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Melanie Jackson is mother of two, Midwife in private practice, PhD graduate, part-time blogger, obsessed veggie patch owner and even more obsessed crocheter

Monday, 21 November 2011

Intervention Management of birth and its association to maternal morbidity

*Reader warning - this one will need a good cup of tea and a little time, but well worth the read*

This essay aims to define and analyse ‘intervention management’ of labour and birth, followed by the subsequent impact of intervention management on maternal morbidity. The definition of Intervention management will be derived from literature surrounding the concepts of obstetric fear, perception of risk, the medicalisation of childbirth and definitions of ‘normal’ and ‘abnormal’ labour and birth which stem from biomedical philosophy. Research has found that 43% of women experience some kind of morbidity beyond what would be normally expected in childbirth (Danel, Berg, Johnson & Atrash, 2003, p.28). Maternal morbidity will be defined in terms of a mothers ‘illness or abnormal condition’ (Harris, Nagy & Vardaxis, 2006, p.1127) relating to labour and birth and not specifically as a statistical measure of illness or abnormality. The focus of this analysis is on iatrogenic maternal morbidity relating to intervention management in labour and not morbidity associated with pre-existing poor maternal health.   

This analysis acknowledges that morbidity can be long or short term and can be physical or psychological in nature (Weaver, 2004, p.11). The psychological morbidity associated with intervention management will be examined followed by physical morbidity caused by various interventions. It is proposed that intervention management produces iatrogenic effects which compound as a result of the ‘cascade of intervention’ and thus produces an increase in avoidable maternal morbidity. Each intervention will be discussed in an approximate order of its place on the cascade chain to examine maternal morbidity. Interventions discussed include, coming to hospital, admission cardiotocography (CTG), artificial rupture of membranes, continuous CTG, restriction of food and fluids, maternal position, epidural use, episiotomy, instrumental delivery and caesarean section.

In order to fully analyse and define ‘intervention management’, the philosophical assumptions behind it must be explored. Thus, the notion of risk, which has bred a culture of fear surrounding childbirth, will be examined. What logically flows from this analysis is the obstetric philosophy of birth being pathological and the subsequent medicalisation of child birth. The medicalisation of childbirth gives way to the defining of ‘normal’ and ‘abnormal’ by medicine and thus creates a market for modern obstetrics to manage the risk of childbirth by intervening.

The concept and notion of risk is used by modern society to make decisions about and to come to terms with the possibility of outcomes which may entail loss, damage or death (Murphy-Lawless, 1998, p.12). During childbirth there is always the possibility that a woman or her baby may be disabled or die. Since illness and death are considered the domain of medicine it is the obstetric argument that childbirth is risky and dangerous and requires a medical expert to oversee it (Murphy-Lawless, 1998, p.22). Obstetrics argues that its account of birth is authoritative and that intervention is the most certain way to avoid death. Thus, medicine has marketed the message that childbirth can result in death and that death can be escaped by submitting to medical management (Murphy-Lawless, 1998, p.10). By presenting childbirth alongside the discourse of risk, modern obstetrics has created and marketed a need for itself and thus persuaded society to accept their perception of birth, therefore securing birth as their domain (Johanson, Newburn & Macfarlane 2002, p.893 Murphy-Lawless, 1998, p.10). The idea of risk is that the probability of a certain event occurring can be calculated and quantified. Because the complications of labour and birth consistently escape the systems of risk perception and calculation, there is an obstetric tendency to define every aspect of labour and birth in terms of risk in an attempt to explain and predict all possible eventualities (Murphy-Lawless, 1998, p.21). In this sense the labouring female body has become risk laden as the possibilities for something ‘going wrong’ proliferate.

 The use of risk discourse in association with birthing creates fear around the events of labour and childbirth. If an event is perceived as risky, then it is also perceived as scary. By the use of risk discourse, obstetrics has perpetuated the myth that childbirth is to be feared and thus convinced mothers to conform to obstetric management to avoid something ‘going wrong’ (Murphy-Lawless, 1998, p.18). Obstetrics cannot predict and prevent all the possibilities of things that can go wrong, yet have succeeded, with the use of risk discourse to sustain control over the birthing woman (Ballard & Elston, 2005, p.228; Murphy-Lawless, 1998, p.22). Murphy- Lawless states that, ‘the general drive towards intervention, gathered its credibility from the notion of identifiable risk factors and the hope that obstetrics could prevent death by responding to risk factors’ (p.172). Thus the discourse of risk and the resultant fear surrounding childbirth paved the way and provided justification for interventions during labour and childbirth, under the guise that they would prevent death and avoid something going wrong. The obstetric fear of birth combined with the discourse of risk, have led to the assumption of pathology for each labour and birth. Thus, as a matter of biomedical philosophy, birth can only be judged as normal in retrospect because it is always potentially pathological, therefore labour is managed to keep it within the bounds of the medically defined ‘normal’ to make it less risky (Murphy-Lawless, 1998, p.198).

The use of risk discourse has paved the way for obstetric intervention in childbirth which allowed for the process of medicalisation. The term ‘Medicalisation’ applies when a problem is created or taken over by the apparatus of medicine and gives definition to the ways in which medicine has extended its jurisdiction over normal life events (Ballard & Elston, 2005, p.228). The theme of medicalisation implies the extension of medical authority beyond a legitimate social boundary (Rose, 2007, p.700, 702) whereby social phenomena come to be defined and treated as disease (Ballard & Elston, 2005, p.228; McLellan, 2007, p.627). ‘Medicalisation should be understood as a manifesting and ongoing shift in social control processes in modern societies’ (Ballard & Elston, 2005, p.229). Medicalisation occurs when the medical profession uses power gained through their knowledge and expertise to define and control what constitutes health and illness (Ballard & Elston, 2005, p.230). Once medicalisation has occurred, practitioners demonstrate their control by redefining what is considered ‘normal’ and ‘abnormal’ within their newly acquired social process or event (Ballard & Elston, 2005, p.228; Rose, 2007, p.701). Through the process of defining what is ‘normal’, medicine can define what is considered ‘abnormal’ or pathological (Ballard & Elston, 2005, p.228; Rose, 2007, p.701). From a Foucaultian perspective, conformity to the medically defined norm is seen as good behaviour while pathology is seen as deviance and is not socially or medically accepted (Ballard & Elston, 2005, p.231). This is expressed by Parsons who identified ‘the sick role’ which describes the socially accepted role of the ‘sick’, which is to seek treatment and resume their role within society. Failure to conform to this expectation and refuse medical treatment is deemed as deviant and socially unacceptable (Maher, 2003, p.142). By developing a conceptual difference between abnormal and normal the medical profession have secured a large and growing market for their services in perpetuity by the creation of false needs and then catering to these newly perceived needs (Ballard & Elston, 2005, p.230).

As we can see by the social process of ‘problematising’ or medicalising birth, modern obstetrics can justify ‘managing’ labour and birth by ‘intervening’ to make each individual labour and birth conform to the obstetric definition of normal. Thus, by defining what is constituted as a normal birth, obstetricians have monopolised control over events which occur outside the norm under the guise of risk management. ‘By defining the parameters of abnormality and establishing the routine use of medical monitoring and intervention during pregnancy and childbirth, obstetricians have placed undue emphasis on probability of abnormality and thus on the need for all women to be dependent on medical care’ (Ballard & Elston, 2005, p.230). Under the guise of knowledge and expertise, medicine has proceeded to define all aspects of labour, in particular, the parameter of time. The use of medically defined times for labour and birth have justified the use of intervention to ensure each labour fits into the ‘normal’ time a labour should take according to doctors. If a labour is to long it is described as ‘failure to progress’ which is ‘abnormal’ and requires ‘treatment’ (Maher, 2003, p.145). A combination of strict timing criteria for ‘normal’ birth and the perception that childbirth is potentially pathological have encouraged the use of intervention which speeds up the process of birth. This leads to the use of manipulative interventions such as induction, augmentation, forceps, vacuum extraction and rupturing membranes (Murphy-Lawless, 1998, p.200). Just as what is normal can be defined as dangerous, that which is dangerous can be normalised over time (Murphy-Lawless, 1998, p.201) which is what has occurred with intervention during childbirth.

Based on the above stated discussion, the approach of ‘intervention management’ for labour and birth will be defined as, ‘a method of labour and birth care which assumes childbirth is pathological, thus requiring treatment. Using an intervention management approach, birth is controlled by a series of interventions, including pharmacological, instrumental and mechanical to ensure that labour and birth remain within the medically defined boundaries of normal. It is thought that these interventions reduce the risk of childbirth and thus prevent maternal and foetal mortality’. The remainder of this analysis aims to discover and discuss the subsequent impact that ‘intervention management’ has on maternal morbidity.

The use of intervention management to control labour has resulted in increased development and use of technological aids during childbirth which help to monitor birth to identify deviance and risk. When technological aids and intervention are routinely and unnecessarily used, they disturb the normal instinctive and physiological responses within the mother which help to make labour effective and successful. Each intervention has iatrogenic side effects which often require management with an additional form of intervention; this sets up a process which is defined as the ‘cascade of intervention’. The cascade begins with the first intervention and can roll on to the end point of an instrumental or operative delivery (Weaver, 2004, p.19). ‘Inch employed the term ‘cascade of intervention’, to produce a diagrammatic account of possible outcomes, beginning with artificial rupture of membranes which leads to other routine interventions like oxytocin induced induction, epidural, episiotomy and forceps delivery. She built up a picture of how labour goes wrong for women because obstetrics cuts across a woman’s labour in order to prevent a possible outcome which may never arise’ (Murphy-Lawless, 1998, p.204). This analysis proposes that intervention management produces iatrogenic effects which compound as a result of the cascade of intervention and thus produce an increase in avoidable maternal morbidity. To begin, the psychological morbidity associated with intervention management will be examined then each intervention will be discussed in an approximate order of its place on the cascade chain to examine physical maternal morbidity.

When a mother loses control over her birth experience due to intervention management, this can produce emotional and psychological effects of which can be long lasting and affect parenting and future pregnancy and birthing decisions. It is supported in the literature that obstetric intervention during birth produces negative reactions from mothers and can be associated with long term psychological morbidity (De Costa & Robson, 2004, p. 438). Operative and instrumental delivery including caesarean delivery, forceps and vacuum extraction is linked with considerable psychological maternal morbidity including, disappointment, anger, depression, guilt, regret, loss of self esteem, grief reactions, feelings of violation and dissatisfaction with care (Smith, Lumley, Donohue, Potter  & Waldenstrom, 2000, p.1043). In Oakleys ‘Transition to motherhood’ study, she compiled a technology score based on fifteen different forms of intervention that were accepted obstetric practices and found that an outcome of depression in the women who formed her study group strongly correlated with medium to high technology scores, which included the combination of induction, epidural and forceps (Murphy-Lawless, 1998, p.204). Similarly, Porter et al (2003) comment that many women report having more marital adjustment problems, have more problems bonding with their babies and difficulty establishing breastfeeding after caesarean compared to women who have vaginal deliveries. They also found that for some reason having a caesarean discourages women from having further children; women who had caesareans were afraid of further deliveries and as a result had fewer children. Inglis’ study found that there is growing recognition that the effects of a woman’s birth experience can negatively affect her transition to parenthood and that as a result of events occurring during labour, women needed debriefing to recover from being psychologically traumatised by their birthing experience (Inglis, 2002, p.368).

As previously discussed, intervention management stems from obstetric fear and has become mainstream as childbirth has been medicalised. The medicalisation of childbirth requires women to be cared for during labour within the hospital setting. Thus, the first in the chain of the ‘cascade of intervention’ is, going to hospital to experience labour and birth (De Costa & Robson, 2004, p. 438). It is understood that stress and clinical procedures intervene with the physiological process of labour and the stress of transferring to hospital during labour can slow labour and thus create pathology (Maher, 2003, p.141). Sheilds et al (2007) found that women presenting to hospital in the latent stage of labour undergo an increased number of obstetric interventions and that avoiding early admission for women not in active labour reduces the risk of receiving augmentation of labour or an epidural by more than half (Sheilds, Ratcliffe, Fontaine & Leeman, 2007, p.1673). The idea that intervention is more likely to increase with early admission during labour, links well with the previously discussed notion of the ‘normal’ labour time expected by doctors.

A management approach which often accompanies presentation to hospital is an admission CTG. This intervention is often performed routinely on all women presenting in labour to monitor how the baby is coping with labour and allows the staff to determine how to best manage the labour and what interventions are to be employed during the labour to reduce risk (Impey, Reynolds, MacQuillan & Gates, 2003, p.465). Impey et al performed a randomised control trial to assess the neonatal and maternal outcomes in the CTG group and intermittent auscultation group. They hypothesised that there would be a 50% reduction in neonatal morbidity for the CTG group, but instead found that there was no difference between the groups for either maternal or fetal outcomes. They concluded that admission cardiotocography, at the start of a labor in a pregnancy judged to be normal, cannot be justified’ (p.470). In a similar study by Mires et al, it was found that while admission CTG did not improve fetal outcomes it did increase medical intervention with increases in both instrumental deliveries and caesarean section in a low risk population and made a similar conclusion to Impey et al  (Mires, Williams, Howie & Goldbeck-Wood, 2001). These studies support the proposal that intervention management of labour leads to increased intervention and subsequent maternal morbidity in low risk women.

Within the approach if intervention management of labour, interventions are employed to ensure that the length of labour remains within the ‘normal’ limit. In addition to this, as previously mentioned, if birth is seen as pathological, practitioners are eager to have it over and done with as soon as possible. To assist with this, the intervention of artificially rupturing the membranes (amniotomy) is often employed as it is thought speed up the progress of labour (Smyth, Alldred & Markham, 2007, p.2). Murphy-Lawless quotes Nihell who states that ‘the deliberate premature discharge of waters was a very blameable practice, one that all capable midwives reprove and forbid, as it is robbing the part of the most natural and necessary lubrication for facilitating the launch in due course of the foetus’ (Murphy-Lawless, 1998, p.201). Although amniotomy is considered a simple procedure within the intervention management model it does carry risks. It can cause an increase in variable heart rate decelerations in the baby because of cord compression, cord prolapsed and is thought to worsen the pain of contractions (Sheilds, Ratcliffe, Fontaine & Leeman, 2007, p.1672; Smyth, Alldred & Markham, 2007, p.4). While amniotomy doesn’t directly cause maternal morbidity, it is a link in the chain of the cascade of intervention and can lead to continuous CTG. Immediately after amniotomy it is considered good practice to listen to the fetal heart to assess if the intervention has impacted upon the health of the baby (Smyth, Alldred & Markham, 2007, p.4). If decelerations in the heart rate are heard, continuous CTG is warranted as the fetus may be compromised. Thus, if amniotomy leads to the intervention of continuous CTG, it puts a further time limit on labour as doctors will argue that the longer decelerations are present, the more the fetus may be compromised and become distressed which may be an indication for assisted delivery (Gabay & Wolfe, 1997, p.387). The above stated chain of events may give some insight as to why amniotomy is associated with higher rates of caesarean and instrumental delivery then if membranes spontaneously rupture (Sheilds, Ratcliffe, Fontaine & Leeman, 2007, p.1672). Thus, the intervention of amniotomy can indirectly contribute to maternal morbidity due to resultant intervention management to remedy the iatrogenic effects of previous intervention.

          If fetal distress is diagnosed resulting in continuous CTG, the mother will often be advised not to take any oral fluid or eat. Restricting oral food and fluid intake of women in active labour in hospitals is a strongly held obstetric tradition based on the historical concern related to risks of gastric content regurgitation and aspiration into lungs during general anaesthesia. Thus the thought is that if the baby is distress, the mother may require a caesarean delivery and if she did, then she may need a general anaesthetic (GA) and if she did then there is a risk of Mendelsons syndrome which is a result of aspirating stomach contents during GA (Singata & Tranmer, 2002, p.unknown). Thus the philosophy behind intervention management dictates labour management and perpetuates and compounds risk as each intervention is performed. Restricting food and fluid during labour is not only unsubstantiated and unnecessary according to recent literature but predisposes women to dehydration, ketoacidosis, slowed labour (dystocia) and increased maternal stress. Intravenous therapy instead of oral hydration has become common practice, but this has been shown to predispose women to immobilisation and doesn’t ensure adequate fluid and nutrient demands for labour (Singata & Tranmer, 2002, p.unknown). It is evident then that the use of CTG can be combined with the use of intravenous fluid administration (in response to fluid and food restriction), which can both have the side effect of reduced maternal movement and mobilisation during labour and predisposes women to a semi-recumbent position. Women who adopt an upright or lateral position have reduced duration of second stage and incidence of instrumental birth compared with supine or lithotomy positions (Homer & Dahlen, 2007, p.88), highlighting the importance of mobilisation and freedom of movement during labour. Not only do the above stated interventions rob the mother of the freedom to move and control over her labour but they are also associated with the perception or experience of increased pain. Restricted movement means that mothers will often lie or sit on the bed which can result in a reduction in the mother’s ability to manage labour pain and use pain relief methods such as a shower, bath and massage. This can result in mothers requesting an epidural to cope with labour pain. 

          ‘Current pain-relief methods pose a dilemma for obstetrics because they entail sequale to which it must respond with further techniques that also up the odds of something going awry’ (Murphy-Lawless, 1998, p.58). The use of epidural anaesthesia to deal with labour pain is associated with additional intervention due to the effect it has on the maternal mechanisms of labour and alteration of the pelvic floor. The lower body muscle weakness resulting from an epidural inhibits normal fetal rotation which increases the incidence of fetal malpresentations among women who receive epidural anaesthesia (Cammann, 2005, p.719). The use of epidural analgesia early in labour contributes to the creation of fetal malpresentation by relaxing the pelvic floor before the presenting part is flexed and in a favourable position for rotation and descent (Klein, Grzybowski, Liston, Spence, Le, Brummendorf, Kim & Kaczorowoski, 2001, p.245). In addition to fetal malpresentation, epidural anaesthesia has a tendency to prolong the second stage of labour due to reduced maternal ability to push and malrotation of the baby. ‘Strong evidence from 11 trials involving 3280 women shows the association between epidural use and longer second stage’ (Homer & Dahlen, 2007, p.88). These factors increase the incidence of instrumental deliveries (Murphy-Lawless, 1998, p.41). Homer & Dahlen (2007) found 17 trials involving 6162 women which showed that the risk of an instrumental delivery was increased with the use of epidurals. Instrumental birth leads to overall increase in pelvis floor morbidity with increased perineal trauma (Homer & Dahlen, 2007, p.88).

A study by Klein et al (2001), shows the connection between epidural use and the subsequent cascade of intervention which ultimately results in higher rates of maternal morbidity. The objective of the study was to determine if family physicians overall approach to maternity care, as measured by average use of epidural analgesia, was associated with maternal and fetal outcomes. Physicians were separated into cohorts based on their level of epidural use (low, medium or high). The results showed that low versus high epidural users were admitted at a later state of cervical dilation, received less CTG monitoring and oxytocin augmentation, sustained fewer fetal malpresentations and had fewer caesarean deliveries. They concluded that high use epidural analgesia is a marker for a style of practice characterised by fetal malpresentations leading to dysfunctional labours and higher intervention rates, leading in turn to excess maternal morbidity (Klein, Grzybowski, Liston, Spence, Le, Brummendorf, Kim & Kaczorowoski, 2001, p.243). The authors of the above study hypothesised that those physicians who used epidural analgesia often might be creating iatrogenic conditions that lead to a cascade of interventions culminating in caesarean and concluded that high epidural use appears to be a marker for a style of practice characterised by higher intervention rates and excess maternal morbidity (Klein, Grzybowski, Liston, Spence, Le, Brummendorf, Kim & Kaczorowoski, 2001, p.244).

In addition to the cascade of events associated with epidural use during labour, the epidural itself poses a risk to the mother and is a cause of maternal morbidity including a dangerous drop in blood pressure which can have ramifications for organ perfusion and fetal health and may lead to emergency interventions and infection of the epidural site (Britt, 2002, p.78). In addition to the above stated complications, Klein et al observed that epidural use resulted in the need for labour augmentation (Klein, Grzybowski, Liston, Spence, Le, Brummendorf, Kim & Kaczorowoski, 2001, p.245). Due to an epirdurals effect on contractions, augmentation is often required to strengthen contraction and remedy the prolonged first and second stage of labour (Decca, Daldoss, Fratelli  & Lojacono, 2004, p.119). Thus in summary ‘Women receiving epidurals are more likely to require oxytocin augmentation in the first stage of labour, have longer second stages, have persistent Occipito Posterior fetal malpresentation and undergo operative vaginal delivery’ (Sheilds, Ratcliffe, Fontaine & Leeman, 2007, p.1673). Therefore epidural use serves as a link in the cascade of intervention resulting in interventions which increase maternal morbidity.

Women who undergo operative vaginal deliveries or instrumental deliveries are more likely to report sexual problems including painful intercourse and perineal pain compared to women who had unassisted deliveries (Thompson, Roberts, Currie & Ellwood, 2002, p.88). Furthermore, urinary and anal incontinence can be a consequence of instrumental deliveries as a result of damage to surrounding tissues (Johanson, Newburn & Macfarlane 2002, p.893). The morbidity relating to instrumental deliveries can be associated with the use of episiotomy when performing these deliveries. Episiotomies contribute more to anal sphincter disruption and severe perineal trauma then unassisted deliveries; therefore there is an increased risk of incontinence of faeces and flatus (Homer & Dahlen, 2007, p.87)

The culmination of the cascade of intervention and the ultimate management of birth is the complete detour of the birthing passage by surgical extraction of an infant through the abdomen of it’s mother. The World Health Organisation has estimated that almost 15% of women develop complications serious enough to require rapid and skilled intervention with the use of caesarean delivery (Johanson, Newburn & Macfarlane 2002, p.892). There are three major reported justifications for caesarean section; labour dystocia, fetal distress and breech presentation (Weaver, 2004, p.4). Since this analysis focuses on the iatrogenic causes of maternal morbidity, the ways in which intervention management can lead to caesarean delivery. Thus we can conclude that a caesarean section can be an intervention required to remedy the side-effects of the previous intervention in the management of a labour. It had been estimated that serious maternal morbidity occurs in 9-15% of women delivered by caesarean (Weaver, 2004, p.11).  The morbidities associated with caesarean at the time of surgery can include hysterectomy, anaesthetic complications, accidental extension of incision and haemorrhage requiring transfusion (Armson, 2007, p.475). The short term morbidities include wound, uterine and urinary infections, severe abdominal pain and local trauma to bladder, ureters and bowels (Grobman, 2002, p.20; Weaver, 2004, p.11). More serious short term morbidity associated with abdominal surgery in general includes thrombo-embolic complications and paralytic ileus (Weaver, 2004, p.11). It is estimated that 20% of women develop fever after caesarean due to iatrogenic infections (Wagner, 2000, p.1678). Furthermore, thromboembolic disease is approximately 5 times more common after caesarean then a vaginal delivery and can lead to anticoagulant associated major morbidity including post-thrombotic chronic pain syndrome and recurrent thromboembolic disease (Grobman, 2002, p.20). A 14 year study, as explained by Armson, found the overall risk of severe maternal morbidity associated with planned caesarean was 3 times higher than vaginal delivery. This included the risk of postpartum cardiac arrest, wound haematoma, hysterectomy, major puerperal infection, anaesthetic complications, venous thromboembolism, haemorrhage requiring hysterectomy or transfusion, uterine rupture, intensive care admission, postpartum readmission to hospital, problems with subsequent births including reduced fertility, ectopic pregnancy, miscarriage and placenta previa, complications of repeat caesarean birth and increased cumulative costs (Armson, 2007, p.476; Thompson, Roberts, Currie & Ellwood, 2002, p.88). Thompson found that, compared with women having unassisted vaginal births, women who had caesareans were significantly more likely to report exhaustion or extreme tiredness and at 24 weeks postpartum and were more likely to report other urinary problems when women having unassisted vaginal deliveries (Thompson, Roberts, Currie & Ellwood, 2002, p.88).

 In the longer term, caesarean delivery is thought to cause an increase in morbidity rates relating to, miscarriage, ectopic pregnancy, sub fertility, infertility, abdominal adhesions causing intestinal obstruction, placenta abruption, placenta previa, placenta acreta and antepartum haemorrhage (Abu-Heija, El-Jallad & Ziadeh, 1999, p.7; Grobman, 2002, p.21; Murphy, Stirrat, Heron & ALSPAC study team, 2002, p.1914; Porter, Bhattacharya, Tijlingen & Templeton, 2003, p.1983; Wagner, 2000, p.1678). Studies have consistently demonstrated that one caesarean is associated with a 2-4 fold increase in the occurrence of placenta previa, and the risk increases with each additional caesarean. It is suspected that due to the uterine scar, fertilised ovum that would normally have not implanted and been passed out, get caught on the scar and implant there (Abu-Heija, El-Jallad & Ziadeh, 1999, p.7). These cases of placenta previa tend to be more morbid then those that occur independent of prior caesarean and are associated with a significantly greater need for transfusion and hysterectomy (Grobman, 2002, p.21). The underlying mechanisms for an association between caesarean and subsequent sub fertility and infertility are unclear and may relate to infection, adhesion formation or placental bed disruption. These mechanisms seem plausible in the light of the associations between caesarean and subsequent ectopic pregnancy, placenta previa and placental abruption. (Murphy, Stirrat, Heron & ALSPAC study team, 2002, p.1916). Thus it is obvious that the risks and morbidity of an initial caesarean are not limited to the immediate post operative period but continue to accrue during future pregnancies (Grobman, 2002, p.21).

In conclusion, this analysis has defined intervention management of labour and birth as, ‘a method of labour and birth care which assumes childbirth is pathological, thus requiring treatment. Using an intervention management approach, birth is controlled by a series of interventions, including pharmacological, instrumental and mechanical to ensure that labour and birth remain within the medically defined boundaries of normal. It is thought that these interventions reduce the risk of childbirth and thus prevent maternal and foetal mortality’. This definition is based on the analysis of literature relating to obstetric fear of childbirth, the notion of risk, the medicalisation of childbirth and subsequent definitions of what is normal and abnormal in labour. Intervention management has led to the majority of women birthing their babies in hospital where they are under the control of medical staff who promise reduced risk during child birth. Risk is reduced by intervening to ensure labour and birth remain within the medically defined bounds of normal. This essay proposed that these interventions produce a cascade of other interventions in an attempt to manage the risk of the previous intervention. Each intervention carries risks and side effects which compound the possibility of maternal morbidity and increase the likely hood of further intervention. The cascade culminates at instrumental or caesarean delivery which carry a substantially higher risk of maternal morbidity then spontaneous vaginal delivery. Therefore, this analysis concludes that intervention management of labour and birth has the subsequent impact of increasing maternal morbidity in the short and long term. These morbidities are both physical and psychological.  

(references available on request)

Thanks for reading!

Kind regards
Melanie Jackson (homebirth midwife)

For more information on Melanie or her midwifery services please visit www.ellamaycentre.com

Tuesday, 5 July 2011

Placenta Pleasantries and Possibilities – what to do with your placenta

As a homebirth midwife there is always that week in antenatal care where my clients and I discuss what will be done with the placenta. Some choose to freeze it to decide later, some wish to just dispose of it, others feel a connection to their placenta and wish to celebrate and commemorate it and some, like every other mammal on earth, choose to consume it. So when I ask the question, ‘so what do you think you’ll do with your placenta’, they almost always say, ‘well what are my options’. This blog post aims to give you a few ideas if you wish to immortalise, commemorate, celebrate, honour or harness the power of your placenta. 

 Placenta Prints

The placenta has an amazing network of blood vessels which can make for an amazing placenta print. A print is made by using the placenta, along with its bloody coating, as a stamp to outline and detail the placenta on paper. Here’s one I did for a client recently – the amazing tree of life!

Homeopathic Placenta Remedy
I’ve never done this personally but a dear midwife friend of mine does it regularly and swears by its benefits.

You can also find details about this http://www.placentalremedy.com/

Placenta Encapsulation
This is where the placenta is steamed, dehydrated, ground to a powder and put in capsules to make consuming it more palatable for mothers who choose to do this. Googling the benefits of consuming your placenta in this way will reveal some anecdotal evidence about its benefits. See the picture diary below of how a placenta is encapsulated.

Rince the Placenta under running water
to remove as much blood as possible
Cut off membranes and cord
Cut placenta into quarters
steam placenta for approximately
20 mins or until cooked through 
Slice placenta thinly

place thin slices onto trays
of a food dehydrator.
            Dehydrate placenta slices for 6-8 hours ensuring that before you grind the slices they are sufficiently dry. You can know this because when you break the pieces they will be crisp and snap. If the slices bend they are not dry enough and need to be dehydrated further.

Grind placenta peices in a
food processor, coffee grinder
or with a mortar and pestle
until a powder
Fill capsules as per instructions
on 'cap-m-quik' capsule filling equipment
Burying your placenta
Some women like to bury their placenta In the garden, it can be a ceremonious occasion and from reports, the placenta is quiet good for your plants. Some women choose a new plant to plant on top of it. Word is that it should be buried at least a foot down in the soil... this should also stop it from being dug up by pets in the yard.

I’m sure there are more things that could be done with your placenta- but these are the main things I’ve seen done with the amazing life giving organ- the placenta... if you’ve got something else that you have done with your placenta I would love to hear about it!

Kind regards,
Melanie Jackson (Homebirth Midwife)

Homebirth in the Hawkesbury

Introducing Emma Fitzpatrick- bringing Homebirth to The Hawkesbury
Emma Fitzpatrick is a midwife located in the Hawkesbury, and has commenced practice with Midwives @ Sydney and Beyond, Private Midwifery group practice. Emma has over 11 years extensive experience working with women and their families throughout pregnancy, birth and the postnatal period. With a background  of practising midwifery in a clinical setting, Emma birthed her first three children within a hospital setting, then had the incredible pleasure of birthing her fourth baby safely at home in the water.
Emma is experienced in supporting women and their families in antenatal education, breastfeeding and lactation support, surrogacy support and induced lactation, as well as supporting women to birth physiologically in both clinical and home setting.
Emma has a passion for homebirth, and aims to see Homebirth in the Hawkesbury as a valid care option for women and their families.
If you would like to Book Emma as your midwife or enquire about her services her details can be found at http://www.ellamaycentre.com/
I can't reccomend Emma highly enough- she is an amazing midwife!
Kind regards,
Melanie Jackson (Homebirth Midwife) xo

Thursday, 7 April 2011

The Word on Co-sleeping

There were angry and joyous mothers alike when the story broke in the 'Daily Telegraph' that co-sleeping was actually protective against Sudden Infant Death Syndrome (SIDS). (See link below for full story)


After reading the article I remembered where I had heard this information before- an essay I did about breastfeeding in 2008 which spoke about the protective aspects of co-sleeping against SIDS and also the benefits of activities that promote closeness between mum and baby.

Co sleeping is thought to regulate the babies heart and breathing rate and babies who co-sleep with their mothers are more likely to be successfully breastfed which reduces the risk of the baby dying of SIDS. There are safe and unsafe ways to co-sleep. If parents have been drinking, using medications which cause drowsiness, use strong perfumes or chemicals on their person, sleep in a waterbed or very soft surface, are very obese or have been using illicit drugs then co-sleeping is not recommended.

this is a snippet out of my essay for your enjoyment:

‘A study by McCoy, Hunt, Lesko, Vezina, Corwin, Willinger, Hoffman & Mitchell (2004) found a strong relationship between bed-sharing and breastfeeding and found that it facilitated breastfeeding by providing closer contact between mother and infant and therefore greater opportunity to breastfeed. While there is a fear that co-sleeping increases the risk of SIDS, this is a contentious issue as literature also exists that gives weight to the argument that co-sleeping actually reduces the risk of SIDS when practiced appropriately (Buswell & Spatz, 2007, p.23; Naish & Roberts, 2002, p.56). The idea that co-sleeping encourages breastfeeding should be adapted and the hospital should encourage mothers to maintain closeness between themselves and their babies as much as possible to assist them with breastfeeding.

Another practice which promotes closeness, instinctual behaviour, breastfeeding and bonding, is the use of a carry pouch or sling. Mothers who carry their babies in a sling, close to them throughout the day are much more in tune with their babies eating and sleeping rhythms which allows them to breastfeeding more effectively and they have more settled babies (ACNM, 2007, p.644, Lennart, 2008, p.2; Naish & Roberts, 2002, p.44). Encouraging the use of a sling to encourage closeness and breastfeeding can be an effective way of settling babies throughout the day and assisting the mother to be more aware of his feeding needs (Feldman, 2004, p.150; karl, 2004, p.292; Moore, Anderson & Bergman, 2007, p.2; Naish & Roberts, 2002, p.36). Skin-to-skin contact is an important part of the instinctive process of breastfeeding for both mother and baby (http;//www.breastfeeding.asn.au/bfinfo/bla.html).

Allowing mother and babies to live in close proximity by encouraging co-sleeping, baby-wearing and skin to skin contact can facilitate breastfeeding by promoting baby-led attachment. This method of encouraging attachment involves placing the baby on the mother chest and allowing the baby to discover the nipple and attach themselves with minimal support from the mother (Lennart, 2008, p.1; Naish & Roberts, 2002, p.3). The baby follows a pattern of instinctive behaviours to get to the breast (http://www.breastfeeding.asn.au/bfinfo/bla.html). Infant-led attachment almost always lends to correct attachment to the nipple due to it being less forced and hurried; the baby attaches in its own time (Naish & Roberts, 2002, p.36). This form of attachment is only successful provided the mother and baby are healthy and allowed sufficient skin-to-skin contact following a birth that has not been interrupted. The baby must be allowed to go through its pre-feeding rituals of licking, smelling, touching and mouthing the breast before attaching to get acquainted with the nipple (Lennart, 2008, p.1; Naish & Roberts, 2002, p.36)’

In my searching I also came across an interesting blog post on the topic at :


For more information on co-sleeping some helpful books are:

'Three in a Bed: the benefits of sleeping with your baby' By Deborah Jackson

'The Attachment Parenting Book' by Dr Sears

Love Mel xo

For information on Melanie and The Ella May Centre go to www.ellamaycentre.com

Sunday, 20 March 2011

Risk is in the Eye of the Beholder

For this past year I have been researching what motivates and influences mothers to choose a free-birth or ‘high-risk’ homebirth as part of my PhD thesis ‘birthing outside the system’. It has become dramatically obvious that women who make choices that are seemingly against the system have a very different perception of risk than our medically minded counterparts.

                The concept of risk is just that, a concept, one that can be perceived and understood differently by everyone based on their previous experiences, research and influences throughout life. Obstetrics argues that their definition or perception of risk is ‘right’ and authoritative (Murphy-Lawless 1998 p.22) and touts their management and intervention as the best and most sure way of reducing the risk of childbirth. Medicalised management of birth is a hallmark of mainstream birth services; these services perceive their management of birth to be the only ‘right’, ‘best’ and ‘safe’ way to birth, dismissing all other options as ‘dangerous’, ‘irresponsible’, ‘risky’ and ‘wrong’, but, what if medical management of birth is ‘wrong’? What if they unequivocally have it wrong? This is certainly the question asked by the highly intelligent, critical and knowledgeable women who have shared their stories for my research. 

                For mothers who choose to birth at home, medical interventions and interruptions in the birth process are seen as ‘dangerous’ and ‘risky’. They feel that the risk of something going wrong at their birth proliferates the more they part-take in or make themselves vulnerable to the medical management of birth. One woman explains, ‘I look at interference a bit like risk, every time someone new comes across you or does something, that’s a risk that something goes wrong, every time you get a medication there is a risk it’s the wrong one, every time they do something there’s a risk that flows onto something else, so if no-one is doing anything to you or performing any unnecessary tests, then there is no risk there’- (homebirth mother). This is in dramatic conflict with the medical message that interventions are designed and employed in order to reduce risk.

                The medical use of risk language alongside birthing generates fear around the process of labour and birth and if birth is marketed as risky, then it will be perceived as scary. By the use of risk language, obstetrics has perpetuated the myth that childbirth is to be feared and thus throughout history convinced mothers to conform to their birth management in order to avoid something going wrong (Murphy-Lawless 1998, p.18). The medicalisation of birth has allowed obstetrics to redefine what is considered ‘normal’ and ‘abnormal’. By developing a conceptual difference between abnormal and normal the medical profession have secured a large and growing market for their services in perpetuity by the creation of false needs and then catering to these newly perceived needs (Ballard & Elston, 2005, p.230). By the social process of medicalising birth, modern obstetrics can justify managing labour and birth by intervening to make each individual labour and birth conform to the obstetric definition of normal. By defining what is constituted as normal birth, obstetricians have monopolised control over events which occur outside the norm under the guise of ‘risk management’.

Women who remain unconvinced by the obstetric definition of ‘risk’ see no reason in accepting medical interventions and therefore see no reason to enter hospitals. The very place they are most at risk of being subjected to interruption and intervention while they are trying to give birth is at hospital. Home birthing women see intervention as risky and thus will not be convinced to accept them as a way of avoiding adverse outcomes; in fact, they believe that the risk of adverse outcomes at birth is increased by unnecessary intervention. One mother comments, ‘I don’t see induction now as the safe way out, actually having an induction now is the risk to me, that is tempting fate, not carrying a well baby to full term and comfortably to post-dates, that’s not the risk, it’s the unnecessary induction’ (homebirth mother). Another mother also comments, ‘they interfere so that’s why things happen, they end up with forceps or vacuum or caesarean because they put up drips (to speed labour) and they just stuff women up’ (homebirth mother).

The question must be asked, how can it be that modern medicine believes they can make birth safer by interfering, to avoid complications and minimise risk when a home birth mother believes interventions make her birth more dangerous, will cause complications and increase her risk? Is it possible that both are right? if not- who is wrong? The answer lies in what women have described to me as ‘medically indicated intervention’ and ‘necessary intervention’. The women who have contributed to my study saw the absolute necessary place of obstetrics in emergency care for birth complications; we can all agree that when a caesarean is legitimately needed we want a skilled obstetrician (not a midwife) to perform the surgery, but where the bone of contention exists is- who defines necessary?

Just like modern obstetrics and home birthing women have different perceptions of ‘risk’ they also have different definitions of necessary. Women who birth their babies at home see ‘necessary intervention’ as one that is ‘medically indicated’ and a response to a real threat to the mother and baby, one that is truly required because the mother and baby are at risk of death or damage. One mother was asked during her interview if she think thought there was a right place for intervention, she replied, ‘yeah, if there is a problem, if there is a risk, there’s something possible that’s going to affect the mother or the baby and that’s their only way of getting out a healthy baby then yeah, that’s the advantage of living in today’s society’ (home birth mother).

You might ask, why else would an intervention be performed if not for the safety of the mother and baby? The answer not only lies in the findings from my study but also my personal experience working in the hospital system. Deviating from the medically defined norm of time in pregnancy will find you shafted into an induction, not because you and your baby are at risk, but because the hospital policy says so. Not dilating at the medically defined speed will see you augmented with medication, which will see you strapped to the medically defined ‘best’ way of monitoring your baby, which will see you in much greater pain then if you had free movement, which would increase the ‘risk’ of you needing pain medication, which would increase the ‘risk’ that your baby will need to be pulled out with forceps and need intervention to breathe, which will increase the ‘risk’ of breastfeeding being unsuccessful.  Digressing from medical definitions of normal and hospital policy will see you managed with intervention, not to decrease your risk, but to increase your conformity to the medically defined boundaries of normal- which may or may not be right. 
Risk is in the eye of the beholder, every day we make decisions about the risks we are willing to take. You take a risk getting in your car, buying sushi, having sex, taking a panadol, going for a jog, drinking hot coffee and gardening on a hot day, I took the risk today of aggravating my repetitive strain injury while typing, but it was a risk I was willing to take. The medical system and home birthing women perceive risk differently and are willing to take different risks based on different motives, but while each ones perception is different, it is not less or wrong, just different. What is ‘right’ and ‘best’ can only be determined by each individual and where the conflict lies is in who defines what is ‘best’ and which risks are ‘right’ to take.   
If you would like to, or know someonw who you think would like to participate in this research please e-mail mkjackson@live.com.au. For more information on accessing a homebirth midwife visit http://www.ellamaycentre.com/

with love
Mel xo

Thursday, 10 March 2011

The hormones of love and birth

Michel Odent
on the hormones of love and birth
After re-watching ‘The business of being born’ the other day I felt inspired by Michel Odent’s comments on the role of love hormones in maternal bonding. I remembered that on my shelf I have a copy of his book, ‘The Scientification of Love’ and set about reading it with much gusto- often calling out to the ever-understanding and patient Dan, ‘whoa man, you should hear this!’. It reminded me of the very simple ingredients and low-key basic necessities of the birthing woman that facilitate a physiological labour, birth, breastfeeding, bonding and parenting experience. Every woman, midwife, doctor and doula should heed the words in this book – they will enlighten you as to how and why birth works given the right carers and setting. The simplicity and logic of his arguments are astounding and so refreshing in a world where birth is portrayed as complex, dangerous and unpredictable.

To give you just a taste I have included a small excerpt from ‘The scientification of love’ which was a timely reminder of the delicate and basic needs of a birthing woman and the midwives role in protecting these needs.

‘To give birth a woman needs to release a certain cocktail of hormones... The crucial thing is to realise that they all originate in the same gland- the brain. Today the traditional perceived separation between the nervous system and the endocrine system is obsolete. There is only one network and the brain is also an endocrine gland. But it is not the whole brain which is active as an endocrine gland, only its deepest part. We might say that when a woman is in labour the most active part of her body is her primitive brain- those very old structures of the brain (the hypothalamus, pituitary gland etc) that we share with all other mammals. Modern scientific language can also explain that when there are inhibitions during the birth process (or any sexual experience) they originate in that other brain, the new brain, the part of the brain which is so highly developed among humans- the neocortex.

Physiologists might also interpret a phenomenon which is familiar to midwives and some mothers- or at least to those who have had the experience of unmanaged and un-medicated birth. During the birth process there is a period when the mother behaves as if she were ‘on another planet’, cutting herself off from our everyday world and going on a sort of inner trip. This change in her level of consciousness can be interpreted as a reduction in neocortical activity. Birth attendants who understand this essential aspect of the physiology of labour and delivery would not make the mistake of trying to ‘bring her back to her senses’. They would readily appreciate that any neocortical stimulation in general and any stimulation of the intellect in particular, can interfere with the process of labour. From a practical point of view, it is useful to review the well-known factors which can stimulate the human neocortex: language, particularly rational language is one such factor’

‘when considering the birth process from the perspective of physiologists, it is clear that a labouring woman needs to first feel secure and that a midwife is originally a protector, a mother-figure, the mother being the prototype of the sort of person with whom one feels secure’ p.28-31

I will be speaking at the Capers conference in Brisbane in May 2011 and so will Michel Odent ; I can’t wait to hear what he has to say and feel privileged to be sharing a podium with the likes of him. On that note... I highly recommend this book and am going to read the rest of it right now... and I recommend you do the same.

For more information visit www.ellamaycentre.com
With love
Mel xo

Tuesday, 1 March 2011

Midwives @ Sydney and Beyond - Trail blazing with evidence based models of maternity care

a creative way of rolling with the punches

At the end of 2010 the legislative changes imposed on privately practicing midwives and allied health professionals alike meant that we had to obtain personal indemnity insurance in order to maintain our professional registration. Two packages were offered to midwives and for the first time since 2001 privately practicing midwives had insurance to practice. As with all good things- there is a catch, with insurance and registration come regulation and then professionalisation of the midwifery industry.

This regulation does not impact hospital based midwives severely but has meant that privately practicing midwives are held more accountable for their practice and must maintain transparency more than ever. Access to insurance also paved the way for medicare and PBS numbers for midwives who choose to be 'eligible' for these benefits which allow clients to get some of the out-of-pocket cost of hiring a private midwife back and also allows eligible midwives to refer their clients for antenatal testing and screening without first consulting a GP.

This arrangement is all theoretically good news for the profession of midwifery and women alike who can now access the care of their own midwife regardless of birth setting or 'risk' status. Attached to 'eligibility' and medicare is the requirement to work collaboratively with other maternity care providers, this theoretically improves continuity of care for women who choose to hire a privately practicing midwife to birth in hospital or require specialist care if complications arise during pregnancy or birth. It all sounds very complicated, and it is- and still being ironed out, like all new government policy. The changes to the face of privately practicing midwifery are inevitable and regulation of the profession has happened whether we choose to acknowledge it or not.

Midwives @ Sydney and Beyond was born out of the need to 'roll with the punches' of these changes. Melanie Jackson, Jane Palmer, Robyn Dempsey and Hannah Dahlen got together with the agreed aim of forming a private midwifery group practice to provide midwifery care to our client’s where ever they choose to birth. The Quality and safety framework under which we work allows the women 'right of refusal' and the midwife has a 'duty of care'- this clause within the framework allows mothers choice and midwives freedom to support women in this choice. We embrace and help inform a woman’s choice during pregnancy, birth and beyond and are dedicated to providing women with continuity of care, one-to-one attention and an uninterrupted physiological birth and baby-feeding experience. This concept of a group midwifery model of care is somewhat new to the private midwifery sector and we are very much feeling our way through the legislative changes as we adapt to the new world order - the benefit is that we get to do it together!.

Midwifery models of care are highly researched and supported by rigorous evidence and provide gold standard outcomes to women who choose this option for their pregnancy, birth and baby feeding experience.

Below is an excerpt from the Cochrane database of systematic reviews on midwifery models of care:

Midwife-led versus other models of care for childbearing women

Midwife-led care confers benefits for pregnant women and their babies and is recommended.

In many parts of the world, midwives are the primary providers of care for childbearing women. Elsewhere it may be medical doctors or family physicians who have the main responsibility for care, or the responsibility may be shared. The underpinning philosophy of midwife-led care is normality, continuity of care and being cared for by a known and trusted midwife during labour. There is an emphasis on the natural ability of women to experience birth with minimum intervention. Some models of midwife-led care provide a
service through a team of midwives sharing a caseload, often called ’team’ midwifery. Another model is ’caseload midwifery’, where the aim is to offer greater continuity of caregiver throughout the episode of care. Caseload midwifery aims to ensure that the woman receives all her care from one midwife or her/his practice partner.

All models of midwife-led care are provided in a multi-disciplinary network of consultation and referral with other care providers. By contrast, medical-ledmodels of care are where an obstetrician or family physician
is primarily responsible for care. In shared-care models, responsibility is shared between different healthcare professionals.

The review of midwife-led care covered midwives providing care antenatally, during labour and postnatally. This was compared with models of medical-led care and shared care, and identified 11 trials, involving 12,276 women. Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects.

The main benefits were a reduction in the use of regional analgesia, with fewer episiotomies or instrumental births. Midwife-led care also increased the woman’s chance of being cared for in labour by a midwife she had got to know, and the chance of feeling in control during labour, having a spontaneous vaginal birth and initiating breastfeeding. However, there was no difference in caesarean birth rates.

Women who were randomised to receive midwife-led care were less likely to lose their baby before 24 weeks’ gestation, although there were no differences in the risk of losing the baby after 24 weeks, or overall. In addition, babies of women who were randomised to receive midwife-led care were more likely to have a shorter length of hospital stay.

The review concluded thatmost women should be offeredmidwife-ledmodels of care, although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.

Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women.Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2.

It is important to know your needs, desires and philosophy about pregnancy, birth and baby-feeding and ensure your carer and place of birth match these desires to ensure the greatest success and satisfaction in your parenting journey  

with love
Melanie xo

for more information on Midwives @ Sydney and Beyond visit http://www.ellamaycentre.com/