Hannah G Dahlen

Rates of obstetric intervention among low-risk women giving birth in private and public hospitals in NSW: a population-based descriptive study

Objectives To compare the risk profile of women giving birth in private and public hospitals and the rate of obstetric intervention during birth compared with previous published rates from a decade ago. Design Population-based descriptive study. Setting New South Wales, Australia. Participants 691 738 women giving birth to a singleton baby during the period 2000 to 2008. Main outcome measures Risk profile of women giving birth in public and private hospitals, intervention rates and changes in these rates over the past decade. Results Among low-risk women rates of obstetric intervention were highest in private hospitals and lowest in public hospitals. Low-risk primiparous women giving birth in a private hospital compared to a public hospital had higher rates of induction (31% vs 23%); instrumental birth (29% vs 18%); caesarean section (27% vs 18%), epidural (53% vs 32%) and episiotomy (28% vs 12%) and lower normal vaginal birth rates (44% vs 64%). Low-risk multiparous women had higher rates of instrumental birth (7% vs 3%), caesarean section (27% vs 16%), epidural (35% vs 12%) and episiotomy (8% vs 2%) and lower normal vaginal birth rates (66% vs 81%). As interventions were introduced during labour, the rate of interventions in birth increased. Over the past decade these interventions have increased by 5% for women in public hospitals and by over 10% for women in private hospitals. Among low-risk primiparous women giving birth in private hospitals 15 per 100 women had a vaginal birth with no obstetric intervention compared to 35 per 100 women giving birth in a public hospital. Conclusions Low-risk primiparous women giving birth in private hospitals have more chance of a surgical birth than a normal vaginal birth and this phenomenon has increased markedly in the past decade.

General obstetrics: Does size matter? A population-based study of birth in lower volume maternity hospitals for low risk women

Objective  To study the association between volume of hospital births per annum and birth outcome for low risk women.

Pregnancy-Related Lumbopelvic Pain: Listening to Australian Women

Objective. To investigate the prevalence and nature of lumbo-pelvic pain (LPP), that is experienced by women in the lumbar and/or sacro-iliac area and/or symphysis pubis during pregnancy. Design. Cross-sectional, descriptive study. Setting. An Australian public hospital antenatal clinic. Sample population: Women in their third trimester of pregnancy. Method. Women were recruited to the study as they presented for their antenatal appointment. A survey collected demographic data and was used to self report LPP. A pain diagram differentiated low back, pelvic girdle or combined pain. Closed and open ended questions explored the experiences of the women. Main Outcome Measures. The Visual Analogue Scale and the Oswestry Disability Index (Version 2.1a). Results. There was a high prevalence of self reported LPP during the pregnancy (71%). An association was found between the reporting of LPP, multiparity, and a previous history of LPP. The mean intensity score for usual pain was 6/10 and four out of five women reported disability associated with the condition. Most women (71%) had reported their symptoms to their maternity carer however only a small proportion of these women received intervention. Conclusion. LPP is a potentially significant health issue during pregnancy.

Immediate or early skin-to-skin contact after a Caesarean section: a review of the literature

The World Health Organization and the United Nations International Childrens Emergency Fund recommends that mothers and newborns have skin-to-skin contact immediately after a vaginal birth, and as soon as the mother is alert and responsive after a Caesarean section. Skin-to-skin contact can be defined as placing a naked infant onto the bare chest of the mother. Caesarean birth is known to reduce initiation of breastfeeding, increase the length of time before the first breastfeed, reduce the incidence of exclusive breastfeeding, significantly delay the onset of lactation and increase the likelihood of supplementation. The aim of this review is to evaluate evidence on the facilitation of immediate (within minutes) or early (within 1 h) skin-to-skin contact following Caesarean section for healthy mothers and their healthy term newborns, and identify facilitators, barriers and associated maternal and newborn outcomes. A range of electronic databases were searched for papers reporting research findings published in English between January 2003 and October 2013. Seven papers met the criteria. This review has provided some evidence that with appropriate collaboration skin-to-skin contact during Caesarean surgery can be implemented. Further evidence was provided, albeit limited, that immediate or early skin-to-skin contact after a Caesarean section may increase breastfeeding initiation, decrease time to the first breastfeed, reduce formula supplementation in hospital, increase bonding and maternal satisfaction, maintain the temperature of newborns and reduce newborn stress.

The incidence of preeclampsia and eclampsia and associated maternal mortality in Australia from population-linked datasets: 2000-2008

OBJECTIVE To determine the incidence of preeclampsia and eclampsia and associated mortality in Australia between 2000 and 2008. STUDY DESIGN Analysis of statutorily collected datasets of singleton births in New South Wales using International Classification of Disease coding. Analyzed using cross tabulation, logistic regression, and means testing, where appropriate. RESULTS The overall incidence of preeclampsia was 3.3% with a decrease from 4.6% to 2.3%. The overall rate of eclampsia was 8.6/10,000 births or 2.6% of preeclampsia cases, with an increase from 2.3% to 4.2%. The relative risk of eclampsia in preeclamptic women in 2008 was 1.9 (95% confidence interval, 1.28-2.92) when compared with the year 2000. The relative risk of a woman with preeclampsia/eclampsia dying in the first 12 months following birth compared with normotensive women is 5.1 (95% confidence interval, 3.07-8.60). CONCLUSION Falling rates of preeclampsia have not equated to a decline in the incidence of eclampsia. An accurate rate of both preeclampsia and eclampsia is vital considering the considerable contribution that these diseases make to maternal mortality. The identification and treatment of eclampsia should remain a priority in the clinical setting.

Undone by fear? : deluded by trust?

Normal birth is on the ‘endangered list’ in much of the developed world, and if we do not critically examine our beliefs about birth and understand where these beliefs have come from and how they shape us and the care we provide for women, we will not be able to facilitate normal birth and help turn this juggernaut of intervention around. We cannot talk about normal birth unless we talk about fear and trust, for they are at the heart of what is happening to birth, and we cannot talk about women’s fear unless we firstly talk about our own. Fear is a great gift but trust is an even greater one, and by reducing fear we make space for trust. By learning not to manufacture fear, we are able to respond appropriately when fear is real and this protects us and the women we care for. By learning to trust in a responsive way – not a blind way – we learn to be truly alive and help to create amazing possibilities with women. When we allow fear to ‘undo’ us or become ‘deluded’ by trust, we rob women and ourselves of the chance to live life fully, safely and with meaning—and a life without meaning is no life at all.

The EPIIC hypothesis: Intrapartum effects on the neonatal epigenome and consequent health outcomes

There are many published studies about the epigenetic effects of the prenatal and infant periods on health outcomes. However, there is very little knowledge regarding the effects of the intrapartum period (labor and birth) on health and epigenetic remodeling. Although the intrapartum period is relatively short compared to the complete perinatal period, there is emerging evidence that this time frame may be a critical formative phase for the human genome. Given the debates from the National Institutes of Health and World Health Organization regarding routine childbirth procedures, it is essential to establish the state of the science concerning normal intrapartum epigenetic physiology. EPIIC (Epigenetic Impact of Childbirth) is an international, interdisciplinary research collaboration with expertise in the fields of genetics, physiology, developmental biology, epidemiology, medicine, midwifery, and nursing. We hypothesize that events during the intrapartum period - specifically the use of synthetic oxytocin, antibiotics, and cesarean section - affect the epigenetic remodeling processes and subsequent health of the mother and offspring. The rationale for this hypothesis is based on recent evidence and current best practice.

What are the facilitators, inhibitors, and implications of birth positioning? A review of the literature.

BACKGROUND From the historical literature it is apparent that birthing in an upright position was once common practice while today it appears that the majority of women within Western cultures give birth in a semi-recumbent position. AIM To undertake a review of the literature reporting the impact of birth positions on maternal and perinatal wellbeing, and the factors that facilitate or inhibit women adopting various birth positions throughout the first and second stages of labour. METHODS A search strategy was designed to identify the relevant literature, and the following databases were searched: CINAHL, CIAP, the Cochrane Database of Systematic Reviews, Medline, Biomed Central, OVID and Google Scholar. The search was limited to the last 15 years as current literature was sought. Over 40 papers were identified as relevant and included in this literature review. RESULTS The literature reports both the physical and psychological benefits for women when they are able to adopt physiological positions in labour, and birth in an upright position of their choice. Women who utilise upright positions during labour, have a shorter duration of the first and second stage of labour, experience less intervention, and report less severe pain and increased satisfaction with their childbirth experience than women in a semi recumbent or supine/lithotomy position. Increased blood loss during third stage is the only disadvantage identified but this may be due to increased perineal oedema associated with upright positions. There is a lack of research into factors and/or practices within the current health system that facilitate or inhibit women to adopt various positions during labour and birth. Upright birth positioning appears to occur more often within certain models of care, and birth settings, compared to others. The preferences for positions, and the philosophies of health professionals, are also reported to impact upon the position that women adopt during birth. CONCLUSION Understanding the facilitators and inhibitors of physiological birth positioning, the impact of birth settings and how midwives and women perceive physiological birth positions, and how beliefs are translated into practice needs to be researched.

Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on land : a descriptive cross sectional study in a birth centre over 12 years

BACKGROUND the option of giving birth in water is available to most women in birth centres in Australia but there continues to be resistance in mainstream delivery wards due to safety concerns. Women in birth centres are more likely to give birth in upright positions and be attended by experienced midwives and obstetricians who are comfortable facilitating normal birth. The aim of this study was to determine rates of perineal trauma, postpartum haemorrhage and five-minute Apgar scores amongst low risk women in a birth centre who gave birth in water compared to six birth positions on land. METHODS this was a descriptive cross sectional study of births occurring in a large alongside Sydney birth centre from January 1996 to April 2008. Handwritten records were kept by midwives on each birth in the birth centre over twelve and a half years (n=6,144). Descriptive statistics and logistic regression were applied controlling for risk factors for perineal trauma, postpartum haemorrhage and the five-minute Apgar score. FINDINGS waterbirth (13%) and six main birth positions on land were identified: kneeling/all fours (48%), semi-recumbent (12%), lateral (5%), standing (8%), birth stool (10%) and squatting (3%). Compared to waterbirth, birth on a birth stool led to a higher rate of major perineal trauma (second, third, fourth degree tear and episiotomy) (OR 1.40 [1.12-1.75]) and postpartum haemorrhage (OR 2.04 [1.44-2.90]). Compared to waterbirth, babies born in a semi-recumbent position had a significantly greater incidence of five-minute Apgar scores <7 (OR 4.61 [1.29-16.52]). CONCLUSIONS waterbirth does not lead to more infants born with Apgar score <7 at 5 mins when compared to other birth positions. Waterbirth provides advantages over the birth stool for maternal outcomes of major perineal trauma and postpartum haemorrhage.

Homebirth, freebirth and doulas: Casualty and consequences of a broken maternity system

In Australia private homebirth remains unfunded and uninsured and publicly funded homebirth models are not widely available. Doulas are increasingly hired by women for support during childbirth and freebirth (birth intentionally unattended by a health professional) appears to be on the rise. The recently released Improving Maternity Services in Australia--The Report of the Maternity Services Review (MSR) exclude homebirth from the funding and insurance reforms proposed. Drawing on recent research we argue that homebirth has become a casualty of a broken maternity system. The recent rise in the numbers of women employing doulas and choosing to birth at home unattended by any health professional, we argue, is in part a consequence of not adequately meeting the needs of women for continuity of midwifery care and non-medicalised birthing options.