hopes for a natural birth, she found that the environment at Mary Birch had a greater impact on her than she’d imagined it would.

… The progression she’d experienced at home, from two centimeters to four, slowed drastically when she arrived at the hospital. A doctor told her that it might help if he broke her water. So she allowed it. But nothing happened …

… Dover lists her regrets: Not waiting and laboring longer at home. Allowing the Pitocin at 12 hours. Giving in to the epidural after 8 more hours. But the regrets go as far back as her pregnancy, when she chose to stay with Sharp.

“I should’ve just switched … “In order for me to switch to Scripps and go to one of the birth rooms at Scripps, which has a much better record, would have meant changing everything: changing my primary care physician, changing my OBG. I would’ve had to totally change my insurance policy. And at the time, I already had a pediatrician picked out for her and everything. We’d interviewed, and just the idea of doing all of that was overwhelming. I thought I didn’t have the strength to do it.”

… “[The doctor] said, ‘You need a C-section,’” she says. “I said, ‘I don’t understand why I need a C-section. Everything seems to be fine. Her heart rate’s not dropping.’ And he said, ‘Well, she’s stuck.’”

“… I was totally against using the suction, but anything besides the total hands-off. He said, ‘I don’t want to hurt your baby, and you don’t want to hurt your baby.’ I started crying. And I just finally said, ‘Fine. Cut me open.’” …

∗ ∗ ∗

The obstetrician a woman chooses plays as large a role in her birth experience as the place she chooses to deliver her baby. Some doctors have a reputation for being more inclined to help with a natural birth, and others for being less inclined …

Thompson cites the “bait and switch,” where a doctor claims to support a woman’s birth choices up until the final weeks, when it’s too late to change doctors. Messer says she’s seen doctors who’ve initially said they’d support the hypnobirthing process but later changed their minds.

“All of a sudden it’s, ‘That’s not going to work. No, you can’t be on your hands and knees. That’s not safe, and this isn’t,’” Messer says. “And that’s at 40 weeks. So now, where can I switch?”

… Christine Stewart, a petite redhead and mother of twin girls born at Mary Birch in September 2009, says she experienced something similar with her doctor.

… “… we took a Bradley Method childbirth class,” Stewart says, “which is a 12-week class, pretty in-depth, and we decided we wanted to do natural, unmedicated labor.”

When she first mentioned this to her doctor, Stewart says the doctor told her to “keep an open mind” and not to “fixate on any particular way of labor and delivery.” At the time, Stewart thought the doctor didn’t want her to be disappointed if natural birth didn’t work out, but now she speculates that the doctor was always leaning toward a C-section.

At 36 weeks, the doctor suggested they induce her at 38 weeks. Stewart refused.

“From what I can tell,” she says, “it’s just common that it’s more manageable to have twins at 38 weeks because of size. Sometimes they’re concerned about size. But [my girls] were normal-sized.”

The doctor suggested 39 weeks, then 40. Finally, Stewart agreed to induce at 41 weeks if she hadn’t gone into labor by then. But it was unnecessary. At 40 weeks, three days short of her original due date, Stewart went into labor.

Stewart chose Mary Birch because it had everything she was looking for. Originally, she’d wanted to deliver at Best Start Birth Center in Hillcrest, but they don’t accept women who are pregnant with twins. Mary Birch, she says, seemed like the next best thing.

“It had the facilities, doctors on hand, and all these different classes — prenatal yoga — and since I was diagnosed high-risk because I had the twins and since I was over 35,” she says, “I just thought their whole entire focus is for women and newborns, so I’ll probably get the best care because they’ve got all the resources for that.”

Stewart had heard about other women going into the hospital prematurely and getting “strapped down” immediately. But in her natural childbirth class she’d learned that mobility helps with labor. So she and her husband didn’t go in right away.

Once they did arrive at the hospital, Stewart was four centimeters dilated. She gave the nursing staff her birth plan, which stated that she did not want any mention of pain medication.

“Thankfully, they did not offer medication. They were respectful of that … I was slowly dilating in a normal time frame. They were telling me that was normal …

… Christine Stewart believes that the main reason she ended up having a C-section was that her nurses had no training in natural childbirth.

“Ultimately, the outcome was because there was no one in the labor room who had the experience to help get the babies in position to be delivered,” she says.

By the time the doctor arrived, Stewart was fully dilated. She knew her babies were healthy, that they were both head down, in a good position, face forward. Her blood pressure was not elevated, she had no fever, and she’d been in labor for less than 24 hours. Everything was normal except that the babies were wedged in, each trying to get out first.

… At 2:00 a.m., the doctor came in and said, “It’s time to meet your girls.”

… I kind of resigned myself, like, ‘If this is what we have to do, this is what we have to do.’ I felt like crying because it just went against everything I had hoped for, everything I had planned and practiced for.”

“I think the hospital has some standard protocols, and I think that if you don’t follow their standard protocols, they just don’t know what to do with you,” she says. “And a C-section is manageable. They know exactly how to do it, and I think at 2:30 in the morning it’s, ‘We can manage this, and then we can all go home.’”

∗ ∗ ∗

Last March, when her first son was two and a half years old, Elizabeth Cooper-Schultz had her second child in the back bedroom of her UTC apartment, in the company of her husband, her midwife, two apprentice midwives, and a doula.

Today, Helen Dover is pregnant again. When I ask if she plans to give birth at Mary Birch, she and Henry simultaneously answer, “No.”

“What I’ve learned is that at Mary Birch, everybody’s going to try to get you to do the birth that they want you to do,” Dover explains.

For their next baby, the Dovers will stay with Sharp in order to take advantage of the tests, which would cost them thousands of dollars out-of-pocket. They will also register at Mary Birch so that they are prepared in the event of an emergency. But they have hired a midwife to help them birth at home.

“We’re going just to get what doctors are good for,” Henry says, “and then to use the midwives for what they’re good for.”….

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Labour induction methods compare favourably

Jan 22nd, 2012

… a method of inducing labour that dates back to the 1930s “has been found to work as well as modern treatments but with fewer side effects”.

The news is based on a large Dutch trial that examined inducing labour using of a simple mechanical device, called a Foley catheter. Researchers tested the device against the use of hormone gels designed to trigger contractions. The study … found that both techniques led to similar rates of spontaneous vaginal deliveries, instrumental deliveries … and women requiring a caesarean section.

The Foley catheter also seemed to lead to fewer side effects in the women and their babies, although using the method of induction … led to longer labours …

Current guidelines from the National Institute for Health and Clinical Excellence (NICE) recommend the use of hormone gels for induction of labour, but not the routine use of mechanical devices for induction … This new, relatively large trial has shown no important differences between the two methods used in these women. It is possible that the mechanical technique might find a place for women where there may be risks from using hormone gel …

… a high proportion of induced labours are performed because a woman’s cervix is not ready for the birth and does not open appropriately.

This randomised controlled trial compared two methods for inducing birth in women who had single babies and a reason to be induced. The women were either induced using mechanical means (a Foley catheter) or with application of a hormone gel into the vagina. A Foley catheter is a mechanical device that helps open the cervix. A fluid-filled balloon is inflated in the cervix, which stretches it until it is at an appropriate size to allow birth. The prostaglandin hormone gel mimics the natural mechanism by which a woman’s hormones cause the cervix to open.

The researchers say that hormonal induction has become the method of choice in several countries, but that use of the Foley catheter may result in similar numbers of successful inductions without the need for a caesarean section. They also say that the Foley catheter induction may have several advantages over hormone methods, such as not causing “over-stimulation” of the birthing processes …

… the caesarean section rates were much the same between the two groups: 23% of women who had been induced using a Foley catheter required a caesarean section compared to 20% of the women induced using the hormone gel … Likewise, a similar number of women in each group needed extra mechanical help with the birth, such as the use of forceps (11% in the Foley catheter group and 13% in the hormone gel group).

A greater number of women induced with the Foley catheter required a caesarean because they failed to progress in the first stage of birth (12%) than the hormone gel group (8%) … Similar proportions of each group had a caesarean section because their baby was becoming distressed (7% in the Foley catheter group compared to 9% in the hormone gel group).

… Fewer women in the prostaglandin hormone group (59%) needed an additional hormone called oxytocin to stimulate uterus contractions than in the Foley catheter group (86%). The time from the start of induction to birth was on average 29 hours (range 15-35 hours) in the Foley catheter group and 18 hours (range 12-33 hours) in the hormone gel group.

The groups did not differ in terms of painkillers taken, haemorrhage, overstimulation or health status of the baby. Fewer babies delivered with the Foley catheter (12%) needed to be admitted to the general ward (not an intensive care ward) than those induced using hormones (20%). More women treated with the hormone gel (3%) had suspected infections during birth compared to those induced with Foley catheter (1%) …

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Doctors driving the increase in caesareans

Jan 19th, 2012

THE popular belief that caesareans are on the rise because women are too posh to push is incorrect, a new study shows.

University of Queensland researchers surveyed 22,000 Queensland mums …

… 48 per cent of women in private hospitals who had a caesarean did so on the recommendation of their [obstetrician].

Just under 40 per cent of women in public hospitals said the same.

… only 10 per cent said they had wanted to have their baby born that way.

“… the majority of women would prefer to have a vaginal birth,” …

“The increase in caesareans seems to be largely driven by the recommendations of doctors.”

… some women are going into the procedure underprepared.

Only 52 per cent of women … reported making an informed decision to have a planned caesarean …

Interesting research that backs up what midwives have known for a long time: the main driver for increased caesarean rates is not the mother’s choice to deliver by caesarean, but rather the recommendation of her obstetrician, who in most cases will be recommending a caesarean for non-essential reasons. I say this with confidence because upwards of 45% women do not “need” to deliver by caesarean for the sake of their babies or themselves. No-one could be justified in believing that caesarean rates this high are necessary in the majority of women who experience a healthy pregnancy. Private midwifery caesarean rates are well under 10%, with many private midwives having caesarean rates of around 5%.

The lesson is that a woman’s choice of care provider has the greatest impact on her mode of birth.

It is more important that her health issues, her choices and preferences for care, her previous birth experiences and her geographical location.

A woman’s choice of care provider will literally determine whether she undergoes a (possible unnecessary) caesarean or a natural birth. Late pregnancy and labour are not the times to be asking your care provider if their recommendations (for induction or caesarean) are truly necessary: women are simply too vulnerable in that state to make informed decision, and besides, informed decisions take take to research to come to an “informed” decision. When time is of the essence – in late pregnancy and labour – informed decision making almost goes out the window. Ultimately, the best strategy is to interview your potential care providers and peruse their statistics on birth. They say they support natural birth … but what are their stats on natural birth? What % of their patients have a caesarean, induction, epidural? If your care provider is vague and non-committal, that should speak volumes. If their rates are high and you are aiming for a low-intervention birth, it is not too late to identify this and seek a care provider whose philosophy – and outcomes – are more aligned to what you are hoping to achieve.

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Scheduled C-Sections: Interfering with Nature?

Jan 17th, 2012

… I had really easy pregnancies … By the end of each pregnancy, I was ready to do just about anything to get those babies out of me, but I never wanted a C-section … I never even read the C-section chapters in all my pregnancy books. Why would I? I always knew I wanted to deliver my babies naturally, as in no drugs or medical interventions at all.

I went to my OB for a regular checkup on my due date for my first baby and was told that I was measuring small and needed an ultrasound. I felt fine, no contractions, cramping or anything at all, really. Baby was moving around and I felt fine. Back in the doctor’s office I was told that my amniotic fluid was a little low and they were going to “get me delivered today.” Huh? Um, ok. I guess we’re having a baby today! Yay!

I was hooked up to monitors and Pitocin and within 5 minutes … doctors and nurses descended on me … It took them 11 minutes to find [the heartbeat] … they were prepping me for a C-section. I was terrified. Why did I need a C-section? They said they thought my baby wouldn’t tolerate labor. What does that mean?

I was taken to a surgical suite, strapped to a table, IVs in each arm, numbed from the chest down, catheterized, bright lights in my eyes, a curtain hung between my face and my belly. My husband was brought in just before they made the incision. No pain. No sensation at all. Then the “tugging” of my body being stretched apart and a tiny, perfect, healthy baby being pulled out. I couldn’t see her being born with the curtain between me and the doctors and I couldn’t see her when they took her across the room so the pediatricians could check her over. Once she was delivered, I was given “something to relax me” that nearly knocked me out. They brought my swaddled daughter over to me and placed her on my chest, but I couldn’t touch her since my arms were strapped to the table. Then they took her off to the nursery. The doctors chatted with each other about their upcoming travel plans whilst they sewed and taped me back together. Then I was bandaged, dressed and taken to recovery.

About an hour later, they brought my baby to me, but I couldn’t sit up and I was shaking so violently from the drugs that I was afraid I would drop her if I tried to hold her. I managed to nurse her throughout the night … My baby was healthy and perfect but I felt like I had surgery and someone gave me a baby. Not like I had given birth. I expected birth to be difficult and intense and sweaty and painful and amazing, but instead it was cold and surgical and terrifying and left me feeling completely disconnected from how my child came into the world.

Two years later, I was pregnant again. I called my OB (who was on maternity leave herself) and she told me there was no reason I couldn’t have a natural birth. That was all I needed to hear. I found a midwife and learned everything I could about giving birth after a C-section. I learned that each medical intervention can lead to the need for more and as long as the baby is not in distress, labor should proceed on its own … After 25 hours of unmedicated labor, attended by my husband … and the midwife, I gave birth to another perfect, healthy baby girl. Two years later, I did it again. That time it only took two hours to deliver a 9lb baby boy.

… Speaking from experience, a C-section is much more difficult than a natural birth. After I delivered my second and third babies, I felt completely fine. Better than ever, actually. After the C-section, I couldn’t hold my baby, couldn’t sit up or go to the bathroom without assistance, and I couldn’t laugh or sneeze without feeling like all my insides would burst out of my incision. In some cases, a C-section can be a lifesaving procedure, but it is in no way an easy alternative to giving birth.

Tasha Schlake Festel
I can definitely understand the appeal of a scheduled C-section. We’re all busy, juggling jobs, other kids, and countless glamorous social obligations, so penciling in “have the baby” at a time convenient for all totally makes sense. In fact, it is one of the only things you, as a mother of a newborn, will be able to control for the next 25 years.

But there’s no way I’d do it. I’ll have my babies the old fashioned way. Well, the old fashioned way plus drugs, that is.

… While a C-section is a fine and respectable choice, I was adamant about not wanting to have my children surgically removed from my body … the history of mammalian life on earth has proven that mother’s bodies are built to birth babies without surgical intervention … Third of all, with everything else so planned and premeditated, it’s kind of romantic to have that one thing – the most important thing in the world, the birth of your child – to be unexpected.

I had the vision of waking up in the middle of the night, rolling over to my husband, nudging him gently and saying, “Honey, it’s time.” And then we’d hug, giggle, and bolt out of bed, grabbing our pre-packed and coordinated suitcases. My husband would fumble with the keys, act all cute and nervous, and run out to start the car. He’d drive off without me, only to turn around immediately, usher me in to the car and oh, how we’d laugh!

Shockingly, it didn’t work out like that – or anything close to it … I was induced … with both of my pregnancies … due to relatively minor complications …

Pitocin’s best friend is named Epidural. With my daughter, I tried just hanging out with Pitocin, but found it to be a violent companion. Epidural was a lovely counter. After overcoming my “irrational” fear of having a needle stuck into my spine to numb the bottom half of my body, I thoroughly enjoyed the experience of childbirth. Several hours of painless contractions and 12 minutes of physical labor later, my daughter arrived and all was well.

Fast forward two years and five days, and I found myself hanging out with Pitocin and Epidural again. This time, I expected Pitocin to be a moody bitch, so I opted that we not hang out alone. The thing is, drugs or not, at the end of the experience you get a baby. You don’t get extra credit for doing it without pain medication. There is no trophy, no reward, no prize. It’s a baby. And you can either be exhausted from pain and effort, or just be exhausted from effort. I went with Option B.

Or at least I meant to. Here is some important advice. Do not let your labor and delivery nurse tell you that what you are feeling is “pressure” when you know damn well that it is pain. Stick to your guns. Demand more medication. Having round 2 of the pain killer kick in just in time for the delivery of the placenta is a few minutes too late, no matter how “good looking” your doctor tells you said placenta is. Of course, pain is a great motivator, so after two hearty pushes, unwavering determination and ample swearing, I was happy to hold my little boy.

I found out the hard way that I am not really “made” for a second dose of pain killer, as did the other new parents who were admiring their newborns when I threw up all over myself and the carpet in front of the nursery window … Oops! But thankfully, I didn’t feel the delivery of that placenta. That would have sucked.

The point of pregnancy is to have a baby when you’re done with it. However that happens is a personal choice. I can’t imagine ever choosing to schedule surgery to accomplish this goal, but I don’t judge those who do. It’s a decision that should be made thoughtfully with your partner and your OB. Realize that your best-laid plans will likely not be followed, but get used to it. That’s life as a mom.

Holly DeSouza
As much as I love being a mom, I hated being pregnant.

… I had a difficult pregnancy filled with first and third trimester bed rest, frequent fainting spells, constant morning sickness, two episodes of the flu (!!!), three threatened miscarriages, and weekly trips to MGH and Melrose Wakefield Hospital due to some freak occurrence where I could not feel the baby moving and could only see her when she was really kicking me. The silver lining to all of the hospital trips was my husband and I knew really early on the sex of our baby.

At 20 weeks, I felt I already endured enough and wanted an end date where I was guaranteed I would meet my daughter. I asked to schedule a C-section. When I was denied, I started begging and whining and pleading my case of hardship. My ob-gyn was steadfast and would not schedule a C-section. I tried every trick any formerly pregnant woman gave me so I could have the “luxury” of a C-section. My ob-gyn kept telling me to hang in there and, if I carried full term, we could discuss it …

At the end of the day, turns out my doctor was not a dummy after all in not agreeing to an elective C-section for me. What women without a gaggle of nannies tend to discount is how busy you will be after the baby comes, how much longer the recovery time generally is after a C-section, and how greatly your priorities will shift once the baby is out of the womb. If you do not need a C-section for medical reasons, there should not be an option to have a C-section. I never looked ahead myself at both sides of the coin. All I wanted was a promise I could have a pain-free delivery. Picking her birth date was an added bonus. After a difficult pregnancy with a lot of down time, I am so thankful I did not have an elective C-section because I was up and running and enjoying my daughter as soon as she was delivered to my world.

Laurie Hunt
Well, if I truly had my way I would request the stork bring my children. Especially the first one …

It happened too quickly … and the epidural did not work. You have not lived until you have experienced back labor without drugs. Trust me. The second time was a much better experience because I literally ran to the hospital at the first hint I might be in labor and asked them to meet me in the parking lot with the epidural. The drugs worked this second time around and while labor took longer it was a much better experience.

…

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First-time mums learn the hard way: informed mums choose private midwives

Jan 15th, 2012

A recent article has suggested that first-time mums have overly unrealistic ideas about their birth – that it will be a natural, uncomplicated birth, when in reality it is not, for the majority. We know that women choosing care through the general hospital system will experience high rates of interventions, leading ultimately to a caesarean. But few women know that if they engage a private midwife for a hospital or homebirth, they will experience much lower rates of intervention, but with the same level of safety. Care with an eligible private midwife will attract medicare benefits, and obstetric care is readily available if it is needed. The article below described one woman’s experience of general hospital care. I can only assume that this reporter has written the article in response to the outcry about the original research.

HERVEY Bay first-time mum Jasmine Adame has experienced first-hand just how difficult childbirth can be.

And she agrees with new research … that suggests that many first-time mums are unprepared for the realities of a complicated labour.

Jasmine delivered her little girl … at Hervey Bay Hospital after spending a day and a half in labour.

In the end, she was told her labour had stalled and she had to have an emergency caesarean.

We are not told how long labour stalled for, whether she had her own midwife with her throughout her labour (unlikely since this is not available to most women through the general hospital system) and we are also not told how far through her labour she was. It is true that some caesareans are performed for “failure to progress” when the woman’s cervix is less than 3 centimeters dilated, indicating that she is not yet in established labour.

Jasmine had attended antenatal classes prior to having her first child and said it was the midwives who held these classes who gave her the best idea of what labour was actually going to be like.

Hospital classes are great at telling women about hospital policies, but independent childbirth education will inspire women with confidence about what their bodies are capable of, with the right support.

“I knew it wasn’t going to be fun.

“But I didn’t expect it to be as horrid as it was,” she said.

It sounds like she didn’t have the care of a midwife who was known and trusted. Most women I work with will experience their labour extremely positively, as if it was the best (hardest and most challenging, but oh so rewarding) experience of their life.

… The chances of having a medically uncomplicated birth were actually 21%.

This applies to women birthing in the general hospital system, where they will not be cared for by one midwife who is known to them, chosen by them and trusted by them. The chance of a medically uncomplicated birth when a woman chooses private midwifery care is around 70% – 80%. This is a huge difference.

Because she had been focused on a natural delivery, the decision to deliver the baby by caesarean took Jasmine by surprise – and the time between the decision and the birth was very swift, allowing her little time to adjust …

This is addressed during care with a private midwife, where there is ample time to explore all options and possibilities, so that there are few surprises on the day (or night!). Hour-long appointments allow plenty of time for questions and education. The possibility of a first-time mum “needing” a caesarean in the general hospital system is 25%, or one in four. Given this large minority, we would think that all women going through the hospital system would be thoroughly appraised of this possibility. In my private practice, a mere 3% first-time mums need a caesarean. This is not because we push the boundaries of safety: it is because women who are well supported, well-informed, relaxed and confident about their birth will generally start labour on their own at term, labour normally and birth their babies unassisted by any instruments or operations.

Hopefully Jasmine will choose private midwifery care with her next pregnancy (private midwifery care is available for a planned hospital birth), where she can expect an 80% – 90% chance of a vaginal birth following her caesarean in her first pregnancy. Or will she choose to go back to the general hospital system, where she has a mere 15% chance of a vaginal birth?

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Delivering better maternity care

Jan 8th, 2012

Despite countless inquiries, initiatives and ministerial pledges … maternity care remains one of the NHS’s problem areas …

In recent weeks there have been two significant pieces of evidence published that will help shape practice affecting the UK’s 800,000 births a year. The National Institute for Health and Clinical Excellence (NICE) produced new guidelines for the NHS in England and Wales on the circumstances in which mothers-to-be should be able to have a Caesarean-section delivery.

Meanwhile the landmark Birthplace study … sought to clarify the relative risks of having a baby at home, in hospital or in a birth centre run by midwives; the study found all settings carried a low level of risk. Both documents aim to advise maternity teams on how to give mothers and their babies the best possible experience.

… It is no wonder maternity services are under pressure … England has had a 22% increase in births over the past decade …

But the maternity workforce is not just short of midwives, the roundtable heard. Of those 800,000 annual births, 94% of them take place in hospitals where doctors are present along with midwives; the others, at home (2%) and in birth centres (4%), have midwives solely in charge. But the Royal College of Obstetricians and Gynaecologists (RCOG) believes the 2,186 senior doctors working as consultants in that area of medicine is too few. It wants the NHS to boost numbers to 3,000-3,300.

Mothers-to-be would benefit because every hospital maternity unit would have a consultant on hand 24/7 and less experienced doctors would no longer be in charge overnight and at weekends …

… “the current system of maternity care is unsustainable. You have to reconfigure”. The participant meant that some maternity units should be closed – merged, in effect – so fewer, larger childbirth centres could offer mothers a better service, partly thanks to more specialist staff handling a greater number of deliveries concentrated in the same place.

It makes little sense for large urban areas to have separate maternity units just a few miles apart, a view confirmed for the speaker by seeing that sort of setup on a recent visit to Leeds and nearby towns.

Many health professionals support the concept of reorganisation. And the reconfiguration of neonatal care services in 2003, which led to fewer units dealing with sick babies but offering enhanced care, is a potential model to follow, another participant added. But there is a major obstacle to overcome first: … To close your core maternity service is a death trap as an MP. So that will not happen,” …

… simply creating fewer, but larger, hospital units is not the answer and there needs to be more midwife-led birth centres, either standalone units or situated beside hospitals, in case a mother needs urgent medical attention …

There was also a strong consensus that the huge proportion of births occurring in hospitals, 94%, is too high. While there was support for moving towards an equal split – 33% at home, 33% in birth centres and 33% in hospital – there was also a recognition that politics, entrenched attitudes and the tightest NHS budget in a generation means that will probably remain just an aspiration for the foreseeable future.

… In 2007, Maternity Matters promised women in England a choice of birth place, but the reality is that many still do not get that. One participant working on the NHS frontline said pressure on maternity services was so great in some places that midwives who usually help women to have home births are having to work, instead, on labour wards, thus depriving those seeking a home birth of that supposedly guaranteed right.

Similarly, surveys by the Healthcare Commission and its successor as the NHS regulator for England, the Care Quality Commission, have shown the promise to women of one-to-one care from a midwife during their labour is also not honoured for as many as a quarter of mothers-to-be, who are left alone and find it stressful …

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Myths and Truths of Obesity and Pregnancy

Jan 4th, 2012

Ironically, despite excessive caloric intake, many obese women are deficient in vitamins vital to a healthy pregnancy …

… Many obese women are vitamin deficient …

Forty percent are deficient in iron, 24 percent in folic acid and 4 percent in B12. This is a concern because certain vitamins, like folic acid, are very important before conception, lowering the risk of cardiac problems and spinal defects in newborns. Other vitamins, such as calcium and iron, are needed throughout pregnancy to help babies grow.

… vitamin deficiency has to do with the quality of the diet, not the quantity. Obese women tend to stray away from fortified cereals, fruits and vegetables, and eat more processed foods that are high in calories but low in nutritional value.

“Just like everybody else, women considering pregnancy or currently pregnant should get a healthy mix of fruits and vegetables, lean proteins and good quality carbohydrates. Unfortunately, these are not the foods people lean towards when they overeat,” noted Thornburg. “Women also need to be sure they are taking vitamins containing folic acid before and during pregnancy.”

… In 2009, the Institute of Medicine revised its recommendations for gestational weight gain for obese women from “at least 15 pounds” to “11-20 pounds.” According to past research, obese women with excessive weight gain during pregnancy have a very high risk of complications, including indicated preterm birth, cesarean delivery, failed labor induction, large-for-gestational-age infants and infants with low blood sugar.

If a woman starts her pregnancy overweight or obese, not gaining a lot of weight can actually improve the likelihood of a healthy pregnancy …

… Obese women have increased rates of respiratory complications, and up to 30 percent experience an exacerbation of their asthma during pregnancy, a risk almost one-and-a-half times more than non-obese women.

… Breastfeeding rates are poor among obese women, with only 80 percent initiating and less than 50 percent continuing beyond six months, even though it is associated with less postpartum weight retention and should be encouraged as it benefits the health of mom and baby.

… it can be challenging for obese women to breast feed. It often takes longer for their milk to come in and they can have lower production …

Preconception care and a healthy eating and exercise program before pregnancy, that is maintained during pregnancy, can be helpful.

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Infection after Caesarean killed mum, inquest told

Dec 22nd, 2011

A young mother died from heart failure brought on by an infection after an emergency Caesarean section, an inquest has been told.

While a post-mortem found 34-year-old Terri-Louise Moore died as a result of a clot on her lung, a doctor caring for the Ballymena woman said he believed an infection was the cause of death.

Mrs Moore … was 33 weeks pregnant when admitted to Antrim Area Hospital …

She underwent an emergency Caesarean section and a healthy baby girl was born, but Mrs Moore’s condition deteriorated after the birth and she was given antibiotics for an infection.

… doctors discovered Mrs Moore had a clot on her right ovary — an extremely rare complication — on December 7.

… Doctors began to treat Mrs Moore with a clot busting drug but she … failed to respond to treatment.

… Dr Lee attributed her death to “a prolonged sepsis” which “caused myocardial suppression” …

Caesareans are helpful and life-saving procedures in some cases, but there are some risks – some rare, and some more common. When limited to genuine need, we can help make caesareans safer.

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Inducing labor doesn’t raise risk of uterine rupture in VBAC

Dec 20th, 2011

Inducing labor doesn’t increase the risk of uterine rupture, once length of labor is taken into account, in women attempting vaginal delivery after a cesarean delivery …

… After accounting for length of labor using a time-to-event analysis, researchers found that the risk of uterine rupture with induced labor was similar to that of spontaneous labor … Women with an initial unfavorable cervical exam (<4 cm dilation) had a higher risk of uterine rupture with induced labor than spontaneous labor ... and those with cervical dilation <2 cm and 2 cm-3.9 cm on the initial exam were at greatest risk.

Women who undergo induced labor may spend more time in active labor than those with spontaneous labor ...

Interesting research, as common understanding has it that induction is never a wise choice in a VBAC, and many women who need an induction who have previously had a caesarean are advised to undergo a repeat caesarean. If induction can be safely carried out, this would help to reduce our high caesarean rates.

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Unneeded cesareans are risky and expensive

Dec 9th, 2011

Cesarean deliveries are over-used … and reducing the number of surgical births would save health-care dollars and protect women’s health. Those are the conclusions of a new white paper issued today by the California Maternal Quality Care Collaborative.

… in the last 15 years, the rate of surgical birth has increased from 22 to 32 percent of California deliveries with no measurable benefits for new mothers or their babies.

This is a concern because cesareans aren’t risk-free. After surgical delivery, women experience more pain, infection and hemorrhage than women who give birth vaginally. Women who have had a prior cesarean also have more problems with subsequent pregnancies. The placenta can become deeply implanted in scar tissue from the old incision, causing hemorrhage at the second delivery …

The white paper, which was funded by the California HealthCare Foundation, uncovered striking evidence for over-use of cesarean: Among low-risk women having their first baby, the rate of the surgery varies from nine percent to 51 percent of births based on the mother’s geographic location within California. As a press release about the paper says:

This large variation among California regions and hospitals cannot be explained by medical factors alone and therefore suggests that labor management practices and local attitudes help drive the use of cesareans during labor.

Reasons for the increase also include: physicians’ concerns about medical liability and avoidance of risk, as well as specific labor practices such as the increased reliance on labor induction, early labor admission, lack of patience in labor, and the virtual disappearance of vaginal birth after a prior cesarean …

“Over the last 15 years, cesarean deliveries have become so common that in some hospitals and communities they are considered ‘normal births’ despite the increased risks,” …

The white paper makes several recommendations for how to reduce unnecessary cesareans, including removing perverse financial incentives … encouraging VBACs … improving public education about the risks of cesarean delivery, and implementing statewide quality-improvement activities for better labor practices.

Unfortunately, there is no mention of the role of the midwife in preventing the first caesarean, or in helping a VBAC woman have a successful VBAC.

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NICE caesarean guidelines

Dec 7th, 2011

The National Institute for Clinical Excellence in the UK has released new guidelines that give women the right to request a caesarean under their public health care system, the NHS. These new guidelines have been quite controversial.

LIVERPOOL’S top midwife last night welcomed new guidance to give pregnant women the choice of having a Caesarean.

The National Institute for Clinical Excellence (NICE) said the option should be given to women who are genuinely fearful of childbirth or have had difficult births previously.

But the authority said it was not recommending offering the procedure for all mothers-to-be.

… “If a woman has had a really traumatic time with a previous birth and cannot face the risk of a similar experience, we would agree to her opting for an elective Caesarean.

“Also, we work with women who actually suffer from what is a recognised phobia around childbirth.

… Some pregnant women say they have had to fight to get a Caesarean on the NHS when they feel they have a genuine reason to justify one. It is hoped the guidelines will prevent this and make the situation across England fairer.

NICE says the number of Caesareans could actually decrease, because of counselling measures brought in to explain the risks and also the likelihood of a natural birth being safe.

… “If a woman just said it was what she wanted for no good reason, we would spend some time with her and support her to make the right decision. “The recovery from a natural birth is much quicker.

… Very, very few women opt for a Caesarean unless they need one for themselves or to safeguard the baby.”

… “This guideline is not about offering free Caesareans for all on the NHS; it is about ensuring that women give birth in the way that is most appropriate for them and their babies.

“For a very small number of women, their anxiety about childbirth will lead them to ask for a CS.

“The new recommendations in this guideline mean that these fears will be taken seriously and women will be offered mental health support if they need it.

“If the woman’s anxiety is not allayed by this support, then she should be offered a planned CS.”…

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Simulator to predict chance of caesarean?

Dec 4th, 2011

Traditionally, doctors and midwives have used a technique called pelvimetry to measure the pelvis and try to determine its adequacy for giving birth. But pelvic size is just one factor in how smoothly labor will go, rendering the method largely insufficient.

Scientists in France have been working to take some of the guesswork out of labor predictions … their newly developed software, called Predibirth, predicts birth outcomes quite accurately.

The researchers used their software to process magnetic resonance images of 24 pregnant women, capturing the pelvis and fetus, and then simulating 72 possible trajectories the baby’s head might take through the birth canal. The program then uses this data to score the mother’s chances of having a normal (vaginal) birth.

… Of the 24 women in the study, the 13 who delivered normally all had highly favorable birth outcome scores. Three women who had high-risk scores underwent elective C-sections. Of the five women who underwent emergency C-section, the three with obstructed labor had high-risk scores, and the two who experienced heart rhythm abnormalities had mildly favorable or favorable scores.

More accurate measurements of labor risks might not only keep C-section rates lower and help identify necessary C-sections before they become emergencies, but these measurements could also better inform those who want to deliver at home whether it is safe to do so.

I wonder if all of those women had undergone extensive preparation for birth and had sought continuity of midwifery care? Of 24 women, only 13 delivered vaginally. That is only 54%! Private midwifery care generally had rates of normal birth up around 90%.

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New NHS Guidelines to Bring Down Caesarean Birth (caesareans on request)

Nov 26th, 2011

The National Institute for Health and Clinical Excellence (NICE) issued guidelines to the NHS asking that no woman, who prefers caesarean delivery, should be refused, but health care providers should explain to the woman the health risks of a surgery.

It is expected that such information would bring down the rate of surgeries performed.

NICE committee believes most women would choose a vaginal delivery if they are given proper information and the latest guidelines do not recognise that women choose a caesarean because they were “too posh to push.”

Contrary to the phrase often used by media “too posh to push,” most women opted for a caesarean for reasons related to physical or mental safety, the Nice committee said.

Once women have a discussion about the risks and benefits with health professionals, “they want to opt for the safest option. A lot of the anxiety is related to lack of information and lack of knowledge,” …

Women may have the wrong impression from listening to friends and relatives or using the internet …

… The Guardian reports that new recommendations to the NHS will bring the numbers down marginally …

… Some women fear vaginal delivery … usually during first birth or those who have suffered a traumatic experience during an earlier delivery.

… Lack of midwife support can contribute to a traumatic delivery and cause women to seek a caesarean next time …

“Our services fail women badly at the moment … We hear from too many women who have found their experience traumatising in some way.”

“If caesarean rates go up following the change to the guidelines, it will be evidence that women are not getting the quality of midwifery support they need to instill confidence and feelings of safety while giving birth.”

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Should I have a caesarean section?

Nov 13th, 2011

In the UK, the National Institute for Health and Clinical Excellence (NICE) is considering allowing women to access maternal choice caesarean on the NHS, that is, with public funding. Currently, this option was not available to women and the idea that it might soon be available is causing a lot of debate.

What every mother wants most is a healthy baby. And not to have her pelvic floor wrecked by a prolonged and painful vaginal delivery. Already one in four babies is removed surgically from their mother’s womb for inconsistent reasons, and at considerable expense to the NHS. Now, the latest National Institute for Health and Clinical Excellence (Nice) guidelines (albeit in draft form) say that all women can have caesarean sections if they want one. But should you opt for it if there’s no medical reason to do so? What’s best for your baby and you?

Nice says that women usually ask for a caesarean section because they are scared of giving birth …, they’ve had a bad birthing experience or a previous section. Nice … have now changed their guidance to suggest that a section is also a reasonable option for any women who have weighed up the risks and benefits.

Research now shows there is little difference in risk between a planned vaginal and a planned caesarean section. The planned bit is important though: both an unplanned vaginal delivery (for example a woman who was meant to have a section but went into premature labour) and emergency section (for example if the baby is showing signs of distress during labour) will usually have worse outcomes than planned procedures.

Nice divides the evidence into risks and benefits for mothers and babies. Fewer women who have had caesarean sections will still be breastfeeding their babies by three months. They will, however, take the same time to have sex again as women who have had a vaginal delivery, despite being less likely to have damaged their vagina. Women who had a planned section (not having had one before) will have less perineal pain … and less risk of vaginal bleeding after the baby is born. But they will have an increased risk of needing a hysterectomy, … developing a blood clot … and having a cardiac arrest … Generally the risk of anything bad happening in labour is very small.

The evidence is also poor on which mode of delivery is safest for the baby. One study found an increased risk of babies dying after a section … another did not find that. … it is not easy to obtain good research in this area because you can’t randomise women to plan to give birth vaginally or by a section.

What Nice doesn’t tell you is that having a caesarean, even with regional anaesthetic, feels as if someone is doing the washing up inside your abdomen. When the baby is born, it is tricky to have good skin-to-skin contact. A section is a surgical procedure with all that entails, including a catheter at the time, and afterwards a scar and flappy bit of skin under your scar. It is hard to pick up a toddler, and pretty painful to pick up your newborn in a hurry. However, Nice now says you can drive when you feel you have recovered instead of waiting for the traditional six weeks.

Giving birth vaginally is variable: some women have a quick, painless labour, others have prolonged agony. It is not as controlled as a caesarean … Some women feel they do not get enough support from midwives when they are in labour … For most of us, it hurts and you can’t sit down easily afterwards for a couple of days. The evidence as to what wrecks your pelvic floor – delivering a baby through it or simply carrying it around in your womb for nine months – is not clear.

So what should you do? You should look at the evidence – Nice presents all of the statistics online – and then decide. As a default, I would say that nature gave us a channel for childbirth and it wasn’t a zip on our bikini line. When the writer Sheryl Feldman said: “There is power that comes to women when they give birth. They don’t ask for it, it simply invades them, accumulates like clouds on the horizon and passes through, carrying the child with it,” she wasn’t talking about a caesarean section.

Pregnancy is not a medical condition so it seems counter-intuitive that it could routinely end in a surgical procedure. There are no prizes for bravery in childbirth but there is now good pain relief, and Nice found no evidence that epidurals increase the risk of needing an unplanned section …

Having had a section myself (and given birth vaginally – which, on balance, I preferred), the most significant part of Nice’s new recommendations is that women should have a say in what music is played in the operating theatre.

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Caesarean link to respiratory infections in babies

Nov 5th, 2011

A new study from Perth has found that babies born by elective caesarean are more likely to be admitted to hospital with a serious respiratory infection, bronchiolitis, in the first year of life.

This was a ten-year study that analysed the birth data of over 212,000 babies.

Bronchiolitis is generally caused by respiratory syncytial virus (RSV), and is one of the most common reasons for babies to be admitted to hospital. Bronchiolitis also has been shown to be associated with an increased risk of asthma in children, and it is known that babies born by elective caesarean experience more asthma than babies who were born vaginally or born by caesarean after labour had commenced.

Previous research found an increased risk of hospital admissions for respiratory infections in children less than 2 years of age, delivered by elective caesarean.

It is thought that labour stimulates the baby’s immune system and strengthens it. babies who are born by elective caesarean do not experience labour, and therefore their immune systems are not primed in the same way.

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Caesarean link to infant respiratory infections

Nov 2nd, 2011

Babies born by elective caesareans are more likely to suffer a serious respiratory infection in their first year of life …

The decade-long study into the incidence of Bronchiolitis found that babies born by elective caesarean were 11 per cent more likely to be hospitalised with the infection than babies delivered by other means.

Researchers at Perth’s Telethon Institute for Child Health Research analysed birth data and hospital records for 212,068 babies over a 10-year period in WA for the study …

… while the increase was relatively modest, it highlighted the risk to a child’s immune system when elective caesareans were the chosen birth method.

“We compared elective caesareans with other modes of delivery because with elective caesareans we could be confident that labour had not begun and therefore the baby would not have been exposed to [natural] chemicals that are released during the labour process,” Dr Moore said.

“It is increasingly plausible that delivery without labour could impair a newborn’s immune system and may also explain the known link between c-sections and an increased risk of asthma.”

… Bronchiolitis is generally caused by the common respiratory synctial virus and is one of the most common reasons for babies to be admitted to hospital.

She said that while most children recover from the infection quickly, it can make the child more prone to other respiratory illnesses such as asthma later in life.

… the research … pointed to the need for more research into the suspected role of various chemicals that are produced by mothers during labour in priming a newborn’s immune system.

“Given that caesarean rates are rising in Australia, this potential impact on the immune system might be another factor that parents and doctors may consider if choosing a caesarean for other than medical reasons,” she said.

“As it’s the first time we have reported such an association, it’s really important that the message get out there that women and their clinicians need to consider this when opting for a caesarean.”

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Charging women for non-medical caesareans?

Oct 2nd, 2011

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’,” …

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Is caesarean now the ‘normal’ way to give birth, and should we be worried?

Sep 13th, 2011

There’s no doubt that caesarean sections are an essential procedure that can save the lives of women and babies. But around one in three Australian women will give birth by caesarean section – and that’s not just to save lives.

… The rising caesarean section rate in most of the developed world has not resulted in reduced rates of stillbirth or infant death – quite the contrary.

One Australian study showed that babies were more likely to be admitted to a neonatal intensive care unit if they were born by elective caesarean section than other types of delivery. A previous caesarean section also increases the risk of stillbirth.

In terms of outcomes for women, those who have emergency and elective cesarean sections are less likely to exclusively breastfeed. And there is growing evidence that caesarean operations increase the risk of the mother dying or becoming ill with blood loss, blood clots, abdominal organ injury and the need for a hysterectomy.

It’s important to consider the risks of caesarean births. But rather than just focus on the polarised “vaginal birth vs caesarean birth” debate – which pitches doctors against midwives, and doesn’t help women who are stuck in the middle – we need to focus on the ways we can support all women to have the best outcome from childbirth.

It seems that one of the driving forces behind the rising caesarean section rate is fear … about labour and birth, and from doctors and midwives who are themselves fearful of the birthing process.

… we should be examining why women are fearful of labour and birth and what our health system can do to reduce this fear.

Our health system is generally an unfriendly one for pregnant women and it’s likely that this compounds the fear of birth. It’s common for a pregnant woman receiving care in the public system to see up to 30 different caregivers through pregnancy, labour and birth and the postnatal period.

The opportunity for pregnant women to develop a meaningful relationship with her health care provider, discuss her fears, affirm her needs and develop confidence in labour and birth are minimal.

… One of the disturbing elements of birth in the 21st century is the lack of respect for privacy for labouring women. The entourage of people appearing uninvited into labour rooms in most hospitals is astonishing. Each labour and birth can have a multitude of spectators, including a midwife, obstetrician, registrar, resident, student midwife, medical student and on it goes.

… To address this problem and encourage Australian women to give birth normally, … In NSW, the Towards Normal Birth Policy was released last year and provides 10 steps towards supporting more women to go into labour and ultimately have a normal birth.

The policy recognises that ”… unnecessary interference in the natural process may disturb the expected course and may lead to a cascade of intervention.”

The challenge is to redesign the health system to facilitate women’s confidence and trust in birth. Fundamental changes need to occur to ensure all women are supported during pregnancy and feel confident in their ability to give birth, including:

Continuity of caregiver;

Increased options for the style of birth, with access to a birthing pool;

A positive environment, free of disruptions; and

One-to-one midwifery care in labour so women are never left alone or fearful.

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

Sep 9th, 2011

Private Midwife:

Provides autonomous pregnancy, birth and postnatal care for women who are experiencing normal, healthy pregnancies

Provides care in consultation with an obstetrician when a woman’s pregnancy has risk factors (eg high blood pressure, prem labour, concern for baby’s growth, gestational diabetes etc)

Transfers responsibility for care to an obstetrician if complications emerge and continues to provide care within the midwifery scope of practice

Supports women to birth normally with a high rate of natural birth

Supports women to breastfeed

Provides pregnancy, birth and postnatal care

Pregnancy appointments allow time for questions, education and discussion with appointments typically 45-60 minutes in duration

Women are highly likely to report satisfaction with their care and experience

Private Obstetrician:

Provides autonomous care for women regardless of risk factors

Receives referrals from midwives for women with risk-associated pregnancies or births

Always provides labour and birth care (including caesarean) in collaboration with a midwife

Obstetric care on average results in a high degree of intervention such as induction, epidural, caesarean and episiotomy

Provides brief in-hospital consultations after the baby is born, followed by a 6-week check

Pregnancy appointments are generally no more than 15 minutes in duration

Collaborative care: private midwife and private obstetrician

Receive autonomous pregnancy, birth and postnatal care from one midwife and one obstetrician regardless of risk factors

No transfer of care if risk factors emerge

Supports women to birth normally with a high rate of natural birth

Supports women to breastfeed

Provides pregnancy, birth and postnatal care

Pregnancy appointments allow time for questions, education and discussion with appointments typically 45-60 minutes in duration

Women are highly likely to report satisfaction with their care and experience

Provides autonomous care for women regardless of risk factors

Supports women to birth naturally, including with twins, a breech baby or a VBAC

Visit my website to explore birthing services.

‘Peanut ball’ reducing C-section rate

Sep 5th, 2011

… the tool for nurses and doctors seeking to help women deliver a baby is a peanut-shaped exercise ball.

Banner Health now equips all of its hospital labor and delivery wards with so-called peanut balls.

The idea stemmed from nurses seeking to curb rising Caesarean-section rates at hospitals nationwide. C-sections are more expensive, pose health risks for patients and take longer to recover from.

… peanut balls could provide a natural alternative to more invasive birthing techniques such as C-sections or vacuum pumps.

… The ball is used on women who receive epidural … The peanut-shaped ball fits comfortably between the patients’ legs, opening their pelvis to create a path for the newborn.

… The C-section rate for the group of women who used the ball was 13 percentage points less than for the group that did not use the peanut ball …

The best way to lower the caesarean rate is for women to experience one-on-one continuity of care from the same midwife from pregnancy right through to when the baby is 6 weeks old. Women cared for in this way can expect very low rates of caesarean, and of the it interventions that generally lead to caesarean. caesarean rates for women cared for in private midwifery practice are around 5%.

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Caesarean section? Vaginal birth? Your choice!

Aug 15th, 2011

Visit my website to explore homebirth and hospital birth.

Much has been said and written about an article in The Age this weekend. The article is about a randomised study that will compare the outcomes of 500 women who choose a caesarean and 500 women who choose a vaginal birth. The study will explore psychological and physical outcomes for the women and their babies, including depression and breastfeeding rates. It will only compare vaginal births with caesareans for healthy women with uncomplicated pregnancies.

The study has created much debate, including issues of ethics (beneficence, autonomy, non-maleficence) and professional duty of care. I wonder if part of the “answer” will not be answered by this study, since the study only addresses outcomes from the first pregnancy, but most women do not have one child, they have two, on average. It’s reasonable to assume that a woman who has an elective caesarean for her first baby, will go onto have an elective caesarean for her second baby.

In the current maternity system in NSW, a woman who chooses a vaginal birth for her first baby has the following outcomes:

only 52% women having their first baby will have a normal birth

33% will be induced

23% will have forceps or vacuum

25% will have a caesarean – and of these women, only 12% will have a vaginal birth in their subsequent pregnancy.

In other words, only 75% of first time mums who elect to have a vaginal birth will actually have one.

In contrast, a first time Mum who chooses a vaginal birth with a private midwife has about a 95% chance of having a vaginal birth.

The real question isn’t the outcomes of a first-time Mum’s pregnancy when she chooses a vaginal birth or a caesarean, but rather, what happens for the average woman who has two children, who has elected a caesarean with her first versus a vaginal birth with her first baby. In other words, how about we compare the outcomes of women who have two caesareans, with women who elect to have a vaginal birth the first time around, 75% of whom will birth vaginally, and 25% of whom will have a caesarean.

Such a study would address the issue of second caesarean risks. Serious maternal morbidity (eg placenta praevia, placenta accreta, uterine rupture, need for hysterectomy and blood transfusion) increases progressively with increasing number of cesarean sections a woman has. The first caesarean is generally very safe but increasing numbers of caesareans are perhaps not so safe.

A further issue with the study is that it does not suggest any method or support for the women who elect to birth vaginally. Will they be supported with one-to-one midwifery care, as this is known to increase vaginal birth rates? Will they include homebirthing women who are highly motivated to birth normally and without interventions? Or will it be standard obstetric / hospital-based births with high rates of intervention that are already known to result in reduced breastfeeding rates and a dissatisfaction with the birthing experience? I will wait to read the results.

Drop in caesareans a tick for midwives

Aug 12th, 2011

A falling rate of caesareans at Wairau Hospital points to a good working relationship with Marlborough midwives, say obstetricians at the Blenheim hospital

Obstetricians Melissa Smith and Gary Fentiman said caesarean rates at the Blenheim hospital fell from 33 per cent of the 559 total births in 2010, to 29 per cent …

The caesar rate was about average for New Zealand although national statistics had not been kept since 2007 …

This caesarean rate sounds very high, considering most women in NZ choose a midwife as their lead maternity carer, and midwifery care is known to result in low caesarean rates.

Internationally, rates ranged from over 60 per cent in some parts of Brazil and 50 per cent at some United States hospitals, to below 1 per cent in third-world areas with a high death rate for labouring mothers and babies.

Another sign of success in the Wairau maternity department was an over-80 per cent success rate for women attempting a vaginal delivery after a previous caesarean.

Behind the healthy statistics was good communication and mutual respect in the maternity team, the obstetricians said. “The patients are well-managed by their midwives with our back-up,” …

… Only rarely did Marlborough women demand a caesar with no attempt at vaginal delivery although this trend was showing up in cities, the obstetricians said.

During six months at Wairau, about six expectant mothers had walked through Dr Smith’s door asking to book a caesarean.

After reassurance, four went on to have vaginal deliveries, one required a caesarean and one was still pregnant.

When a woman demanded a caesar there was always a story; a bad experience in the past, advice from a friend, sister or mother leading to fear and lack of understanding, she said.

… Dr Fentiman said midwifery had been the victim of some media-bashing since Government introduced the lead maternity carer model in 1996.

… In Marlborough, self-employed midwives care for pregnant women with back-up from hospital obstetricians who attend complex births and are on-call if needed.

Obstetricians see pregnant women whose births might not be straightforward, to help plan their labour.

Of labours expected to be trouble-free, about 30 per cent are attended by an obstetrician who provides help ranging from advice through to performing a caesarean …

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“I’ve been told my baby is big”

Aug 10th, 2011

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

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

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

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

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

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

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

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

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

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

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National C-section rate highest ever, study says

Jul 23rd, 2011

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More than one in three babies in the U.S. is now delivered by cesarean section …

Thirty-four percent of single-baby births in 2009 were done surgically, the highest percentage ever.

… “This is a big issue, and this is actually going to come under a lot of scrutiny in the coming year,” …

… changing physician practices, such as inducing labor and a desire by physicians and patients to schedule convenient times for labor, may be leading to the increase …

… no data exists to show “that higher rates improve any outcomes, yet the C-section rates continue to rise.”

“At the end of the day, the C-section rate has risen … over the past decade, and we don’t have any improved baby outcomes to show for it …

In fact, hemorrhaging from C-sections is one of several possible factors in the state’s increased maternal death rate … The number of women in California who died from pregnancy-related complications rose from 5.6 out of 100,000 live births in 1996 to 14 out of 100,000 in 2008 …

… “but we do know [caesarean] causes increased morbidity, or complications, so the thought is if you do enough of them, you’re going to see more direct complications.”

… the main risk comes when women have a second, third or fourth C-section. As the procedure’s use increases, more women will have multiple C-sections, meaning the risks will be increasingly present in the future …

Steep rise in first-time mothers being induced

Jul 17th, 2011

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A huge jump in first-time mothers having their labour induced is a worrying trend that is putting women at unnecessary risk …

The proportion of labour induction among women who carried their babies to term rose from 18.6 per cent of all births in 1990, to 26.2 per cent in 2008.

… and the majority of those [inductions] were carried out before the 41st week of pregnancy.

… at the same time, the rate of stillbirth remained steady.

“Induction seems to be increasing and that doesn’t seem to be improving the outcomes for babies,” …

More older mothers and increases in instances of medical conditions, such as gestational diabetes, explained only some of the rise … Women who were more likely to undergo induction … tended … to have private health insurance.

… the study was worrying because it showed inductions were often not done for conventional reasons such as high blood pressure or prolonged pregnancy.

”Unspecified” reasons were given for between a third and half of all inductions …

… as the rates of induction had gone up, so had the rate of caesareans. Between 2001 and 2007, fewer than half of the women who had their labour induced went on to have a natural birth, with a third of inductions resulting in caesareans.

… women were often put under subtle pressure by doctors to undergo inductions and did not have the risks of further interventions explained to them.

“If you knew your chances of having a normal birth were less than half, you would think more carefully about what is being advised,” she said. “They trust us and they trust the advice that they are getting is correct and that is very concerning.”

… Women who had a caesarean for their first birth were more likely to have the procedure for subsequent births, leading to increased risks of complications such as the placenta growing through the uterus wall …

Perhaps a policy needs to be developed whereby all inductions need to be cleared by a committee of at least 2 senior doctors and 2 senior midwives, prior to authorisation by the induction committee. Sometimes a meeting with senior clinicians can help to generate other options instead of resorting to induction. This would, however not be applicable in the private sector, where most of the inductions are performed.

In NSW in 2008, one private hospital had a 38% induction rate, while another private hospital had a 41% induction rate. At those hospitals, only 1 in 5 women went into labour spontaneously. Interestingly – and perhaps in conflict with this article – at those same hospitals, while around 50% first-time Mums were induced, only 1 on 5 first-time Mums had a caesarean – so it doesn’t necessarily follow that a high induction rate leads to high caesarean rates. Both of those hospitals have caesarean rates that are in-line with the NSW State average.

I am not suggesting that inductions are wonderful and all women ought to be lining up for them – and the increase in non-indicated inductions is indeed worrying because there should always be a valid reason to bring a pregnancy to an end sooner than nature (and the baby) had intended. There’s no doubt that induction rates and caesarean rates are very high – too high – in private hospitals. But I’m not sure that one is leading to another because the bulk of the caesareans are performed electively, ie, prior to labour starting. The most common reason for an elective caesarean is a previous caesarean (I’ve never accepted that this is even an indication because VBAC is safe … but I’ll have to concede to the majority view that “previous caesarean” is somehow a justifiable reason for another caesarean). Also, as my stats have shown above, despite the huge rate of inductions in first-time Mums, there’s not a corresponding increase in the caesarean rate amongst first-time Mums.

So, I wonder if there’s something else at play here. I wonder if it has something to do with continuity of care and trust being protective. So that women may be augmented and induced without it impacting the caesarean rate, provided that those women receive continuity of care from someone they trust. In private hospitals where induction rates are higher than in the public sector (along with all types if intervention), women receive continuity of obstetric care and although we might assert that, “women were often put under subtle pressure by doctors to undergo inductions and did not have the risks of further interventions explained to them”, it is also true that, “They trust us and they trust the advice that they are getting”.

On the other hand, in the public system, continuity of care is not generally a feature of the care provided. Women are often seen by a different midwife or doctor at every visit, they receive impersonal care from a stranger, and by-and-large, they are terrified. Add “induction” to the mix, and viola! You have a caesarean. I wonder if the cause of the caesarean was the lack of continuity of care and trust, rather than the intervention itself. More on that later!

Cesarean Increase Driven by Subjective Indications

Jul 4th, 2011

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According to a new study, half of the increasing rate of cesarean births is attributable to primary cesarean births. Among primary cesarean births, subjective indications, such as nonreassuring fetal status and arrest of dilation, contributed to a greater proportion of such deliveries than objective indications such as malpresentation, maternal-fetal, and obstetric conditions …

The rate of primary cesearean deliveries increased at 6.0% per year …

… [higher] cesarean delivery rates … add to costs but do not improve maternal or neonatal outcomes.

Caesarian births in Uganda go back to pre-colonial days

Jun 22nd, 2011

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Not too long ago, the Bunyoro of north-western Uganda fed expectant women intensively in preparation for childbirth …

“Women in the community used to cook groundnut soup, beans and millet bread,” …
“They also used to steam sweet potatoes, cassava, green bananas and dark green vegetables. Mothers ate these foods before and after conception to reduce pregnancy-related complications like anaemia and malnutrition.”

… traditional birth attendants gave antenatal care to expectant women and could detect complications well in advance.
“We never used to go to hospital. If the woman’s passage was too small for the baby to pass through, for instance, an episiotomy would be performed using the sharp edge of a reed. The mother would bleed, but she would eventually be fine. We used herbs to help heal the wounds,” she said.

Sometimes, however, the delivery got more complicated and the birth attendant recommended the Caesarean section. This is a life saving emergency obstetric care performed only on a doctor’s recommendation.

It was being performed more than 100 years in Uganda by Banyoro surgeons in pre-hospital days. In 1879, Catholic missionary Robert Felkin witnessed a Caesarean section being performed on a young woman in Bunyoro.

… “… The patient was intoxicated with banana wine. The surgeon made a quick cut upwards from just above the pubis to below the umbilicus, severing the whole abdomen wall and uterus so that the amniotic fluid escaped. Bleeding points were torched with red hot irons.

“The surgeon completed the uterine incision, with the assistant holding up the sides of the abdomen wall with his hands and hooking two fingers into the uterus. The child was removed, the cord cut and the child handed to an assistant…

“The peritoneum, the abdominal wall, and the skin were secured with seven sharp spikes. A root paste was applied over the wound and a bandage of bark cloth was wrapped around it. Within six days, all the spikes were removed.”

Thank goodness we live in Australia in 2011!!!

What Felkin saw is essentially what happens today in C-section surgery rooms, but with vastly advanced technology …

… the seriousness with which doctors view the surgery is gradually diminishing as many women from across the region view it as a social trend.

“Some women think that vaginal birth will make them age faster, but this is not true. Women are back to their former selves a few weeks after delivery,” …

… “There is an increasing number of mainly young women who say normal births will overstretch their organs. This is not true.” …

QLD: Mums-to-be pushed into caesareans with private hospitals leading the way

Jun 13th, 2011

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SOME of the state’s biggest private hospitals are performing caesareans on more than half the women giving birth …

The caesarean rates among the highest in the country were uncovered in hospital birth statistics from 2007-2010 obtained by The Sunday Mail under Right to Information laws.

Queensland’s “caesars palace” was the North West Brisbane Private Hospital, which performed the surgery on 56.8 per cent of women giving birth. Toowoomba’s St Vincent’s Hospital and The Wesley Hospital in Brisbane rounded out the Top 3, with rates of 54.8 per cent and 51.8 per cent respectively.

The latest figures … will reignite the turf war between midwives, who espouse natural birth, and obstetricians who defend surgical intervention.

Caesarean births are recommended as safer options for women having large babies, twins or breech births, as well as older mums and women who have had previous caesareans.

Latest recommendations from Canada suggest that vaginal birth is safest for most breech babies. NSW Health promotes vaginal birth for twins and of course we know that vaginal birth after a caesarean is safer than elective repeat caesarean provided that the birth takes place in a facility that has resources available to perform an emergency caesarean if needed. And “big” babies? This cannot be known with any accuracy ahead of time and the current recommendation is for a planned vaginal birth.

But some critics say growing numbers of medical professionals are convincing mothers to undergo caesareans just to streamline private maternity ward schedules and maximise revenue.

Across the state the figures add weight to the theory, with caesareans accounting for 27.6 per cent of births in public hospitals and a huge 48.3 per cent in private hospitals.

We know that this difference is not comprised of women requesting caesareans: only 2-3% women actually request a caesarean. Most are told they “need” a caesarean because their baby is “big” (3.3Kg), “late” at 39 weeks and 6 days, a previous caesarean, breech, twins, IVF, mum is “overweight”, mildly elevated blood pressure (130/80) and so on. I have heard all of these and more, as “valid” reasons for caesarean.

Several new mothers approached by The Sunday Mail last week said they had been pushed into having caesareans by private hospital obstetricians after initially wanting to give birth naturally.

One Coolum mum, 45, said her obstetrician told her she had “no choice” because the baby would “not fit through my birthing canal”.

This can not be known ahead of time. The only way to find out is to labour and see how it goes. Dedicated, exclusive, one-to-one midwifery care in labour from a midwife who is know to the woman by name and trusted by the woman, is the most important factor in ensuring a normal birth.

… “I just wanted a natural birth, to me that was important …

I think personal responsibility also plays a part here. If a woman genuinely wants a natural birth, she needs to consider which care provider will maximise her chances of achieving this. Consumers of any service are wise to research options thoroughly before they go ahead with them. We do more research about buying a car, house or holiday than we do when choosing our care providers. Having chosen an ill-suited care provider, it is never too late to change.

Another mum … desperate to avoid a caesarean, said her obstetrician also tried to book an induction because she had passed her due date in the Christmas-New Year period.

“The obstetrician said we can book you in for an induction because we just don’t like calling people in on public holidays,” …

But doctors point the finger at today’s “too posh to push” mothers, who they say demand caesars, as well as older mothers who have an added risk with vaginal births.

Australian College of Midwives spokeswoman Professor Jenny Gamble said the health system was driven by profit.

“It’s all about less night disturbance and more throughput; it all comes down to money,” she said. “It’s a fee-for-service model the more women obstetricians see, the more they earn.”

Australian Medical Association Queensland president Dr Gino Pecoraro rejected as “urban myth” claims that obstetricians earned more for caesarean births.

Private Hospitals Association Queensland said birthing decisions were not made by the hospital.

This is true: hospitals do not make any decisions about birth: those decisions are made by the doctor and patient. As we have read in this article, many of the decisions are “guided” by the doctor. The other factor in these escalating caesarean rates is litigation. When caesarean rates increase and doctors are reluctant to attend VBACs, the caesarean rate will automatically increase.

Not all doctors have high caesarean rates and some are very supportive of normal birth BUT … if a woman genuinely wants a normal birth, the best advice is to go a normal birth specialist.

Caesarean births cost more for healthy women– new study

Jun 6th, 2011

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A new paper calls for a re-think of how we calculate the risks and benefits of caesarian sections versus vaginal births in healthy … women …

“Australia is experiencing an increase in unexplained caesarean section births in healthy populations of women. The effect of this increase on health services has been justified by the belief that caesarean section is cost neutral when compared with uncomplicated vaginal birth. However, our research shows that many hidden costs associated with caesarean sections are not being considered when balancing the risks of this procedure with the benefits,” …

“… the economic burden to the health system of serious morbidity associated with caesarean section in the absence of medical risk has been omitted from calculations comparing costs of caesarean birth and uncomplicated vaginal birth. However, unexplained caesarean section is associated with serious morbidity in current and subsequent pregnancies for mother and baby … maternal mortality for elective caesarean section was higher by a factor of 2.8 times compared with vaginal delivery. Morbidity affecting babies creates a stressful experience for mothers and interferes with early healthy mother/baby interactions. Neonatal intensive care unit (NICU) admissions have been found to delay the maternal bonding and breastfeeding and there is an increased risk of ongoing respiratory problems including wheezing and asthma.

“Maternal morbidities associated with surgery increase the probability of re-hospitalisation to twice that of vaginal birth. Readmission is associated with increased suffering, higher costs, disruption to early parenting and increased family burden. Primary caesarean delivery also is associated with genital tract injury, wound infection, systemic infections and depression. Primary caesarean section is reported as conferring serious risk of complications in the second pregnancy for both mother and baby, including double the risk for unexplained stillbirths, spontaneous abortion, ectopic pregnancy, infertility, uterine scar rupture and caesarean hysterectomies which are associated with life-threatening consequences for women.

“However, despite these findings, the rates unexplained caesearian births are increasing without apparent consideration of the negative, and in severe cases, life threatening effects to the health and future fertility of those women concerned and to the overall capacity of the healthcare system to absorb the increasing demand for operating theatre resources. The false understanding that elective caesarean birth is cost neutral when compared with a normal vaginal birth has misled practice and contributed to overuse. It is important to expose costs to women and the healthcare system of morbidities associated with unexplained caesarean section to inform policy development and women’s choices. Hidden costs in terms of serious morbidity affecting women’s future health and fertility associated with caesarean delivery in the absence of medical risk need to be calculated into the overall cost burden …

Middle-class mothers ‘should be talked out of caesareans’

May 30th, 2011

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One in four births in Britain today is now carried out by caesarean, a major operation which costs the NHS thousands of pounds a time.

The rate has more than doubled since 1980, and some research suggests their growing popularity has been driven partly by more affluent mothers demanding them – those who critics say are “too posh to push”.

Many obstetricians consider the rate to be too high.

Now the National Institute for Health and Clinical Excellence (Nice) has issued draft guidance saying women who want caesareans simply because they fear giving birth naturally, rather than for a clinical reason, should be made to have a full discussion about their options.

It says the doctor should offer to set up a separate appointment so that the woman’s concerns about childbirth can be addressed.

The guidance … recommends: “When a woman requests a CS [caesarean section] because she has a fear of childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her fears in a supportive manner.”

Doctors should “discuss the overall risks and benefits” … “to ensure the woman has accurate information”.

Women should still be able to have caesareans if they do not want to give birth normally … “If after providing support, a vaginal birth is still not an acceptable option to the woman, offer a planned CS.”

… the balance of risks to mother and child between caesarean and natural delivery is “controversial” …

… while 30 years ago mothers having caesareans “were more likely to come from deprived social backgrounds”, by 2000 they were more likely to be from “higher social classes”.

… Other research indicates that women rarely actively choose them, and that more than nine in 10 are performed on medical advice …

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

May 26th, 2011

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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.

Choosing C-section may not prevent incontinence

May 17th, 2011

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… a Cesarean section may not lower a woman’s chance of incontinence later in life — unless she delivers all of her children that way …

The findings question the suggestion that by choosing a c-section over vaginal delivery, women might be protecting themselves against urinary or fecal incontinence down the road.

… In women who had given birth only through vaginal delivery, 55 percent reported experiencing urinary incontinence. That compared to 59 percent of women who had at least one baby through vaginal delivery and one via C-section. In women who only had C-sections, the rate of urinary incontinence fell to 40 percent.

Rates of fecal incontinence 12 years down the line were about the same — between 11 and 14 percent — in women who had only given birth through vaginal deliveries or C-sections alone, or had given birth through both modes of delivery.

Regardless of how they delivered their children, women who were heavier, had given birth more times, and were older at their first delivery reported higher rates of incontinence.

… cesarean section does not protect from subsequent” urinary incontinence.

Obesity, elective cesarean contribute to U.S. maternal mortality rate

May 15th, 2011

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In the 14 years that I’ve worked in the world of obstetrics, I’ve witnessed three maternal deaths. All three occurred in the immediate postpartum period, all were unexpected, and all were devastating for everyone involved, but most of all for the families and children left without a mother.

In the U.S., when a woman goes into the hospital to have a baby everyone expects that she will come home a few days later, happy and healthy, with a new baby. While this is usually the case, maternal death does still occur.

… Women in the US are more likely to die from pregnancy-related causes than women in Canada, Poland, Croatia and Greece, just to name a few. And black women in the United States are four times more likely to die from pregnancy-related problems than white women.

… it has changed little over the past 20 years. The Joint Commission on Hospital Accreditation has warned that the maternal mortality rate may be increasing once again.

… why are mothers still dying in the United States when we spend more on health care than any other country in the world?

Some of the most common causes of maternal death in this country are hemorrhage, postpartum blood clots and underlying cardiac disease.

The CDC cites the rise of obesity and elective cesarean rates as possible contributing factors to the problem. Hypertension, diabetes and asthma — all culprits in pregnancy-related complications — are all more common in obese women.

Although the risks of cesarean birth are relatively minimal, studies have shown a higher mortality rate when compared to vaginal birth …

C-Sections Could Have a Role in the Obesity Epidemic

May 14th, 2011

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Young adults born via Cesarean section are more likely to be obese than those delivered vaginally, suggesting C-sections could be feeding the obesity epidemic …

But the theory is controversial, and scientists are still a long way from conclusively pinning some blame for obesity on higher rates of C-sections.

… The team looked at a number of other factors that could potentially explain the connection, like heavier birth weight, or income and education levels (more-educated mothers had a higher C-section rate).

But even after accounting for these factors, C-section remained linked to a 58% increase in the risk of adulthood obesity …

… it’s possible that C-sections could directly affect the risk of becoming obese later in life.

… infants born via C-section are not exposed to the beneficial bacteria in the birth canal, and so they might take longer to accumulate Bifidobacteria and other microbes that could influence their metabolism.

Similarly, obese adults tend to have fewer of those friendly bacteria in their digestive tract than normal-weight people do ….

Cutting C-sections cuts costs, medical risks: article

May 12th, 2011

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Health-care service providers and politicians looking to cut health-care costs might want to consider taking a scalpel to the number of caesarean sections performed each year without medical reason …

… a first-time C-section costs about $2,265 more than a vaginal delivery.

“Canada’s health-care system could save close to $25 million if the rate of first-time C-sections, let alone repeat C-sections, could be reduced to the 15 per cent recommended by the World Health Organization,” …

Canada’s caesarean section rate is at about 27 per cent …

A greater incidence of maternal obesity in Canada, as well as older mothers in general, mean riskier pregnancies and more caesarians than in other countries, … but the current rate is still too high.

“No one agrees on what the rate should be,” says Bourgeault, noting that the WHO guideline of 15 per cent could be too low, “but pretty much everyone agrees that anything higher than 30 or even in the high 20s is too high.”

… The hospital has developed a three-pronged approach to reducing caesarian rates: doing a better job of informing expectant mothers of their choices, keeping track of which doctors are performing the surgical procedures, and changing their policies around inductions.

Interestingly, they have ignored the number one intervention that has been shown to reduce caesarean rates: exclusive one-to-one midwifery care in labour for all women.

“There’s a higher risk of caesarean section if your labour is induced so they give it a little extra time for the woman to go into labour, and it’s much more likely that women will give birth vaginally and avoid a caesarean section,” …

… “Compared to vaginal delivery, C-sections pose greater risk of cardiac arrest, hysterectomy, infection, fever, pneumonia, blood-vessel clotting and hemorrhaging, as well as risks for the baby,” …

The myth that the article wants to bust is the common belief expectant mothers are the ones driving the increase in the number of C-sections. Instead … it’s doctors, not pregnant women, pushing the scalpel option.

… only eight per cent of mothers asked for C-sections, and of that number most had already given birth that way. In a similar study in the U.S., fewer than one per cent of respondents indicated a preference for surgical delivery.

“Interestingly, most of the mothers who had a C-section indicated that it was their health care provider who made the decision,” …

Doctors pushing C-sections: study

May 11th, 2011

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It’s not women who are “too posh to push” who are driving up rates of caesarean sections across Quebec and Canada, but rather doctors who are too quick to turn to the surgery …

Many obstetrician-gynecologists are choosing to perform C-sections when dealing with an extremely difficult labour, even though there are guidelines on how to proceed that don’t automatically call for a caesarean section …

The rate of C-sections has increased by almost 10 per cent from 1995 to 2009, the latest year for which complete figures are available. Today, about one in four women give birth in Canada following a C-section.

… “Unnecessary C-sections lead to unnecessary harm and expense, so we should find ways to curb them.”

… Some obstetricians stand to benefit financially from planning a C-section. However, the fees paid to doctors for a C-section are no longer much higher than for a vaginal delivery …

Shoemaker attributes much of the increase to the choices that obstetricians make. “It is more probable that some doctors turn too quickly to the surgical solution,”…

… it’s no longer standard procedure to perform a C-section for a breech birth. However … that is still the case at other Montreal hospitals …

Oh to have a 25% caesarean rate! Australia’s rate is 31%.

One in three Queensland babies born by c-section

May 3rd, 2011

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Queensland has the highest rate of caesarean-section births in Australia, with one in three mums now giving birth in this way …

… dramatic rise in the proportion of women having caesarean sections, from a national average of 21.1 per cent in 1998 to 30.9 per cent in 2007.

… Queensland had the highest rate of caesarian-sections, with 33.1 per cent of births occurring in this fashion in 2007, while Tasmania had the lowest rate (28 per cent).

In Queensland, six in 10 c-section births happened without labour.

… Unlike their New South Wales counterparts, women in Queensland public hospitals could “demand” a C-section without a medical reason …

Dr Pecoraro, himself an obstetrician and gynaecologist, said he believed it would be patronising to refuse that request if the woman had done her research and made an educated decision.

He said one in seven women had genital herpes, which babies could contract during a vaginal birth, while a large number identified as survivors of sexual abuse and may prefer a c-section.

“When I started practising I was so surprised at how accurate these figures are,” he said.

While there were some health risks from c-sections, women who relied on assisted reproduction often decided to have one because they had enlisted more “emotional captial” in the birth.

“Some of them want a bit more control and some of them see having their own c-section gives them a bit more control rather than putting it out to the cosmos,” Dr Pecoraro said.

… “It stems from fear; they are afraid of what may happen to them in labour,” …

He said if doctors could help decrease the fear by educating women about the birth process, that was one way to reduce the c-section rate.

“All the doctors realise that it’s a relatively high number and it does seem to be increasing and it does raise alarm bells,” he said.

Dr Pecoraro said decisions were best made by the woman and her doctor.

It was “incredibly common” for women to ask their doctors to tell a husband or mother-in-law that a c-section was the best option …

Midwives play a really important role in alleviating fear and anxiety around birth. Many midwives will see women with a history of a previous traumatic birth, intense fear or birth or of pain during birth or women who have a history of child abuse and who prefer to have a caesarean. However, with continuity of care, sensitivity and the establishment of a supportive and therapeutic relationship, many women will feel confident to start labour naturally and “see what happens”. The result? Most of the time women birth naturally and drug-free … and amaze themselves!

Childbirth: More Labor Interventions, Same Outcomes

May 2nd, 2011

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Hospitals vary considerably in the frequency with which they induce labor and perform Caesarean sections. But a new study finds that these differences do not seem to affect how newborns fare in these facilities.

Dr. J. Christopher Glantz, a professor of obstetrics at the University of Rochester, reviewed records of almost 30,000 births … Some hospitals relied heavily on induced labor and Caesarean sections, while others performed the procedures much less often.

Dr. Glantz measured neonatal outcomes in three ways: whether a child was moved to an intensive care hospital, whether a child needed immediate assisted ventilation and whether a child received a low Apgar score.

He found no difference in outcomes for babies born in the hospitals with the highest rates of these procedures and those with the lowest. The result suggests that routine reliance on the procedures does little to improve outcomes …

The recipe for safe, empowering, minimal-intervention birthing is:
A woman who is positively motivated to have a natural birth
Who is well-prepared for pregnancy, labour, birth and parenthood
Who is supported by one midwife and one obstetrician right the way through her pregnancy, birth and postnatal experience
Care providers who collaborate, communicate, respect and trust one another, who work for the best interests of the woman and her baby

Probe into mass Caesarean birth

Apr 27th, 2011

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

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

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

Link Found Between Mental Health Problems And A Fear Of Childbirth

Apr 18th, 2011

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

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

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

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

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

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

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

No Link Found Between Overall Wellbeing Of Newborns And More Interventions At Delivery

Apr 15th, 2011

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In low-risk pregnant women, high induction and first-cesarean delivery rates do not lead to improved outcomes for newborns …

The finding that rates of intervention at delivery – whether high, low, or in the middle – had no bearing on the health of new babies brings into question the skyrocketing number of both inductions and cesarean deliveries …

” … interventions entail some risk for the mother, and there is no evidence in this study that they benefit the baby,” … ” … if you are getting the same outcome with high and low rates of intervention, I say ‘Do no harm’ and go with fewer interventions.”

… larger studies are needed to better understand the relationship between intervention and outcome. In the meantime … it’s hard to justify high rates of interventions – especially elective – in low-risk pregnant women without any known benefits to newborns, given that these interventions pose maternal risks …

C-section puts children at food risk

Feb 26th, 2011

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

Considering Evolution And C-Sections

Feb 24th, 2011

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

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

Jan 31st, 2011

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

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

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

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

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

Induced labor may double the odds of C-section

Jan 24th, 2011

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

However … this guideline is “not followed rigorously.”

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

Health chiefs encourage more home births over caesareans

Jan 17th, 2011

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

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

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

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

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

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

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

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

Jan 2nd, 2011

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

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

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

Caesarean rate continues to rise

Dec 28th, 2010

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

Obstetrical anesthesia: new data on the risks

Dec 26th, 2010

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