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Epidural

The Unkindest Cut: Countdown to a C-Section

Jan 25th, 2012
by Melissa Maimann.
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… “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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First-time mums learn the hard way: informed mums choose private midwives

Jan 15th, 2012
by Melissa Maimann.
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A recent article has suggested that first-time mums have overly unrealistic ideas about their birth – that it will be a natural, uncomplicated birth, when in reality it is not, for the majority. We know that women choosing care through the general hospital system will experience high rates of interventions, leading ultimately to a caesarean. But few women know that if they engage a private midwife for a hospital or homebirth, they will experience much lower rates of intervention, but with the same level of safety. Care with an eligible private midwife will attract medicare benefits, and obstetric care is readily available if it is needed. The article below described one woman’s experience of general hospital care. I can only assume that this reporter has written the article in response to the outcry about the original research.

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

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

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

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

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

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

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

“I knew it wasn’t going to be fun.

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

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

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

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

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

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

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

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Thank this doc for the episiotomy you won’t have

Jul 10th, 2011
by Melissa Maimann.
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When you picture a birth activist, you probably imagine a 20-something woman marching in the streets with an enormous belly.

You are less likely to envision a 70-something academic and grandfather.

And yet physician Michael C. Klein has had – and continues to have – a remarkable impact on the lives of mothers and babies around the world.

Klein is the first to admit that he owes a good measure of the birthing wisdom that first sparked his career to a group of midwives he met in Ethiopia, back when he was on a year-and-a-half leave of absence from medical school at Stanford University.

… “The midwives let me catch babies,” …

He was fascinated by natural childbirth: by the way midwives delivered babies without episiotomy …

What he learned from those midwives set the stage for Klein’s entire career, igniting his interest in old and new birth technologies and the need to improve maternity care.

It also set him on a collision course with his professors when he returned to Stanford. “If you want to practice primitive medicine, you will have to go to the county hospital,” he was told. His crime? Delivering babies without episiotomy.

Fortunately, Klein is not someone who is easily dissuaded. Faced with resistance, he simply applies additional gentle, consistent pressure. That was his style then and it continues to be his style today … he reviewed the information on episiotomy in every edition of Williams’ Obstetrics from the 1920s through the early 1990s in his quest to challenge the traditional wisdom about the procedure …

His best-known study … turned decades of obstetrical thinking on its head by demonstrating that episiotomy caused the very types of trauma that it was believed to prevent …

… What drives his research is his concern about mothers and babies … he’s also troubled by the fact that technology is becoming a routine part of the birth environment, even though research suggests that epidurals and non-stop electronic fetal monitoring should only happen when specifically warranted.

“The fundamental problem is not about normal childbirth; it’s about making normal childbirth abnormal,” he explains. “When we treat high-risk women in high-risk settings, we lower their risk. When we treat low-risk women as if they were high risk, we increase their risk and create complications. That is what we are doing today.”

His research has shown that the younger generation of obstetricians (those age 40 or younger) is more likely to support the routine use of technology during birth than older obstetricians … Klein blames this on fear of normal birth, the result of simply not having attended enough normal births to build confidence in the process.

Today it’s midwives who tend to be the guardians of normal birth … midwives’ thoughts and beliefs about birth are very much in synch with those of normal birth.

… the Society of Obstetricians and Gynaecologists of Canada (SOGC)… recently issued a press release objecting to comments he made in a press release issued by the University of British Columbia describing his most recent research.

Klein, in turn, describes the SOGC as a very progressive organization. His issue is with the obstetrical profession as opposed to the SOGC itself: “The problem is that society has invested surgeons with control over normal childbirth.”

He’d really prefer to sidestep the politics entirely to focus on what matters most to him. “I’m primarily interested in the well-being of mothers and babies rather than the internal politics of medicine. I see nothing incompatible with promoting family practice and midwifery.”

Labouring over options for pain relief

May 10th, 2011
by Melissa Maimann.
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Ma.Fe Jackson didn’t want to miss any part of the birthing experience, so she refused to have an epidural …

“Childbirth is very, very painful, but that’s normal and it’s only for a short time,” says the new mom who gave birth in February to first baby, Angelique.

Jackson is Filipino and most Filipinos don’t have epidurals, she explains. Besides, she’s scared of needles, which is how an epidural is administered.

Pain may be a normal part of childbirth, but most North American women today don’t experience it.

In Edmonton in 2009, 57 per cent of the 11,782 women who gave birth in hospital asked for an epidural … The majority of those who didn’t have an epidural had some other form of pain relief …

Thirty years ago only two to four per cent of women had epidurals.

“We only used them for longer, more complicated labours,” … “There was a general desire to have a natural childbirth because there was a feeling that birth had become medicalized.

“Now, I would say the majority of women are coming in and they’ve already decided that they will have an epidural as soon as they get into labour. It’s really swung the other way.”

Even women who plan to have an epidural only as a last resort, usually end up having one …

Dr. Michael Klein, a family physician, pediatrician and neonatologist from Vancouver, thinks the trend reflects the lack of knowledge that women having babies, especially first babies, have about labour and delivery.

His maternity research … shows one-third to one-half … aren’t fully informed about childbirth, including the effects of an epidural.

That may have something to do with the fact that only one-third of first-time moms-to-be sign up for prenatal classes. The majority get their information, or misinformation, as Klein calls it, from highly questionable Internet websites.

A similar survey of 5,000 health providers who care for these women, found they too were similarly lacking in information, says Klein, professor emeritus of family practice and pediatrics at the University of British Columbia, and senior scientist emeritus at the Child and Family Research Institute in Vancouver.

Although the epidural is considered safe, there are risks …

“ … epidural headache, and in very rare cases you could have a significant neurological problem because of it,” …

“ … it will lengthen the first and second stages of your labour significantly, that you’re more likely to have an epidural fever, and that it increases the likelihood of forceps or vacuum … You’re more likely to have an episiotomy or perineal trauma, and the issue of caesarean sections tend to be avoided altogether because doctors actually believe that even an early epidural will not cause a problem.”

… in general, younger obstetricians (under age 40), were more supportive of the role of birth technology in normal birth, including routine epidural analgesia, than physicians over 40, and they were less appreciative of the role of women in their own birth. They also saw caesarean section as a solution to many perceived labour and birth problems.

“ … I think women really need to know the full picture,” he adds. If they were fully informed he believes fewer women would ask for an epidural.

Klein is best known for his research that found routine episiotomies caused the very problems they’re supposed to prevent …

… Klein acknowledges that birth is painful, but argues many women would be able to handle it without drugs if they had support.

“There is a difference between pain and suffering, and no one is in favour of suffering,” Klein says. “You suffer when you are abandoned, when people aren’t there to help you with your pain.

“Nobody is going to deny there is pain in labour nor that it is significant, but if you are cared for by somebody who understands the pain and tells you only have a contraction or two as intense as this until you’re fully dilated and you’ll be much more in control of the pain, if you had that kind of information, you might decide to hold off (having pain relief).”

… “Midwifery intervention has positive outcomes that no other intervention that we have to offer in medicine can even touch. If we all practised that way we wouldn’t be having this discussion,” …

Childbirth: More Labor Interventions, Same Outcomes

May 2nd, 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

Call for ban follows horrific epidural error

Apr 2nd, 2011
by Melissa Maimann.
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MEDICARE NOW AVAILABLE FOR MIDWIFERY CARE THROUGH THIS SERVICE!
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SKIN antiseptics should be banned completely from the sterile equipment table used during epidural procedures to prevent them being injected by accident, recommends an internal Health Department investigation …

Antiseptics should be distinctively coloured so they could not be mistaken for the saline solution injected into the spinal column ….

And anaesthetic procedures should be standardised across all NSW hospitals …

The report into the accident … also contains harrowing new details of how the two clear fluids – decanted into identical metal dishes – were switched while 32-year-old Ms Wang was giving birth to her son …

She suffered severe neurological damage and remains in the hospital’s rehabilitation wing.

Doctors realised a first attempt to introduce the catheter into Ms Wang’s epidural cavity had failed when they noticed blood in the catheter, indicating it had hit a vein or artery …

When the anaesthetic team tried again to insert the catheter, they noticed the fluid had ”a slight pinkish tinge” – which should have indicated it was the powerful antiseptic chlorhexidine.

Instead they assumed it was saline, believing the colour was ”due to the blood contamination from the previous first attempt”, and they went ahead with the procedure.

The doctor withdrew the catheter after Ms Wang called out in pain but by then eight millilitres of toxic antiseptic, mixed with saline from the first attempt, had been infused into her body.

Ms Wang, who remains disabled and in pain, told The Australian Women’s Weekly this week: ”There have been times when I thought that it would be better if I was not here, so that [husband] Jason and Alex can go back to normal life.”

… The report’s authors asked the Health Department to consider using coloured syringe plungers, different-sized syringes or sterile labels to distinguish fluids.

The authors also recommended that the department consider using antiseptics that were more visually distinctive than chlorhexidine as well as impregnated swabs instead of liquid antiseptic.

A NSW Health spokeswoman said the report recommendations had already been implemented at St George and Sutherland hospitals and would be considered in the development of statewide rules …

When Given Control, Women Use Less Epidural Anesthesia During Delivery

Feb 16th, 2011
by Melissa Maimann.
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If women are given control of the amount of epidural anesthesia they get during labor and delivery, they use about 30 percent less medication than when given a standard dose from a doctor …

“We looked at patient-controlled epidural anesthesia, and found the women were basically as comfortable as women on a continuous dose, and there was a 30 percent reduction in the amount of anesthesia used,” …

… The study found no differences in the time of labor, or the rate of Cesarean deliveries … there was a trend toward fewer deliveries that required instrument assistance, such as forceps, in the patient-controlled group …

Women in the patient-controlled group did report slightly higher pain scores when they got to the pushing part of the delivery, but also reported being satisfied with their pain relief overall …

Great results, but not unexpected: this is not a new concept; patient-controlled analgesia is often used for post-operative pain management. Better still is if all women were supported with one-to-one midwifery care for pregnancy and labour, because this form of care carries no risks at all and results in very few epidurals being needed.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Childbirth deaths from spinal anesthesia rising

Jan 4th, 2011
by Melissa Maimann.
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The number of U.S. women who die from anesthesia complications during childbirth has fallen sharply in recent decades. But deaths specifically related to so-called regional anesthesia, which includes epidurals and spinal blocks, have crept upward since the mid-1990s …

… such deaths remain rare. But … the results point to an area where anesthesia can be made safer for women.

… Regional anesthesia is considered quite safe. But in rare cases, patients can have a severe allergic reaction to the anesthetic, or the drug can cause breathing or heart problems.

… researchers found that between 1979 and 2002, childbirth deaths related to any anesthesia complication dropped by 59 percent among U.S. women.

There were three such deaths for every million live births between 1979 and 1990, compared with just over one death per million births between 1991 and 2002 …

However, while deaths related to general anesthesia kept falling in the 1990s, those related to regional anesthesia rose slightly, from 2.5 deaths for every million C-sections between 1991 and 1996 to 3.8 per million between 1997 and 2002.

“I think the main thing is to get good prenatal care, and keep any medical conditions you have under control during pregnancy,” …

What about helping women to prepare and plan for a drug-free birth? This seems like the most logical step. In Australia, almost 50% women have an epidural in labour. If this figure was around 5% (for labour, not caesareans), this would make an enormous difference.

… Most of the women who died – 48 of the 56 — had undergone a C-section. In the rest of the cases, the type of delivery was not reported.

Deaths related to general anesthesia during C-section declined markedly over the decade. From 1991 to 1996, there were 17 such deaths per one million C-sections; that rate fell to 6.5 per million for the years 1997 to 2002.

In contrast, deaths related to regional anesthesia during C-section inched up.

The reasons for the increase are not known … the overall drop in anesthesia-related deaths since the 1970s is likely related to factors like safer drugs, better monitoring of women’s heart rates, blood pressure and oxygen while under anesthesia, and an improved understanding of how individuals can react to anesthesia.

But … the medical profession may have become too narrowly focused on preventing deaths related to general anesthesia, which typically is more risky.

Research in the 1970s and 80s … showed that pregnant women were 17 times more likely to die from general anesthesia than regional. And people reacted to that.

“A good part of our energy was tunnel-visioned toward general anesthesia,” … “Maybe we’ve let the pendulum swing a bit in the other direction.”

It is hard to study the potential reasons for the increase in deaths linked to regional anesthesia, precisely because they are so rare …

Melissa Maimann, Essential Birth Consulting 0400 418 44

Obstetrical anesthesia: new data on the risks

Dec 26th, 2010
by Melissa Maimann.
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Virtually all Los Angeles hospitals offer epidural anesthesia to patients in labor. It allows a remarkable degree of comfort from labor pains …; unfortunately, it is not without risk. In many cases, anesthesia is optional; however, it is a necessity for a cesarean delivery. A new study … reviewed 12 years of obstetrical anesthesia-related deaths … The authors reported 86 deaths that were associated with complications of anesthesia; these deaths represented 1.6% of total pregnancy-related deaths. Pregnancy-related mortality ratios for deaths related to anesthesia was 1.2 per million live births for 1991–2002, which was a decrease of 59% from 1979–1990. Deaths mostly occurred among younger women; however, the percentage of deaths among women aged 35–39 years of age increased significantly. The delivery method could not be determined in 14% of the cases; however, the remaining 86% were in women undergoing a cesarean delivery. Case-fatality rates for general anesthesia were 16.8 per million in 1991–1996 and 6.5 per million in 1997–2002; for regional (epidural or spinal) anesthesia, they were 2.5 per million in 1991–1996 and 3.8 per million in 1997–2002.

Overall, the leading causes of anesthesia-related pregnancy deaths for 1991–2002 were: intubation, … failure or induction (starting general anesthesia) problems (23%); respiratory failure (20%), and high spinal or epidural block (16%) … The causes varied by the type of obstetric anesthesia administered. About two-thirds of deaths associated with general anesthesia were caused by intubation failure or induction problems; however, for women whose deaths were associated with regional anesthesia during cesarean delivery, (26%) were caused by high spinal or epidural block, followed by respiratory failure (19%), and drug reaction.

The authors concluded:

* Anesthetic-related maternal mortality decreased nearly 60% when data from 1979–1990 were compared with data from 1991–2002.
* Although case-fatality rates for general anesthesia are decreasing, rates for regional anesthesia are rising.

Melissa Maimann, Essential Birth Consulting 0400 418 448

‘We know the reality of childbirth’

Dec 22nd, 2010
by Melissa Maimann.
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A new report on NHS maternity care has revealed divisions between midwives and obstetricians. One of the disputes … is over the best way to give birth. While midwives, and the government, advocate natural birth, many female obstetricians opt for a caesarean when they have their own children. Do they know something we don’t?

… Sher, 38, chose an elective caesarean … because she decided it was the safest method … Sher makes decisions on delivery and surgery every day, and she understands the consequences more than most – she is a consultant obstetrician.

One London study … reported that 31% of female obstetricians would personally prefer a caesarean birth. In the US, the figure is almost 50%. Many female surgeons and GPs quietly take this option too – though, as one told me, “to admit as much is still massively un-PC”.

In April 2007, the then health secretary, Patricia Hewitt, launched her strategy for the future of maternity care. Maternity Matters trumpeted “choice”, promising better access to “normal” deliveries via home births and midwife units. Her plans chimed with recent guidelines from the National Institute for Clinical Excellence (Nice) drawn up to reduce caesareans – currently 23% of all births – by advising obstetricians against granting them without medical justification. The official disapproval of elective C-sections means Sher daren’t talk under her real name; Stephanie Sher is a pseudonym.

So while the government promotes “normal” deliveries to the public, its employees are privately planning caesareans. Why do so many obstetricians opt not to push? What do they know that we don’t?

It’s important to remember that it is the obstetrician’s and the surgeon’s task to remedy the rarer complications and consequences of childbirth. Unlike midwives, who oversee successful, normal births every day, doctors bear witness to the worst-case scenarios.

Inevitably this difference in experience manifests itself in an ongoing debate on how best to manage childbirth. Midwife groups advocate normal delivery and “natural” births while obstetricians tend to see medical intervention as a benefit rather than a bane. Yesterday, the healthcare commission published a report highlighting several key problems in Britain’s maternity services, one of which was an inherent tension between midwives and doctors on maternity wards. Caught up in the middle are the mothers.

Maternity experts across the board believe that a straightforward vaginal delivery is by far the best for both mother and baby. Most women agree: 63% of mothers see childbirth as a natural experience that should not be interfered with unless necessary. In “putting women at the centre of maternity provision”, the government’s strategy reflects the overwhelming consensus.

Nevertheless, among all the furore that surrounds the issue of childbirth, for Sher and her colleagues, one thing is clear: the government’s promotion of delivery “choice” is a promise rarely kept. “There is nothing wrong with hoping for a natural event,” Sher says, “and for everything to happen beautifully. But it just isn’t like that for a large proportion of women.”

Sher’s greatest fear was not the pain of spontaneous labour. It was the prospect of emergency intervention, if the birth went wrong. According to the most recent NHS maternity statistics made available (2005-6), just under half (47%) of expectant mothers have a regular, uncomplicated “normal” labour. The rest have interventions ranging from induction, to forceps, to an emergency caesarean. In other words, when a woman tries for a normal birth and the best, safest kind of delivery, she has only a 50% chance of achieving it. For a significant number of others, the birth will be more complex.

I wonder if those women had access to one-to-one midwifery care for their pregnancy, birth and postnatal care? When women are put through a system that sees women having a different midwife at every antenatal visit, shifts of midwives in delivery suite and then shifts of midwives in postnatal, it’s no wonder that most women do not experience a natural birth. bur when women are cared for by the same midwife right from the first visit to 6 weeks postnatal, the outcomes are very different. The ability to develop trust, rapport and understanding are paramount to experiencing natural birth.

With odds like this, it is not illogical to consider alternatives, particularly not if your line of work exposes you to the most extreme of cases. Many obstetricians find the second safest solution is a planned caesarean. The National Caesarean Section Audit (2001) revealed half of obstetricians think this is the safest delivery method for the baby – though not for the mother.

The surgical risks of a planned caesarean include haemorrhage, thrombosis and infection. Scarring on the uterus means the more caesareans you have, the more risky later pregnancies become. But Sher knew she only wanted two children and made the choice that suited her best – both were delivered by C-section. The baby’s safety was her primary motive – but not, she adds, the only one. “The other issue was the risk of pelvic floor damage. Again small, but to me, just not worth it.”

… Michelle Thornton, a colorectal surgeon, sees around 100 women a year suffering from faecal incontinence. “I’m seeing the end result of a traumatic birth,” she says. “Very few of my colleagues would opt for a vaginal delivery and, if any of them asked me, then it’s an elective C-section.”

What about planning for a natural vaginal birth and preparing well for an intact perineum and a short second stage? Private midwives are expert at working with women to achieve these aims. Most women who birth with private midwives do not need stitches and experience a healthy return to normal pelvic floor function.

… Not all experts agree that the risks of a surgical birth outweigh the benefit of protecting the pelvic floor. But calibrating clinical percentages is different from witnessing the lives of women with faecal incontinence, says Thornton. “It’s definitely altered the way I think about childbirth. The thought of being faecally incontinent – to have a life like my patients – I don’t think I’m strong enough.”

… Thornton has half a dozen women in their early 30s. They have “bonding issues with their babies . . . as well as young partners expecting to resume a normal sexual relationship. Two of the couples have split up because of the traumas.” She counsels patients both psychologically and physically. “Emotionally it is tough,” she says. “Having those patients with you when they get upset is tough.” When treatments fail, “it’s terrible, because the patient is absolutely gutted”. Her patients know a permanent colostomy is the only solution. Imparting this news always makes Thornton anxious. “It’s a terrible feeling. It’s like giving them a cancer diagnosis.”

When it comes to medical matters, we assume that knowledge is a good thing. Looking at the childbirth choices made by some female doctors, we might think their superior professional experience makes them right. But many admit their exposure to complications inevitably taints their personal choices. Is it really better to know what they know? Perhaps it’s not that most women don’t know enough – but that female doctors, and particularly obstetricians, know too much.

… If you’ve seen deliveries, she says, “you know the reality.” And “maybe that’s why doctors go and have caesareans – they know it is quite a risky time”.

Interesting, as many midwives opt for homebirths when they have their babies.

Consultant obstetrician Virginia Beckett also puts it plainly: “When I was 14 weeks pregnant I dealt with 12 stillbirths in one 24-hour shift. You can imagine that might skew your view of how to manage your labour.” (Beckett has had two caesareans, the first because her baby was breach, the second was elective). On that particular shift, her baby was too small for her to feel any movement. Emotionally drained and anxious, she scanned herself in the middle of the night. She needed to know her own baby was still alive.

Beckett has worked in obstetrics for more than 16 years, but dealing with stillbirths “doesn’t get any easier”. As the obstetrician, you “go in with the machine and with the patient’s eyes boring in to the side of your head, make the diagnosis and break the news”.

Every time it happens Beckett finds it “heartbreaking, sometimes I do cry actually, not in front of the patient. You feel terrible . . . But there’s nothing you can do.” In the middle of a busy shift there is no time to reflect. “You can’t spend half an hour coming down from every case,” Beckett says, “because there will be another one along in a minute.”

Complications include “abruptions, where the placenta separates and mum and baby can bleed to death. We see people having seizures with pre-eclampsia or eclampsia. We see people’s uteruses rupturing when they’ve had a caesarean section in the past. We see acute fetal distress. We see very complicated vaginal deliveries using instruments, at which various degrees of injury can be sustained . . . All life is here as they say.”

It is the obstetrician’s job to control the less palatable, natural, consequences of childbirth. And they are very good at it. The UK is one of the safest places in the world to have a baby. And of the 1,917 babies born each day in this country, just 11 will be stillborn. “We know that when we work effectively we’re able to make a difference and that’s why we keep doing the job. When it goes to plan, you feel very positive.”

And when things go badly? “You feel absolutely awful: drained and disempowered, really.” Choosing a caesarean, admits Beckett, is one way of redressing this because “you realise how out of control things can be sometimes” and ultimately, “how fragile life is”.

The medics making this choice are unlikely to find support among their colleagues in the midwife unit or even, in some cases, their employers. Current Nice guidelines discourage obstetricians from offering C-sections on “maternal request”. Instead, natural births top the government’s maternity “menu”, with home births promised alongside other “normal” delivery options by 2009.

Privately, however, many obstetricians believe women should be able to choose a caesarean, if they are aware of the risks. Consultant obstetrician Sara Paterson-Brown has publicly asserted a woman’s right to an informed choice because “mothers must live with the consequences”. Her hospital has not since suffered a stampede of women eager for the surgeon’s knife. “Women are counselled and fully informed and recommendations are made,” she says. “We don’t feel threatened by women expressing their choice.”

Paterson-Brown won’t tell me how her own children were delivered, but resolutely feels “the best way to have a baby is normally with no complications. The trouble is, you don’t know if that’s going to be you or not.”

The vast majority of women want a vaginal birth. Just 3% of women even ask for a caesarean without medical indication. Almost 25% will end up having one anyway – largely in emergency circumstances – and a substantial number find their “normal” delivery will go seriously off plan. “There is a lot of luck involved,” says Beckett, “and sometimes the luck isn’t there for you.” Doctors know this, lay women don’t; and when things go wrong, they blame themselves.

Luck? Is it “luck” if we get a uni degree? Is it “luck” if we pull off a dinner party? Is it luck if we get through a very busy week with everything achieved as planned? Or, is it good planning, good information, good support and confidence in our abilities? There is so much a woman can do to achieve a positive, natural birth: she can inform herself, plan for a great birth, increase confidence and engage supportive care providers. Without this, intervention is the most likely result because that is the world we live in today: a world that is fear-ridden and that seeks to control that which we do not fully understand. I believe that most pregnancy and childbirth “complications” are mediated emotionally and mentally. When women are supported, informed, confident, prepared and cared for by a care provider who supports natural birth, she is most likely to birth her baby naturally.

Dr Abigail Fry remembers one birth as a medical student which turned from “calm” to “completely crazy” when a cautious doctor intervened. It became a difficult forceps delivery. Afterwards she remembers “the registrar doing the woman’s stitches and saying: ‘Do you think this bit, you know, should go there?’ And I was like ‘I don’t know!’ It was a mess.” Unlike her obstetric colleagues, Fry chose a home birth.

… “I really enjoyed it.” …

A recent study also found a huge polarity between pregnant women’s expectations of birth and the reality. Expectant mothers need not be frightened by rare, unlikely risks, but they should be given realistic information about the pain and unpredictability of childbirth.

How is that not frightening women? “It’s going to hurt like nothing else … it’ll be excruciating. Oh, and by the way, birth is also unpredictable so don’t have any expectations because they’ll be shattered”. How about, “The sensations of birth can be managed in many ways such as with water, hot packs, movement, position changes (etc). Birth can be unpredictable and so it might be helpful to spend some time going through some of the more likely issues that can come up and to look at how they might be managed at the time.” The latter is far more empowering and less fear-provoking than the former.

Instead there exists a misguided, competitive birth culture; where “lucky” or natural “birthers” are praised for their success, while mothers who “succumb” to medical intervention openly admit they’ve “failed”. Elective caesarean births are so low on the league table they can barely be mentioned without fear of acrimony.

“Women need education,” says Linda Cardozo, a professor in urogynaecology, who blames the “brand of doing it naturally” for this competitive approach as well as the trend for the “madness” of home births. “Most are perfectly safe,” Cardozo admits, “but if something does go wrong you’re in the wrong place to deal with it.” Childbirth is a natural process, but she thinks we’ve forgotten it’s also “a natural process for far more mothers to be damaged and far more babies to die, and medical intervention is absolutely wonderful because it’s prevented that”.

But this does not make Cardozo an advocate of elective caesareans. She remembers colleagues choosing them 20 years ago, but personally felt differently. “You see bad experiences in all deliveries, not just vaginal,” she says, besides which, “I truly don’t believe the risk is worthwhile.

Caesarean section is an operation and all operations carry a complication rate.” So Cardozo did what most women in the UK do, and delivered her three children vaginally, in hospital. Two were twins, one delivered by forceps. “And I’m not incontinent – yet,” she says …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Bathing better than pethidine as pain relief during labor

Nov 20th, 2010
by Melissa Maimann.
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Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

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I’ve often heard it said that the use of water in labour and birthing is better than an epidural.

According to a large survey of new mothers, a bath or a shower relieves pain in childbirth more effectively than anesthetic gas or pethidine. The survey also found that breathing techniques, massage, hot packs and hypnotherapy were more effective than pethidine … and nitrous oxide … The survey has renewed the debate of drug overuse during child birth that could potentially harm babies.

… 77 per cent of mothers said they used drugs in birth to relieve pain, including 56 per cent who had an epidural or spinal block. The survey included 510 first-time mothers and found the most effective pain relief was an epidural or spinal block, with an average rating of 9.1/10. This was followed by breathing techniques, and TENS machines followed by massage, hot or cold packs, showers and baths.

Australian College of Midwives president Hannah Dahlen also agreed that drugs like pethidine were overused. “It’s a real shame on our system for not providing more water…We’re very slow to change old habits and, for some reason, putting a bath in a delivery ward and letting a woman get in it seems a much more scary option for some people than sticking a needle in someone’s spine and filling them up with anaesthetic,” she said.

One-to-one midwifery care from a midwife who is known to the woman and trusted by the woman, is also essential in helping a woman birth her baby drug-free. Support is a vital ingredient!

Melissa Maimann, Essential Birth Consulting 0400 418 448

Your body, your choice

Nov 17th, 2010
by Melissa Maimann.
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The transforming experience of childbirth is increasingly blotted by medical interventions. Are women making informed decisions?

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

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

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

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

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

Wong’s experience isn’t unique.

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

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

Birth trends

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

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

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

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

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

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

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

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

Medical interventions

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

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

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

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

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

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

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

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

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

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

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

The big ‘C’

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

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

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

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

Disturbed birth

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Take control

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

Outdated medical procedure behind catastrophic epidural injury

Aug 24th, 2010
by Melissa Maimann.
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Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

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THE medication practice that led to the catastrophic neurological injuries of a Sydney woman, Grace Wang, during an epidural was phased out of other hospitals more than a decade ago.

Ms Wang was poisoned during the birth of her first child in June at St George Hospital when an antiseptic skin preparation was accidentally injected into her spinal canal in place of an anaesthetic. The case has rocked NSW Health and shocked the public.

The two substances – both clear liquids – were placed in separate dishes on a sterile table in the delivery room, the Herald has learned, and were mixed up as a consequence of being unlabelled. Other hospitals insist drugs are drawn by the anaesthetist directly from their original vial or ampoule into a syringe.

… the practice of drawing medications from stainless steel dishes was routine a generation ago. ”It was identified as being an undesirable and unsafe practice.”

The antiseptic infused into Ms Wang’s spine, chlorhexidine, has increasingly been used in the past five years in NSW because it mixes readily with alcohol, which accelerates drying and the epidural catheter can be inserted sooner.

The chlorhexidine wrongly injected into Ms Wang, who has suffered severe pain and can no longer walk, is understood to have been mixed with alcohol.

… The shift to chlorhexidine has been controversial, and a senior anaesthetist told the Herald betadine – the yellow iodine-based antiseptic which is easily distinguishable from clear epidural drugs – was probably safer …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Toxic epidural ravages mother

Aug 21st, 2010
by Melissa Maimann.
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A very sad story. This family is desperate to hear from anyone who might have experienced anything similar so that they can be guided with treatment.

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ALEXANDER Zheng’s cot is still unassembled in a Sydney apartment where he has never been.

Home, for now, is a bassinet wedged into a room in the high-dependency unit of St George Hospital, where the two-month-old’s mother lies catastrophically injured.

Grace Wang’s spinal canal was injected with a powerful antiseptic instead of anaesthetic, in what should have been a routine epidural to ease the pain of her first child’s birth.

The devastating medical mistake – inconceivable in its magnitude – has poisoned her nervous system, leaving the 32-year-old distressed, confused, in shocking pain and unable to walk or even sit.

She has lost the strength to hold Alex, and rarely asks about her baby, as she did constantly after his birth.

The future may not bring relief, as Ms Wang’s physical and psychological condition has deteriorated since the accident on June 26, and new symptoms continue to emerge.

In the first three relatively hopeful weeks, her husband, Jason Zheng, cooked for Ms Wang and fed and changed Alex, who has apparently not suffered from the drug error.

Now Ms Wang has had surgery to relieve fluid pressure on her brain, and Mr Zheng maintains a vigil beside his increasingly frightened and disoriented wife, leaving little time for his son. The longed-for baby – who followed three miscarriages – is cared for by a nurse the hospital provides. The couple have no family in Sydney, where they migrated from China.

”It’s like we are ignoring that we have a son,” said the distraught father, who will begin legal action.

… Alex snuggles close when placed alongside his mother, but breastfeeding has been impossible for fear the many medicines she is taking may affect the milk.

”Every day she’s suffering and she says she wants to give up,” Mr Zheng said. ”She was crying last night when she touched her son. I just want to change my body to hers.”

Another thing Mr Zheng wants, and which motivated his decision to speak publicly, is to make contact with anyone who has suffered similarly, in the hope their doctors may advise on Ms Wang’s treatment.

Epidural administration of chlorhexidine – used to clean skin before injections and strong enough to neutralise resistant hospital bacteria – is so rare that Ms Wang’s doctors have identified only one other case.

Angelique Sutcliffe, from Britain, was paralysed for life after the chemical entered her epidural in 2001. But this was just a droplet – a fraction of the eight millilitres infused into Ms Wang.

Managers at St George Hospital yesterday admitted error and pledged to support the family, but would not explain the possible source of such a fundamental mistake in a commonplace procedure: nearly 40,000 epidurals were conducted in 2006, the most recent New South Wales statistics show, in 43 per cent of all births.

The state’s Minister for Health, Carmel Tebbutt, said: ”This is an extremely distressing case and I offer my sincere apologies.”

She said investigations had been ordered.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Who controls childbirth: women or doctors?

Jul 15th, 2010
by Melissa Maimann.
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Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

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

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

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

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

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

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

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

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

No answer.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

Anaesthetists object to ‘midwife bias’

Jun 2nd, 2010
by Melissa Maimann.
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Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

Link

Anaesthetists have called for a rewrite of new draft maternity guidelines, arguing that they ignore their role in childbirth, are biased towards the use of midwives and could leave women vulnerable to complications.

The guidelines that are referred to are not legally-binding guidelines, but guidance for how collaboration between midwives and obstetricians could work. Midwives use the Australian College of Midwives’ Guidelines for Referral and Consultation which determine cases that we can look after autonomously and cases that we must refer on. Clearly, administering an epidural in outside the scope of a midwife’s practice, and so of course we would refer such cases to the relevant specialist, being an anaesthetist.

President of the Australian and New Zealand College of Anaesthetists Kate Leslie said the new draft guidelines underplayed the fact that at least 30 per cent of women having a baby opted for an epidural and at least 30 per cent had a caesarean section, which required anaesthesia.

That may well be the case in our obstetrically-led maternity services, however the guidance is for all midwives, including those in private practice and whose working in midwifery-led services such as birth centres. In such settings, epidural and caesarean rates are nowhere near the 30% rates that are quoted. Caesarean and epidural rates are around 5-10%.

The college is incensed that the latest draft National Health and Medical Research Council document – called National Guidance on Collaborative Maternity Care – mentioned anaesthetists just four times.

Professor Leslie said the document “showed overwhelming bias towards the role of the midwife with insufficient guidance on collaboration with anaesthetists”. She said it also favoured midwives over anaesthetists.

There is no overwhelming bias towards the role of the midwife: the midwife is involved in every single birth that takes place in this country, whether pubic, private, operating theatre, delivery suite, birth centre or home. Midwives play a key role in each and every birth, unlike obstetricians and anaesthetists whose expertise is needed in a minority of cases.

“A claim that midwives can provide all aspects of routine pregnancy, labour and birth and postnatal care is misleading,” Professor Leslie said.

It’s actually an accurate claim: we do provide all routine care. We refer on to obstetricians and anaesthetists for care that is non-routine. In this way, we provide a safe and responsible level of care to pregnant and birthing women.

… She said anaesthetists played a crucial role in the antenatal assessment and planning of women with complex medical and obstetric problems and in resuscitating women.

Complex medical and obstetric problems are not managed by the midwife autonomously. They are co-managed by a midwife and obstetrician, and in some cases, they are managed solely by an obstetrician. If the anaesthetists are of the opinion that their role is not respected, they may need to speak with obstetricians who are the ones to manage women with complex medical and obstetric conditions.

Melissa Maimann, Essential Birth Consulting 0400 418 448

The Mother Friendly Childbirth Initiative

Apr 23rd, 2010
by Melissa Maimann.
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Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

Link

… maternal mortality is on the rise in the U.S … two of the four preventable pregnancy-related deaths were associated with cesarean section-the failure of hospital staff to pay attention to worsening vital signs after women have the operation, and the staff’s inability to respond appropriately to hemorrhage resulting from a cesarean. The two others are uncontrolled high blood pressure and undiagnosed fluid build-up in the lungs of women with pre-eclampsia … by following the principles of the evidence-based Ten Steps of The Mother Friendly Childbirth Initiative (MFCI) and giving low-risk women access to midwifery care mothers’ lives could be saved.

… The Initiative is an effective wellness model of maternity care that offers safe choices to overused and costly high-tech birth interventions that often lead to avoidable cesareans …

… compared to maternity care provided by physicians to low-risk women, women cared for by professional midwives have a lower incidence of hypertension and pre-eclampsia, fewer hospital admissions for complications during pregnancy, fewer cesareans and more VBACs … the risks of maternal mortality are increased with repeat cesarean section compared to vaginal birth after a prior cesarean …

The Mother Friendly Childbirth Initiative:

1. Offers all birthing mothers:
• Unrestricted access to the birth companions of her choice, including fathers, partners, children, ¬family members, and friends;
• Unrestricted access to continuous emotional and physical support from a skilled woman—for ¬example, a doula,* or labor-support professional;
• Access to professional midwifery care.

2. Provides accurate descriptive and statistical information to the public about its practices and procedures for birth care, including measures of interventions and outcomes.

3. Provides culturally competent care—that is, care that is sensitive and responsive to the specific beliefs, ¬values, and customs of the mother’s ethnicity and ¬religion.

4. Provides the birthing woman with the freedom to walk, move about, and assume the positions of her choice during labor and birth (unless restriction is specifically required to correct a complication), and discourages the use of the lithotomy (flat on back with legs elevated) position.

5. Has clearly defined policies and procedures for:
• collaborating and consulting throughout the perinatal period with other maternity services, including communicating with the original caregiver when transfer from one birth site to another is necessary;
• linking the mother and baby to appropriate community resources, including prenatal and post-¬discharge follow-up and breastfeeding support.

6. Does not routinely employ practices and procedures that are unsupported by scientific evidence, ¬including but not limited to the following:
• shaving;
• enemas;
• IVs (intravenous drip);
• withholding nourishment or water;
• early rupture of membranes*;
• electronic fetal monitoring;
other interventions are limited as follows:
• Has an induction* rate of 10% or less;†
• Has an episiotomy* rate of 20% or less, with a goal of 5% or less;
• Has a total cesarean rate of 10% or less in community hospitals, and 15% or less in tertiary care (high-risk) hospitals;
• Has a VBAC (vaginal birth after cesarean) rate of 60% or more with a goal of 75% or more.

7. Educates staff in non-drug methods of pain relief, and does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication.

8. Encourages all mothers and families, including those with sick or premature newborns or infants with congenital problems, to touch, hold, breastfeed, and care for their babies to the extent compatible with their conditions.

9. Discourages non-religious circumcision of the newborn.

10. Strives to achieve the WHO-UNICEF “Ten Steps of the Baby-Friendly Hospital Initiative” to promote successful breastfeeding:
1. Have a written breastfeeding policy that is routinely communicated to all health care staff;
2. Train all health care staff in skills necessary to implement this policy;
3. Inform all pregnant women about the benefits and management of breastfeeding;
4. Help mothers initiate breastfeeding within a half-hour of birth;
5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants;
6. Give newborn infants no food or drink other than breast milk unless medically indicated;
7. Practice rooming in: allow mothers and infants to remain together 24 hours a day;
8. Encourage breastfeeding on demand;
9. Give no artificial teat or pacifiers (also called dummies or soothers) to breastfeeding infants;
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospitals or clinics.

Melissa Maimann, Essential Birth Consulting 0400 418 448

FAQs

Apr 15th, 2010
by Melissa Maimann.
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Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

home birth: how messy is it

Homebirth generally isn’t messy. Many women labour and birth in a birth pool and any bodily fluids are easily contained. Towels and plastic sheeting come in handy and midwives are very good at leaving the house as it was found. Plastic bags collect any garbage, the placenta is collected in a bowl or container, and sheets and towels can be washed.

midwives home birth still legal

Yes, it’s still legal and it will remain legal after July 2010.

how many hours a day do you spend breastfeeding

Breastfeeding can take a long time! Some women spend about 50% to 2/3 their time feeding, especially if it’s a newborn baby. Newborns can healthily feed every couple of hours for an hour at a time. This feeding pattern is helpful to encouraging the mother’s milk supple, allowing bonding to occur, help the baby’s palate and jaw muscles to form well and assist the baby’s digestion.

i would like a private midwife but im giving birth at a public hospital

Women may take private midwives with them to pubic hospitals. Women may book into hospital, have all their pregnancy care with their private midwife, birth in hospital with their midwife and hospital staff, and then return home to continue care with their private midwife.

in home birth, what happens if emergency c-section is needed?

In homebirth, midwives are always on the look out for any signs of things not going well in the pregnancy or labour. This allows for women to be seen by doctors or transferred to hospital before true emergencies occur. Most “emergency” caesareans are not in fact emergencies in that they are life and death situations. They most commonly occur because a labour is not progressing and the baby will not come out any other way. However, in the event that a caesarean is needed, the midwife and woman simply transfer to hospital and are offered the best obstetric and midwifery care possible in the circumstances. planning a homebirth does not commit the woman to birthing at home if circumstances make it that hospital would be safer.

what’s the difference between a midwife and obstetrician

Obstetricians are doctors who have completed a degree in medicine and a degree in surgery. They then complete several years of internship and residency before going back to specialise in obstetrics. An obstetrician is a highly trained and educated doctor who specialises in the care of pregnant and birthing women, mostly dealing with complications. Obstetrics is a surgical specialty.

Midwives are qualified to care for women throughout pregnancy, birth and postnatal. They care for healthy women who are experiencing normal pregnancies. If a woman’s condition warrants consultation with an obstetrician, this can be arranged without fuss. Midwifery care generally affords women lengthier consultations, more personalised care and a greater satisfaction with the birth experience. Women who
are attended by midwives are more likely to experience a normal birth, to breastfeed and to receive fewer interventions in their pregnancy and labour such as induction, epidural and episiotomy.

water birth private hospital

Good luck! Private hospitals (in Sydney at least) do not allow for water births. If anyone knows of a private hospital that allows waterbirths, please let me know! Nabmour allows waterbirths but it is not in Sydney.

how to avoid hospital birth

Well, if you don’t go to hospital, you can avoid a hospital birth. I guess the question is – how can you prepare well for a homebirth so that you minimise your chances of needing to go to hospital? I think an excellent approach is to book with a midwife and explain that you would really like her to help you to birth at home.

how to choose a midwife

See here.

limitations of using a private obstetrician for maternity care pregnancy

1. You’re more likely to have intervention in your pregnancy and labour
2. Your obstetrician is likely to work with other obstetricians, sharing on-call over the weekend. So it’s possible that your obstetrician will not be available to you when you’re in labour.
3. You will be attended by hospital midwives in labour and postnatally who you may not have met.

Melissa Maimann, Essential Birth Consulting 0400 418 448

FAQs

Apr 8th, 2010
by Melissa Maimann.
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Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

birthing centre epidural

It’s not possible to have an epidural in a birth centre. If you need an epidural, the midwife will move you to the delivery suite.

epidural private hospital

On the other hand, it’s very pssible to have an epidural in a private hospital. In some private hospitals, almost 90% women have an epidural.

gestational diabetes midwifery home birth

While it might be possible to birth at home with gestational diabetes, it’s best to speak with your midwife.

homebirth midwives central coast nsw

There are no homebirth midwives on the Central Coast. There is one who will travel up from Sydney.

midwife managed pregnancy Sydney

Private midwifery care will enable midwife-managed pregnancy care. With a private midwife, you choose your own midwife and she will provide all of your pregnancy, birth and postnatal care.

no intervention birth

No-one can guarantee no intervention in birth and also guarantee safety. Most births do not need intervention of any kind. No examinations, no induction, no epidural, no caesarean, no forceps or vacuum and so on. But some women, some babies, or some labours will occasionally need some help, and it can be hard to predict at the start of the pregnancy which ones might need help, and which ones are fine. The best strategy would be to contract a private midwife who you trust, and allow her to provide your care in partnership with you.

the right time for consulting mid wife during pregnancy

It’s best to consult with a midwife as soon as you find out you’re pregnant, especially if you’re choosing a private midwife as we tend to book out fairly fast.

Melissa Maimann, Essential Birth Consulting 0400 418 448

FAQs

Mar 20th, 2010
by Melissa Maimann.
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Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

What are the disadvantages of birthing in hospital?

Most women who birth in hospital do not have the same midwife with them throughout pregnancy, birth and the postnatal stay. They have different midwives for pregnancy care, then another lot of midwives for the birth (sometimes 3-4, depending on how long the woman is in delivery suite and whether the midwife has a student midwife working with her), followed by another lot of midiwves who work in shifts in postnatal. The lack of continuity means that the woman does not have the opportunity to really develop a deep sense of trust with her own midwife, something that is intrinsic to positive and safe birthing experiences.

Women who are attended by hospitals have hospital policies drive their care. Policies around induction: when and how it’s done; when a caesarean is done; how often they are to be examined; which women are to be continuously monitored; which babies are to be admitted to the nursery and so on. It’s a bit like checking a box and then applying a treatment or intervention – without first checking if that treatment or intervention is genuinely needed in the woman’s case.

When women have their own midwife with them – either for hospital, birth centre or home birth, they have the full range of options open to thema nd they are fully informed and able to make their own decisions around pregnancy and birth care.

birthing options

To learn more about birthing options, why not come along to the Essential Birth Consulting workshops?

Can I have a midwife as additional support in pregnancy?

Absolutely! It’s a great way to supplement and complement the care option that you have chosen. You can have a midwife as additional support whether you’re going to a public or private hospital, and even if you also have a private obstetrician. See here for details of birthing statistics with and without your own midwife.

midwife medical offset?

It’s called the net medical expenses tax offset. Contact your registered tax agent or accountant for more advice. my understanding is that once you have $1500 in out-of-pocket medical expenses (doctor’s fees, midwifery, prescriptions, optical, dental etc) you can claim 20% the cost through tax.

midwifery care fees

Private midwifery costs somewhere between $3000 and $6000. Essential Birth Consulting has new payment structure where families may choose to pay by the hour, potentially making this the best value midwifery service in Sydney, at around $3000 for a complete package of pregnancy, birth and postnatal care. Birth support is available for around $1500.

Are there any homebirth classed in sydney?

Yes! Why not come along to the Essential Birth Consulting workshops?

access to rebate on midwife visits

After November this year, women who are planning a hospital birth with a private midwife will be able to claim a medicare benefit for midwifery services. The benefit amount is not known at this stage and it is likely that there may be some out-of-pocket expenses too, but it will bring down the cost once Medicare benefits are payable.

Are hospital births unnecessary?

Every woman will need to come to her own conclusions on this one. My opinion is that home is the safest place for a low-risk, healthy woman to birth her baby. Leave hospitals for those who need them! In that case, most women would actually birth at home.

bowral midwife educator

I’d recommend Peter Jackson’s Calmbirth classes.

Can i have an epidural with a midwife?

Absolutely! Although many women find that they don’t need one when they’re cared for by the same midwife and supported well in labour. My experience has been that the call for an epidural is mostly a call for more support and suggestions for getting though the labour. Epidurals are a good option for some women in some labours.

Can midwives administer oxytocin at a home birth?

Yes, if it’s to manage excessive bleeding after the baby is born, but we cannot use it to induce or augment the labour. Those interventions must be attended in the hospital as they carry risks to the baby. Midwives routinely carry oxytocics to births in case they are needed.

Cost of homebirths in the illlwarra

Private midwifery costs somewhere between $3000 and $6000. Essential Birth Consulting has new payment structure where families may choose to pay by the hour, potentially making this the best value midwifery service in Sydney, at around $3000 for a complete package of pregnancy, birth and postnatal care.

Does having gestational diabetes mean a c section?

This would be a good one to ask your care provider. Generally speaking, gestational diabetes does not automatically mean having a caesarean.

Private midwife public hospital sydney?

Yes, it is possible to take your own midwifey with you in a public hospital. This service provides this as an option. Women book with their private midwife, booki into the hospital, receive all of their pregnancy care from their midwife, labour at home as long as possible with their midwife (even having the option of staying home if all is well), head off to hospital when the time is right, and then come home as soon as possible and continue care for 6 weeks. In the hospital, a hospital midwife will also be assigned to you.

Pprivate midwives in Sydney’s east?

Yes, this service provides private midwifery services in the eatern suburbs.

Reasonable obstetricians north shore 2010

What is reasonable? What is important to you? At the end of thr day, it’s about choosing a care provider who is suited to your needs. As experts in abnormal pregnancy and surgery, obstetricians are ideal care providers for risk-associated pregnancies. If your pregnancy is normal and you prefer a more natural option, midwifery care will best meet your needs. Private midwifery is the oldest form of continuity of midwifery care, however there is a price attached to this model as it is a private service. Public options are free but will lead you down the path of hospital policy and interventions.

What is the difference in cost between public and private?

Private has costs attached: obstetrician, paediatrician and anaesthetist fees, private hospital fund excess / co-payment, any other fees and charges from the private hospital (eg TV, phone, parking etc) and also tests and ultrasounds. Public is free if you have a Medicare card.

Transition into parenthood

These are highly recommended childbirth education classes that prepare couples well for the changes in pregnancy, birth and parenthood.

vbac north shore private?

It’s very unlikely to happen at North Shore Private! Around 5% of the women who have previously had a caesarean go on to have a vaginal birth in that hospital. Private midwifery care – either for home birth or hospital birth – increases that percentage to 80-90%.

water birth private hospital sydney

None of the private hospitals in Sydney allow waterbirth. Waterbirth is the norm in a homebirth and may be an option in a public hospital if there are midwives on shift – and baths / pools available – to facilitate this.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Couple sues Redcliffe hospital over stillborn baby

Mar 2nd, 2010
by Melissa Maimann.
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PARENTS of a baby delivered stillborn … claim medical staff repeatedly ignored warning signs their unborn baby was distressed.

… Documents … allege a midwife ignored and turned down the volume of an echocardiogram alarm that sounded for more than three hours …

The documents also claim Mrs Body was diagnosed and treated for deep vein thrombosis and thrombophilia (blood clotting) …

She alleges the hospital ought to have known her medical history and the risks associated and failed to recognise a natural birth “could not be performed safely”.

The documents show Mrs Body was admitted to hospital at 8am on February 26, 2007, and was monitored at half-hour intervals between 9.30am and 3pm.

Her waters were broken by a doctor about 4pm and at 4.30pm an epidural was administered.

It is alleged that at 5.10pm an echocardiogram alarm attached to Mrs Body began making loud noises, but the volume was turned down by a midwife … four other times when the alarm sounded … it was turned down by the same midwife.

Monitors alarm quite often. They do not tell the midwife that the baby is distressed, they prompt the midwife to check the trace and ensure that it is ok. If the midwife determines that the baby is fine, the monitor sound is turned down.

The echocardiogram alarm continued to sound until 8.20pm but medical staff did not respond to it.

It wasn’t until 9.30pm, when Mr Body requested for Mrs Body to have an internal exam that one was performed, court documents claim.

It’s normal practice to leave 4 hours between examinations.

By 10.40pm, Mrs Body was told the baby’s heart rate was “low” and “we need to get her out now”.

This is not an uncommon scenario when a woman has had intervention in her birth. In this case, the woman had her waters broken, had an epidural and presumably also had a syntocinon infusion. All of these can stress babies. I also wonder what position she had been labouring in. It’s common for women with epidurals to labour on their backs and this does not help the baby to navigate the pelvis and be born, and it promotes fetal distress.

Paige Hannah Body was delivered by vacuum extraction about 11pm. She was not breathing and could not be revived … The State Government is yet to file a defence.

Melissa Maimann, Essential Birth Consulting 0400 418 448

FAQs

Feb 23rd, 2010
by Melissa Maimann.
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Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448.

informed consent and childbirth

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

how to minimise labour intervention in a hospital?

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

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

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

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

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

How much is a private midwife

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

What is a good caesarean rate?

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

What is the best hospital in sydney for delivering babies?

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

Is there a birth centre at westmead hospital?

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

C section or natural delivery midwife?

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

giving birth after birth trauma

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

high risk midwife sydney

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

how many births proceed naturally

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

No labouring of point on use of epidurals

Feb 8th, 2010
by Melissa Maimann.
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The use of epidurals in Ireland during labour has roughly doubled over the past 20 years. “This development isn’t a good thing. Because of the increased risk of potential complications during childbirth, administering an epidural during labour is not only undesirable — it’s also often unnecessary.”

That is the message from Dr Denis Walsh, Associate Professor of Midwifery at the University of Nottingham, who says a more naturalistic approach to labour-pain management should be considered.

… “There’s a physiological purpose to labour pain; it’s a natural state rather than a problem. So normal labour shouldn’t need to be treated as a pathology,” said Dr Walsh.

“Administering an epidural can interfere with the body’s natural responses. During labour the body releases endorphins, which not only affect the state of consciousness, but also stimulate movement. Studies have shown that walking and increased physical activity during labour can assist in the process.” An epidural, in most cases, requires that a woman remain in bed.

… Epidurals have been shown to increase the duration of labour, and cause a decrease in oxytocin. Additionally, the baby may become malpositioned to transverse or posterior.

Studies have shown a correlation between the use of epidurals and an increase in the use of forceps to aid delivery, by up to 40 per cent, and some recent research has indicated that epidural anaesthesia can lower prolactin levels in response to breastfeeding in the days following birth.

… women need to be presented with all the information regarding epidurals before undergoing anaesthesia. … “Some 50 per cent [of anaesthetists] didn’t mention the risk of intervention with forceps. The need to communicate all the risk factors is essential.

“… if a woman is in severe distress, or there are complications, of course it should be administered.

“But during a normal birth, there are other ways to make the mother more comfortable,” …

“… it’s the support given to the mother, not pain management, that’s the more significant factor in a positive experience of childbirth. Key to a positive experience is one-to-one support from a midwife.

“… One-to-one support has been shown to reduce the number of Caesareans carried out, and reduces the number of epidurals. A midwife can help in pain management both physically, for instance [with] massage, and psychologically, by offering emotional support.”

Dr Walsh suggests that access to water-immersion facilities … could reduce the need for epidurals. There is evidence to show a correlation between water immersion during the first stage of labour and a reduction in the use of epidurals …

It’s my experience that women who are well prepared for labour and who are supported in their labours with one-to-one midwifery care, do not need epidurals. A mere 3% of women who use my services choose an epidural for their labours and 80% use no pain relief at all.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Pain relief ‘doesn’t lead to more satisfying births’

Feb 7th, 2010
by Melissa Maimann.
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Despite fewer epidurals, the majority of women in midwife-led units were happy with their pain relief.

MOST IRISH first-time mothers opt for the epidural … But reducing the pain levels doesn’t necessarily mean a more satisfying birth experience …

The HSE report involved a study of … women who had babies in the Midwifery-led Units (MLUs) … despite having fewer epidurals, 83 per cent of women in the midwife-led units expressed satisfaction with their pain relief, compared with 68 per cent of women in the consultant-led unit.

… midwife-led care was as safe as consultant-led care, resulted in less intervention, gave birthing mothers greater satisfaction and was more cost-effective.

… the epidural was very effective in complicated labours, for example where the birth was being induced or sped up.

However, in normal pregnancy … three forms of care reduced epidural use: one-to-one care in labour given by a midwife; access to water immersion, … and access to self- hypnosis or hypnobirthing.

“When those three forms of care are widely available for women, we see quite a low rate of epidural, even in first-time births. These forms of care are available in birth centres and in home birth situations … ”

… the downsides of epidural use … included an increase in forceps or vacuum delivery, a lengthening of labour and an increased need for oxytocic drugs to induce labour.

“Research on women’s satisfaction with labour has found that the one-on-one support they got from the midwife was a much more important part of the actual experience than the experience of pain. Paradoxically, a lot of women talk about a high level satisfaction along with a high level of pain.”

Dr Peter Boylan … had a different opinion … “The epidural is undoubtedly the most effective form of pain relief … for a first birth … A lot of women find that it transforms what is a miserable experience into one they actually enjoy because they are not suffering the awful pain,” he said …

Melissa Maimann, Essential Birth Consulting 0400 418 448

The Unkindest Cut

Sep 19th, 2009
by Melissa Maimann.
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“I’m afraid of something happening to me that I don’t want,” I said. The other women nodded their heads. “Yeah,” said another, “when you’re out of it.”

We had been instructed to form a group separate from our partners to discuss our fears about the labor experience and our expectations of what we would get out of this Childbirth Education Class, now in its first session. But for some of us it was like therapy in a bomb shelter. The issue looming overhead was not the risk our own bodies might present to us, but the risks we knew were standard protocol in the hospitals we were suddenly being farmed out to.

… we learned in mid-May that no more births could take place … [at] the Birth Center … the Birth and Women’s Health Center had been part of the for-profit Associates in Women’s Health Care for the past four years. But midwifery, the care provided at the Birth Center, is not terribly profitable when placed alongside the cash cow of modern obstetrics …

… “One cannot help an involuntary process. The point is not to disturb it.” So renowned French physician Michel Odent articulated the philosophy that has been the cornerstone of birth assistance worldwide since human birth began.

… in the early 1800s the average woman in this country gave birth at home attended by a woman midwife … However, in the 1900s birth moved to the hospital, due in part to industrialized America’s starry-eyed wonder at technology and the male-dominated medical profession, and in part because physicians who’d formerly shunned poor women began to offer their services at free clinics for the purposes of experimentation and instruction …

… “Over the past 30 years, obstetric management has converted what should, in most cases, be a healthy, normal process into a high-tech event.” And while some would argue that we’re better safe than sorry in our caregivers’ preparedness for crisis … the vast majority of hospital births in this country find mother and baby at greater risk for complications due to unnecessary medical intervention …

… “The best way to avoid a c-section is to be informed,” … Despite informed consent laws and assurances from administrators that all procedures are the mother’s decision, few women go into labor confident that they know better than their doctors which procedures are useful and when …

… hierarchical protocols in hospitals sharply reduce the authority of midwives in favor of the medical model, making the obstetrician the authority.

Why not trust the obstetrician? Won’t she or he want what is best for the patients? The answer is complex and alarming: Not always … For example, a woman’s likelihood of having a cesarean depends very little on her or her baby’s physical condition. The factors that sway the statistics much more include where she is giving birth (a hospital, freestanding birth center, or at home), who is assisting (an obstetrician, family practitioner, or midwife), hospital culture and policies, and–the strongest determinant–her caregiver’s cesarean rate. These factors influence not only who has cesareans, but who receives most of the medical procedures and drugs currently in fashion. These include fetal heart monitoring (the machine that goes ping!), episiotomies, IV, labor induction, epidural anesthesia, forceps and vacuum delivery and a host of other technologies that studies show compromise the health of the patients with little or no benefit.

One more factor significantly increases the likelihood of unnecessary procedures: profit. Obstetricians often receive hundreds of dollars more for ceseareans than vaginal births, and hospitals can receive thousands of dollars more. An epidural jacks the bill up another grand. Fetal heart monitoring saves hospitals money by allowing one nurse to monitor several babies, as does the heartless practice of whisking the baby away to the nursery once born.

The philosophy of obstetrics management posits that childbirth is a pathological condition requiring the intervention of surgeons. Hospitals are our culture’s centers of crisis and disaster, and that is why the majority of births do not belong there.

… In the 1970s, women’s dissatisfaction with the medical model of childbirth gave rise to the concept of the freestanding birth center. Birth centers, usually located close to but separate from a hospital, provide more supportive, less technologically oriented maternity care for low-risk women by certified nurse-midwives. By 1989 there were 132 freestanding birth centers operating in the US, delivering about 20,000 babies each year … birth centers offered medical care comparable to hospitals for low-risk women, often at half the price …

I asked the eight women in Childbirth Education class if any were planning a home birth, and only one raised her hand … Home birth in Tucson, together with prenatal and postnatal visits by a midwife, costs around $2,000–a pittance compared to the astronomical costs of hospital birth, which can be over $10,000. Ironically, though most of us had been “lucky” enough to have insurance that covered the birth center, none of our plans cover home birth however inexpensive, so hospital birth has become our only affordable choice.

… Now the 49 women who were due to deliver at the birth center next month, and those like myself who were due not long after, are hauling our backaches around Tucson to check out our alternatives.

Melissa Maimann, Essential Birth Consulting 0400 418 448

The great Caesarean section debate

Sep 9th, 2009
by Melissa Maimann.
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PARENTING: WHAT IS IT with Irish women and obstetricians? Most of us feel so much safer putting our pregnancy in their care. That makes absolute sense for the minority of expectant mothers who have complications. But why do the rest of us not see midwives as the experts on normal birth? It is abnormal births that are the business of consultants, …

… “Sometimes the idea of ‘my obstetrician’ is flaunted like a Prada bag. … I have never seen it in any other country to that degree, except in America,” says Krysia Lynch, press officer for the Association of Improvements in Maternity Services (AIMS) – Ireland.

“They feel if they get an obstetrician, somehow it is going to be safer. What a lot of women don’t realise is that what you’re doing with an obstetrician is you are getting continuity of care, that is the only thing that is different; when you are going for antenatal visits you are seeing the same person.

However, when women are in labour, they are cared for by midwives they have not met before, so there’s not true continuity of care.

“But when you have your baby it is the same midwives that will deliver your baby as are delivering the public patient in the next room and I think a lot of woman feel very taken aback by this,” Lynch suggests. (Although I would have thought that at that point in labour, you should be glad that you don’t need the services of your consultant.)

There is plenty of evidence to suggest that the “medicalisation” of straightforward births increases the risk of complications, with one intervention leading to another, until an emergency Caesarean section is the best option. Some pregnant women, terrified of the pain and unpredictable nature of labour, see a planned Caesarean as the best choice from the start.

A planned caesarean can almost be guaranteed, whereas a planned vaginal birth is not a certainty. Women planning vaginal births are sometimes encouraged to also consider the possibility of a caesarean, whereas women planning caesareans are not encouraged to consider the possibility of a fast labour and natural birth. Women who plan caesareans generally want the certainty that a caesarean brings.

This ultimate intervention into the natural birth process has risen dramatically in the past 15 years.

Australia’s CS rate is most likely around 35% now. It was 31% in 2006 and CS rates increase every year. Our low VBAC rate suggests that most women who have a primary caesarean will have an elective repeat caesarean for their next birth. This is contrary to the best evidence around VBAC.

According to the World Health Organisation, Caesarean sections should account for no more than 15 per cent of all births. It found there were no additional health benefits associated with a higher rate.

… There is no doubt that a Caesarean section increases the risk to both mothers and babies, when compared with spontaneous vaginal birth, and it is also significantly more expensive for the health service.

… the reasons behind this increase are much more opaque …

… known risk factors, such as older maternal age at birth and the earlier gestational age of the child, only explained half of the increase in the rate among first-time mothers …

… “If we are saying the section rate is too high, we have to come up with logical reasons as to how we can decrease it.”

I have a few suggestions:
1. Increase the numbers of women who receive primary midwifery care. Encourage midwifery care for all low risk and healthy women.
2. Encourage home as the normal place for birth to occur for all healthy and low risk women.
3. Provide continuity of midwifery care for all high risk women (in conjunction with obstetric care).
4. Ensure that all women having their first babies, all VBAC women and all women who have previously been traumatised by their birth, have continuity of midwifery care.

… Our maternity services certainly have an excellent safety record … Ireland had the lowest rate in the world of women dying during or just after pregnancy – one out of 47,600 women, compared with one in 4,800 in the US …

… the factors at play in driving up the rate of Caesarean births seem to range from medical and health policy issues to cultural and social influences.

The huge variation in rates from hospital to hospital indicates the complexities of the situation …

… Caesarean rates range … from a low of 18 per cent … to 37 per cent …

… we have no national guidelines on Caesarean section … “If we did, and they were applied across the board, we would have possibly lower C-section rates.”

Secondly … “We have a high birth rate, too few midwives; we have quite inadequate circumstances for dealing in proper one-to-one care for women in labour.”

She sees a third major factor being the “inappropriate” use of routine foetal heartbeat monitoring, known as CTG. Research shows that continuous monitoring of the heartbeat leads to a substantial increase in the risk of a woman having a Caesarean section.

… “More C-sections will be performed for abnormal foetal heart rates, but they may not really be abnormal foetal heart rates.”

Fourthly, there is a perception that Caesarean section is a safe and trouble-free intervention – that is a view held not only by the public but also by the consultants, she argues. “Women are not informed of complications.”

… “sometimes come to classes with the notion that maybe they would go for an elective section … It has become sort of accepted that this would be an option. I think some women would be very glad if there was a reason an elective section had to be performed.”

She attributes much of that to fear: “They are not hearing that many good stories from their friends, their sisters and their cousins about birth – particularly birth in the current maternity services. It doesn’t really allow women to build up any degree of confidence.”

What Healy describes as “my precious baby syndrome” among older mothers is also a factor. “They have either waited a long time to have their first baby, or perhaps in some instances unfortunately it took a long time to conceive their first baby.

“People are acutely aware that they don’t have too many shots at this and they need to be taken better care of. In actual fact, Caesarean isn’t safer at all, but the general population thinks that it is.”

When she hears back from clients who have had an emergency Caesarean section, they typically talk about feeling very grateful that their baby was saved and that nothing terrible went wrong.

“That is great, except what I would often question is what went before it? Was there a cascade of intervention that is a well-known phenomenon in the medicalised birth?”

Research shows that continuity of care, typically provided in midwife-led units, and lack of time pressures, increases the chances of a normal birth.

Mothers are not caught in the following cycle: induction causing greater pain, leading to the need for epidurals, which slow down labour, that is speeded up with synthetic hormones, which result in faster and harder contractions, that may distress the baby and require a surgeon to come to the rescue.

… the way to cut the rate of Caesareans is to look at more low-tech solutions and to get more midwives in there.

“Conceiving your baby for most people is not a high-tech activity; birthing your baby also shouldn’t be,” she adds. “If we supported women, they would have a more enjoyable experience, which is a better start to motherhood.”

… the philosophy of any given maternity unit is also influential. “If you have a high section rate, you have a high instrumental delivery rate, you have a high intervention rate.”

The fear of litigation is there, he agrees, but not a significant factor …

… In Dublin’s three public maternity hospitals, the principal increase has been among women who have had previous Caesareans …

… “… Obstetric care doesn’t make sense, unless a woman has complications.”

She believes changes are imminent as policymakers focus on normal birth and the cost of intervention. Positive findings are coming through in research on the few midwifery-led schemes.

“In 10 years’ time I think we will be looking at a very different maternity system,” Donegan says. “But while consultants are seen to be the experts on maternity care, I think Mary Harney is going to have her work cut out for her.”

Melissa Maimann, Essential Birth Consulting 0400 418 448

Outcomes of planned home birth with a registered midwife versus planned hospital birth with midwife or physician

Sep 1st, 2009
by Melissa Maimann.
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More research to prove the safety of low risk home birth. It’s interesting to note that VBACs are included in this home birth study as low risk. For the record, there were 2 uterine ruptures, both in the hospital-doctor-attended births. The rate of rupture was therefore 0.0154%. Much lower than the oft-quoted 0.7%. The midwives must be doing something right!

Giving birth at home with a midwife present is as safe as a hospital delivery accompanied by a doctor, suggests a new Canadian study …

Actually, they got that bit wrong. Midwife-attended home birth was not found to be as safe as doctor-attended hospital birth: it was found to be the safest. The safest way for a low risk woman to birth is at home with a midwife, then in hospital with a midwife, and the most dangerous way to birth, according to the study, was with an obstetrician in hospital.

The study … analysed nearly 2,900 planned home births in British Columbia that were attended by regulated midwives, more than 4,700 planned hospital births attended by the same midwives and more than 5,300 hospital births attended by physicians.

The research found that women who had a planned home birth had a lower risk of having to undergo obstetric interventions such as electronic fetal monitoring, epidural, assisted vaginal delivery and caesarean section, and adverse outcomes such as hemorrhage and infection.

The babies born at home were also less likely to suffer birth trauma, require resuscitation at birth and less likely to have meconium aspiration, where they inhale a mixture of their feces and amniotic fluid.

The perinatal death rate per 1,000 births was also low across all three groups.

But it was lowest amongst the midwife-attended home births.

“The decision to plan a birth attended by a registered midwife at home versus in hospital was associated with very low and comparable rates of perinatal death,” the authors said. “Women who planned a home birth were at reduced risk of all obstetric interventions assessed and were at similar or reduced risk of adverse maternal outcomes compared with women who planned to give birth in hospital accompanied by a midwife or physician.”

The findings add to the ongoing debate about the safety of home births. According to the study, research from North America, the United Kingdom, Europe, Australia and New Zealand has not found a link between planned home births and an increased risk of complications …

This research adds to the growing body of research that is no longer suggesting – but proving – that low risk home birth is safe. I think we can mount a strong case that the Australian Government is now putting women at risk by failing to indemnify midwives for home births after 2010.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Specialists want doctors to reduce c-section rate

Jun 16th, 2009
by Melissa Maimann.
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I was shocked just by the title of this article!

Leaders of Canada’s pregnancy specialists are urging doctors not to induce labour unless there are compelling medical reasons.

The call is part of a campaign to “normalize” childbirth and efforts to reduce Canada’s soaring cesarean section rate. Some studies suggest inducing labour in a first-time mother significantly increases her risk of a C-section.

… Doctors say several factors are driving induction rates, including the number of older first-time mothers, medical legal concerns and convenience.

“[Women may say], ‘My husband is going somewhere, can’t you get my baby out Monday?’ ” …

For most expectant mothers, labour begins spontaneously, at about 40 weeks into the pregnancy.

Induction of labour occurs when medications such as prostaglandin and oxytocin are used when a woman is past her due date to ripen the cervix and get the uterus contracting.

“The message … is, be patient and do not consider inductions before the end of the 41st week,” said Lalonde. “If you wait that extra week to 10 days, you will find that most women … will go into spontaneous labour.”

He says “the number one risk” of induction is that it leads to earlier decisions about a C-section … Nearly 28% of babies were born surgically in Canada in 2007-08 … That’s up from 5% in 1969.

… Induction can lead to longer, more painful labour and continuous electronic monitoring of the baby’s heart rate, which itself increases the risk of C-sections, because it generates “a lot of information. In fact, too much information,” says Dr. William Ehman … “So you are trying to sort out the important things versus what’s not important.”

Research shows that, in healthy pregnancies, checking the baby’s heart rate after contractions by listening, or using a hand-held device, reduces the risk of interventions.

But a recently released Canadian survey of more than 6,000 women who have given birth in the last few years found most women (91%) experienced electronic fetal monitoring during labour …

Ehman worries that women, and their doctors, have lost confidence in the ability to give birth without technological interventions.

… “Nature prepares the uterus better than we can,” Ehman said. “There’s probably a whole host of things that triggers labour in the first place — and mainly it’s probably the baby. So when the baby is ready it facilitates labour by lots of mechanisms that we can’t do.

“We can add these chemicals and get the uterus contracting. But we just know that the numbers say that inductions, if they are done unnecessarily, are going to increase the risk of a C-section.”

A very positive article from a doctor. Unfortunately, it’s what midwives have been saying for many many years. Australia’s CS rate is 31% (well, that was in 2006… I dread to think what it might be now); the CS rate in canada was only 28%. I hope that the changes to the provision of maternity services that are proposed to take place at the end of 2010 will help to bring down our caesarean rate.

Melissa Maimann, Essential Birth Consulting 0400 418 448

The Truth about Hospital Birth: Why Hospital Is Not An Ideal Place for a Natural Birth

Jun 5th, 2009
by Melissa Maimann.
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For further information on hospital birth or natural birth, contact Melissa Maimann at Essential Birth Consulting.

Hospital birth … which woman does not want to give birth in hospital in these days? Ask any pregnant woman where she is planning to give birth, and you will find that 96%+ of them will answer, “hospital”.

Less than 3% women will plan to give birth in a birth centre, and approximately 1.5% to 2% will succeed. 0.2% women Australia-wide will birth at home.

Hospital has been the first choice for women who are planning to give birth. Women choose to have their babies in hospitals because they are afraid not to. They are scared that if something goes wrong and they are not in hospital, that their baby will die, or that they will be harmed. They think that having a baby is like undergoing a major medical event so that they feel safe to be close to modern technology and a skilled obstetrician. The more the obstetrician costs, they better they must be. The more equipment and technology available in the hospital, the better it must be.

They are equally scared that if they don’t have a hospital birth, then they or their babies would die. In short, women no longer trust their body to give birth, despite the fact that it has been shown throughout centuries that women’s bodies are perfectly suited to give birth.

Some people argue this point, saying that mortality rates have come down dramatically since we moved birth to hospitals. And yes, mortality has come down and birth has moved to hospital. But it is not a cause-and-effect relationship. In fact, when birth moved to hospitals, MORE women and babies died. They died of infection because doctors would work on cadavers and then attend women in birth. They did not know about infection control.

The mortality rate came down after sanitation improved. Another important change was the development of a transport system that saw food being delivered to people year-round – fruit especially. Improved education and literacy also made a big impact. This all combined to improve the health of women and babies. Later, when contraception became more widely available, women were able to space their children, and this too meant healthier women and babies.

It is very rare, that a woman asks herself whether labour and childbirth are really life threatening and dangerous. This is because all women today are being bombarded practically from childhood to womanhood by the message that childbirth is dangerous. The fact that media portray that childbirth is full of complications and that most women will need medical help to give birth helps to reinforce this myth. How many TV shows depict birth as being easy, safe, painless and non-technical? Very few. And many women poo-haa those scenes saying, “oh, she must have been lucky”. Luck has nothing to do with it. Preparation, choice of care provider and place of birth, and determination have everything to do with it.

For most women, labour and childbirth are normal events.

Labor And Childbirth Are Normal Events
Women who are healthy and have low risk pregnancies should be able to give birth naturally if they are given correct information and preparation on how to do so. I am not of the belief that women need any pain relief in a normal labour. And without the use of pain relief, the vast majority of women will birth without complication.

Most Childbirth Complications Are Iatrogenic
Complications and/or horrible birth experiences that some of these supposedly low risk women experience are not caused by their body’s inability to give birth, but are often caused by medical interventions introduced one after another, during the hospital birth.

It looks something like:
- have an induction because you’re a couple of days past your due date
- this involves giving you gel so your cervix softens
- when your cervix is soft, your waters will be broken
- you will then need a drip to start labour
- because you have a drip (which can stress the baby), you will need continuous monitoring of your baby’s heart rate – that’s that monitor that they strap to your belly. Or, the staff may screw an electrode into your baby’s head and you will have 1 less belt on your tummy
- the drip will be increased until you are in good strong labour
- hopefully this process does not stress your baby. But most likely, it will stress you.
- unable to access the bath or shower or move into positions that help your body to birth your baby, you will need pain relief.
- you start on the gas
- the contractions are too strong for the gas
- you accept a dose of pethidine or morphine
- that wears off.
- you accept an epidural
- you will be examined regularly to assess progress
- you are now in bed, immobilised.
- your baby cannot move effectively through your pelvis
- your baby, unable to descend through your pelvis aided by gravity, and pounded by strong contractions, may become distressed
- if you are not yet fully dilated, you will have a caesarean
- if you are fully dilated, you will have forceps or a vacuum. Maybe an episiotomy too. And stitches
- you have an injection to speed the delivery of the placenta. Your uterus may be tired from the strong syntocinon-induced contractions. You may have a post-partum haemorrhage.

That’s called the cascade of intervention. Google it. It makes for interesting reading!

It is clear that for the most part, it is the hospital or doctor that causes the unnecessary complication of what is supposedly to be a low risk labour. This is achieved by interfering with the course of normal pregnancy or labour every step of the way. One intervention simply leads to another. Sometimes, it even starts in pregnancy with an ultraound because the baby is too big ….

In the scenario described above, see if you can count how many interventions the woman had (answers at the bottom). Let me know if I’ve missed any!

Of course, medical technology can be a life saver for true emergency situations. And I wholeheartedly promote hospital birth for high-risk women. But, the majority of women are not in this category. According to WHO, 80% women have healthy pregnancies.

You may have heard the legal phrase, “innocent until proven guilty”. Unfortunately, this does not apply to pregnant and birthing women in the hospital system. They’re guilty (high risk) until proven innocent (low risk) …. and unfortunately, that’s not until after the labour is over. In obstetric terms, birth is only normal in retrospect. Whereas midwives will always look for normality.

It is therefore not surprising that with this kind of birthing philosophy, birth becomes a more and more of a medical event rather than a normal family event.

Fetal Monitoring
Aside from this kind of obvious interventions, there are other routines along with the ‘dos and don’ts’ within the hospital policies that can potentially cause complications. The routine use of fetal monitoring during hospital birth, for instance, may seem harmless. But it also means you’ll have to lie still for the duration of the monitoring. You may be able to assume other positions, but continual movement will not permit the monitoring to pick up the baby’s heart rate. Unless a “clip” – read – thin wire that’s screwed into the baby’s head – is used.

To make things worse, the trace obtained from this machine (CTG) is often misinterpreted. Studies have shown that if you show the same trace to several people, they’ll all give different interpretations. And if you show the same trace to the same person, a few times over, each time the person will give a different opinion regarding the welfare of the baby.

Indeed, it has been shown that the use of CTG is associated with a dramatic increase in caesareans, without providing an improvement in outcome, compared to the use of the doppler to monitor the baby’s heartbeat.

Hospiral Policies
Interestingly, a lot of hospital policies are not in place to make birth easier. You would think that hospitals would help you to have a more natural experience. Rather, they are designed for the sake of efficiency and legal protection. As an institution, hospitals are more interested in managing the patients, than accomodating every client’s whim. The welfare and feelings of the woman are often taken out of the equation in the policy-making process. As long as the woman and baby are alive at the end of the process, it doesn’t matter whether women and babies are suffering unnecessarily. Suffering is hard to measure legally, whereas outcomes such as low apgar scores and duration of labour, are easier to measure and account for.

When you birth in an institution, no matter how person-friendly it seems to be, at the end of the day, you are on a production line. It is very process-oriented. The midwives are usually expert at not having you feel that you are on that conveyor belt. But you are. You are a thing to be processed according to hospital policies, deviations from which will not be tolerated because it interferes with the smooth running and efficiency of the whole machine (institution). The faster you can be put through the conveyor belt, the better for the institution. They can then have more through-put (income). Or, they (or their share holders) can benefit from fewer expenses (staff time) related to a shorter stay in delivery suite.

Thank you, Doctor
Unfortunately, many women think it’s normal to suffer greatly during childbirth. It is also quite common that they continue to believe that their bodies are abnormal and cannot withstand childbirth. They feel forever grateful to the hospital and their doctor, the one who saved them from the misery of childbirth, or who saved their baby from death. Little that they know that the source of disaster can be from the hospital intervention, not because of their bodies.

Hospital Is Not A Good Place For Healthy Babies
Finally, hospitals may not also be a great place to greet your newborn into the world. Aside from the fact that a hospital is a place full of antibiotic-resistant germs, a lot of hospitals also do not treat the newborn as respectfully or as kindly as you want it to be. In addition, there is usually separation between mother and baby after birth. At least for some time – maybe the baby will be in the same room as you, but may be assessed on the resuscitaire (how many women ask that their baby be assessed in the bed or on the floor or in the bath / shower with them?)

Also, many babies are separated from you over night “to let you get some sleep”. This sounds like a good thing at the time, until you get home and do not know what to do with your baby in the wee hours of the morning.

To Sum Up – The Truth Of Hospital Birth
In short, if you are planning to have a natural birth in hospital, consider the following:

Hospitals are rampant with medical intervention which can increase the risk of complications. As a result, you are at higher risk of having an unnecessary cesarian section if you choose a hospital birth.

You are not in control of your birth. Instead, hospitals control the birth through policies.

Hospitals are full of policies (routines) that are neither evidence-based nor birth-friendly.

In hospital, birth is viewed as a medical, not a normal, event. The health care professionals at the hospital are trained in pathology of birth, not normal birth.

The hospital environment may be impersonal and less cozy. This may impact your birth experience.

It’s almost impossible to have an intimate birth at a hospital.

Hospital Birth – YES or NO
After pondering the above facts, I hope you can now make your own decision on where you want to have your natural birth.

You have to realise that if you choose hospital birth, you have to be ready with all the consequences. A lot of time, requesting or rejecting certain procedures can cause irritation and misunderstanding between patient and the hospital staff. This friction may create a hostile or awkward environment which can make you feel uncomfortable and hard to relax.

Is this the environment you would like to be for your labour and birth ?

What are the other options?

There is good news!! There are two other options.

1. If you are a healthy woman, having a normal pregnancy, birth your baby at home with a registered midwife.

2. If you prefer to birth in hospital, or if you need to birth in hospital because you have a high risk pregnancy, employ the services of a private midwife. She can provide your antenatal (pregnancy) and postnatal (after baby is born) care and birth with you in hospital.

If you birth in hospital, expecting a natural birth, and you do not have a private midwife with you, this is much the same as doing your supermarket shopping in Bunnings. Newsflash! Bunnings do not sell groceries. Do not be disappointed when you do not find groceries in Bunnings. Rather, do your research and make choices that are aligned to the sort of birth you want to have. If you desire a natural birth and you’re healthy, have a home birth or a private midwife for a hospital birth. You do not need anyone’s permission (hospital, doctor etc). No more than you need their permission to have a massage or eat chocolate mousse. Private midwifery is known to carry a high natural birth rate and deliver excellent clinical outcomes to women and babies. The World Health Organisation recognises midwives as primary care providers for healthy, low risk women because midwifery care is know to deliver the best outcomes for this large group of women. For high risk women who are birthing in hospital, private midwifery will see you experiencing the minimal amount of intervention necessary.

ANSWERS:
1 gel
2 waters broken artificially
3 syntocinon drip to start labour
4 syntocinon drip to keep labour going
5 continuous monitoring
6 immobility
7 lack of access to the required tolls to facilitate normal labour
8 gas
9 pethidine or morphine
10 epidural
11 labouring in bed, unaided by gravity
12 caesarean or forceps or vacuum
13 vaginal examinations
14 forced (directed pushing) – needed with an epidural

These are the direct interventions. But what about the indirect interventions?

15 birthing in an unfamiliar environment
16 birthing with strangers
17 lack or direct one-to-one midwifery support
18 lack of continuity of care (can be assumed since vew few women are able to access this option in Australia)
19 imposed time limits on labour
20 managed third stage
21 separation of mother and baby after birth: a baby who is born after an operative delivery (caesarean, forceps, vacuum) will be taken to the resuscitaire for assessment by a paediatrician
22 breastfeeding will be impacted
23 bonding will be impacted.

Have I missed any? Let me know.

So …… 23 interventions when you thought you were only signing up for one!

Melissa Maimann, Essential Birth Consulting 0400 418 448

The Benefits of Using a Midwife During Childbirth

May 11th, 2009
by Melissa Maimann.
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For further information, contact Melissa Maimann at Essential Birth Consulting.

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

So, what is a primary care provider?
A primary care provider is someone who is responsible for your pregnancy and birth care. It will either be a doctor or a midwife, and in some circumstances, it will be both. Women may choose birth centre, homebirth or hospital midwifery care to benefit from primary midwifery care.

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

Caesarean rates rise as mothers get older

Apr 12th, 2009
by Melissa Maimann.
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For further information, contact Melissa Maimann at Essential Birth Consulting.

Link to article

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting.

Birth by surgery: The skyrocketing cesarean rate

Mar 30th, 2009
by Melissa Maimann.
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For further information, contact Melissa Maimann at Essential Birth Consulting.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

….

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

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

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

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

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

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

…

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

…

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting.

UK: Mothers face crackdown on epidural births

Mar 1st, 2009
by Melissa Maimann.
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For further information, please contact Melissa Maimann at Essential Birth Consulting.

From http://www.timesonline.co.uk/tol/news/uk/article5822051.ece

Mothers face crackdown on epidural births
Sarah-Kate Templeton

HOSPITALS are under attack from staff and patients for trying to stop large numbers of women from having epidurals during birth … The controversial restrictions … aim drastically to reduce the number of women having epidurals, caesareans or other artificial procedures to 40%.

In some hospitals the proportion of first-time mothers now having epidurals is far higher at 60%.

The targets are contained in a guidance document, Making Normal Birth a Reality, drawn up by the National Childbirth Trust (NCT) with the backing of the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists.

The document argues that mothers and doctors are too ready to resort to medical intervention and that any such procedure brings risks …

Professor James Walker, a consultant obstetrician at Leeds Teaching Hospitals NHS Trust, said … “Epidurals should not be done without reason; they should be kept to a minimum. There are some women, however, who require an epidural because they cannot cope with the pain in any other way.”

Belinda Phipps, chief executive of the NCT, argues, however, that there are medical reasons for trying to restrict the procedure. An epidural, she says, is more likely to result in a baby being delivered with forceps or a ventouse – a suction device – because the mother is less able to push the baby out.

A British review … found the procedure prolonged labour and increased the chance of further medical intervention by 40%.

When I did my midwifery degree, midwives were supported by management and other midwives to support women through natural labour, if that was their intention. We all know that at some point in labour, many women want something, anything – epidural, caesarean, whatever! But that is where the skill of the midwife really comes in. It is about calming the woman, helping her to change position, getting her a hotpack, moving into the bath, talking calmly to her, surrounding her with love and supportive people – these “interventions” are both safe and effective.

Epidurals have been demonstrated to have complications associated with their use: longer labour leading to augmentation (breaking waters or using an infusion of syntocinon), fetal distress from augmentation, malpositioning of the baby (such as posterior), back ache, spinal tap, infection, increase in the caesarean rate as a consequence of being continuously monitored, and forceps or a vacuum birth because of the woman’s inability to feel to push.

With all these consequences of epidurals, is there any question why there’s a push towards normal birth?

It does, however, beg the question – who should decide what intervention a woman has in her bitrh? Surely it’s the woman’s choice, and hers alone. I agree with this comment, and happily support women through hospital births where they may elect to have an epidural. However, I tend to find that a well-informed woman who has attended comprehensive childbirth education and perhaps Calmbirth classes, will be far less likely to choose an elective epidural.

Smriti Singh, mentioned in the article, alludes to the potential for birth trauma related to the pain of birth. Most quality research points to their being less birth trauma for women who have experienced natural birth, than women who have experienced interventionist birth. Mitigating factors are things such as birth preparation, having an awareness and understanding of all available options, and the presence of a supportive person during your birth.

Melissa Maimann, Essential Birth Consulting.