Homebirth: What to expect

Posted on February 4, 2013 by Melissa Maimann

Homebirth care is always individualised to the needs of the woman and family. The following information can help you to understand what may happen in labour, to give you a sense of your options and lessen any surprises. When you birth at home, you can expect to:

- Wear whatever you like in labour
- Have vaginal examinations when / if you want them. Your midwife may suggest an examination if she feels it is needed, which is not very often as we know that babies are born whether vaginal examinations are performed or not and many women prefer to avoid them wherever possible.
- To have your temperature, blood pressure and pulse taken when it is necessary to do so – sometimes this is not done at all
- Have your baby’s heart beat listened to with a hand-held doppler that allows you to remain in the bath or shower.
- If additional fluids are needed, you can expect your midwife to offer you lots of drinks – this will also help to keep up your energy levels. In fact, your midwife will probably offer food and fluids regularly throughout your labour anyway.
- We don’t use ID bands at home. Not for Mum, not for baby. No chance of anyone getting lost, everyone knows who’s who, and no mother is handed the wrong baby!
- Your waters are very unlikely to be broken at home.
- You can expect to give birth in the position that’s most comfortable to you at the time. For many women, this is kneeling (so you can catch your own baby) or all fours (and your partner can catch the baby).
- Waterbirth is a common birth method at home.
- While “pain relief” is not offered, your midwife will make suggestions to assist your level of comfort such as position changes, hot packs, bath, shower, massage and so on.
- You will find that your body will push instinctively when the time’s right.
- Many women will not tear and episiotomy is very rare at home.
- Placentas usually come of their own accord, in their own time provided that the blood loss is not excessive.
- Your baby’s cord will be cut after the placenta is born, and some women prefer to leave it intact and have a lotus birth.
- There is no separation of mother and baby.

Learn more about private midwifery care, antenatal shared care and antenatal classes

Measuring the bump

Posted on December 12, 2012 by Melissa Maimann

You might have been wondering what your midwife does and feels when she feels your pregnant belly.

During an antenatal visit, your midwife will ask to feel your pregnant belly. The medical term for this is palpation, often referred to by midwives and obstetricians as an abdominal palpation. The aim of regularly feeling your belly is to monitor the changing size of your uterus and the growth and position of your baby as the pregnancy progresses. Palpation does not hurt your baby because they are surrounded by a cushion of amniotic fluid.

Your midwife will measure your belly from the top of your uterus (womb) to your pubic bone, and the measurement in cm ought to equal the number of weeks that you are pregnant, +/- 2cm. this means that at 34 weeks, it would be fine for your uterus to measure anywhere between 32 and 36cm.

If your bump measures much more or less than what was expected, your midwife might discuss with you whether an ultrasound scan is needed.

The size of your uterus should continue to grow, reaching the base of your sternum by 36+ weeks, and as your baby’s head engages deeply in your pelvis, your uterus will come down a bit lower.

After 36 weeks, your midwife will also be interested to know if your baby’s head has engaged. This is when the largest part of your baby’s head is within your pelvis, so that only a small amount of your baby’s head can be felt outside of your uterus.

Although engagement of your baby’s head does not mean your labour will start any time soon, it is a very good sign that you will birth normally and healthily. Your baby’s head can engage anytime from 1 to 4 weeks before the birth, and if you have had a baby before, it might not engage until labour starts.

Your midwife will also feel the position of the baby, which is important in labour.

The most important thing about having your midwife feel your belly is to have the same midwife do it every time. We each measure slightly differently, and what is important is the differing results from one care provider, rather than the differing results between care providers. This is where private midwifery care really benefits women and babies.

After about 14 weeks, your midwife may also ask to listen to your baby’s heartbeat, and this is something that most women are excited to hear.

If your midwife listens to your baby’s heartbeat and is concerned by what s/he hears, s/he may discuss with you whether some additional monitoring is needed, and this is usually done by way of CTG, which is a machine that monitors and records every heart beat for 20-30 minutes.

Learn more about private midwifery care and shared care.

Risk assessment in pregnancy and birth

Posted on May 20, 2012 by Melissa Maimann

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

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

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

How can risk assessment be useful?

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

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

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

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How can fathers play a bigger role in pregnancy and childbirth?

Posted on May 13, 2012 by Melissa Maimann

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Fathers are more keen than ever to be involved with their babies around the time of birth but, despite a government push to engage men more fully in their children’s lives, this “golden opportunity” to include them is often lost, with many men ignored or sidelined in ante- and postnatal care.

… a growing body of evidence is making it clear that fathers who are engaged in pregnancy and birth are more likely to remain engaged in their children’s lives. Secondly, the roundtable heard, because mothers’ levels of satisfaction with their care in childbirth is affected to some extent by how well their partner was treated by the midwife. As one participant put it: “Respecting women matters and you don’t respect a woman if you don’t respect her man.” Thirdly, because fathers provided not only welcome but also extremely effective support to new mothers, especially in the postnatal period. That support could be invaluable, the roundtable was told, not only to the new mother and her baby, but also to the hard-pressed midwifery services.

… Antenatal care focused very much on the birth and pain relief options, which were mostly about the mother-to-be’s physical experience, rather than about issues around caring for the baby once he or she arrived, which would engage and include the father equally.

This can be a function of the current model of care in hospital which focuses on getting as many women through the system as possible, but not necessarily meeting every woman’s informational and emotional needs. Families seeking private midwifery care will find that with hour-long appointments and structures childbirth education throughout pregnancy, both the Mum and dad feel well-prepared for both birth and baby care.

And at the delivery itself, men were being seen as merely low-grade supporters when they in fact had huge emotional needs of their own, which were going unnoticed. At the birth, as one participant said, “fathers are expected to provide a bit of massage or to fetch glasses of water when in reality this is a moment of enormous emotional watershed for them”. If their needs were being unmet, they were less likely to feel valued in the whole process of bringing a new child into the world. “Fathers are looking for ways in, but they are experiencing feelings of detachment, or are being treated as little more than onlookers,” said another contributor. “Birth is a critical turning-point, a time when they can feel and properly appreciate that they have a baby for the first time.”

… One contributor pointed out that there was a tendency for the maternity services in general to be rule-bound and risk-averse, which could militate against changes such as allowing both parents to stay with their new baby overnight, a practice known as “rooming-in” …

Certainly, there is much scope to involve fathers more fully in the birth of their children, in the pregnancy care and also in the postnatal care.

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Homebirth transfer rates: cause for concern?

Posted on May 10, 2012 by Melissa Maimann

What is a woman really asking when she asks her midwife what the midwife’s transfer rate is?

Women often interview several private midwives when they are choosing the right midwife for their needs. Women will ask many questions of their prospective midwife, and one of the more common questions is, “What is your transfer rate?” meaning, “what percentage of the women who book with you for homebirth, end up transferring to hospital?”

On the surface, this seems like a fair question. But what is the woman really asking? I consider that the woman is really asking, “If I book with you, what’s my chance of being transferred?” and when women ask the same question of several midwives, they are most reassured by the midwife with the lowest transfer rate because they perceive that they have the lowest chance of transferring if they go with the midwife with the lowest transfer rate.

Is it a fair assumption to make, that the midwife’s transfer rate, representing her previous client’s outcomes, are a valid guage for the current woman’s likelihood of transfer? Often I find that transfers can’t be predicted at the time a woman books-in for care. If we could predict it, we’d recommend a planned hospital birth. Considering transfer rates from this perspective, a midwife’s transfer rate has no bearing on the current woman sitting with her. As well as this, some transfers occur because the woman has requested it – eg a request for transfer for an epidural, but not on the advice of the midwife as the labour is actually progressing very normally. The other situation that can arise is that the midwife forsees problems occurring and makes some recommendations to avert those problems, but the woman considers the recommendations and declines to follow them. In these cases, again, the midwife’s transfer rate has no bearing on each new client who interviews a midwife.

What’s a “good” homebirth transfer rate?

Well, many might argue that the lowest transfer rate is the best transfer rate. You’re setting out for a homebirth, right? So why go to the midwife with a “high” transfer rate?

I did some scouting around on the internet and found that transfer rates range from 10% through to 50%. The Netherlands has a transfer rate of 52%! This surprised me. In the Netherlands, 86% women start in “primary” care (midwifery care), 28% are transferred in pregnancy and 17% are transferred in labour, leaving 41% women birthing with midwifery care. Of this 41%, 30% occurred at home and 11% occurred in hospital.

The St George hospital homebirth program reported a transfer rate of 37% for its first 100 births and this was in a low-risk clientele (at the start of pregnancy). Their outcomes were excellent, however and the satisfaction of the women and midwives using / working in the service was very high.

Private midwives’ transfer rates vary – anywhere from 10% to 40% in some States of Australia as well as overseas. So there’s a wide fluctuation. What can we deduce from these transfer rates?

Well, with the exception of the Netherlands – which has large numbers – we can’t really deduce very much at all. You never can when you’re dealing with small numbers. Private midwives in Australia typically don’t attend more than 25-30 births a year, and some as few as 5 births a year. One transfer in 5 births is 20%, whereas if that same midwife had attended more births without complication, perhaps the transfer rate would have only been 10%.

There are a couple of things to consider with high and low transfer rates:
1. The risk status of the women at booking
2. The midwife’s adherence to safety and risk management guidelines and her outcomes.

The midwife with the lowest transfer rate might simply have a low transfer rate because she only attends very low risk women: women who have birthed without complication before, who have no health history and who have no problems in their current pregnancy.

The midwife with the high transfer rate might not be transferring willy-nilly, she might just be taking on a higher risk group of women and adopting a wait and see approach – eg, “yes, you have a family history of high blood pressure and you’ve had it with every pregnancy thus far, but let’s try some preventative measures and see what happens this time”, and continue with homebirth plans. If this woman’s blood pressure went up, she would have been transferred, contributing to the midwife’s “high” transfer rate. The low risk / low transfer rate midwife might not have accepted this woman for homebirth at all, hence the difference in transfer rates.

The other thing to consider with transfer rates is the midwife’s commitment to safety and risk management. Some midwives may have low transfer rates because the decision to transfer is prolonged, or because risk factors are denied. Is it good to have a low transfer rate if women or babies have been compromised?

But getting back to the question, “If I book with you, what’s my chance of being transferred?”, this question is impossible to answer.
1. We can’t tell the future. Family history and health history might shine some light on possible issues for the pregnancy, but not necessarily. We can’t predict all the paths a pregnancy can follow.
2. A woman’s determination to move towards – and remain in – a state of health and wellness is a life-long journey that pre-dates the pregnancy.
3. Although midwives will make recommendations with the aim of homebirth in mind, it is the woman’s right to consider the advice and decline it. Declining a midwife’s advice may well mean that a transfer will become necessary.
4. Midwives’ statistics are only relevant to her past clients, not the client sitting with her currently.
5. For many midwives, the goal is really safety: safety for woman and baby. We strive to achieve the safest birth in the setting that can best meet the needs of our client.

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Planning a homebirth vs having a homebirth

Posted on May 5, 2012 by Melissa Maimann

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

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

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

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

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The Benefits of Using a Midwife During Childbirth

Posted on May 4, 2012 by Melissa Maimann

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

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

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

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

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

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

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

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

Visit my website to learn more about my services.

Why Birth at Home?

Posted on May 3, 2012 by Melissa Maimann

Homebirth provides a familiar and safe environment for birthing. This helps to keep stress hormones low, and positive birth hormones high, and can therefore make the birth easier and less painful. Women choose a homebirth because they believe in their body’s ability to birth, wish to involve their partner and other children more, or prefer to reduce the chance of intervention in their labour. And becuase let’s face it: pregnancy and birth are normal, healthy and natural experiences. We don’t go to hospital to experience other normal, healthy and natural bodily experiences such as food digestion, urination, menstruation, defecation …. we trust that our bodies work, and that these processes work too.

Women choose homebirth to:
Experience fewer complications in labour
Reduce the need for interventions
Use less pain medication
Remain in comfortable and familiar surroundings
Have a baby who has fewer problems after the birth
Increase their success with breastfeeding
Improve bonding with their baby
Provide a gentle birth for their baby
Involve other siblings and family
Have choice and control
Reduce birth trauma
Receive care from the same midwife right the way through
Benefit from having more choices available
Have a great birth!

Visit my website to learn more about my services.

Birthing in hospital with your own private midwife

Posted on May 2, 2012 by Melissa Maimann

Many women prefer to birth their babies in hospital, but they want to have the same midwife all the way through their pregnancy, birth and post-birth period. It’s about building trust, having a familiar face and being understood and supported. During your pregnancy, we explore what birth means to you and discuss your goals for pregnancy and birth, focussing on what’s important to you, what you need, and looking at ways of making the birth as positive and healthy as possible.

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

Your care

As your private midwife, I provide clinical care, information, advice and emotional support as you journey through your pregnancy and birth. I meet with you regularly in pregnancy so we can learn about each other, and so you can more feel comfortable with me. I help you formulate a birth plan and de-brief previous birth experiences.

When your labour starts, we will be in frequent contact and we will decid whether I should see you at home before heading to hospital, or whether we will meet at the hospital. I will remain your midwife in hospital, caring for you through your labour until your baby is safely born. Early discharge from hospital is encouraged, and we will continue your care at home for 6 weeks.

It’s important to have an understanding of how the general hospital system (public or private) works, to really appreciate why it is so valuable to have your own privat midwife for a hospital birth. Hospital midwives are often busy caring for other women in labour: a hospital-employed midwife often cares for 2-3 labouring women at any given time, while also answering phones, performing administrative roles and so on. When you have your own private midwife with you, she is dedicated to you, and hospital staff are not involved in your care unless invited. This means you have the undivided attention of the midwife you know and trust. Other than your partner and chosen support people, formal birth support is not needed as your private midwife will be right by your side, supporting you all the way.

You benefit from:
- higher chance of normal vaginal birth
- minimal intervention during birth
- professional advice and clinical care
- lowest chance of caesarean
- lowest chance of episiotomy
- lower requirement for pain relief
- higher breastfeeding rates
- lower rates of pregnancy admissions to hospital
- access to midwife means you can change to home birth at any time and have that mifwife as your primary care provider
- midwives can monitor your baby in pregnancy and labour
- midwives can monitor your health in pregnancy and labour
- midwives can liaise with other health professionals if needed

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Is Homebirth Right for me?

Posted on May 1, 2012 by Melissa Maimann

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For most women, home birth is a safe and responsible decision. Homebirth is possible for women who:

Are having their first babies
Are having their second, third or subsequent babies
Have had a previous traumatic birth
Had a very fast birth last time
Prefer a more natural experience
Are healthy

Why choose homebirth?
Some women find that having their baby in the comfort of their home provides a supporting environment.

This helps to keep stress hormones low, and positive birth hormones high, making the birth easier and less painful.

Other women homebirth because they believe in their body’s ability to birth, wish to involve their partner and other children, or prefer to reduce the chance of intervention in their labour.

A number of different research studies have looked into the safety of homebirth – all reliable research has found that for healthy women, homebirth is a safe option.

Keeping Homebirth Safe
A common question I am asked is, “What if something goes wrong?” Private midwives take several precautions to keep home birth safe. This includes things such as:

Screening women carefully so that only low-risk, healthy women birth at home
Careful monitoring during pregnancy and labour to ensure that any possible risks are detected early, allowing time for transfer to hospital or consultation with obstetric staff
Building a relationship with the woman that is based on mutual trust and respect. This is central to an effective relationship between woman and midwife.

Midwives who birth with women at home are educated and experienced to assess the wellbeing of mother and baby throughout pre-pregnancy, pregnancy, birth and the postnatal / neonatal period. Midwives use the ACMI Guidelines for Referral and Consultation to support clinical decision-making in consultation with the client. Of course, with a homebirth, you have the right to make your own informed decisions about your care and your decisions are respected.

The Cost of Homebirth
Some people believe that private / independent midwifery care is expensive. I have prepared the following table to explain how the services are broken down. Home birth services are very comprehensive, and home birth midwives spend many hours with women and their families, building a strong relationship during the pregnancy that carries through to the birth and beyond. Typical home birth services consume a whopping 72 hours of a midwife’s time!

PLUS
On-call – for the duration of the pregnancy: you need to be available for whatever might come up
Research
Administrative tasks
Professional consultation with other professionals on the client’s behalf

As you can see, the service provided by a private midwife is comprehensive and does not compare easily with other maternity services in terms of continuity of care, hours of contact, follow-up and availability. When you choose a home birth with an independent midwife, you are choosing gold standard service.

As you can understand, when midwives provide this level of service, it is impossible to book more than two or three clients each month.

Some women ask me whether I will provide reduced services such as no postnatal care, one or two antenatal visits, a late booking, and so on, in order to reduce the cost. I prefer to provide a comprehensive service and the women who book with me see the value in this approach. A home birth is an investment in you and your baby, afterall. And you deserve the very best.

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Decision-making: Heart and Head

Posted on April 20, 2012 by Melissa Maimann

Through my practice, I have a lot of women coming to me who are experiencing conflict with regards to the choices they have made for their pregnancy and birth. Typically, they find (sometimes quite late in their pregnancy) that perhaps the choice they made right back at the start of their pregnancy, no longer works for the, or the choice that they made was perhaps not as well informed as they thought it was. Some women find it hard to take the attitude of interviewing potential care providers before pregnancy (or very early in pregnancy) and then choosing the midwife or obstetrician who is best able to meet their needs. The end result can often be a woman who chooses an obstetrician with the goal of a natural birth, only to discover that their doctor will only “deliver” their baby if they’re on their back in bed with an epidural in place. Or that induction is performed by 40 weeks, or that all women have their waters broken and all first time Mums have an episiotomy or so on. And sometimes, the more reading a woman does, the more she realises that this is not what she wants.

I often ask the question, “What was it that made you decide on this particular care provider?”

And the responses are generally very interesting.

• My GP referred me
• My mother / sister / friend / neighbour used this midwife and she said she’s wonderful
• Well, when I got pregnant I went to my GP. She asked me if I have private health insurance and I said yes, so she wrote a referral to Dr XX.

I ask these women if they considered any other options. “What options?” comes the response.

I’m amazed that with the marvels of modern technology, internet etc, women don’t know they have other options. We have options with all sorts of things in life, and we don’t shy away from discovering them either! It seems to be to be an interesting handing-over of responsibility when it comes to pregnancy and birth, and I’m curious why it happens with pregnancy and birth, but not in other aspects of life. Do we buy a particular computer – that can’t meet our needs – because it was recommended and we didn’t know there were other computers on the market? Do we buy a large house when we need a small house because it was recommended by the real estate agent?

In most other situations where choices are involved, people will engage in a process of assessing options.

We might list all the possible options and then assess each option across a range of qualities.

We ask questions.

We consider what it is that we really want, and then match it to what’s available, seeking the most compatible choice.

But sadly, this does not happen with pregnancy and birth. Perhaps it should?

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Hospital says No to cesarean

Posted on March 1, 2012 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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“I’ve been told my baby is big”

Posted on February 2, 2012 by Melissa Maimann

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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The Unkindest Cut: Countdown to a C-Section

Posted on January 25, 2012 by Melissa Maimann

Link

… “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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Choosing the best care provider for your needs

Posted on January 21, 2012 by Melissa Maimann

Choosing the best practitioner for your needs is a very important and personal decision. Ultimately, there is no right or wrong choice: some women will choose a private obstetrician, others will choose a private midwife and others will choose public hospital care. Some women will make an initial choice of care provider and decide to change care providers during the pregnancy. Other women will make one choice in their first pregnancy and then a different choice in a subsequent pregnancy. What’s important is to have an accurate understanding all the options available so that you can feel confident to choose the best option for your needs. The best people to talk to are the people who actually provide the service, rather than a GP who is removed from the actual services of an obstetrician / midwife / public hospital. Get referred to a private obstetrician or two; interview them; reflect on how you feel after meeting them. Go and visit your local public hospital. Have a tour and speak with the midwives there. And interview a couple of eligible midwives. You do not need a GP referral to see an eligible midwife and you can claim their services through medicare. An eligible midwife is a private midwife who has met an additional registration standard that enables them to have a Medicare provider number.

When you are considering a care provider, it’s also necessary to consider where you would like to give birth and to ensure that your care provider can attend you in your chosen setting. You might choose to birth your baby in a public hospital as a public or private patient, in a private hospital as a private patient, in a birth centre or at home. It can be helpful when trying to make a decision to write down a list of questions you may have and also consider what is important to you as you make your choices. For example:

What do I want from my care?
What type of practitioner would I feel most comfortable with?
What do I need from my practitioner to feel comfortable and safe?
Do I want public or private care?
Is continuity of care important to me?

These are questions only you can answer. Other questions are for your care providers to answer with you, and it’s a good idea to interview a few care providers – midwives and obstetricians – before making a choice. Midwives and obstetricians will charge a fee for interviews and you are able to claim this through Medicare (your midwife will need to be eligible in order for you to claim a Medicare benefit). It is important during the interview that you ask all the questions that are on your mind, and to be aware of how you feel throughout the interview. Your care provider should inspire you with confidence, help you to feel at ease and comfortable, and the appointment should feel unhurried.

Likewise, your care provider may like to “interview” you, and this is so that your care provider can be sure that s/he can meet your needs. Maternity care is provided in a partnership and so it’s important that both parties feel really comfortable with the other.

There are many questions you might wish to ask your care provider; the best suggestion is to consider what is important to you and write a list of questions.

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Medicare-funded midwifery care: What you need to know

Posted on January 20, 2012 by Melissa Maimann

I am an eligible midwife. This means that my private patients can claim some of the cost of private midwifery care, much the same way we do when we see a GP. As well as Medicare benefits, some private health funds will provide benefits for childbirth education with a midwife, and costs may also be claimed through tax as a medical expense (more on that one from your Accountant). Medicare benefits and tax benefits combined are between $2,500 and $3,300. This means that care with an eligible midwife will be up to $3,300 cheaper than care with a non-eligible private midwife.

What is a Medicare-Eligible Midwife?

In order to claim Medicare benefits from care with your midwife, you will need to ensure that your midwife is eligible. An eligible midwife meets certain advanced requirements of a registration standard:

Current general registration as a midwife in Australia with no restrictions on practice;

Midwifery experience that constitutes the equivalent of 3 years full time post initial registration as a midwife;

Current competence to provide pregnancy, labour, birth and postnatal care to women and babies;

Successful completion of an approved professional practice review program for midwives working across the continuum of midwifery care;

40 hours per year of continuing professional development relating to the continuum of midwifery care (20 hours in addition to standard requirements);

Pregnancy care:

45-60 minute consultations in your home or in my clinic

Childbirth education

Continuity of carer

Medicare benefits

Obstetric back-up

Birth in hospital – or at home

Continue your care with the same midwife you know and trust, with specialist obstetric back-up readily available

Postnatal care

Consultations in your home and / or my rooms

Medicare benefits

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I’m pregnant and I have private health insurance. What are my options?

Posted on January 18, 2012 by Melissa Maimann

Great question! There are a few options available to you as a private patient, as well as all of the options that are available to public patients. The private options are either a private midwife, or a private obstetrician.

Private midwife
To receive care from a private midwife and obtain Medicare benefits, your midwife will need to be an “eligible midwife” (meet an additional registration standard) and work with an obstetrician or a doctor who provides obstetric services. Some private midwives are able to provide labour and birth care in hospital settings, while others are only able to provide labour and birth care at home. All private midwives can provide pregnancy and postnatal care. Hospital options may include private or public hospitals; it’s best to ask your midwife which hospitals she attends births at. Eligible midwives provide complete continuity of care: the midwife you book with will be the same midwife who provides all of your pregnancy, birth and postnatal care.

Private obstetrician
Private obstetricians provide pregnancy, birth and postnatal care, although birth care would also be provided by hospital midwives who may be unknown to you until birth. Private obstetricians deliver babies at public and private hospitals. Continuity is provided during the pregnancy, but birth care is mostly provided by hospital midwives. Postnatal care is almost always provided by hospital midwives, with your obstetrician visiting you each day in hospital and at 6 weeks.

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Physiological third stage for women at low risk of postpartum haemorrhage

Posted on January 13, 2012 by Melissa Maimann

Link

No previous study has focused on true physiological third stage for women at low risk of postpartum haemorrhage. Physiological third stage is often chosen by women who birth at home or in a birth centre, however hospital policies urge active management of the third stage (injection of syntocinon, immediate clamping and cutting of the cord and then pulling the placenta out) because studies have shown that this form of management reduces bleeding. However, it is unfortunate that those studies have either a) not clearly defined physiological management or b) have not managed the “physiological” third stages in a physiological manner. Hence, those studies have shown that active management is the safer option and hospitals have gone with those recommendations.

This study clearly defines what is meant by physiological management and also the women who are suitable for physiological management. Some women are at a higher risk of PPH and so active management was recommended to those women in the study.

The study compared active management which was standard at the tertiary hospital, with physiological management which was the norm at the free-standing birth centre. At the tertiary unit, 11.2% low-risk women experienced a PPH. At the midwifery-led unit, where physiological management was practiced, PPH only occurred in 2.8% women. Active management was associated with 11.5% PPHs compared with physiological management which was 1.7% PPHs. Active management was associated with a seven to eight fold increase in PPH for low-risk women.

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An amazing homebirth story

Posted on January 9, 2012 by Melissa Maimann

Isabel is an amazing, strong woman who came to me for pregnancy care. She had planned to move overseas, and as you’ll read, her pregnancy came as a surprise. She planned a homebirth with a midwife overseas – but the story has a twist in it! We went about the pregnancy, preparing thoroughly for an active, natural and drug-free birth. I was thrilled to receive Isabel’s birth story, and she has kindly agreed to share it here.

Thank You to all the women out there who shared their birth stories and experiences which gave me to determination to birth at home. Now it is my turn to write the story I have been so looking forward to… I hope I help inspire another mum-to-be to have the great confidence in her own ability and her body’s ability to birth her baby safely and naturally…love Isabel xx

Our beautiful birth story of baby Zachary by Isabel and Jed

It started in mid-April when I noticed an unusual change in my body. I pee-ed my pants when I sneezed. Even though I have a very weak bladder control and recurrent cystitis I had never done that before. I decided to get a urine test and after 4 weak positives I decided the product was defective and I needed to go see a real doctor tomorrow.
Half way through a busy day at work as a Veterinarian, caring for animals, it hit me that I might be pregnant and that we weren’t really ready for this big change in our lives. I broke down and cried. I left work early to go see the doctor. Jed met me at the clinic and we saw the doctor together. The doctor promptly told me, “My Dear, there isn’t such a thing as false positive results. Only false negative are possible. You ARE pregnant!”

I guess at that point both Jed and I had a lot of conflicting feelings. We had only just gotten married less than a month ago. We had a wedding dinner to attend in Malaysia followed by a honeymoon which required us to trek over 4000km up a mountain. At the same time it was such a big surprise and blessing to know that we were able to have a baby. We both set about sorting through our feelings and thoughts for a couple of weeks before letting the rest of the family and friends know about it.

It was a smooth pregnancy and we had amazing help and support from friends and family. We learnt so much from our lovely midwife, Melissa Maimann and our ante natal teacher, Julie Clarke. It was basically life changing. I had known I would have needed to hit the books for this but who would have thought I find so much conflicting information. It was hard making the right choices. It was doubly hard to not have my sisters around which I rely on so much for guidance. Jed was so good and read everything I told him to. I only had to chuck temper tantrums once a month. =)

In the end, I decided I wanted to have a home birth because I dislike being told what to do with regards to my body and I strongly dislike needles. I spent a lot of time visualising what my ideal birth/labour would be like and tried to get the support network I needed to achieve this dream. It wasn’t easy finding medical people to agree so in the end I realised it would probably just be Jed, Alicia and my mom helping me. I prayed to whoever was listening that everything would go smoothly and I that neither Zachary or I would not need medical help.

Fast forward about 9 months to December, my mucus plug came out throughout the day on the 13th with no signs of labour. So we decided to head over to the homeopath for back up help if needed to get the contractions going.
Almost a week later, on the 22nd of December my waters broke at 2am. It was such a surreal feeling as I sneezed and wet the bed. I was surprised at how wet the bed was and decided to stand up and this big gush of clear warm water ran down my legs. I then realised that my waters had broken and that I would be meeting my baby today.
I woke Jed up and told him the news. Since there were no signs of contractions once again I decided to take the homeopathic remedy and we both went back to sleep.

By 4am, I was uncomfortable enough to wake up and walk around. I emptied my bowels multiple times and drank lots of water and ate some fruit. At 5am I woke Jed up and told him to pump up the exercise ball and warm up the heat packs. By 6am, contractions were regular and about 15 minutes apart, Jed started filling up the bath tub. However, there was no hot water because the water heater had been turned off. So off he woke mom up to take over comforting me and went to boil many many pots of water.

I sat on the bathroom floor rocking on the exercise ball and constantly visualising a soft open cervix and my baby descending nicely. I breathed nicely through each contraction remember our Calmbirth classes.
Heat packs placed on the lower back and under the belly helped with the discomfort as well.
The exercise ball was good for sleeping and resting on between contractions. Around 7 o’clock the bath tub was finally ready, got in and felt lots better. Alicia came shortly after and took over from mom. She gave awesome back rubs and was such a grounding energy which was exactly what I needed to get things done. Things went quickly after that.

Jed got into the water around 8am and I knelt down with my arms wrapped around him. Contractions were about 5 minutes apart then and required a lot more attention. I kept reminding myself that each contraction meant one step closer to seeing Zachary. I felt him slowly pressing down on my cervix and my cervix dilating.
Vocalising helped during the contractions. Jed was a great help reminding me to breathe and not hold my breath.
He was like a rock I knew I could rely on. Did a few self vaginal exams and could feel Zachary’s head progressing downwards.
At about 8.20am I realised I was in transition, his head was crowning and I wasn’t fully dilated. Was upset and freaked out but Alicia reminded me to trust in my body. Took a deep breath and focused on opening my cervix up. A few minutes later I was ready to push, Zachary came out head first with a hand. I rested for a few seconds till the next contractions came and looked up at Jed and said “Are you ready? He is coming.” Jed caught Zachary Francis McKenna at 8.38am
We were both ecstatic and sat there admiring for a while. He started crying almost immediately and looked around at all of us.
Stood up and tried to birth placenta but couldn’t so I went back to the room. He started feeding soon after and I was enjoying his skin to skin contact. The doctor arrived soon after he advised us to clamp the cord and get the placenta out.
Jed was frantic and really wanted the placenta out because he was worried about bleeding. I was getting a little annoyed by his constant fussing. We clamped the cord and Jed cut it. The doctor applied gentle traction and got the placenta out. Finally we were left alone for some quiet time.

I would like to thank my lovely husband for supporting me through the pregnancy and birth and agreeing to a home birth and studying so hard.
I would also like to thank Melissa and Julie for their teachings which allowed me to have the confidence to do this, although neither of them endorsed free birthing they were not judgmental.

No amount of thank you can express my gratitude for having Alicia around to show me there were many options and that we need to take charge of our own births.
Many thanks to my Mom and Dad for allowing me to use their house. Last of all, Thank You to all the women out there who shared their birth stories and experiences which gave me to determination to birth at home.

Visit my website to learn more about my services.

I’m pregnant! What are my next steps?

Posted on January 2, 2012 by Melissa Maimann

If you have just found out you are pregnant, congratulations! You might be feeling a range of emotions: excited, fearful, overwhelmed, happy, anxious … this is all very normal! Many women who contact me feel unsure about what to do next and are anxious to know all their options before making a choice, so I have put together a few tips to make you feel a little more confident.

Although many women see their GP as their first port of call when they are pregnant, it’s handy to know that women may also see an eligible midwife who can order all the necessary pregnancy tests and any scans that are needed. An eligible midwife can also talk with you about the available options for your pregnancy and birth care, in a relaxed and unhurried setting. An eligible midwife can help you determine your due date and arrange any referrals that you may need. She can book you into a hospital, refer you to an obstetrician if needed, and also provide full pregnancy, birth and postnatal care.

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How do Midwives Work?

Posted on January 1, 2012 by Melissa Maimann

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

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

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

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

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

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

Visit my website to learn more about my services.

Midwives Use Rituals To Send Message That Women’s Bodies Know Best

Posted on December 31, 2011 by Melissa Maimann

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In reaction to what midwives view as the overly medicalized way hospitals deliver babies, they have created birthing rituals to send the message that women’s bodies know best.

The midwife experience uses these rituals to send the message that home birth is about female empowerment, strengthening relationships between family and friends, and facilitating participatory experiences that put mothers in control, with the ultimate goal of safe and healthy deliveries less focused on technological intervention.

These are some of the findings from an Oregon State University researcher and licensed midwife who witnessed more than 400 home births in order to document an extensive list of practices utilized by midwives to express the symbolic difference between home and hospital births.

… “We know, for instance, that midwives have better health outcomes in some areas, such as reduced rates of surgical delivery and labor induction, than hospitals. But I wanted to examine how ritual might play a part in producing these positive health outcomes.”

… evidence shows that hospital births result in about triple the rate of cesarean section for low-risk women compared to midwife-attended home births …

What she found was a network of common practices, messages and beliefs that resulted in midwives constructing woman-centered rituals around pregnancy and birth that were set up in opposition to what they believe are the overly medicalized practices of hospitals.

For instance … midwives conducted many of the same diagnostic procedures as a physician would prenatally, from blood pressure and weight checks to blood testing and fetal heart tone evaluation …

… “Many midwives also downplayed the centrality of monitoring and resuscitation equipment setting them off to the side, or placing them under baby blankets during labor so women would not be reminded of the technology in the room. Mothers and babies were still monitored closely, but the monitoring was not made the central focus.”

The differences aren’t so much in practice … but in performance.

Cheyney also documented the use of common phrases to create birthing mantras. She lists phrases such as “don’t fight it,” “let your body do it,” “open,” and “let it be strong,” as key components … Many mothers … reported feeling strong and capable during their labors, and women who compared their hospital birth to their home birth reported feeling like they were “doing something, rather than just lying there passively waiting.” Midwives also commonly expressed the statement that they were simply “guardians,” and that women have all the tools inside of them to birth their own babies.

… It is Cheyney’s belief that both of these sets of rituals have caused a wide chasm between … hospital births and the 1 percent who choose home births.

“Just as women and their doctors who deliver in the hospital often feel convinced that their birth was the only safe and ‘correct’ way, women and midwives who deliver at home feel strongly that they have the solution,” … “They believe it with every cell in their body because they have lived it.”…

There is definitely something special and unique about homebirth that cannot be summarised in words alone.

Visit my website to learn more about my services.

Hospital births for healthy women? What does the research say?

Posted on November 27, 2011 by Melissa Maimann

The recent Birthplace Study was the first of its kind to compare outcomes for low-risk, healthy women who gave birth in midwife-led units (both alongside and freestanding), obstetric units and at home. My previous blog post described the findings for first-time Mums birthing at home, but what did the findings say about hospital birth?

The study is extremely positive and shows that birth is generally very safe for mothers and babies who are low risk and healthy. In fact, the chance of something going very wrong for the baby was so low that the researchers had to combine mortality and morbidity to get any meaningful data. There were so few deaths in the study (38 out of nearly 65,000 births) that they had to combine a host of adverse outcomes in order to come up with any statistically significant results. Therefore the “primary outcome” included baby deaths and serious morbidity (injury / illness) to the baby. Overall, a low risk woman had a 4.3/1,000 risk of having a “primary outcome” (that is, death or serious injury to the baby). For women birthing in hospital, the figure was 4.4/1,000 and was actually lower for babies born at home and in midwifery-led units. Imagine that: the risk to the baby overall was highest in hospital!

Breaking this down further, if we look at first-time Mums separately to second and subsequent time Mums, the figures look different. First time Mums had a 5.3/1,000 chance of a “primary outcome” overall. This rose to 9.3/1,000 for women who planned to birth at home, and fell to 4.5 for women birthing in a midwifery-led unit. It was 5.3/1,000 for first-time mums who birthed in hospital. Again, we see that hospital birth confers some increased risk for first time Mums.

Now looking at women birthing for the second (or subsequent) time, we find that the overall risk of a “primary outcome” was very low: 3.1/1,000. This was higher in an obstetric (hospital) unit at 3.3/1,000, lower in a midwifery-led unit (2.7/1,000) and lowest for women birthing at home (2.3/1,000). So once again, the study is showing that hospital is not the safest place to birth a baby if you are a low-risk, healthy women.

If you are having your first baby and are low-risk, the safest place to birth is in a midwifery unit, and if you have birthed before and are low-risk, the safest place to birth is at home.

Of course, midwifery units have limited capabilities to provide higher levels of care, and as labour and birth are unpredictable, there needs to be robust transfer arrangements in place. Some 10-45% of women transfer in birth. This figure is lowest for women who have birthed before, and highest in first-time Mums. As well as robust transfer arrangements, women – particularly first-time Mums – need to be aware of the chance of transfer and to be comfortable with this possibility. This is best accommodated if the woman can transfer in with her own midwife.

What were the intervention rates like?

Not surprisingly, intervention rates were highest in women who planned a hospital birth. 93% women who planned a homebirth had a normal birth, versus only 74% women in the hospital. 11% had a caesarean in the obstetric (hospital) unit, versus a mere 2.8% in women who planned a home birth. 24% women had their labours sped up with a syntocinon drip in the planned hospital birth group, versus only 5% in the women who planned a homebirth. 31% women had an epidural in the planned hospital birth group, versus 8% at home. And of course, episiotomy rates were lowest at home.

It is clear that being in hospital greatly increases risks for all low risk mothers compared to being at home or in a midwife led unit (either alongside or freestanding).

It is clear that low-risk women have much to gain by planning a birth with midwives in a birth centre or some other form of midwifery-led care. Planned homebirth does increase the risks to the babies of first-time Mums, with an increase in adverse outcomes for babies from about 0.5% to just under 1%. But what is it about planning a homebirth that increases the risk to the baby? The study used intention to treat analysis, so we are not able to know how many of those adverse outcomes occurred in those who transferred to hospital after a planned homebirth, versus those that happened in the births that actually occurred at home. We do know that the outcomes of homebirth transfers are generally worse than those who had been planned to occur in hospital, and first-time Mums are more likely to transfer. We also know that birth is generally riskier for a first-time Mum than a woman who has birthed before.

Regardless, the study is extremely positive in supporting the role of primary midwifery care and the excellent outcomes that low-risk women can achieve when they choose a midwife as their care provider. Imagine the benefits as well for high-risk women who receive midwifery care with appropriate and timely obstetric care.

Visit my website to learn more about my services.

Turbulent times

Posted on October 28, 2011 by Melissa Maimann

A lot has been happening in the world of homebirth and midwifery. Many will have read the articles about homebirth, freebirth, midwives and maternity care that are appearing in our papers on a daily basis.

I have not posted for a couple of weeks now, for three main reasons: one I have been really busy with my practice which has not been this busy for about two years. Second, I attended the Australian College of Midwives National Conference – the ACM worked really hard to deliver an excellent conference that was appreciated by all. I had the fantastic opportunity to meet midwives from around Australia and share ideas, discuss practice and talk birthy things. I was pleased that the conference was in Sydney, because as those of you who know me will know, in my non-midwifery life I rescue and care for injured and orphaned native birds, and so I was able to make a trip home most days of the conference to feed everyone at home. They were hungry but they all survived! I digress. The third reason for not posting was that the recent issues have made me re-assess things like responsibility, accountability, safety, choice, control, autonomy, beneficence, informed decision-making and many other issues. I have no answers to report. Just lots of reflection.

Midwifery and maternity care are going through turbulent times and as professionals and organisations, I feel that we have done a major disservice to women that they feel safer birthing at home – with or without a registered midwife – in the presence of risk factors – because they so strongly believe that the hospital system will not enable them to birth in the manner of their choosing. It is a sad reflection on the health system and the professionals who work within it. Women who cannot access midwifery care because they are planning a VBAC. Women who are told that if they insist on birthing vaginally with twins, they must accept continuous monitoring, induction, epidural and birth in stirrups for twin two. Women whose only option is to birth in a hospital that is two hours from their home. We have all heard the stories.

My biggest disappointment is the lack of midwife admitting rights. We are one year into the maternity reforms on November 1 this year. We have eligible midwives with Medicare provider numbers, ordering tests and working with doctors to provide safe care to women and babies – yet we cannot access hospitals to provide this care. I well understand that there are a lot of hurdles to be overcome with midwife admitting rights, and life has taught me that nothing in life is impossible.

The release of the homebirth position statement – which I fully support as an evidence-based and safe way to provide care – combined with the lack of midwife admitting rights, is disastrous for women and midwives. Higher risk women are forced into a position of birthing in hospital without their midwife if the midwife complies with the position statement but has no admitting rights – otr else freebirthing, potentially with disastrous consequences. Overnight, this change occurred and women are fuming.

It is impossible to believe, but an eligible midwife who crosses all the “T”s and dots all the “I”s will suffer incredibly in terms of restriction of clientele, however if she were to remove her name from the register – something that I understand is very easy to do – she may do just as she pleases with no accountability, regulation or practice standards. Midwives are placed in the untenable situation of a dwindling practice, or unregistering and having a flourishing practice. Until admitting rights are in place, midwives will have no place to birth with their higher-risk clients. This situation does not see the Government supporting midwives or women. It is creating a disaster.

The various politics of homebirth and midwifery has created an enormous rift between midwives. It seems that there are the bunch who have elected to become eligible, forge ahead with collaborative arrangements, push for admitting rights and accept the increased regulation that is upon us as our profession matures. The other group opposes the increased regulation and restriction of choice, supports midwife- (or non-midwife)-attended homebirth for any woman who wants it and really wants things to just go back to how they used to be, before insurance became mandatory. Many midwives sit comfortable in the middle of this debate. It is sad to watch such division and animosity amongst midwives. We seem to lack a capacity of saying, “We don’t share each other’s vision and we have made different choices, but we are midwives and we will support each other”. As one midwife said to me, “We are each doing the best we can for the women we care for and we’re making the best of a rotten situation”.

I know 2012 will be better than 2011. Who knows? Maybe it’ll be an historic year where for the very first time, women will birth on their own terms, with their chosen midwife, at home or in hospital. I wonder how many women will insist on homebirth in spite of significant risks, if they are able to birth in hospital with their own midwife and in the manner of their choosing.

Visit my website to explore birthing services.

Choosing Your Midwife

Posted on October 3, 2011 by Melissa Maimann

Midwives are qualified and educated to care for women throughout normal pregnancy, birth and the postnatal / newborn period. Midwives are also known as the experts in natural birth, attending water births, home births and hospital births. Finding the best midwife for your needs can be a challenging task, but it’s one of the most important decisions a family will make when they decide to work with a midwife. The midwife’s knowledge, skill and experience are key to a safe and satisfying pregnancy and birth experience.

When engaging the services of a private midwife, most people will make contact by phone call or email, and then arrange for an initial consultation. At the consultation, the midwife and family interview each other to explore whether the relationship feels right for them and meets their needs. Midwives will ask about the woman’s health history, her care needs, her previous birth experiences, her attitudes and beliefs about birth and her expectations of her midwife.

What sorts of questions can women ask their midwife? Well, there are lots of questions you could ask and I’ve included some below.

Be sure to ask about qualifications and experience, including whether your midwife is an eligible midwife. You are able to claim medicare benefits if your eligible midwife has a collaborative arrangement and is able to access obstetric care for you if it becomes necessary. If you are told, “I have three years of experience” ask where that experience was obtained – in a hospital? Private practice? If in private practice, how many births does she attend a year? 2? 20? Generally for private practice, the more experience that is gained, the better: when a midwife works in private practice, she works alone and needs a good level of skill, experience and judgment to practice safely. Experience is always the best teacher.

Ask your midwife about her relationships with hospitals and doctors. This will provide insight into your midwife’s ability to negotiate and communicate.

Many women ask for references but this can be tricky as they would come from former clients of your midwife. This of course brings up issues of confidentiality, and it is against the Public Health Act for midwives to place testimonials on their websites. You can ask your midwife if she has any former clients who would be prepared to speak with you, but be mindful of confidentiality processes and women’s rights to privacy. What your midwife can do, is to provide a summary of the feedback that she has received from her clients. This will tell you that your midwife is engaged in quality assurance processes and would also provide a way of reading feedback from previous clients.

Ask your midwife what her service includes and does not include. Also ask about fees, back-up arrangements and obstetric back-up arrangements.

Are there any questions families should not ask their midwife? Generally, interviews with midwives can be approached as a job interview. Questions that are appropriate in a job interview would be fine to ask your prospective midwife. Questions regarding religion, marital status, age, previous birth experiences, previous terminations and other personal questions ought not be asked.

Finally, it’s really important that you feel comfortable with your midwife and that you feel that you trust her. Reliability is important, as is trust, respect and honesty.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Charging women for non-medical caesareans?

Posted on October 2, 2011 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Visit my website to explore birthing services

Private midwife at public hospital

Posted on September 29, 2011 by Melissa Maimann

Our local newspaper wrote an article about the model of care I am able to offer women:

THE owner of Essential Birth Consulting at Bexley, Melissa Maimann, 33, has become the first private midwife in Sydney to be accredited to deliver babies in a public hospital.

She said this was exciting news for expectant mums who want a personalised delivery but might be experiencing a high-risk pregnancy.

Ms Maimann said her model of care was unique in Australia because it included access to a back-up obstetrician.

“I am able to support women with risk-associated pregnancies because obstetric care is available,” she said. “This is a real benefit to women as often those with high-risk pregnancies are limited to obstetric care with little, if any, midwifery input.”

Ms Maimann, who established Essential Birth Consulting five years ago, has helped deliver about 76 babies.

She was profiled in the Leader last December for becoming the first private midwife in St George to receive accreditation to provide Medicare-funded private midwifery services. This has equated to savings of about $2500 a client.

Ms Maimann limits bookings to an average of two births each month to ensure a high quality service for families. She supports natural births, including water birth, and vaginal birth after caesarean, vaginal twin and vaginal breech births.

“We know that continuity of care is the single most important factor for women in the pregnancy and birth care and I am proud to offer it,” she said.

“Women may have care conveniently in their home or in my Bexley clinic.”

There were 295,700 registered births in Australia in 2009, Australian Bureau of Statistics figures showed.

Details: 0400 418 448 or essentialbirthconsulting.com.au

Midwives still ‘on the fringes’

Posted on September 28, 2011 by Melissa Maimann

A fantastic article that my colleague in WA was interviewed for. It explains the issues perfectly.

REFORMS to the way midwives operate in WA may have been introduced last year, but unless doctors and hospitals get on board, the reforms are meaningless according to Gosnells midwife Pauline Costins.

Mrs Costins is the first eligible private practice midwife in the State following the reforms.

The changes made it possible for her to provide a midwife service not attached to a hospital that women could claim a Medicare rebate for.

Hospitals and doctors play a part in births, at least for most women, especially those with high-risk pregnancies, so there is a level of interaction required between private midwives, doctors and hospitals.

But Mrs Costins said doctors and hospitals had not been receptive to the reforms.

… “I’ve written to 40 doctors and received one response, which was a polite ‘no’.”

… She added many hospitals would not allow her to provide her services in their hospitals

“I can’t take women into hospitals as a midwife, I have to drop them at the door. They don’t want me operating in their hospital.”

Mrs Costins said Kelmscott Armadale Memorial Hospital had made her a casual employee to let her provide her services at the hospital, but that was just a temporary solution.

She added that as well as giving a personalised service, a private midwife … offered six weeks of postnatal care in comparison to hospital midwives who provide about three days.

A spokesperson for the Australian Medical Association WA said the association was willing to meet with midwives to discuss collaborative agreements.

Our experiences in NSW have not been too dissimilar. I have contacted 26 obstetricians requesting a collaborative agreement; I am very fortunate that one Obstetrician has agreed and our model of care is working really well. As for admitting rights (recommended in the Maternity Services Review), NSW is yet to finalise a policy directive to enable midwife admitting rights. This is disappointing for women and midwives alike.

Visit my website to explore birthing services

Study researches birth satisfaction for first time mothers

Posted on September 18, 2011 by Melissa Maimann

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A pilot … study investigating factors that contribute to birth satisfaction for first time New Zealand mothers has led to a bigger nationwide study examining how birth preparation impacts on birth satisfaction.

… birth satisfaction is important because how a mother perceives the birth of her child influences her confidence in mothering abilities and consequently the early mother/child relationship. In turn this impacts on the child’s sense of security as well as family psychosocial health. … women … wanted to feel safe, have good relationships with those caring for them, and to have responsibility for and control over their birth processes.

“… they had a desire to take part in decision-making about medical interventions considered necessary,”

“These factors all contributed towards a woman experiencing birth satisfaction. In particular, vulnerable women appreciated the close relationships they established with their midwives.”

She also found that those women needing an intervention to give birth, such as a forceps delivery, were very grateful that skilled obstetric help was available.

“However, a poor relationship between midwife and specialist could contribute towards distress experienced by the women, as did an obstetrician’s lack of attention to bedside manner,” she says.

“On the other hand … a few minutes taken by the obstetric team to introduce themselves and explain their roles resulted in her retaining a sense of personal control throughout the intervention. This resulted in an empowering and very satisfying birth experience for her, despite the necessity of an unexpected medical intervention” …

Continuity models are becoming more popular, though still not the norm for most women. Private midwifery care delivers the most effective continuity for women, where women choose their own midwife and are cared for by that same midwife for their pregnancy, birth and new parenting experience.

Visit my website to explore birthing services.

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

Posted on September 13, 2011 by Melissa Maimann

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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.

Visit my website to explore birthing services.

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

Posted on September 9, 2011 by Melissa Maimann

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.

Choosing the right care provider

Posted on September 7, 2011 by Melissa Maimann

Choosing the right practitioner is a very personal decision and there is no right or wrong choice. Some women will make an initial choice of care provider and decide to change care providers during the pregnancy other women will make one choice in their first pregnancy and then a different choice in a subsequent pregnancy. What’s important is understanding all the options available so that you can feel confident to choose the best option for your needs.

What do I want from my care?
What type of practitioner would I feel most comfortable with?
Do I want public or private care?

These are questions only you can answer. Other questions are for your care providers, and it’s a good idea to interview a few care providers – midwives and obstetricians – before making a choice. Midwives and obstetricians will charge a fee for interviews and you are able to claim this through Medicare (your midwife will need to be eligible in order for you to claim a Medicare benefit). It is important during the interview that you ask all the questions that are on your mind, and to be aware of how you feel throughout the interview. Your care provider should inspire you with confidence, help you to feel at ease and comfortable, and the appointment should feel unhurried.

There are many questions you might wish to ask your care provider; the best suggestion is to consider what is important to you and write a list of questions.

Visit my website to explore birthing services.

I’m pregnant and I have private health insurance. What are my options?

Posted on September 2, 2011 by Melissa Maimann

Great question! There are a few options available to you as a private patient, as well as all of the options that are available to public patients. Specifically, the private options are either a private midwife, or a private obstetrician.

Private midwife
To receive care from a private midwife and obtain Medicare benefits, your midwife will need to work with an obstetrician or a doctor who provides obstetric services. Some private midwives are able to provide labour and birth care in hospital settings, while others are only able to provide labour and birth care at home. All private midwives can provide pregnancy and postnatal care. Hospital options may include private or public hospitals; it’s best to ask your midwife which hospitals she attends births at.

Private obstetrician
Private obstetricians can provide pregnancy, birth and postnatal care, although birth care would also be provided by hospital midwives who may be unknown to you until birth. Private obstetricians deliver babies at public and private hospitals.

Visit my website to explore birthing services.

Hospital births continuing through our service

Posted on August 29, 2011 by Melissa Maimann

Given the troubled times for midwives attending hospitals in a birth support role – either for planned hospital birth or in a homebirth transfer situation – I have had many calls from current clients and women who are exploring their birthing options, asking if hospital births are still going ahead through this service. I wanted to provide reassurance that yes, my hospital birth service is continuing! I am continuing to take bookings for hospital birth and I am able to attend hospital births in the full capacity of a midwife.

Owing to an ongoing collaborative agreement and hospital arrangements, hospital births are continuing. Women book with me early in their pregnancy and have all of their care with me. Women also see an obstetrician twice in their pregnancy. Birthing takes place in a hospital setting complete with waterbirthing. We support VBAC, twin and breech births. It is an all-risk model too, so women don’t need to be “low risk” to benefit from continuity of midwifery and obstetric care. It also means that there is no “transfer” if a woman’s pregnancy becomes high risk: she can still receive the same wonderful care and support from her chosen midwife and obstetrician.

Hospital staff are not routinely involved in the care of women who book through our service and we have gone to great lengths to create a birth centre feel to the birthing rooms. Rooms are quiet, warm and peaceful and we have a variety of tools available to support natural, active birthing such as floor mats, bath, shower and birth balls and of course many women also choose to bring personal items from home.

After the baby is born, we support early discharge with many women choosing to go home four hours after the birth. Of course women may stay longer if they wish. I visit daily for the first week, twice in the second week and then weekly until discharge at 6 weeks.

Should there be any issues along the way, we have ready access to a specialist obstetrician who is known to the woman from pregnancy.

So the short answer is YES! I am able to continue to attend hospital births and am receiving many calls about the popular model of care.

Visit my website to explore birthing services.

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

Posted on August 21, 2011 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Occasionally she has transferred cases to hospital …

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

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

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

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

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

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

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

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

Visit my website to explore homebirth and hospital birth.

Well-off mothers spend thousands on private midwives

Posted on August 16, 2011 by Melissa Maimann

An article
from the UK explains that women are spending thousands of pounds on private midwives to achieve the ‘perfect’ birth. The situation is not too different to the Australian experience.

In the UK, private midwives charge between £1,800 and £5,000 for a birth, but their services are in high demand from professional, well-educated women who have become disenchanted with the hospital experience. The number of mothers paying for private midwives to attend home births has tripled in the last eight years.

Demand has become so high in parts of London and the South East that some expectant mothers have been unable to find a private midwife to assist them.

Many of the expectant mothers are older and have been put off by previous experiences in NHS maternity wards.

Women who engage private midwives claim they can form a relationship with one person rather than seeing a succession of strangers.

Midwives understand that women want continuity of care and someone to talk to them and answer their questions. Women don’t want routine and unnecessary interventions in their pregnancy and birth, and they want more extensive postnatal care.

The Australian experience is the same as that in the UK. Women seek private midwifery care for home birth or hospital birth so that they can form a relationship with one person who will be with them from their first antenatal appointment, through to birth and 6 weeks after their baby is born.

In Australia, eligible midwives can provide medicare-funded care which makes private midwifery care more affordable to women, thanks to the maternity reforms.

Visit my website to explore homebirth and hospital birth.

Dutch abandon home birth

Posted on August 7, 2011 by Melissa Maimann

A recent article informs us that:

RISK OF DEATH INDUCES DUTCH WOMEN TO ABANDON HOME BIRTHS

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

concern at the disproportionally high baby death rate in home birth

the rising popularity of epidurals, a pain relief option in labour which is only available in hospitals.

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

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

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

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

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

For babies who started labour in primary (midwifery) care: 0.96/1000

For babies who started labour in secondary (obstetric) care: 0.24/1000

For births that took place in primary care: 0.91/1000

For births that took place in secondary care: 0.45/1000

For births that were referred from primary care to secondary care in labour: 1.09/1000

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

The study concludes that:

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

and:

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

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

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

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

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

Homebirth Position Statement

Posted on August 6, 2011 by Melissa Maimann

The Australian College of Midwives (ACM) is Australia’s professional body for midwives. Recently, ACM was charged with the task of preparing a position statement on home birth. This position statement will have a great impact on the future of home birth services in Australia, so it is of enormous significance to home birthing women and their midwives. As well as a position statement, ACM has developed a Guidance which clarifies the expectations for private midwives when providing midwifery care for a planned homebirth.

The documents are:
Literature Review
Homebirth position statement
Guidance for private midwives attending homebirths

Probably the best way to read these documents is to start with the literature review because it provides the context for the guidance and position statement.

ACM’s literature review was restricted to studies which met all of the following criteria:

Studies of planned homebirths with a registered provider/s, compared with planned hospital birth

Research articles that also addressed maternal and neonatal outcomes

Articles from developed countries, written in English and with a publication date between 1995 and 2011.

Any articles that did not describe studies which included a comparison group, investigate planned homebirths or relate to maternal and/or neonatal outcomes were excluded. This rigorous process identified eleven studies which formed the basis of the literature review. The review covered 352,655 homebirths from Australia and around the world.

In general terms, the studies say that for a low-risk, healthy woman and baby, midwife-attended home birth does not increase the chance of the baby dying or being harmed. Home birth does, however, increase the chance that the woman will have a drug-free, intervention-free birth: that her labour will most likely start on its own, progress normally and lead to a normal birth with little likelihood of needing any stitches. Also, she is far more likely to breastfeed and to experience her birth as very positive and satisfying. This is important because it is well-known that interventions carry risks and that there can be a cascade effect, so that when you begin with one intervention, you often end up doing more interventions as the labour progresses (eg induction leading to long labour, leading to epidural, leading to forceps delivery). This is all minimised in the group of women and babies who birth at home with a qualified midwife who has a link in to the hospital with ready access to obstetric and paediatric care if needed.

However, a small number of studies demonstrated that home birth increases the rate of perinatal mortality. The research suggests that the inclusion of high risk factors in home birth, increases the chance of a baby dying or being seriously harmed during birth (most commonly through low levels of oxygen). Other issues may relate to the time and distance to travel from home to hospital during labour if transfer is needed, as well as the woman’s acceptance or refusal of recommended interventions once she has transferred. It is important to note that the outcomes of women and their babies who transfer to hospital during labour will generally compare unfavourably with those not transferred due to the change in risk status of the women.

The ACM concludes that, “It seems evident from the literature that planned home birth is a safe option for women who are at low risk of complications and who receive care from qualified attendants with adequate access to support, advice, referral and transfer mechanisms.”

With that conclusion in mind, the ACM has developed a position statement on home birth, and following on from that, guidance for private midwives who attend home births. Much discussion has been had about these documents on various forums and email lists. Some excerpts from the position statement and guidance follow:

It is the position of the Australian College of Midwives that home is an appropriate place of birth for women considered to be at low obstetric risk, and that women must be supported in safe, planned homebirth, by midwives and/or other appropriately qualified and regulated health professionals with adequate access to support, advice, and referral and transfer mechanisms.

Some women may choose a planned homebirth even when this is not recommended by her care providers. In such circumstances, a midwife should, after discussions with each woman and in consultation with other health professionals, work with the woman looking for options and resolutions within midwifery professional standards to address the woman’s needs.

Following documented discussions and appropriate consultation and referral as may be indicated, a midwife has the right to decline to continue to provide, or to accept, midwifery care if it is felt that this would require the midwife to practise outside of the midwife’s scope, skills and competencies.

Midwives have a duty of care to each woman they provide care to, and this means that in labour, or urgent situations, a midwife must attend the woman.

In the absence of a consistent definition of ‘low obstetric risk’, low obstetric risk is considered to be a pregnancy, labour and birth that are anticipated to be problem free.

There are some contraindications to a planned homebirth which women should be informed of at booking. These are;
• Multiple pregnancy
• Abnormal presentation (including breech presentation)
• Preterm labour prior to 37 completed weeks of pregnancy
• Post term pregnancy of more than 42 completed weeks
• Scarred uterus

Issues identified as “B” or “C” in the Australian College of Midwives National Midwifery Guidelines for Consultation and Referral (“the Guidelines”) would require consultation with an Obstetrician prior to proceeding with a planned homebirth. Consultation is mandatory for the midwife providing care.

Women must be made aware of the midwife’s obligation to consult at – or prior to – booking-in.

Ideally, midwives should meet the criteria for gaining notation as an Eligible Midwife.

Midwives must ensure that they have documented processes in place for consultation and referral

Any decision to provide care for a planned homebirth should take into account the possibility of transfer to a hospital and the time needed for transfer to that hospital in the event that this is deemed necessary. Women should be counselled on the possibility of transfer, and midwives should ensure that the supporting hospital is provided with a care plan/documentation around the woman’s intention for a planned homebirth.

Midwives must utilise documented evidence-based guidelines to support antenatal, intrapartum and postnatal midwifery care.

Midwives should undergo a formal professional peer review process at least once every three years.

At – or prior to – booking, the midwife must advise the woman of situations where homebirth cannot be supported. At any time, the midwife is not obliged to participate in a homebirth that the midwife considers will increase the risk of harm to the woman or her baby.

Women must be respected in the choices that they make, and that includes choices to refuse a recommended course of action at any stage of her pregnancy,

An information pack should be made available to women that should include a ‘Terms of Care’ document outlining the terms under which midwifery care will be provided.
Information should also include the potential for transfer to hospital for unforseen complications.
The following information must be provided to women at the onset of their care, ideally in writing, followed up in discussion and signed by the woman:
• Midwifery scope of practice, including the Australian College of Midwives Guidelines for Consultation and Referral;
• Philosophy of care;
• Choice of birth setting, including requirements for homebirth;
• Contact information for the midwife;
• Back-up arrangements;
• Standards of practice and protocols, including consultation and referral
• Responsibilities of the woman;
• Confidentiality and access to the woman’s records (privacy agreement); and
• Financial arrangements

It’s fair to say that ACM’s position statement and guidance are not ideologically- or belief-driven. It’s clear that the documents are driven by evidence. ACM has tackled the conflicting issue of the woman’s negative right to autonomy versus the midwife’s responsibility to practice safely and within accepted standards of care. While much is being said on various forums, email lists and face-to-face about these documents, somehow, I can’t help but wonder if the issue is really about the restriction of home birth to low-risk women, or the fact that at this point in time, a woman and private midwife have no option but to birth at home.

In the whole of Australia, there is currently no clinical privileging except in one small hospital. A high risk woman’s only option via this new position statement is to birth in hospital, however her private midwife would not be able to attend in the full capacity of midwife – or even as a support midwife: it has recently come to our attention that the midwife cannot legally attend in hospital at all.

I’ll explain why: the MIGA insurance policy covers privately-admitted patients. If the woman is admitted as a public patient after being transferred from a home birth (either in pregnancy or during labour), MIGA insurance does not provide indemnity cover to the midwife in respect of the birth. Most women planning a home birth will have a back-up hospital booking as a public patient. Hence, when the midwife goes in with the woman, the midwife’s insurance does not cover her. It is against the requirements of registration to work without insurance, except at a home birth. In other words, the midwife would be attending the woman in hospital against the requirements of registration.

In time (hopefully sooner rather than later), midwives will have admitting rights where we can admit, care for and discharge our own private patients, all funded by Medicare and indemnified by MIGA but in the meantime, this is not possible.

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

Undisturbed birth

Posted on August 2, 2011 by Melissa Maimann

What is it?

Most animals in labour will separate themselves from other animals and labour alone, often somewhere quiet and dark. Many animals will birth during the night. We often forget this, but human beings are animals too and we share similarities with other animals. It’s often found that women labour best when they are warm, in a darkened, quiet, peaceful and private setting. Like home.

How does privacy and isolation contribute to easier and less complicated labour?

We know from animal experiments that when mice are moved into an unfamiliar environment in labour, their labour is more difficult and longer. Observing the mice also made their labour longer and more difficult. What do we often do to women in labour in hospitals? We observe them in an unfamiliar environment … and wonder why their labour slows. The scenario is compounded when the woman is cared for by unfamiliar staff whom she has not met before, and whom care for multiple women at the same time.

Anything that disturbs a birthing woman’s sense of safety and privacy has the potential to disrupt the birth process.

This is because the hormones that are involved in birth are secreted by the brain, and these hormones need to flow unopposed by hormones that peak when we are fearful, tense and anxious. Anything that inhibits this flow of hormones such as bright lights, unfamiliar sounds, a cold room, beeping, unnecessary conversation, observation and expectations of behaviour – will very likely interrupt the natural birth process, making it longer and more painful.

Ultimately, home is the best environment for promoting a safe, calm, relaxed, peaceful, warm and safe feeling. But not every woman wants a home birth, and not every woman is considered to birth at home (eg with twins, a breech aby, high blood pressure and so on). So the challenge is to recreate the optimal environment in the birth unit. It’s entirely possible! Soft music and lighting, bean bags, floor mats, baths, showers and continuity of midwifery care through pregnancy, labour and the postnatal period are a good place to start!

Visit my website to explore homebirth and hospital birth.

Expectant mothers need facts, not fear

Posted on July 21, 2011 by Melissa Maimann

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

Link

Here we go again. A debate about home vs hospital birth.

There is only one thing … that’s more emotive than where you give birth to a baby, and that is how you feed it.

This week, the Royal College of Obstetricians and Gynaecologists … proposed that more women give birth away from doctors and hospitals. I really want to see how this works, because if there’s anyone more scared of home births than the parents, it’s doctors and midwives. (Note: not all, I know.)

I’m not a doctor, nor a midwife. I have slightly more experience of pregnancy and birth than some, by virtue of being co-founder of a parenting website for the past seven years and working as a lay rep in a large maternity hospital for four. But really, my opinion, just like so many birthing women, counts for little.

Look at what this report says: “The model we are proposing focuses on the needs of the woman and her baby by providing the right care, at the right time, in the right place, provided by the right person and which enhances the woman’s experience.” Sound great, doesn’t it? But who will decide what the right care, at the right time, etc, is? Who listens to what a mother … wants?

Hospitals are so tied by NHS policy and guidelines, and are so scared of being sued that midwives who once were perfectly capable of delivering breech babies, big babies or twins at home (yes, it can be done) no longer can, or do. So it’s easier to book everyone into the hospital. What will change? How will it change? There aren’t enough midwives as it is.

When I decided to try for a home birth I had to take myself out of the NHS system (an option that may no longer exist soon because of the threat to our independent midwives, but that is another story, for another time) because the idea so terrified almost everyone I met. I was simply deemed too high-risk. But this wasn’t based on any analysis of my actual, individual risks. It was because I ticked two boxes: “over 40″ (this is still being cited as a reason not to have a home birth) and “previous C-section” (ditto). One of the paediatricians at the hospital where I was a lay rep told me I was being irresponsible, that my scar would tear (the risk of uterine rupture is, in fact, very small) and that I’d kill myself and my baby.

“Don’t expect us to attend to you” were her actual words. Amazingly, because I wasn’t on a dual suicide/infanticide mission, and I didn’t want to leave my firstborn motherless, I asked two separate, senior midwives to go through my previous notes with a fine-tooth comb. Conclusion: no reason at all not to try for a home birth if you want to …

For many … the thought of giving birth at home is terrifying. I toyed with the idea of a home birth with my first for about 10 minutes. It was only when I saw firsthand what hospitals could offer and after five years of researching birth that I was brave enough even to think about it for my second baby.

I’ll cut to the chase. I had my home birth without drugs or incident. Yes, it was fantastic. No, you shouldn’t have to have a home birth if you don’t want to, no more than I should have had to go to hospital if I didn’t want to. This brings me on to something that no report can ever address, and that’s the baggage we all – health professionals included – bring into maternity services: our own experiences. They should inform, but not dictate.

There is one bit of the report that I think is underplayed: … “Women themselves need the support and encouragement of society, including the professionals, to take responsibility for their own health”. Indeed, we all need to take responsibility for how babies are born. Women need to stop dramatising labour, especially to their daughters. (Maternal influence is huge on a daughter’s subsequent expectation of her own labour.) Health professionals need to stop lecturing a woman on how to give birth and start listening to what women want – and then provide consistent, accurate, non-emotive information to help her set the agenda.

We all need to stop projecting our own experiences and think that’s how it will/should be for everyone else. Only then can we hope to reverse this collective hysteria that surrounds giving birth. People who make TV programmes and films: I have a special message for you, because how you portray birth is so hugely influential. I know it makes for better TV to have a woman on her back, in a hospital, screaming and tearing off her husband’s earlobes, but please, counterbalance this with women also giving birth quietly, in a position other than prone and sometimes at home. It’s partly because of you that it took me nearly 40 years to realise that it could be done.

Melissa Maimann & Andrew Pesce: Collaborating for success

Posted on July 18, 2011 by Melissa Maimann

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

ALTHOUGH only a handful of collaborative arrangements have been signed between obstetricians and midwives since national maternity reforms were introduced in November, calls for a policy rethink are premature and counterproductive.

In fact, the reforms provide an exciting opportunity for collaborative maternity care that is safe, locally responsive and woman-centred.

A variety of private maternity care models are possible and we are confident these will build on Australia’s strong record of safety and quality in maternity care. They will also meet the needs of women who want the familiarity and the comfort of knowing the obstetrician and midwife who will be with them through their pregnancy, birth and new parenting experience …

Obstetricians may be concerned that the new arrangements mean they will not be directly involved in patient care until something goes wrong, while some midwives fear that the arrangements will be used to control midwifery practice, adversely impact on childbirth choices and promote anticompetitive restriction of trade.

We believe we are the first private obstetrician-midwife team in Australia to have successfully negotiated a formal collaborative arrangement and we are very happy with how it has progressed since our first discussions.

The first woman under our joint care gave birth in March this year and we have several others booked through to January 2012.

We share a similar philosophical approach to maternity care and have agreed practice guidelines that we believe to be safe, evidence-based and woman-centred …

… Women appreciate the continuity of care, and the assurance that an obstetrician they have met will be involved if medical assistance is required. Feedback from women so far has been outstanding. The main criticism has been that this model of care is not available in other hospitals.

One of the reasons why there are currently so few collaborative arrangements has been the time taken by the Australian Health Practitioner Regulation Agency to endorse eligible midwives and by public maternity units to credential midwives in private practice.

… Our agreed guidelines are explained to patients before they engage our services and childbirth choices are not restricted. In fact, choices are enhanced as the midwife is able to attend births in the full capacity of a midwife in hospital.

Importantly, our model of care does not dictate “transfer” of care, merely a shift in the balance of obstetric and midwifery care because we recognise that every pregnant woman needs her own obstetrician and midwife. We support midwife care during waterbirth, vaginal birth after caesarean section, physiological birth positioning and physiological third stage.

Change is often difficult as we all tend to be creatures of habit. This change brings with it many opportunities for obstetricians and midwives in private practice to work together in ways that are beneficial to both and, importantly, to the women in their care.

… The maternity reforms will succeed if we remember that midwives and obstetricians are in it for the same reason — to provide safe care that meets the needs of our patients, within a respectful, professional environment.

Dr Andrew Pesce is an obstetrician practising in Sydney and immediate past president of the AMA. Ms Melissa Maimann is a midwife in private practice based in Sydney.

Home birth has pros and cons

Posted on July 15, 2011 by Melissa Maimann

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The number of at-home births is small but growing as pregnant women weigh the idea of a drug-free and surgery-free birth in a familiar setting versus the risk of harm to the baby in case of complications.

When most pregnant women go into labor, they pack their bags for the hospital. When Lara Carlos felt the contractions in November 2008, she set up a birthing tub in her bedroom.

For the next several hours, Carlos alternated between padding around her home and squatting and pushing in the tub. Her midwife poured water down her back and dabbed her forehead with cold towels. When the baby (they chose the name Vincent) arrived at 1:21 a.m., he spent his first few hours cuddling with his parents in their bed.

Carlos … is one of a small but growing number of women who are choosing to deliver their babies at home. Her first son, Ivan, had been delivered in a hospital, and she says she found labor at home a dramatic improvement.

“In the hospital, there were seven medical students in the room when I was pushing my son out,” she said. “At home, it was a very quiet, slow experience, and the water helped me to relax.”

Though home births account for only about 1% of all births each year … they increased by 20% from 2004 to 2008 … The practice is most popular among well-educated mothers who favor natural childbirth without the drugs or surgeries a hospital might use.

… The increase has reenergized the fierce debate over the safety of at-home delivery. The practice is officially frowned on by the American College of Obstetricians and Gynecologists … because the absence of emergency medical equipment and specialists accustomed to dealing with complications means that problems during labor could cost the baby’s life.

“All the existing scientific evidence, as well as state and national statistics, make it ultra-clear that home birth increases the risk of death,” …

The American College of Obstetricians and Gynecologists does acknowledge that home births are associated with fewer medical interventions than hospital births … 61% of women who had vaginal delivery received an epidural in 2008, the year the report studied. And a 2006 national survey of women’s childbearing experiences showed that 55% were given Pitocin to speed labor.

“There’s no doubt that once you end up in a hospital, you end up with more interventions — that’s what drives some families away,” … home birth is reasonable as long as women have few risk factors …, have an emergency backup plan and understand the risks involved.

Women also turn to home birth in order to avoid caesarean sections, which have become more common as obstetricians became increasingly reluctant to take chances at the slightest sign of fetal distress …

What’s more, many hospitals do not allow women who have previously had a caesarean to attempt a vaginal birth because of the risk of uterine rupture, even though a 2010 National Institutes of Health advisory panel concluded that the risk of uterine rupture during a vaginal birth after one caesarean was just 1% and that more women should be offered the choice. Women wishing to have a VBAC (vaginal birth after caesarean) may have no option but to do so on their own turf.

Sarah … had two caesareans but chose a home birth for her third pregnancy, successfully delivering a baby girl in January 2010.

“We had visited numerous hospitals, and the first time I mentioned a VBAC, I was just shut down completely,” Bolson says. Doctors refused to consider it because of the chance of rupture, she recalls, and one said he couldn’t risk having his medical malpractice insurance skyrocket.

She eventually found a certified professional midwife who was willing to help her deliver at home, with a backup plan of transfer to a nearby hospital. Though initially worried about complications, “after I was able to release the fear, I was free to birth without any inhibition.”

Many home-birth moms also say they object to other aspects of hospital births, such as having to lie in a bed, abstain from food during labor and be monitored by an army of nurses.

“I believe in the intuitive power of the human body,” said Mayim Bialik, an actress and natural-birth advocate who has given birth at home. “I believe in having as much privacy as possible, in being able to move freely, to eat when I want, drink when I want, and to be surrounded by the sounds and smells of what is familiar to me.”

“Other mammals go off on their own to labor,” adds Dr. Stuart Fischbein, a Los Angeles-based obstetrician who has been delivering exclusively in homes since 2010. “When a patient goes to a hospital, she gets told to lay flat on her back strapped down with monitors with constant interruptions from hospital personnel — does that sound conducive to having a normal labor?”

Arrangements for a home birth go something like this: Early in the pregnancy a woman finds either a … midwife … The midwife provides some or all of the woman’s prenatal care and is on call as the woman approaches her due date …

During labor, many women use water tubs because they find the water soothing and pain-relieving; others choose to just move about their homes as they see fit. The midwife monitors the fetus’ heart tones with a Doppler device, and most also bring equipment such as oxygen tanks, anti-hemmorhagic medication, local anesthetic and suturing supplies in case of tearing or bleeding. If an emergency arises that the midwife can’t manage, home-birth moms are advised to transfer immediately to a hospital.

The core of the home-birth debate lies with the safety of the baby — and here, opinions and the data are sharply divided. A 2005 study of 5,418 births in the U.S. and Canada during 2000 … found that the neonatal death rates of at-home births were comparable to those of births in hospitals.

But a July 2010 analysis published in the American Journal of Obstetrics & Gynecology examined the outcomes of 12 home-and-hospital-birth studies and found that babies born at home die at two to three times the rate of those born in hospitals …

… the distance to the nearest emergency room can sometimes mean the difference between life and death. “Saying, ‘trust birth’ is like saying ‘trust the weather,’” she says, referring to a slogan occasionally used in natural-birth groups.

Just as vocal online communities have sprung up to promote home birth, so too have others populated by women whose home-birth attempts turned into tragedies … Liz Paparella’s fourth child was stillborn on her living room couch because her midwife failed to take Paparella to the hospital when she began bleeding during labor.

“I never thought it was more dangerous to have a baby at home than at the hospital,” says Paparella, who had given birth successfully at home two times previously. “In birth, the risk can change from low to high in a matter of minutes.”

… A clear answer to the safety question is hard to find because nearly every home-birth study has some flaw that is flagged by one side of the debate or the other as invalidating the results. Given this uncertainty, Ouzounian cautions women to research, prepare and choose wisely.

Home births, he says, should be considered only by those who have a well-trained midwife and are experiencing no complications with their pregnancy …

“Under the right circumstances, with the right patient selection and with a … midwife attending, the overall maternal complication rates with home births are comparable” to those of a hospital birth …

But he also advises women not to think about birth in black-or-white terms: There are many ways to make delivery more “natural” even if it takes place in the hospital …

Fischbein says that doctors could be more accommodating to their patients by providing them with information about all of their birth options — at home and in the hospital — and stand ready to serve as backups for those who wish to labor at home with a midwife.

“There’s room in this world for low-risk home birthing and for hospital birthing,” he says. “We really should support each individual woman’s right to choose how to deliver her baby.”

Rules on patient safety hit midwives

Posted on July 13, 2011 by Melissa Maimann

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

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Homebirth supporters claim bureaucrats are restricting women’s choice by stopping some midwives from managing higher-risk homebirths, particularly women who have had a caesarean delivery.

Homebirth Australia said it was aware of more than 20 recent cases … where midwives had been deregistered or had conditions imposed on their registration because of claims they were working outside safe guidelines.

… The Weekend West is aware of a WA midwife who was ordered last week to stop providing care for planned homebirths in women at higher risk, including those who had a caesarean and wanted to have a normal birth in the next pregnancy.

The Australian Health Practitioner Regulation Agency wrote to the midwife, saying the condition was imposed by the WA Nursing and Midwifery Board because the midwife had not proved he or she could provide a safe homebirth environment for a planned vaginal birth after a caesarean.

“The board formed the reasonable belief that because of your alleged conduct issues, you pose a serious risk to persons, and it is necessary to take immediate action to impose conditions on your registration to protect public health or safety,” the letter said.

… the move could force women to have unattended homebirths, putting them and their babies at risk. “We can’t by stealth deregister or pose conditions on midwives which rob women of access to a registered health professional,” she said.

Australian Medical Association WA president Dave Mountain … questioned whether the health system should allow higher-risk women to exercise the choice of homebirth when there were clear risks for them and their babies.

What a huge ethical debate – largely unresolved. All women have the right to autonomy – the right to make choices, have control over what happens to their body, to accept or reject advice and interventions, to decide when, where and by whom they will be cared for, to access care – or not. It is a fundamental human right that is enshrined in law.

On the other side – the health practitioner has a duty of care to the woman and her unborn baby and is obliged to provide safe care at all times. Safety is defined in terms of what the average midwife would do, or by accepted professional standards, or by laws relating to practice. A health practitioner cannot be incited to practice unsafely: they must make a judgment and adhere to professional standards.

So where does this leave us all when the two positions collide? Although we have guidelines on what we ought to do in those situations, as we can see from the above article, they do not hold water. The consequence for now is an increase in the number of women opting to freebirth – that is an unassisted homebirth (no midwife present). I am hopeful that in time, the regulatory authorities will support midwives to support all women.

Maternity Reforms: Good news for expanded birthing options

Posted on June 28, 2011 by Melissa Maimann

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

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

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

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

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

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

Midwives Deliver Change

Posted on May 19, 2011 by Melissa Maimann

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Midwives are urging all political parties to support the development of birth centres in Ontario …

“Birth centres provide a safe, supportive environment where women can access prenatal, labour, birth and post-partum care,” said Katrina Kilroy, RM, president of the AOM. “We believe they can improve maternal-newborn care while cutting health care costs.”

Birth centres are well established in the US, UK, Australia and Quebec. Ontario midwives currently attend births in both home and hospital, but there is increasing demand from women and families for another out-of-hospital birth option. Birth centres help divert healthy women and newborns from hospital, which in turn lowers costly intervention rates such as c-sections. They provide for community-based care in a family-oriented environment.

… There are over 500 Registered Midwives in Ontario, serving communities in 85 clinics across the province. Midwives have privileges at most Ontario hospitals. They have been provincially funded and regulated since 1994.

A midwife is a registered health care professional who provides primary care to women with low-risk pregnancies. Midwives provide care throughout pregnancy, labour and birth and provide care to both mother and baby during the first six weeks following the birth. The Association of Ontario Midwives is the professional organization representing midwives and the profession of midwifery in Ontario …

Childbirth: More Labor Interventions, Same Outcomes

Posted on May 2, 2011 by Melissa Maimann

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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

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

Posted on April 26, 2011 by Melissa Maimann

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

We’ve received some really positive feedback:

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

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

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

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

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

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

Women having their first babies, maybe feeling unsure of what to expect

Women who previously experienced dis-continuous care from care providers who were unknown to them

Women who are planning a natural birth but perhaps with a more challenging pregnancy

Women who want a home birth / birth centre birth but with a known obstetrician available if needed

Women who really desire a sense of control over their birthing experience

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

Baby death shows need for collaborative care

Posted on April 13, 2011 by Melissa Maimann

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The death of a baby during delivery demonstrates the need for collaborative arrangements between doctors and midwives …

A coronor ruled this week that a baby girl who died of asphyxia … had not been “adequately monitored” during labour and could have potentially been saved if the midwife had referred the case to an obstetrician earlier on.

… coroner John Hutton, made 21 recommendations, many of which involved models of collaborative care to ensure women and their babies are better protected from inadequate care.

President of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), Dr Rupert Sherwood said the inquest highlighted why the college has always insisted on collaborative arrangements between doctors and midwives.

… “This highlights two critical aspects of good collaborative care between midwives and doctors.

“Namely the importance of following established protocols such as fetal heart monitoring when indicated, and timely referral to another member of the team with training and expertise to intervene in a safe and timely manner’ …

Continuity of midwifery care and gestational weight gain in obese women: a randomised controlled trial

Posted on April 6, 2011 by Melissa Maimann

MEDICARE NOW AVAILABLE FOR MIDWIFERY CARE THROUGH THIS SERVICE!
Want to know more about home birth, hospital birth or Medicare-funded private midwifery care? Email Melissa Maimann or call 0400 418 448.

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The increased prevalence of obesity in pregnant women in Australia … is a significant public health concern. Obese women are at increased risk of serious perinatal complications and guidelines recommend weight gain restriction and additional care.

There is limited evidence to support the effectiveness of dietary and physical activity lifestyle interventions in preventing adverse perinatal outcomes and new strategies need to be evaluated. The primary aim of this project is to evaluate the effect of continuity of midwifery care on restricting gestational weight gain in obese women to the recommended range.

The secondary aims of the study are to assess the impact of continuity of midwifery care on: women’s experience of pregnancy care; women’s satisfaction with care and a range of psychological factors.

Methods: A two arm randomised controlled trial (RCT) will be conducted with primigravid women recruited from maternity services in Victoria, Australia. Participants will be primigravid women, with a BMI[greater than or equal to]30 who are less than 17 weeks gestation.

Women allocated to the intervention arm will be cared for in a midwifery continuity of care model and receive an informational leaflet on managing weight gain in pregnancy. Women allocated to the control group will receive routine care in addition to the same informational leaflet.

Weight gain during pregnancy, standards of care, medical and obstetric information will be extracted from medical records …

Increasingly, midwifery continuity models of care are being introduced in low risk maternity care, and information on their application in high risk populations is required. There is an identified need to trial alternative antenatal interventions to reduce perinatal risk factors for women who are obese and the findings from this project may have application in other maternity services.

A fantastic research study and I would be very interested to learn the results. It is well-known that continuity of midwifery care is beneficial for low-risk women; the unanswered question remains: how does continuity of midwifery and obstetric care benefit women with complicated pregnancies? My hunch is that this form of care is most beneficial for women and babies.

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

Baby dies after mum waits five hours for a room

Posted on March 26, 2011 by Melissa Maimann

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

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

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

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

She remembers her baby was still kicking and seemingly fine.

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

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

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

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

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