Risk assessment in pregnancy and birth

Posted on May 20, 2012 by Melissa Maimann

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

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

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

How can risk assessment be useful?

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

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

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

Visit my website to learn more about my services.

Are modern births lasting two hours longer than in 1960s?

Posted on April 3, 2012 by Melissa Maimann

An article (http://www.sunjournal.com/news/maine/2012/04/03/moms-today-spend-two-more-hours-giving-birth-1960s/1176573) suggests that modern births last two hours longer than in 1960s. How can this be so? The process of birth hasn’t changed since the 1960s.

This is really a conseqnce of the way we care for women in labour today, as opposed to the 1960s. What has changed? I think the main difference is the rate of epidurals, which were seldom used in the 1960s but are now a common element of modern-day childbirth.

Epidurals are known to prolong labour, and often a woman who has received an epidural will also need to have her waters broken and a drip to speed the labour once the epidural thas taken effect.

Another aspect is the increase in inductions: it is well-known that when women start their labour on thei own, the labour tends to be faster and less painful than when midwives and obstetricians use medication to start the labour.

So the take-home message? Plan an active, drug-free birth, well-supported by your partner and midwife and you can expect an easier birth.

Visit my website to learn more about my services.

Are drugs ‘better for labour pain’?

Posted on March 16, 2012 by Melissa Maimann

Link

New research shows taking drugs to relieve pain during labour works better than alternatives like massage, machines and hypnosis.

Painkillers like an epidural, and gas and air, are more effective than softer approaches, but do have more side effects.

… being immersed in water, relaxation techniques, acupuncture, massage and non-opioid drugs may work with fewer adverse effects.

I don’t suppose there is any doubt that pharmacological methods of pain relief are superior than natural methods for the absolute relief of pain. We can use epidurals for operations; who would even doubt that it would be ineffective for use in labour?

If we focus on pain “relief”, then yes, drugs are the answer.

But if we focus on labour pain as a healthy pain that we can work with, and focus our energy in pregnancy on learning ways of working with the pain, we then find that most women feel they don;t “need” pharmacological pain relief in labour.

When we really think about it, an average labour might be around 8 hours. But is this 8 hours of pain? No. When labour is in full swing, contractions might come every 3 minutes and last for a minute. That means that we would have a contraction for a minute and a break for two minutes. In other words, the eight hour labour has now become two hours and forty minutes of contractions and five hours and 20 minutes without a contraction. Does that sound more manageable? Next, we know that the whole contraction isn’t intense, it is only the peak of the contraction that is intense. Maybe about 20-30 seconds of each contraction. It’s much easier to think of ways of getting through 20-30 seconds of intense sensation every 3 minutes, rather than thinking of eight hours of agony. Women who take some time in pregnancy to consider strategies for dealing with the sensations of labour and birth, and who choose a care provider who is experienced in natural, drug-free birth, frequently find that the thought of drugs never even crossed their mind!

Visit my website to learn more about my services.

Increased Risk Of Cesarean Section And Other Complications Following Unnecessary Induction Of Labor

Posted on March 9, 2012 by Melissa Maimann

Link

A new study … reveals that induction of labor at term in the absence of maternal or fetal indications increases the risk of cesarean section and other postpartum complications for the woman, as well as neonatal complications.

… researchers performed a cohort study utilizing a dataset of 28,626 women with spontaneous onset of labor, induction of labor for recognized indications, and induction of labor for non-recognized indications.

[ie, inductions for no medical reason].

Induction of labor for non-recognized indications was associated with a 67% increased relative risk of cesarean section (compared with spontaneous labor).

It also significantly increased the chance of the infant requiring Neonatal Intensive Care Unit nursery care … when compared with the spontaneous labor onset.

Overall, for the best maternal health outcomes, the lowest risk of requiring epidural or spinal analgesia occurred with birth at or after 41 weeks’ gestation, while the lowest risk of sustaining a severe perineal tear was associated with delivery after 37 weeks’ gestation, and labor complications were at a minimum beyond 38 weeks’ gestation. This indicates that the lowest risk of adverse maternal and infant outcomes occurred with birth between 38 and 39 weeks and with the spontaneous onset of labor.

Visit my website to learn more about my services.

Hospital says No to cesarean

Posted on March 1, 2012 by Melissa Maimann

Link

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Visit my website to learn more about my services.

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

Posted on February 24, 2012 by Melissa Maimann

Link

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

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

Visit my website to learn more about my services.

Inducing Labor Better for Big Babies

Posted on February 22, 2012 by Melissa Maimann

Link

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Visit my website to learn more about my services.

New induction policy a threat to women, or a threat to doctors? You be the judge.

Posted on February 7, 2012 by Melissa Maimann

An article in The Newcastle Herald yesterday states that:

pushing a policy to reduce caesarean births are creating rules that are potentially dangerous for patients and threatening to doctors … red tape is threatening professional independence.

It also discouraged treatment tailored to individual patients.

… Compliance with directives telling obstetricians when and how to deliver babies was mandatory, under the threat of disciplinary action and loss of indemnity cover …

… a recent directive requiring a reduction in caesarean section rates to 20per cent by 2015 was an illusory and possibly dangerous target.

What is being referred to here is the NSW Health Policy Directive on induction of labour at or beyond term. It is a well-written and thorough document that can inform best practice for induction of labour. Rather than “telling obstetricians when and how to deliver babies”, it guides practice in a woman-centered manner:

Induction of labour carries inherent risk and must be exercised with caution. There needs to be clear benefits for the mother and/or the fetus.

At term, women must be offered information about the risks associated with prolonged pregnancies, and the options available to them.

Induced labour has an impact on the birth experience for women. Labour is often more painful than spontaneous labour, and epidural analgesia and assisted delivery are more likely to be required.
Treatment and care should take into account a woman’s individual needs and preferences. Women who are having, or being offered, induction of labour must have the opportunity to receive accurate information and make informed decisions about their care and treatment, in partnership with their health care professionals.

This doesn’t sound like an approach that is potentially dangerous for patients or an approach that discourages treatment that is tailored to individual patients.

The article goes on to assert that:

Also concerning was a departmental policy that elective or pre-labour caesarean section must not routinely be carried out before 39weeks gestation, due to risk of respiratory morbidity in babies.

And the problem is? All this is saying is that an elective or pre-labour caesarean should not routinely be carried out before 39 weeks. This is not the same as saying that caesarean can never be performed prior to 39 weeks, yet the contributors to the article go on to say that:

‘‘[The policy] effectively forbids doctors in NSW public hospitals to schedule routine elective caesarean section before 39weeks,’’ …‘‘Anyone doing so risks disciplinary action and may forfeit indemnity cover.’’

This is clearly nonsense!

The policy directive does state that:

Induction of labour must not routinely be offered on maternal request alone.

Health care professionals offering induction of labour must:
• provide the woman with adequate time to discuss the information with her partner/support person before coming to a decision;
• encourage the woman to access a variety of sources of information;
• invite the woman to ask questions, and encourage her to think about her options; and
• support the woman in whatever decision she makes.

Women should be offered support and analgesia as required, and staff should encourage women to use their own coping strategies for pain relief. This includes the opportunity to labour in water.

I fail to understand what is unreasonable about this policy which is evidence-based, woman-centered and flexible so as to meet the woman’s present health needs. Most health professionals practice within evidence-based guidelines, best practice guidelines and accepted standards of practice. These are developed in consultation with industry experts and after consultation of the relevant literature on the subject. I am curious that the obstetricians in this article are critical of a policy directive that is based on evidence and safe practice, citing that such a policy would threaten professional independence. RANZCOG has policies and guidelines, as does the UK Royal College of Obstetricians and Gynaecologists. A mark of a professional body is that it possesses its own information that is unique to the profession. Why has this new policy directive caused such concern for doctors? It is merely suggesting that women should not be induced willy-nilly for no good reason and we have good evidence to justify this position.

Visit my website to learn more about my services.

“I’ve been told my baby is big”

Posted on February 2, 2012 by Melissa Maimann

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

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

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

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

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

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

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

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

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

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

Visit my website to learn more about my services.

Cascade of intervention

Posted on February 1, 2012 by Melissa Maimann

A study has found that first-time mothers who have their care within the general hospital system and have their labour induced, face a greater risk of having a caesarean section than those who wait for labour to start on its own.

In the study, 44 percent women had their labour induced, and 20% of those inductions failed (ie, labour did not start) and caesareans were performed in those cases.

By definition, induction is performed before a woman’s body is ready for labour, and this may point to the reason for such a high rate of failed inductions. In other cases, the reason for the induction is also the reason that the caesarean became necessary. For example, a labour may be induced because of concerns for the baby, and once in labour, the baby shows signs that it is not tolerating labour well and so a caesarean is performed.

The study does point to the issue that inductions should not be performed unless they are genuinely necessary. Up to 50% inductions may not be “indicated”, that is, performed for a medical reason. They might be performed more for convenience, for example. However, if we limit inductions to those which really need to be done, we would lower the caesarean rate.

There are some reasons when an induction might be a good idea, such as when the woman’s blood pressure is high, if the pregnancy goes beyond 42 weeks, if the waters have broken for many hours and labour has not started, if there are concerns for the baby and so on.

Before any induction is commenced, it’s important that women are fully informed by their care provider of the reasons for the induction, the alternatives, the process and procedure, what to expect and the likely outcome.

Visit my website to learn more about my services.

The Unkindest Cut: Countdown to a C-Section

Posted on January 25, 2012 by Melissa Maimann

Link

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

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

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

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

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

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

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

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

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

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

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

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

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

Cooper-Schultz chose the cesarean. …
∗ ∗ ∗

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

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

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

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

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

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

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

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

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

∗ ∗ ∗

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

∗ ∗ ∗

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

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

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

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

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

Visit my website to learn more about my services.

Labour induction methods compare favourably

Posted on January 22, 2012 by Melissa Maimann

Link

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

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

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

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

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

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

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

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

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

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

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

Visit my website to learn more about my services.

Do first-time mothers have unrealistic views about having uncomplicated births, or does the health system fail them?

Posted on January 11, 2012 by Melissa Maimann

An interesting report in The Telegraph states that first-time mums have unrealistic expectations of drug-free, natural, uncomplicated births, when in reality, they have a mere 21% chance of:

a labour that starts on its own (ie, is not induced)
not using an epidural
birthing without the use of instruments or operations

If we exclude from that figure the proportion of women who also birth without stitches, that figure becomes a mere 8%. The papers would like us to believe that

first-time mothers have unrealistic views about having uncomplicated births, increasing the risk of post-natal depression

In other words, postnatal depression is caused by womens’ unmet and unrealistic expectations of an uncomplicated birth.

This suggests that the health system has no part to play in this. It is merely a case of women wanting too much from their experience. If we expect too much, we set ourselves up for disappointment, and this leads to postnatal depression!

Wow!

The article goes on to say that

expectant mothers … believe there is a 56.2 per cent chance of an uncomplicated birth, which means a baby being born without the use of forceps, suction cups, caesarean section or induced labour.

Whereas

the chance of having a medically uncomplicated birth is 21 per cent.

A further 30.7 per cent said they believed women would have uncomplicated births without needing sutures. The actual figure is 8 per cent.

My readers will well know that I don’t subscribe to the view that a crappy birth experience and postnatal depression is all the fault of the health service; but at the same time, it’s not all the fault of the woman either.

We’re each responsible for the choices we make and for informing ourselves of all available options before we make a choice. Health services are also responsible for accurately representing their services and outcomes so that women can make a considered choice. If women have a mere 8% chance of birthing normally and without stitches, that needs to be well-known so that women may seek other care options if they so choose.

The health system is here to provide a basic and safe level of care. If we expect or desire more than what can be considered “basic”, then we do need to look into other options, and these will generally be found in the private system, be it private midwifery care or private obstetric care (although I dare say that the average private obstetrician will have lower rates of normal birth than a public service).

All of that said, it seems appalling that 79% first-time Mums go through the public system and come out the other side with an intervened-with birth. In my private practice, those figures are reversed. Do women know what they are signing up for when the choose their local hospital for care? And perhaps more importantly, should the hospitals be held to account for these poor outcomes, or at least acknowledge that they are failing women?

Most first-time mums should expect to birth without intervention. Most should not need any intervention. The birthing process is a normal, natural, female bodily function. We don’t question the potential for our bodies to ovulate, urinate, digest food, menstruate, circulate blood, metabolise substances and so on. These processes generally “work”; birth generally “works” too. Provided we, as care providers, don’t mess it up with unnecessary interventions and an environment that is not conducive to labouring and birthing a baby.

Visit my website to learn more about my services.

Balancing The Womb

Posted on January 3, 2012 by Melissa Maimann

Link

New research hopes to explain premature births and failed inductions of labour. The study by academics at the University of Bristol suggests a new mechanism by which the level of myosin phosphorylation is regulated in the pregnant uterus.

… phosphorylation of uterus proteins at specific amino acids have a key role in the regulation of uterine activity in labour.

A remarkable feature of the uterus … is that it remains relatively relaxed for the nine months of pregnancy … and then, during labour, it contracts forcibly and the baby is born. A special type of smooth muscle that grows and stretches during pregnancy to accommodate the fetus and the placenta forms the uterus.

Hormones such as oxytocin or prostaglandins promote labour, but the biochemical changes that allow the switch from relaxation to contractions to happen are not fully understood. This makes it difficult to predict when a woman is going to deliver. In eight to ten per cent of women delivery occurs too early … On the other hand when labour has to be induced for medical reasons, it is impossible to know whether the induction will be successful or whether it will require an emergency caesarean section …

… small biopsies of uterine tissue from women who delivered … demonstrated that contractions require both a calcium dependent pathway driven by myosin kinase and a calcium independent pathway that regulates the activity of myosin phosphatase …

… “This study has increased our understanding of the biochemical changes underlying uterine activity and may help in the design of better drugs to prevent preterm labour or to induce labour successfully at term, benefiting many thousands of women and their babies.” …

Visit my website to learn more about my services.

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

Posted on December 20, 2011 by Melissa Maimann

Link

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

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

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

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

Visit my website to learn more about my services.

Christmas baby rush

Posted on December 15, 2011 by Melissa Maimann

The original title of this article was, “Pregnant mums rush Christmas babies”. This is an interesting title as it’s not really the Mums who rush their babies’ births, but rather the doctors who authorise and perform the inductions. Health practitioners are not required to perform interventions that are not in the best interests of their patients. So perhaps the article should read, “Doctors rush Christmas babies”. That doesn’t sound as good as a headline, does it?

Link

MUMS-to-be are having their babies induced so they can be home in time for Christmas.

Women due around Christmas often asked to be induced early so they could spend the festive day with their other children, obstetrician Dr Samantha Hargreaves said.

But obstetrician Dr David O’Callaghan said social inductions increased danger for mother and baby by possibly triggering interventions.

Inductions raised the likelihood of epidurals, forcep and vacuum deliveries, caesarean sections and a slower recovery for the mother.

“The subsequent longer labour is more stressful on the baby, and the use of forceps is more stressful on the baby,” he said.

Richmond mum Michelle Godsall had been planning to be induced on Monday because she did not want to risk giving birth on Christmas Day, but she went into labour early yesterday afternoon.

… She was not aware of any added risks, but understood her labour could be more intense, but she decided it would be worth the extra pain.

In other words, her care providers did not explain the risks of induction.

Northcote mum Sara McCluskey, 38, who is booked in for an induction … said women should be able to have babies how they wanted.

“It’s not a lifestyle choice. I want to be able to spend Christmas with my 2 1/2-year-old daughter, who is just beginning to understand what it’s all about,” Ms McCluskey said.

If that is not a lifestyle choice, what is?

Dr Hargreaves said the surge in demand for inductions was a well recognised trend … She induced women only at 38 1/2 weeks or more into their pregnancy to avoid problems, such as being forced into having a caesarean.

It seems she too has not been informed of the risks, and that some 50% of first time Mums who are induced will actually end up having the caesarean she had hoped an induction would avoid.

Visit my website to learn more about my services.

Forceps delivery tied to lower brain injury risk

Posted on December 5, 2011 by Melissa Maimann

Link

When babies need help coming into the world, forceps may carry less risk of newborn seizures compared with vacuum deliveries or Cesarean section …

In recent years, forceps have fallen out of favor when it comes to aiding a difficult childbirth. Vacuum devices are more often used, while C-section rates have surged.

… that’s all despite a lack of evidence that vacuum or C-section deliveries are actually safer for newborns compared with forceps …

… newborns delivered by forceps were 45 percent less likely to suffer a seizure than those born via vacuum pump or C-section.

On the other hand, babies delivered by C-section were less likely to have one type of bleeding around the brain — known as subdural hemorrhage.

The risks of any of those complications were low, whatever the type of delivery …

Forceps have often been labelled riskier for mothers and babies than a vacuum extraction delivery, however this study questions that belief. My experience has been that a forceps delivery, in the hands of a skilled obstetrician, is perfectly safe for the mother and baby. I have found that forceps are more likely than a vacuum to result in a vaginal birth, while more attempted vacuum deliveries “fail” and end up going to caesarean section. Fewer forceps deliveries “fail”. With a vacuum extraction, the baby is essentially pulled out by its scalp, whereas with forceps, the baby is pulled out by the body parts of its face and skull. I think this method is kinder to the baby. The best approach though is to promote unassisted vaginal birth, where the woman pushes her baby out (or breathes her baby out) without any instruments. This is most likely if the woman has had no pain relief in labour, is assisted to birth in an upright position and is supported by a known and supportive midwife.

Visit my website to learn more about my services.

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

Posted on November 27, 2011 by Melissa Maimann

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

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

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

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

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

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

What were the intervention rates like?

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

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

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

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

Visit my website to learn more about my services.

Foley Catheter is as Good as Gel for Inducing Labour

Posted on October 31, 2011 by Melissa Maimann

Link

New research as found that the use of a Foley catheter appears to be as effective as prostaglandin gel, but with fewer side effects. These were the findings of a randomised trial. The Foley catheter is used to inflate a balloon behind the cervix that simulates the pressure of a baby’s head to make the cervix dilate, likely by stimulating endogenous prostaglandins.

Caesarean section rates were similar in both groups, however more caesareans were performed for failure to progress in the foley catheter group, than the prostaglandin group. +Operative delivery due to fetal distress was less common with the Foley catheter than with prostaglandins.

The Foley catheter group was also more likely to be augmented with Syntocinon, though this was common in both groups and is a general feature of induction.

Why is this research important?
Women who have had a previous caesarean but require induction are often forced into a corner because many care providers are reluctant to induce labour on women who have had a previous caesarean for fear of the scar separating. This often leads to a reluctant decision to have an elective repeat caesarean. However, if women have the option of a foley’s catheter induction, this provides a safer alternative to prostaglandin induction with fewer complications.

Visit my website to explore birthing services.

Natural birth in hospital?

Posted on October 8, 2011 by Melissa Maimann

Here are some ideas to birth naturally in hospital:

Read, read, read. Books, websites, any written info from your care provider … read it all. You also need to know the difference between facts presented to you in an honest and unbiased way, and facts that are being filtered through hospital policy. This is where women benefit from having a private midwife by their side.

For example, “Some risks rise slightly when a woman has high blood pressure. I am uncomfortable with letting your pregnancy continue with high blood pressure because of the risks to the baby and to you if something happens” is an honest and factual statement. You have the right to accept the risks and refuse induction. However, some women hear “I’m going to induce you today because if we don’t do this now, there is a good chance your baby will not make it”. This statement is dishonest, using a woman’s fears and her maternal instinct to encourage her to accept intervention. There is also no discussion of alternative options. Informed consent requires that women are presented with options so that they can make the best decision for them, in their situation.

Be assertive As with most human relationships, a great deal can be resolved with a calm, respectful and firm manner. Know what you want and why you want it. Engage a private midwife to assist you with obtaining relevant and impartial information.

Listen. If you are choosing to use a hospital and an obstetrician for your birth, then you acknowledge that their presence, education and experience have some value. Your wishes are important but be willing to listen even when what’s being said is really not what you want to hear. You must also acknowledge that an obstetrician is trained in all things that go wrong, and they are on the look-out for any sign of things going wrong. Midwives, on the other hand, will promote normalcy and assist your pregnancy and birth to remain normal. These differing philosophies do result in big differences in intervention rates.

Be Flexible. Understand that sometimes things don’t go the way we had planned. There might be some occasions where you’ll be happy to accommodate the hospital policy, and other times when you’ll want to stand your ground.

Ultimately, it is true that the most important aspect of birth is safety and a healthy mother and baby. But that doesn’t mean the other aspects are unimportant, and I firmly believe you can have a great birth – and a safe birth – in any location.

Visit my website to explore birthing services.

Cascade of intervention

Posted on September 1, 2011 by Melissa Maimann

In the study, 44 percent women had their labour induced, and 20% of those inductions failed (ie, labour did not start) and caesareans were performed in those cases.

he study does point to the issue that inductions should not be performed unless they are genuinely necessary. Up to 50% inductions may not be “indicated”, that is, performed for a medical reason. They might be performed more for convenience, for example. However, if we limit inductions to those which really need to be done, we would lower the caesarean rate.

There are some reasons when an induction might be a good idea, such as when the woman’s blood pressure is high, if the pregnancy goes to 42 weeks, if the waters have broken for many hours and labour has not started, if there are concerns for the baby and so on.

Visit my website to explore birthing services.

Expectant mothers need facts, not fear

Posted on July 21, 2011 by Melissa Maimann

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

Link

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

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

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

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

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

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

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

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

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

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

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

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

Steep rise in first-time mothers being induced

Posted on July 17, 2011 by Melissa Maimann

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

Link

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thank this doc for the episiotomy you won’t have

Posted on July 10, 2011 by Melissa Maimann

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

Link

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.”

Arizona hospitals taking stricter stance on scheduled births

Posted on July 2, 2011 by Melissa Maimann

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

Link

Arizona hospitals are taking a stricter stance on doctors and mothers who want to deliver babies before full term.

Banner Health is the latest to join a growing number of hospitals that are informing doctors and expectant mothers that they will no longer schedule deliveries before 39 weeks of pregnancy unless there is a medical reason to do so.

Hospitals are citing medical research that shows even the last few weeks of a full-term pregnancy are critical for a newborn’s development. Babies who are born at 39 or 40 weeks are more likely to have improved brain, lung and eye development as well as lower risk of death compared with babies born earlier.

The change marks a cultural shift for Phoenix-area obstetricians and expectant mothers who have grown accustomed to planning births due to schedules, convenience, family visits or other non-medical reasons.

… Banner Health will stop scheduling elective C-sections or inducing births for pre-term babies beginning July 18. Banner’s decision will impact 19 hospitals …

… convenience births represent 20 to 30 percent of all deliveries at some Valley hospitals.

… 42 percent of babies born … last year were delivered before 39 weeks. Those deliveries covered the spectrum of births, including medically necessary births and natural births that occurred before full term. It included elective C-sections or early inductions of labor, although hospital representatives said they did not have reliable data on the number of such early, elective births.

The rate of Caesarean births climbed steadily over the past decade … In Arizona, 26.2 percent of all births were by C-section in 2007, up from 16.1 percent in 1996 …

… [the] reaction has been mixed among doctors and patients. Some doctors have said they’ve successfully induced labor or performed C-sections before 39 weeks and saw no reason to change.

… doctors have become more receptive to the policy after they reviewed medical data and told their patients about the new hospital policies. It also has emboldened doctors pressured by patients who want to schedule a birth.

“They changed their culture and basically moved forward and informed patients this is policy now,” …

Banner Health cited nearly two dozen medical reasons that would prompt an early delivery. Some common medical reasons could include high blood pressure, kidney disease, pre-eclampsia or placenta previa, a condition in which the placenta is too close to the cervix.

Organizations such as the American Congress of Obstetricians and Gynecology, Joint Commission and March of Dimes have advocated that the medical community adhere to the 39-week standard.

… those final weeks can be critical for a newborn’s development. Full-term babies are less likely to have hearing, vision, feeding or birth-weight problems. Those final weeks of a pregnancy also give the lungs, eyes and brain enough time to fully develop.

Babies born early are more likely to spend time in a neonatal intensive-care unit …

The birth junkies: Why women can become addicted to giving birth

Posted on June 17, 2011 by Melissa Maimann

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

Link

The offer of a Caesarean section might seem heaven sent to any pregnant woman approaching delivery day with rising anxiety.

When I discovered I was expecting my first baby, I’d have paid good money for a general anaesthetic to spare me the agony of childbirth with which I was all-too-familiar, thanks to soap operas and the horror stories other mothers are strangely desperate to share.

I thought, as many women do, that the act of giving birth was a nightmare from which I needed saving — with drugs, surgery, medical intervention and, frankly, anything that might numb me to what was certain to be the most terrifying experience of my life.

But by the time I was expecting my third (and final) baby, I had discovered a secret that the majority of women giving birth in the UK today never have the chance to discover for themselves: I had found out that childbirth could be the ultimate natural high, an experience so powerful and yet fulfilling that it can be nothing short of addictive.

… ‘It was the most amazing experience of my life and I was high on it for months. That’s the part I want to do again and again,’ says one. Another says she loved giving birth so much, she’s considering a career in surrogacy. ‘It just felt so good (OK, it did hurt a little) but it’s hard to explain. I would definitely be a surrogate.’

So when my obstetrician broke the news that baby number three would have to be delivered by C‑section, because the placenta was blocking the way for a natural birth, I burst into tears of utter disappointment.

… I believe women who have had a positive birth experience and enjoyed an unadulterated dose of Mother Nature’s magic recipe should be shouting it from the rooftops. For in the majority of cases there is no need for birth to be the trauma we believe it to be — and that it therefore becomes.

Of course, women who need medical intervention should have the best that can be provided; intervention saves lives. But some 75-80 per cent of births should go as smoothly as nature intended.

The problem is that just a fraction of the number of women who don’t have a medical requirement for intervention are getting to the finish line without being subjected to meddling from midwives and doctors. Meddling that supersedes a woman’s own desires and instincts, and impairs her body’s ability to cope as it is designed to do.

Under normal conditions, a woman is best left to be her own director, behaving in an instinctive and uninhibited way. Only when that is allowed to happen will she get the rush of Mother Nature’s feel-good cocktail: a hormone boost designed specifically to flood her body with exactly what it needs — not just to get her through every stage of labour, but to ensure that she won’t find the process so physically and mentally difficult that she never does it again.

… If you mention oxytocin to most women who have given birth in a UK hospital, they will think of it as a drug, administered by drip, to speed along her contractions.

In fact, in its natural form, it is the ‘love hormone’ — the same one that floods our brains during orgasm, and is also boosted by cuddling, breastfeeding and other positive, loving experiences.

We produce it naturally in massive quantities during labour and birth, and its effects cannot be artificially replicated.

This wonderful stuff reduces fear, increases trust and promotes a sense of connectedness with those around you. There is nothing like it for making a woman feel that everything is in her control and that everyone is on her side.

It is also what gives a new mother that ‘loved-up’ feeling after the birth, helping any memories of pain or anxiety to fade almost immediately.

It is a primal reaction that when our adrenaline levels rise, labour halts, because our brain is telling our body that it’s not safe to proceed. By counteracting fear, oxytocin keeps adrenaline levels in check, which ensures that labour progresses steadily.

What’s more, as a pheromone, oxytocin is contagious, transmitted through the air and picked up by the nose. Studies have shown that when a father attends the birth of his child, his oxytocin levels rise as well, making him part of the love-in and — importantly — more ready to connect with his child.

… After a totally natural birth, it is often very difficult to remember the specifics of it, and that’s the way it should be.

It’s also why a lot of women will often say that … the earlier part of their labour was more difficult than the later parts, when they were much more ‘out of it’ and more flooded with endorphins.

And it’s the reason why inductions are generally harder to cope with, because they artificially accelerate the labour process, hitting the mother with back-to-back contractions, before the body has had time to produce sufficient quantities of hormones and natural pain relief.

I can’t help but think that the shrieking and wailing that make TV programmes like One Born Every Minute such compulsive viewing are merely an indication that something — be it fear or unnecessary intervention — has prevented the woman’s instinct from taking over and allowing the release of the endorphins she needs …

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

Posted on June 13, 2011 by Melissa Maimann

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

Link

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Childbirth intervention rates vary by up to 20%

Posted on June 3, 2011 by Melissa Maimann

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

Link

RATES OF Caesarean and episiotomy can vary by up to 20 per cent in Irish hospitals …

… not only is there inconsistent data keeping in hospitals but there is “a real lack of standardisation across the maternity services, with policies and practices varying from unit to unit”.

On the data gathered on the numbers of births where labour comes on spontaneously, South Tipperary General Hospital scores highest with 68.4 per cent of all labours not induced. Mount Carmel, the State’s only private maternity hospital scored the lowest with just 44.6 per cent of labours occurring without induction.

While the midwifery-led units (MLUs) in Our Lady of Lourdes Hospital in Drogheda and in Cavan General Hospital both record a spontaneous labour rate of 100 per cent … these hospitals only admit women who have gone into labour spontaneously.

On rates of spontaneous vaginal birth, where ventouse, forceps or a surgical procedure such as Caesarean section is not used … mothers at Sligo General Hospital require the least intervention, with 68.7 per cent of all births being spontaneous, while mothers at South Tipperary Hospital receive the most intervention, with 52.3 per cent of all births assisted.

With a difference of more than 20 per cent in the rates of intervention … hospital policy might dictate that interventions be used so that labour progresses at a particular rate, but “the body doesn’t always comply”.

“When hospitals are under time pressure and bed pressure, they need to keep women moving through. There is a little bit of a conveyor belt system,” …

Regarding Caesarean births, the highest numbers were performed in Mount Carmel, at 38.7 per cent of all births, and Kilkenny General, at 35.6 per cent of all births. Meanwhile, at Sligo General, just 18.9 per cent of all babies were delivered by Caesarean.

… women can be up to twice as likely to undergo a Caesarean section depending on the hospital in which they give birth …

… Wexford General records the least number of episiotomies with just over 8 per cent of mums requiring it. The rate at the National Maternity Hospital, however, is more than three times that at 27.1 per cent.

… “These nationwide statistics highlight considerable variations in interventions practices, in particular, induction, Caesarean birth and episiotomy rates, where some maternity units have almost double the rates of others.”

… she hopes the guide gives those parents recommended a particular course of action by a hospital “the confidence and empowerment to ask for the full range of options”.

We have the same situation here with public and private hospitals: generally speaking, lower rates of intervention exist in public hospitals. The lowest rates of intervention occur in births with private midwives, and the highest rates of intervention occur in births with private obstetricians (on average). Some of this will be related to choice: a woman opting for a caesarean may have no choice but to go the private hospital/ private ob path, however we know that a very small percentage of women actually request caesarean. The vast majority of women – especially those expecting their first baby – will expect a natural birth. I would say to those women: choose a care provider and a birth place where the odds are in your favour of achieving a natural birth. There is no point in going to a hospital with a 45% caesarean rate and an 85% epidural rate if you want a normal, natural, drug-free birth. The same way we don’t do our grocery shopping at Myer.

This satnav of the labour ward is driving us the wrong way Birth monitors cost the NHS millions, and were never meant to replace a labouring woman’s default help: the midwife

Posted on April 17, 2011 by Melissa Maimann

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

Link

When I gave birth to my first child … I was as prepared as I could be: positions, breathing, birth plan. What I hadn’t accounted for was an uninvited, domineering presence in a corner of the room that would so dictate proceedings that no one dared act without referring to it. The cardiotocography (CTG) machine, the silent birth partner.

CTG machines measure fetal heart rate and uterine contractions and are now omnipresent in labour wards, but it was never meant to be this way. When they were first developed … they were to save lives by detecting the early stages of hypoxia – babies starving of oxygen in the womb. Following their introduction … from the early 1970s, perinatal deaths went down (although this also coincided with better antenatal screening), but for the last 10 years this figure has remained static. And the number of babies born with cerebral palsy has not decreased in the last 100 years (it’s still not known if cerebral palsy is absolutely a birth injury, or happens at another time).

Meanwhile, there is increasing litigation against the NHS directly related to the misinterpretation of cardiotocograms (CTGs) resulting in babies born dead or damaged. The cost of these lawsuits has risen sevenfold in four years: from £11.8m in 2006 to £85.8m last year.

Without question that CTGs save lives, but there is a big problem – like all equipment they are only as good as the people operating them, and results can be difficult to interpret … they can lead to false positives, which can lead to unnecessary intervention. And because CTGs are a monitoring, not a diagnostic tool, the results should never be read in isolation but as part of a jigsaw.

My first labour … resulted in various interventions – induction, forceps, emergency C-section, lumbar puncture for my baby, IV antibiotics … – many triggered by the CTGs on which we all, slavishly, started to rely. Looking back, I can only compare parts of it to otherwise rational, intelligent people over-relying on satnav and driving up one-way streets, simply because a machine told them to. There were times when the midwives attending paid more attention to the machine’s spewing paper tongue than me. Look at me, I wanted to say, look up.

With CTGs, one midwife can sit in front of a central monitor and keep track of several women in one go. “CTGs are the only way,” one senior member of maternity staff told me, “to stretch one midwife over more than one woman.” Contrary to popular belief, things don’t go wrong in labour from one minute to another, there are warning signs – signs a CTG can pick up, but there has to be someone there to interpret the data and get appropriate help quickly. Otherwise CTGs … [provide] a false sense of security.

With hindsight and after much analysis … there was no real evidence to show my daughter was indeed ever in distress, so I’ll never know if the C-section saved her life or if I took up unnecessary medical time and resources. But at least I had the luxury of musing with a live, healthy baby. About 500 babies die each year as a result of misinterpretation of CTGs.

After the birth I became highly involved with maternity services … The most harrowing case I ever sat in on was that of a woman whose baby showed obvious signs of distress, but the medical staff attending only looked at the last few sheets of the printout … In other words, instead of flinging their arms wide and looking at data that would have given them a good overview, their hands did no more flicking than if they’d been reading a paperback book.

There is another major problem, which has nothing to do with CTGs per se … Remember those unnecessary interventions mentioned earlier? With increasing C-sections … doctors are performing C-sections that may or may not be necessary and have often been decided on by the (mis)reading of a CTG, and there are other women whose babies desperately need C-sections, but are not getting them at all, or in time. Some babies are being monitored to death.

This is not a problem that is going to go away. We have a shortage of midwives that is entirely cash-led … The more continuous the care a woman receives, the less chance of a breakdown in communication. There will now be much talk of retraining staff in the reading of CTGs … and certainly that’s important. But, yet again, it’s a misreading of the situation. The CTG machine was never meant to be the labouring women’s default companion: an experienced midwife was.

The standard of care requires that if a woman is continuously monitored, she should have one-to-one midwifery care. Instead what we often see is one midwife caring for 2 – 3 women at a time and a central monitor at the staff station so that any midwife or doctor in the staff station can monitor all of the active monitors that are in use.

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

Posted on April 15, 2011 by Melissa Maimann

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

Link

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

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

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

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

New limits for older mothers

Posted on April 12, 2011 by Melissa Maimann

MEDICARE NOW AVAILABLE FOR MIDWIFERY CARE THROUGH THIS SERVICE!
Visit my website to explore home birth, hospital birth and Medicare-funded private midwifery care.

Link

DOCTORS should induce older mums by 40 weeks or risk stillbirths, findings from the country’s biggest study into perinatal deaths has revealed.

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

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

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

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

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

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

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

Mother and unborn baby die after hospital staff ignore husband’s pleas

Posted on March 28, 2011 by Melissa Maimann

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

Link

A pregnant woman died and her baby was stillborn at a hospital criticised by the NHS watchdog for poor standards of care …

An investigation has now been launched into the deaths of Sareena Ali, 27, and her first child after her family accused staff of negligence.

The Harrods worker was induced … after being overdue at 40 weeks. Husband Usman Javed said she was in “unbearable pain” just afterwards and his pleas for help were ignored …

She had suffered a ruptured womb that triggered cardiac arrest and major organ failure. Doctors had to carry out an emergency Caesarean on the ante-natal ward alongside frightened mothers-to-be.

Her baby was delivered lifeless and five days later Mrs Ali died. The hospital has accepted liability, admitting she received “unacceptable” standards of care. Two midwives have been suspended pending inquiries.

… Solicitor Sarah Harman, representing Mr Javed, said: “This double tragedy is the worst case I have been involved with. In the 21st century we should not have mothers and babies dying on hospital wards.”

Hospital chief executive Averil Dongworth said Mrs Ali suffered “a very rare medical complication” but added: “The care provided in her early labour was of an unacceptable standard and liability will not be disputed.”

External assessors are making a serious incident investigation.

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

Induced Labor Linked to Raised Risks for First-Time Moms

Posted on March 3, 2011 by Melissa Maimann

I’d like for my readers to appreciate that there is a place for inductions for some women in some pregnancies. And in those pregnancies, an induction might be the best course of action for the mother or the baby – eg pre-eclempsia, gestational diabetes that is not well-controlled, a post-term pregnancy and many other reasons. Certainly, an induction because it’s Tuesday and it fits into the diary is not a good idea. There should be a clear clinical need for all inductions – they are interventions and there should be a valid reason to intervene in any pregnancy.

If your midwife or obstetrician has advised that an induction will be the safest course of action, then this advice needs to be balanced against the information below (and any other information you might learn). If you are unsure, please talk to your midwife or obstetrician and ask them why they have recommended an induction. If you are still unsure, you may wish to seek a second opinion from another midwife or obstetrician.

Link

The increasingly commonplace decision by pregnant women and their doctors to induce labor for convenience rather than for medical necessity entails some health risks to both mother and child …

The new report, which highlights the negative impact of what is known as “elective induction” for first-time mothers, indicates that going that route increases the chances of a Cesarean delivery, while also boosting the mother’s risk for greater loss of blood and a longer post-delivery hospital stay.

“The benefits of a procedure should always outweigh the risks,” … “If there aren’t any medical benefits to inducing labor, it is hard to justify doing it electively when we know it increases the risks for the mother and the baby.”

… about one-third of those who elected to have labor induced had to undergo a Cesarean section compared with just one-fifth of those who were not induced.

… In addition, babies born after induced labor appeared to face a higher risk for needing oxygen following delivery and special care in the neonatal intensive care unit.

The study authors noted that women who had previously given birth might not suffer the same negative consequences … your body knows the drill and can do it again,” …

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

Delivery Even a Bit Early May Mean Developmental Delays

Posted on February 23, 2011 by Melissa Maimann

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

Link

Bucking the notion that being born a few weeks early has no discernible impact on babies, a new study indicates that “late preterm” infants face more developmental delays than their full-term peers and those delays may affect their school performance.

… late preterm babies were 52 percent more likely than term infants to suffer severe delays and 43 percent more likely to experience milder limitations. In motor skills, the preterm toddlers faced 56 percent increased odds of severe delays and a 58 percent increased risk of milder ones.

… 5 percent to 40 percent of U.S. births are now early elective deliveries, meaning that births are induced preterm without a valid medical reason …

Noting that many of these at-risk infants receive little or no specialized developmental follow-up, Woythaler’s data included babies with at least 34 weeks’ gestation from wide economic and racial backgrounds who received complete assessments near the age of 2.

The brain of a baby at 34 weeks’ gestation weighs 35 percent less than it would at term …

Social factors and gender had the greatest impact on the children’s mental scores … with language spoken at home playing a key role … In contrast, gestational age was the most important contributor to physical delays.

… Researchers have found such infants are at higher risk for respiratory problems, worse academic performance and school suspension down the road.

“There’s a reason why normal gestation is 40 weeks,” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Electronic Fetal Heart Rate Monitoring Greatly Reduces Infant Mortality

Posted on February 18, 2011 by Melissa Maimann

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

Link

… There have been a handful of small studies … that looked at the effectiveness of fetal heart rate monitors, but none of them were large enough to be conclusive.

Chauhan and his colleagues … used a sample of 1,945,789 singleton infant birth and death records … Multivariable log-binomial regression models were fitted to estimate risk ratio to evaluate the association between electronic fetal heart rate monitoring (EFM) and mortality …

… 89% of singleton pregnancies had EFM. EFM was associated with significantly lower infant mortality (adjusted RR 0.75; 95% CI 0.69, 0.81); this was mainly driven by the lower risk of early neonatal mortality (adjusted RR 0.50; 95% CI 0.44, 0.57) associated with EFM. In low-risk pregnancies, EFM was associated with decreased risk for low (< 4) 5 min Apgar scores (RR 0.54; 95% CI 0.49, 0.51), whereas in high risk pregnancies EFM was also associated with decreased risk of neonatal seizures (adjusted RR 0.65; 95% CI 0.46, 0.94).

The study demonstrates that the use of EFM decreased early neonatal mortality by 53%.

The authors have not pointed to the increased intervention that may have been used to prevent these adverse outcomes. EFM in itself does not save lives; EFM is merely the prompt that alerts health practitioners to take further action. This action is usually in the form of intervention to hasten birth. I was surprised that in this study, 89% women had EFM. Most pregnancies are considered to be low-risk and therefore not in need of EFM. The alternative – intermittent auscultation – was not defined. In NSW, the policy is to intermittently listen in for the baby’s heart beat every 15 minutes after a contraction, and to listen for a full minute. Under this policy, women are able to be upright and mobile for their labours and births and this has a positive impact on the woman’s experience of birth.

Melissa Maimann, Essential Birth Consulting 0400 418 448

When Given Control, Women Use Less Epidural Anesthesia During Delivery

Posted on February 16, 2011 by Melissa Maimann

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

Link

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

Wales delivers on home birth rates

Posted on February 8, 2011 by Melissa Maimann

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

Link

Wales is leading the way in a rise in home births …

WHEN Lindsey Gage decided to have her baby at home, husband Andrew was anxious.

He worried about the risk, the mess and how long it would take to get to hospital in an emergency.

In the event … Andrew, 34, held Lindsey while she gave birth at their home …

This type of idyllic home birth is what midwives recommend for all women with low-risk pregnancies who want it.

Yet just 4% of babies are born at home in Wales, just up on the 3% figure for across the UK, but still only a tiny proportion.

Until 40 years ago giving birth at home was the norm … This changed with the 1970 Peel Report saying hospital beds should be available for the safety of mother and baby.

Almost overnight giving birth became medicalised, putting doctors rather than midwives in charge.

By the 1990s women wanted to reclaim birth and a National Childbirth Trust study showed intervention was twice as likely in hospital, even in straightforward cases.

… Today, requests for home births are increasing and once again …

Since the Welsh Assembly Government launched its strategy to increase home births in 2002, they have more than doubled …

… rates vary enormously with some areas, including Porthcawl and Pyle, recording 25% to 30% home-birth rates.

… it’s partly growing requests from women, partly the WAG strategy and the fact that Wales is relatively small making communication and change easier.

… England followed this lead after visiting Wales to see how our Know Your Midwife scheme worked …

… Helen Rogers, director of the Royal College of Midwives in Wales, hopes rates will snowball as women see home birth works and says we should still aspire to 10% and more.

Science teacher Clare Sklavounos … who had both her children … at home, has no hesitation recommending it.

Husband Chris delivered both babies in the living room which he describes as an “amazing experience”.

Clare says she began to realise during ante-natal classes that intervention was more likely in hospital and wanted as natural a birth as possible.

After discussing home birth with midwives she says she was confident it was safe and the best option for her.

… “I was totally uninhibited and could eat and drink when I wanted.

“When it started to get intense I got into the birthing pool and gave birth. I didn’t want any pain relief and didn’t need it.

“The midwives were brilliant. They monitored the babies’ hearts during both labours quite regularly but it didn’t feel intrusive and I felt normal afterwards because it was treated as something normal.

“It all felt so natural. I had the labours I wanted.”

Chris says the experience was very different from when his first child Mia, five, from a former relationship, was born.

“Mia was born in the University Hospital Wales in Cardiff. It was my first child and it was amazing but different,” he recalls.

… “I was shattered and got no sleep,” she says.

“I had an epidural which I didn’t want but I did have to have because the baby got stuck and I couldn’t push.

“I was then told to lie on my back and hold my legs up to give birth but it felt wrong. With my second labour at home I stood up and then delivered standing and squatting.

“The home birth was lovely as births go.

… “He got to bond with the baby and he cut the cord.

… Although this type of birth might not be everyone’s choice, the Royal College of Midwives and Royal College of Obstetricians issued a joint statement in 2007 saying home birth should be available to all low-risk women wanting it.

The colleges added that “if women had true choice” home-birth rates would rise to between eight and 10%.

“There is ample evidence showing labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby,” the statement reads.

Not everyone agrees, however.

Last year medical journal The Lancet said “women do not have the right to put their baby at risk” in response to research from the USA suggesting home birth tripled the risk of neonatal mortality – babies dying within a month of birth.

The RCM responded by saying the research didn’t reflect the situation here where midwives are highly experienced and properly equipped to carry out home births.

… Here the RCOG agrees childbirth is unpredictable and says while it supports home birth in low-risk pregnancies, women birthing at home should also have quick access to obstetric care if an emergency occurs.

The RCM, which represents most of the 1,800 midwives in Wales, says choice and proper care are vital wherever you are.

“RCM policy is that women should have choice,” Helen Rogers explains.

“As part of that we expect low-risk women with no complications should be able and encouraged to have home births.

“I believe we are leading the way on this in Wales.

“It’s slow and there are times when I’d like to increase the rate more quickly but it’s a steady increase. I believe midwives are much more confident about home births now.

“In many areas of Wales the demand for home births has always been there and women have pushed for it.

“There has been a world-wide attack on home births. Some of it is the medical profession which seems to think that hospital is the safest place to have a baby.

“But the vast majority of women are fit and healthy and childbirth is a normal, physiological process. They don’t have to be in hospital.”

Helen says there’s no evidence mothers are less safe having babies at home and disputes any suggestion that home birth might be promoted as a way to cut costs.

“I don’t think health boards would promote home birth because it’s cheaper,” she insists.

“It’s more likely they’d cut them and put all staff in one place.

“As services get more cash starved it’s often so-called luxury services, like home birth, that get hit.

“The WAG supports home birth and its strategy to increase home birth has certainly helped.

“We didn’t get 10% home birth rates across Wales although we have more than 10% in many places and that will probably increase throughout Wales as more women have home births.

“A few years back it was only women who went to National Childbirth Council classes who had home births.

“Now women from all walks of life are having them. They’re seeing their friends and husbands’ friends’ wives having home births.”

… Wherever women give birth, studies show those who have positive births are more likely to recover faster and less likely to develop post-natal depression …

… “We find people birth quicker at home because there’s a sense of confidence and security.

“If you feel anxious and frightened you get the flight-and-fright reflex and release adrenalin which stops the labour.

“Anxiety happens because people are frightened of hospitals.

“Hospitals are wonderful places if you need to be there, but if you’re low-risk, home is as safe or safer.”

… “With a home birth women are in control of their birthing experience. They are in their own home and more relaxed.

“Nature gets on with it and you don’t have to interfere. It’s a very nice experience.”

… “When we talk about taking birth away from doctors people ask, ‘What if something happens?’,” she concedes.

“The women we deal with have uncomplicated pregnancies but if we need to transfer women from home or the birthing unit to hospital it’s because labour is not progressing as we’d want.

“Midwives are the experts at looking after women in normal births, not doctors.

“We have very, very experienced midwives with excellent equipment and they continue to train and update their skills. When women choose to go to hospital because doctors are there and it’s safer there are certain times of year, March and August, when junior doctors change rotation.

“In the first instance you might see a junior doctor. Doctors are my best friends and we need to work together but birth is normal and we should encourage women to give birth at home.

“Once you start on intervention it leads to another. If it’s an uncomplicated pregnancy, home and midwife-led birthing centres are social environments whereas hospital is a medical environment.

“I’m not saying things never go wrong but in this country, on the whole, you are dealing with healthy women.” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Value of bed rest for pregnant women questioned

Posted on February 4, 2011 by Melissa Maimann

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

The value of bed rest has been disputed for many years. When I did my midwifery degree in 2000, We were taught that there was very little value, if anything, in bed rest. It only serves to increase levels of depression and increase the woman’s socialisation into the medical model of care via fear. It’s not helpful! Gentle activity is safe; nothing too vigorous, and nothing too stressful.

Link

Margaret Simon spent the last four months of her pregnancy lying in bed on a doctor’s orders, hoping to prevent a miscarriage and a preterm birth. As a result, Simon lost her job, struggled to care for her two older children and grew so unfit that she got winded taking showers.

“Everything that made me who I am, being a wife, mother and employee, all got yanked out from under me,” said Simon, 34, who had been the family bread-winner and described bed rest as the “darkest, most conflicting” time of her life.

As many as 95 percent of obstetricians report having prescribed bed rest or restricted activity to women with complications that may increase the risk for preterm labor, such as high blood pressure, carrying multiples and vaginal bleeding …

Yet experts say there’s little evidence that immobility leads to better outcomes for those women. And although bed rest is often assumed to be a safe intervention, it can be a physical, emotional and financial nightmare for expectant mothers …

The American College of Obstetricians and Gynecologists states that “bed rest, hydration and pelvic rest does not appear to improve the rate of preterm birth and should not be routinely recommended.” … pregnant women should not be systematically prescribed bed rest “due to the adverse effects that bed rest could have on women and their families, and the increased cost for the healthcare system.”

Most doctors are aware of the scant evidence. Yet they perpetuate the old-fashioned practice, mostly because they have no better options … [and] it’s the way things have always been done. A fear of liability and medical malpractice lawsuits plays a role too.

“There’s no evidence-based way to keep someone from delivering prematurely,” …

“The risks of placing a woman on bed rest outweigh the current evidence it improves outcomes,” …

Bed rest isn’t the peaceful vacation one might fantasize about. Women on “modified” bed rest may need to rest for an hour, three times a day. Others stay horizontal 24/7, rising only to use the bathroom. They can’t ride in a car, have sex, walk up stairs, lift a laundry basket, cook dinner or stand in the shower, let alone take care of children or work. Some women take it so seriously they crawl to the bathroom.

Proponents say bed rest can buy extra time for a pregnancy; the closer a baby is born to term, the better. Lying down, they say, can reduce women’s stress, increase blood flow to the uterus, diminish uterine activity and decrease pressure on the cervix.

And then, some say bed rest is just common sense, based on the perception that contractions mean a baby is on the way. Sarah Jacobs, of Brooklyn, N.Y., said that whenever she was up for too long, her contractions increased.

“It was really clear to me that lying down kept the baby inside,” said Jacobs, who was on bed rest for six months during her third pregnancy.

But experts say that most preterm births occur in women without risk factors and that contractions are a poor predictor of preterm birth, as they don’t always produce the changes in the cervix that lead a baby to be born.

“While women might experience worse contractions with activity or standing, it is important to differentiate contractions from labor,” … “Having (contractions) doesn’t always mean you are in labor.”

… The longer women are on bed rest, the more severe their symptoms and the longer it takes them to recover … after you lie around for a while, you begin to ache and your muscles begin to atrophy — starting as soon as 48 hours — so it’s easy to injure the muscles in the postpartum,” …

In addition to losing their conditioning, women on bed rest may experience bone loss and have trouble sleeping. Meanwhile, they tend to lose weight, and low maternal weight can affect the fetus and is associated with preterm birth.

“Doctors don’t realize the dangers,” …

Perhaps the toughest part of bed rest is psychological. The abrupt and sometimes catastrophic disruption of their life, coupled with the stress that comes with a “high-risk” pregnancy, can leave women feeling isolated, helpless and unusually dependent. It often strains the marriage and is hard on other children in the family. Like astronauts in space, women on bed rest may feel estranged from their familiar routines and may experience sensory deprivation and depression …

… Ultimately, Simon’s 9-pound, 14-ounce baby did not come prematurely; she had to be induced at 39 weeks. As awful as bed rest was, she would do it again “because he’s here,” she said. “And he’s healthy.”

Don’t you love the language? She “had” to be induced at 39 weeks. What was the indication? Pregnancy? It was Monday? 39 weeks is not a reason to induce a baby!!

Melissa Maimann, Essential Birth Consulting 0400 418 448

When expectant mothers go beyond their expected date of delivery…

Posted on February 2, 2011 by Melissa Maimann

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

When expectant mothers go beyond their expected date of delivery… the world ends. Well, I think that’s what the author of this article wants us to believe. This is a seriously bad article that I had to share. Everything about it – the accuracy of the information, the language and the style – are cringe-worthy. If your baby hasn’t arrived “on time”, please don’t read this article. Skip to the next one.

Link

You have probably heard of a lady who has gone beyond their expected date of delivery (EDD). This is known as post term pregnancy. “Post-term pregnancy is defined as a pregnancy that extends to 42 weeks and beyond,” …

Actually, no. Post-term pregnancy is one that continues past 42 weeks. A pregnancy is post-dates after 40 weeks, but it is not post-term until after 42 weeks. A baby can be post-mature at any time, but generally a post-mature baby is born after 42 weeks. Not always though – many post-42 week babies show no signs of post-maturity.

Dr Mike Kagawa, an Obstetrician and Gynaecologist … explains that a number of reasons could be behind this. But first it is important to have this at the back of one’s mind. “When we tell expectant mums when the baby will come, it is an estimate,” he says.

Thank goodness for this piece of truth.

The commonest cause thus far is when the dates are wrong …

Another cause of this variation is technology, more so the ultrasound. “The results depend on the individual, the machine used and the timing. When a scan is done too early or too late, it may not be accurate,” …

The earliest scan, and preferably one from the first trimester, should be used if ultrasound is used for pregnancy dating. If the woman is sure of her last period date, has regular periods, has had at least three periods since ceasing breastfeeding and was not on the pill for at least 3 months prior to becoming pregnant, a dating ultrasound may not be necessary.

But as fate would have it, some people genuinely go beyond their due date.

Actually, as fate would have it, a normal pregnancy lasts somewhere between 37 and 42 weeks. It’s perfectly “normal” to go beyond 40 weeks.

“There are two categories of these,” he explains, “The first group do not start labour until induced.” This he says, can not easily be explained but once induced, the labour proceeds normally.

Ah, so those women would simply stay pregnant forever if they were not induced? I don;t know any woman who has been pregnant for ever. Do you? I know of plenty of care providers who have not been patient.

In the second group are those that have medical problems … sometimes the baby may delay because they have congenital they are born with anomalies, health complications especially those involving the brain. An example, he says, is a condition medically termed anencephaly, where the brain lacks its outer covering (or skull). “The pregnancy can even be overdue by two months.”

And we know this because we regularly have women gestating to 48 weeks! The medical conditions mentioned are very rare.

In Dr Caughey’s article, other factors like the baby being male, genetics, previous post-term pregnancy and the fact that one is giving birth for the first time (primiparity) also lead to post-term pregnancy. “All that said, we do not want babies going beyond their due-date,” … as the baby grows, so does the placenta because it is the route by which the baby gets nutrients. At 40 weeks, this growth is no longer proportional. The baby keeps growing, but the placenta does not and yet the baby needs even more nutrients. Inadequacy of the placenta puts the baby at risk of starvation. For this reason, doctors give it up to 42 weeks, if the dates were accurate, then induce labour.

Ok, so this paragraph is kind of ok. There are tests that women can have to determine the condition of the placenta and to ensure that the baby is ok for now. Unfortunately these tests are limited, as with all testing, and there is a margin of error. Also, they only tell us how the baby and placenta re right now, not necessarily how they will be next week or even next month. That said, some women will opt for testing and monitoring and if all’s well, they’ll continue without an induction.

In cases of post-term pregnancy, the delivery is likely to be difficult. “The bones of the baby are harder and it is difficult to manoeuver through the birth canal,” Dr. Kagawa says. These babies may also not be as healthy or robust as those born on time and are kept in the neonatal health care unit for monitoring for some time.

Ouch! The scare tactics. The other approach would be to suggest that until the baby is in a good position for birthing, labour will not start. This is a protective mechanism. If we go inducing the labour with the baby in a non-optimal position, the labour is more likely to be difficult and tor result in a caesarean. An alternate approach would be to encourage the baby to adopt an anterior position and then await spontaneous labour.

The article does not mention the increased chance of having meconium in the waters of post-dates and post-term babies. This is more likely after 40 weeks than before 40 weeks. It is not a problem in itself, but it can become a problem if the baby should become distressed in labour and gasp. It’s recommended that women who have meconium staining have continuous monitoring to keep a closer eye on the baby and any distress that might be occurring. The use of telemetry will ensure that mobility and access to the bath and shower are not restricted.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Obese Women Have Longer Gestation Period

Posted on January 28, 2011 by Melissa Maimann

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

Link

According to a recent study, overweight women have a higher chance of having a longer gestation period. The study also says that obese women are more likely to have induced labour and also a caesarean section.

… one in three women were pregnant even after 10 days of due date as compared to their healthy counterparts.

… more than one third of obese women had to undergo an induced labour as compared to one fourth of women who were healthy …

There is a great value in preconception care. For women who are overweight or obese, or even a healthy weight but seeking improved health and well being prior to pregnancy, preconception care is essential. Midwives and obstetricians provide preconception care.

Melissa Maimann, Essential Birth Consulting 0400 418 448

Induced labor may double the odds of C-section

Posted on January 24, 2011 by Melissa Maimann

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

Link

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

However … this guideline is “not followed rigorously.”

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

As early elective births increase, so do health risks for mother and baby

Posted on January 7, 2011 by Melissa Maimann

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

Link

A dramatic increase in the number of U.S. women and physicians choosing an early childbirth comes with new health risks for mothers and newborns …

The average time a fetus spends in the womb has fallen seven days in the United States since 1992 …

Researchers see an “evolutionarily dramatic event” in the trend, and perinatal health experts see dangers. Shortening gestation could affect lung development and some fine-tuning of brain functions …

… Babies born too early often sleep longer than normal and have trouble learning how to breast-feed, causing dehydration and jaundice

“For every day and every week before 39 weeks, it’s an increasing risk to the baby,” …

… women are significantly more likely to experience C-sections at for-profit hospitals across the state. … the number of women in the state who die each year from causes directly related to childbirth had more than doubled since 1996.

The rise in deaths during childbirth indicates that obstetric health has deteriorated in many important ways …

… A normal pregnancy lasts 40 weeks, although researchers believe it probably is safe to induce delivery at a full 39 weeks. Women often naturally give birth earlier than this, and in some cases medical problems call for an early delivery. The problem comes when babies are forced out of the womb.

Of all births from 1990 to 2006, the number of babies born at 36 weeks increased by about 30 percent, and babies born at 37 and 38 weeks rose more than 40 percent, according to national statistics. There was a corresponding drop in the number of babies born in later weeks. Now, more babies are born at 39 weeks than at full term.

The data examined is considered fresh by academic standards and covers such a long period of time — 16 years — that experts say the trend is unmistakable

… Some early births are scheduled for the convenience of the mother or doctor …

… One mother, Michelle Van Norman, gave birth to her second child … 11 days early in 2006, with no need for urgency … Van Norman, a 31-year old mom living in Las Vegas, said her doctor didn’t seem worried about the date.

“There were no medical reasons for the delivery being early,” Van Norman said. “He told me the week he could do it and asked me to choose which day was best for us.”

None of those days was best for the baby. After his birth by C-section, one of Christian’s lungs collapsed. He spent three weeks in intensive care and 10 days on a ventilator with six tubes going into his chest.

“The whole experience was horrific,” Van Norman said. “It didn’t end with the birth, it continued for the first year of his life, and we still don’t know if the oxygen deprivation has had any affect on him.” When Van Norman’s surgeon cut the cord, Christian seemed robust. The doctor declined to comment about the case.

“The doctor came in the day after and asked where the baby was,” Van Norman said. “When I told him, he asked me if I was joking. “… I swore from that day on I would never put another baby through that kind of torture for any reason.”

In California, the state Department of Public Health, March of Dimes and California Maternal Quality Care Collaborative have released what its authors call “the Toolkit.” The authors note that deliveries at 37 and 38 weeks account for about 17.5 percent of total births in the United States

Babies born early through induction or C-section without a medical reason are nearly twice as likely to spend time in the neonatal intensive care unit … They also are more likely to contract infections and need breathing machines …

“We are finding out that the last weeks of pregnancy really do count” …

“At 35 weeks, the brain is only two-thirds of what it will weigh at 40 weeks.” Many organizations are responding with programs designed to eliminate early elective deliveries …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Childbirth deaths from spinal anesthesia rising

Posted on January 4, 2011 by Melissa Maimann

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

Link

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

Posted on December 26, 2010 by Melissa Maimann

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

Link

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

Fetal ultrasound safe when used prudently

Posted on December 24, 2010 by Melissa Maimann

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

Link

Ultrasound images during pregnancy have helped erase much of the guesswork that formerly challenged those of us who practiced obstetrics. As time has passed, the images have become much sharper and more sophisticated. However, there is still much that is not known about the long term risks of exposure of the unborn to ultrasound.

Fetal ultrasound uses sound waves to make pictures of the fetus and placenta inside the uterus. Since its introduction in the late 1950s, ultrasonography has become increasingly useful. Current real-time scanners depict a continuous picture of the moving fetus on a monitor screen. Very high frequency sound waves … are generally used for this purpose.

… Some small studies have suggested possible ill-effects of fetal ultrasound. These problems have included low birth weight, speech and hearing problems, brain damage, and non-right-handedness. However, these problems have not been confirmed or substantiated in larger studies from Europe.

There are some people who suggest that ultrasound use in pregnancy contributes to the increase in autism diagnosed in recent years. The complexity of some of the studies and concerns have made the observations difficult to interpret.

… the greatest risk arising from the use of ultrasound is the possible over- and under-diagnosis brought about by inadequately trained or under-experienced technicians, especially if working in relative isolation and/or using poor equipment.

Ultrasound scans should best be performed when there is a clear indication to do so. When that is the case, it is safe to use prudently.

Melissa Maimann, Essential Birth Consulting 0400 418 448

‘We know the reality of childbirth’

Posted on December 22, 2010 by Melissa Maimann

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

Link

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

Unnecessary C-Sections on the Rise

Posted on November 22, 2010 by Melissa Maimann

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

Australia’s caesarean rate was 31.1% in 2008.

Link

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Melissa Maimann, Essential Birth Consulting 0400 418 448

Oxytocin Medication Often Unnecessary In Normal Deliveries

Posted on November 21, 2010 by Melissa Maimann

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

Link

It is standard practice … to use oxytocin to stimulate a labour that has been slow to start or has grind to a halt for a few hours. However, it is also fine to wait for a further three hours in first-time mothers …

… Healthy first-time mothers with normal pregnancies and a spontaneous start of active labour were monitored throughout their deliveries, with a follow-up one month later. Those with a slow or arrested first stage labour, were randomly allocated to early oxytocin treatment or expectancy for 3 hours. All of the women were given the same access to pain relief and staff support.

The results showed that there were no differences between the groups in terms of the number of caesareans, ventouse deliveries, major haemorrhages, significant tears, or newborns needing neonatal care. In the expectancy group, treatment with an oxytocin drip was avoided in 13% of women and, as expected, the deliveries took slightly longer time. A month after delivery both groups of women were equally positive or negative about their birth experience.

… “A normal first delivery and positive birth experience are extremely important and impact on future pregnancies and deliveries,” …

Melissa Maimann, Essential Birth Consulting 0400 418 448

Bathing better than pethidine as pain relief during labor

Posted on November 20, 2010 by Melissa Maimann

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

Link

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

Posted on November 17, 2010 by Melissa Maimann

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

Link

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

May 2013
M	T	W	T	F	S	S
« Apr
		1	2	3	4	5
6	7	8	9	10	11	12
13	14	15	16	17	18	19
20	21	22	23	24	25	26
27	28	29	30	31