We need to be reminded about the potential dangers associated with directed pushing

The very talented Dr Rachel Reed has recently written a brilliant blog about directed pushing and it’s harmful effects on both Mother and baby. She has also included evidence to support that women need to be supported and

‘allowed’ to follow their own bodies when it is time to birth their babies. Happy reading…

Supporting women’s instinctive pushing behaviour during birth

The use of ultrasound to estimate fetal weight

Despite the evidence suggesting that Ultrasounds are quite inaccurate at estimating baby’s weight while in utero, clinicians are still turning to ultrasound weight estimate as a form of assessment of the unborn babies wellbeing:

I am currently caring for two clients who have been directly affected by inaccuracies of ultrasound estimation of fetal weight.  My first client had her first baby 2 years ago with an obstetrician who suspected my clients baby may be small by fundal height measurements in cm.  The obstetrician ordered three ultrasounds from 34 weeks which showed average fetal growth.  At 41 weeks, when in early spontaneous labour, my client’s unborn baby showed signs of fetal distress and her baby was born by caesarean section, and he weighed approximately 2100g, which was 1-1.2kg difference from what the ultrasounds had estimated.  Her baby was born requiring significant resuscitation, and gladly he is well and developing normally post birth.

Recently I cared for a client who at 38+5 weeks gestation measured around 34 weeks gestation by clinical fundal height measurement.  An ultrasound was ordered and her baby was estimated to weigh 2100g, which is below the 5th centile for his gestation.  So my client was induced and two days after the ultrasound, she gave girth to a 2990g baby, a completely normal size for his gestation.  Although the induction of labour went well, it was an intervention which clearly could have been avoided if there was a more accurate way of assessing fetal growth and weight in the womb.

It is well known and has been well researched that estimating fetal weight by ultrasound is inaccurate in its estimation but it is widely used and relied upon for the estimation of fetal weight.  This inaccuracy can be either way ie estimating that the baby weighs more or less than it actually does.

The literature supports that it is not uncommon for ultrasounds to be between 8-35% inaccurate in assessing fetal weight http://www.ncbi.nlm.nih.gov/pubmed/23132481  This inaccuracy seems to be greater in women with a high BMI, and for babies that are higher in birth weight >4000g http://emedicine.medscape.com/article/262865-overview#a9

The literature has also studied the various ways fetal weight can be estimated, ie AC, FL (see article http://emedicine.medscape.com/article/262865-overview#a9) to see whether there is one method more reliable than the other.

Low and high birth weight is associated with adverse outcomes for Mothers and babies http://emedicine.medscape.com/article/262865-overview#a9 and it is important for the clinician to be able to determine accurately whether or not a fetus is growing well or potentially compromised within the womb to prevent serious adverse outcomes from occuring.

From the available evidence clinicians are not able to rely on ultrasound to be a very accurate method of determining fetal weight http://emedicine.medscape.com/article/262865-overview#a9; .  At this stage as there is no reliable method for assessing fetal weight in utero, clinicians need to continue with some kind of clinical assessment of fetal weight and wellbeing (fundal height measurements and fetal movements), and if there are concerns about fetal wellbeing it is important to assess the overall clinical picture and to assess each woman individually based on her own individual circumstances and not to rely on the findings of ultrasound alone http://www.ncbi.nlm.nih.gov/pubmed/23132481; http://emedicine.medscape.com/article/262865-overview#a9

How special

Posterior positions…Are they something to be celebrated?

I re post this blog after caring for a few women with posterior presenting babies lately.  Two come to mind who had extremely challenging labours.  One turned after a very long labour with body work constantly, and the other didn’t, ending in a very unexpected caesarean section.  I hope you enjoy the read!

 

As a midwife in private practice, the far majority of my clients are seeking further support, education, advice and debriefing for a previous difficult labour and birth…many of the difficulties due to malpresentation of their babies…due to their baby being in a posterior position (OP). This means the baby is presenting head first, but instead of facing backwards towards the mothers back (OA), the baby faces forward, towards the mothers front (OP)(see below)

posterior baby post vs anterior presentation

As part of my education for my clients I discuss ‘optimal fetal positioning’ in pregnancy. This means adopting certain positions from time to time, avoiding sitting for too long, staying active, in order to encourage baby to present in an ‘anterior’ or ‘more favourable position. The reason why I do this is because sometimes when babies present in a posterior position labour can be very difficult and exhausting for women, and due to many factors, a client may be more likely to have a caesarean section or an assisted vaginal birth than a woman who’s baby presents in an ‘anterior’ position.

Recently I read one of Rachel Reed’s blogs on posterior presenting babies…

http://midwifethinking.com/2010/08/13/in-celebration-of-the-op-baby/

Rachel states in her blog that posterior presenting babies should be ‘celebrated’…and as midwives we shouldn’t be concerned about this position as most babies will rotate to an anterior position during labour. Also she states that teaching optimal fetal positioning is not evidence based practice and that there is in fact no evidence to support that teaching this and adopting these position changes in pregnancy will encourage a baby to rotate to the anterior position.

I read each and every one of the research trials that she referred to and indeed, there appears to be no evidence to support educating women to use ‘optimal fetal positioning techniques’ in pregnancy.

MTM SG 020

HOWEVER…a baby in a persistent OP position during labour results in lower rates of vaginal births, higher rates of caesarean and more prolonged and difficult labours. http://www.scienceandsensibility.org/can-we-prevent-persistent-occiput-posterior-babies/ . Of all women in one particular study who had babies presenting OP in labour, 22-24% of babies did not spontaneously rotate to the anterior position. Of all babies that did rotate to the OA position, 94% had spontaneous vaginal births. Of the 22-24% of babies that didn’t rotate to the OA position, only 3-6% had spontaneous vaginal births (http://www.scienceandsensibility.org/can-we-prevent-persistent-occiput-posterior-babies/)…therefore, I don’t think OP presenting babies can be ‘celebrated’ as such.

labour progressing

That being said, once we know a baby is in the OP position during labour, adopting forward positions and being active may be helpful and there is certainly no evidence that doing so may be harmful. In my experiences, when women are supported to adopt their own positions during labour, many will lean forward of their own accord, using their own instincts.

MTM SG 006

Given that we know that babies who remain OP throughout labour and birth are more likely to require some kind of assistance with forceps, episiotomy, ventouse or caesarean section it would make sense that we should at least be teaching women about the benefits of staying active and strong during pregnancy. Over my 22 years of Midwifery practice, I believe I am seeing a rise in the number of babies presenting posteriorly (OP). After discussion with my fellow Midwifery and obstetric colleagues, they too believe this to be the case. We believe this may be the case due to more time spent in cars and sitting at desks, or even sitting in general. Whilst this is not an evidence based thought (as far as I am aware) it does seem to me that advising women of the benefits of staying active and not being sedentary for prolonged periods of times is beneficial for encouraging wellbeing, fitness, and well presented babies…

here so quickly

 

GDM – The evidence (Dr Rachel Reed)

Yet another great bolg post by Dr Rachel Reed exploring the evidence around GDM, testing, management, and the research evidence. Thank you Rachel xx

Gestational Diabetes: beyond the label

 

Assessment of the progress in labour

I have been on a mission – to find evidence around the so called ‘benefits’ of active management of a woman’s labour.  I have found myself engrossed in reading about “The Dublin method” of active management of labour, and how the intention of adopting such a rigid protocol for ‘managing’ a woman’s labour was intended to reduce certain risks to the woman and baby.  However in implementing rigid policies into hospitals, we are exposing women to other risks…

Rachel Reed writes another beautifully written blog on the assessment of the progress in labour, and in how being so rigid reduces a womans chance significantly of having a physiological birth…

https://midwifethinking.com/

 

Undisturbed physiological birth – Is it achievable in a hospital setting?

I have had the honor and privilege to care for quite a few midwives lately, having their babies either at home or in hospital.  I’ve just come home from a postnatal appointment for a midwife, now Mother who had the most straight forward, physiological and stunning water birth of her first baby.  She said she has rarely seen first time Mothers be able to push their babies out without masses of coaching “Hold your breath and push” type coaching.

How sad is that!

On reflection, I remember early in my career working in Birth suites at one of the biggest Level 3 (has neonatal intensive care) hospitals in Melbourne for 18 months and on leaving the hospital I could count on one hand (5 or less) how many births I had had that were truly physiological over that time.  I worked full time, yes 5 days a week for 18 Months and would have cared for less than 5 women having what I would call a truly physiological birth (Mumma and baby just do their thing, cervix opens at its own pace, baby comes down and Mumma pushes when she feels like it).

How sad…actually tragic is that!  And sadly I think the situation is getting worse from when I first graduated as a Midwife.

So why?  Why so much intervention when our standards of health are so high?  Why do women need so much help? Is all the interference and rigid ‘black and white’ hospital policy causing the issue? Is it that the women are different in some way now from what they were 24 years ago (when I graduated as a Midwife)?

Although I think the issue is a complex one, a number of factors are a cause.  Firstly, I think many women fear the process of labour and birth.  Why wouldn’t they?  After all they hear their friends horror stories of birth, being cut with scissors, screaming in agony, their body couldn’t labour naturally so they had to be induced…oh boy and that was torture!  And I also believe our hospitals have become so medicalised, rigid, and put all women into one basket…the one size fits all approach.

I’m not going to discuss fear in this blog as I think I need to write a blog on fear later.  What I’d like to discuss is intervention in labour, and the problems I think this causes.

Many of my clients planning a hospital birth like the idea of me caring for them at home until labor is very well established (head well down and cervix almost all taken up-dilated).  So we go into hospital and sometimes what has been truly physiological and straight forward has within 2 hrs become pathological…all because of intervention and the hospital’s staff suggestions on ‘what needs to be done’.  Let me share a story with you…

A straight forward uncomplicated first time mother in labour at home, planning a hospital birth, rests in her own bed, walks around her own house, eats her own food, wees on her own toilet…labour usually progresses very well…we go into hospital in what appears to be advanced labour, in 2.5 hours this is what happened;

We need to do a Vaginal examination, no I don’t want one…we need to examine you within the hour…it’s hospital policy.  Woman says OK, she is 7cm dilated.  Very happy.  We would normally break your waters this far along…no thank you…it will help labour to go faster…no thank you.

Platelets have been on the lower side in pregnancy, lets do an FBE to check their level…fair enough, but while we are taking the blood, we would like to leave a cannula in your arm ‘just in case’.  Just in case what?  Just in case you hemorrhoage?  Really, I say, can we consult with an Anaesthetist… consulted…long discussion…he has no issue.

When did you last empty your bladder…it was about 3 hrs ago at home…how much did you wee…adequate amounts. Lets get you up to the toilet to wee…doesn’t feel like weeing… Can I get you back on the bed so I can feel your tummy and see if I can feel a bladder.  No bladder palpable, but lets put an in-out catheter in your bladder and drain it ‘just in case’.  Client agrees…small amount of urine drained (50 mls) and increased chance of bladder infection gained.  Your urine has ketones in it so we would like to put a cannula in now and give you IV fluids…no need for IV fluids…she isn’t vomiting and can drink large amounts of fluids…lets get some apple juice and hydralite.  No, we want to put a cannula in and if you don’t agree I’ll get the senior Dr.  Get the senior Dr then…comes in, full on discussion about IV fluids.  Client declines.

It’s been 2 hrs since your last examination, we want to re examine you, client says not right now…no we need to do the examination at …o clock, it’s essential to see how far you have progressed…about an hour later re examined…7cm!

Are you surprised?…I’m not…not at all.  This woman’s labour was so disturbed, so interrupted, so much cognitive thought processes required. Her ability to birth so undermined when all she needed to do was ‘switch off’ and be ‘allowed’ to do her thing.

Another woman, first time Mother, same scenario, planning a hospital birth, arrives in well advanced labour…midwife greets us with a smile and warm touch…I’ve tried to prepare the room so it is warm, dark and relaxed…it is beautiful.  How clever are you, the Midwife whispers to the woman, let’s run the bath, let’s get you in as I know this is what you would like…warm water running on her belly, sips of water and crunching hydralite icypoles…cold flannels to face as she is so hot…working so hard…baby’s heart beat great, so is the woman…sounds a bit grunty…some gentle efforts to bring the baby’s head down…after some time, quite some time that urge to push gets stronger…soon we see the baby’s head slowly advancing…crowning, born…into the bath, Mothers and Fathers hands gently guiding the baby out.

Both these women presented to hospital in similar circumstances, but both had such different outcomes, I believe all to do with being disturbed or undisturbed, having labour intervened with or ‘allowed’ to take it’s course…

So who writes these hospital policies…especially around ‘active management of labour’ and what level of evidence is used to formulate them?  What evidence is there to support that disturbing a women in perfectly physiological labour with suggestions and in fact demands for vaginal examinations, blood tests, catheters, cannulas etc etc helps facilitate good outcomes?

I will access some of these ‘Active labour’ policies and examine the ‘evidence’ and write another blog!

Mamatoto’s Morning Tea!

Thank you to all my Mummas who came to say hello and to meet at Shillinglaw Cafe in Eltham.  Your bubbas are delicious and so well loved and cared for.  You are all such amazing parents.  Love your energy xxoo Juliana

What a delightful way to return from my holidays

It was an honor and privilege to be part of this amazing birth, my clients first baby, the first Mamatoto baby for 2017, born in the safety of my clients home, surrounded by family, midwives and the dog!

My clients labour was quite quick really for a first baby, but it reminded me of how stunning and spectacular birth can be when we allow nature to take its course, and when we genuinely support women and their families.

I arrived at about 6am, loud roaring sounds coming from the house, wow I thought, she really is moving along and sounds quite close to being ready to birth her baby.  She had just hopped into the birth pool, partner topping it up with hot water, offering her sips of water, and pieces of apple to eat.  Occasional grunting noises, followed by breathing, followed by occasional strong pushes.  All was well, baby’s heart beat very reassuring and despite working very hard, my client was coping very well with very strong contractions.

I decided to call Louise (the second midwife) as I felt this baby would arrive soon, Louise sounded excited and said she was 20 mins away.  My clients partner made it very clear that he wasn’t going to be able to help with ‘that birth stuff’ if Louise didn’t arrive in time and I assured him Louise would definitely make it and that baby wouldn’t arrive before Louise!

Louise arrived and we took it in turns to pour warm water over my clients belly, and she would sometimes lie down in the bath and then flip over into a kneeling position.  All the while Mother and baby coping very well.

After some time I heard my client announce excitedly in a loud voice ‘Oh my, it’s just there!  It’s just sitting there, OMG it’s just there, I can feel the head, I can sooooo do this’ she said. She went on to say she could have 10 children (her partner said that’s what he was worried about!) and that she was actually having fun.

So my client ended up guiding her baby’s head out with her hand placed on her baby’s head, with some pushes, some breaths, some nudges, slowly and gently, all the while Mumma and bubba were in perfect health.  Then the head was born, then the shoulders, and my client wrapped her hands around her baby and guided her up out of the water into her arms.  Her face said it all, joy, absolute delight and amazement at what had just unfolded.

I was on such a high after her birth, thinking of how my client’s relationship as a couple had bonded even more and had moved to the next level.  Hearing the Father of the baby talk about this woman, her power, her strength, her incredibly positive mind set, her awesomeness.  And his support and their mutual respect for each others wishes for the birth.  And what a great start as a new family, such a happy healthy Mother, a baby born gently, through water, into her Mother’s hands and arms. Kept together, skin to skin, early breast feeding, all uninterrupted.

Thank you for choosing me to be your Midwife. I know how privileged and honoured I am to be asked to be part of these life changing experiences for women, their families and their babies. Love Juliana xxoo

 

 

 

Consuming the Placenta

well…5 years ago, if you had have said to me that I would be discussing the topic of eating the placenta with my pregnant clients I would have said “Thats simply disgusting”…”How could one even think about eating their own placenta”…”It is a waste product”!  Then about 5 years ago, one of my clients asked me the question…”Well, what do other Mammals do when it comes to eating the placenta?”

To my suprise, most other Mammals, including primate Mammals eat the placenta or after birth.  There are many reasons why this may be so and have a look at the link below which discusses in detail the reasoning why placental consumption by the Mother after the birth may be beneficial…

Most of my clients now opt for placental encapsulation, where their placenta is dried and put into capsules, rather than eating the placenta raw.  some of my clients now opt for a ‘placenta smoothie’ which on many occasions I have made…frozen berries, milk, vanilla, placenta, and some LSA mix…YUM!!!!

Happy reading…

http://news.unlv.edu/article/steamed-dehydrated-or-raw-placentas-may-help-moms%E2%80%99-post-partum-health

The risk of Uterine rupture in those women wanting VBAC

The instant that Mother and baby meet face to face for the first time

I know I have written blogs about uterine rupture before, but I feel compelled to write again on this topic as ‘uterine rupture’ is often the ONLY topic of conversation that some of my clients have with their care providers, and some times at each and every antenatal visit, all that is discussed with my clients are the risks associated with having a VBAC, and the main topic of conversation is ‘Uterine rupture’.

So what are the chances of such an occurrance, what actually happens when the uterus ruptures, and are there any interventions which may increase the chance of the old scar rupturing?

I’ve found a research study performed on a very large sample size which looks at the rupture rates for women who labour spontaneously, women who are induced with prostaglandins, and also women who induced with oxytocin.  Not suprisingly, it was found that women who labour spontaneously have the lowest rate of uterine rupture, and women whose labours are sped up with oxytocin have the highest rate and chance of this happening to them.

It has always been my firm belief that when labour is left well alone, and when women labour spontaneously, without any natutal or medical induction methods, then labour tends to go well.  This is certainly the case when wanting to avoid major complications such as uterine rupture with women wanting VBAC…

http://www.ncbi.nlm.nih.gov/pubmed/20716251