Hi folks,

Here is an interesting article from Australia. I think some of you may
have already read it.

It's a bit long. I'd put it in the files section but I'm not sure how!
Sorry, I'm a bit of a computer nit.

"High Risk Birth" - Defined by Whom?
by Justine Caines

In the last 5 years working for Maternity Coalition I have worked
tirelessly to help establish one-to-one midwifery care across
Australia. I am passionate that women can choose a midwife in any
setting, but especially at home as I have experienced the beauty of
homebirth. I do not at see myself as conservative or someone who
'sells out' in my role as an advocate. In the last year however I
have been forced to reassess all of this. After 4 very normal
pregnancies with stunning, intervention-free homebirths I was greeted
with the news that I was having twins. In a split second I plummeted
into the category of 'high-risk' - but did I really, and who defined
it anyway?

Breech birth, vaginal birth after caesarean (VBAC) and twins birth can
carry additional risk. The risk must be measured rationally however.
The risk of uterine rupture for example after a primary c/s is not
quite 1%. The vast majority of Obstetricians do not support women to
achieve a VBAC. Many paint a picture of fear and death citing uterine
rupture as a compelling reason to elect for a repeat caesarean. The
risk of spontaneous abortion after amniocentesis is 1-2%. This test
is routinely offered to women over 35 without any of the trappings of
death and injury.

Before I was aware I was carrying twins I had planned another
homebirth. I very much look forward to it. My first thought was "My
homebirth is out the window'. Although I resist becoming a prisoner
to the language of obstetrics that sees women as deficient beings in
need of rescuing, I think some of it had rubbed off. In our advocacy
we spend much of it demonstrating that midwifery care should be a
mainstream option, but also accept the obstetric line that breech and
twins and VBAC belong within a high-risk category. Now with a label
threatening to choke me I sat back and thought, "Where is the
individual rights of the woman and her body here?'

Very few women would knowingly put their baby or themselves at risk.
Why then are women with 'special needs' granted less insight or
knowledge of their body's capacity or their baby's wellbeing? Again
we know the answer. It is because current obstetric practice in
Australia is not about women, or even babies. It is about fear and
control, the necessary ingredients in keeping maternity services
dominated by the medical profession, and keeping the birthing of
babies as big business.

After the huge shock I researched obstetric management of twins. It
seemed at best if I fought hard I could give birth to my babies
vaginally, but I would be very likely to be pressured to have an
epidural (for the fast removal of twin 2, via c/s or forceps), I would
also be pressured to have constant foetal monitoring. In the event of
twin 2 presenting breech I would be likely to have a very managed
birth (via forceps). In the event that I had not given birth by 38
weeks, induction would be strongly recommended. Of course the far more
acceptable option would be an elective caesarean section again at 38
weeks. Despite many twins being born by caesarean section, like many
obstetric practices it is not supported by evidence.

"Virtually no data from controlled trails are available to help
determine the choice between vaginal birth and caesarean section for
women with multiple pregnancy. A single trial has assessed the effect
of caesarean section for delivery when the second twin was in a
non-vertex presentation. As would be expected, maternal febrile
morbidity and need for general anaesthesia was increased with
caesarean section. No offsetting advantages in terms of decreased
fetal or neonatal morbidity or mortality were found." Enkin et al 3rd
Ed Guide to effective care in pregnancy and childbirth ... p.146

At 38 weeks my babies would be smaller and more likely to need
additional care. In the event of a caesarean section I would need to
recover from major surgery and at the same time attempt to breastfeed
2 babies and care for another 4 children. This was considered a safe
option? I was very fortunate to be sent the now out of print book,
"Having Twins' by Elizabeth Noble (copies can be found on Amazon.com
etc). This text reaffirmed my gut feeling that although a multiple
pregnancy required some special care through nutrition and rest there
is no reason that twins should be treated as high risk. The
misconception that all twins arrive early was a consistent theme. Why
does one neglect the power of a woman's mind in determining when and
how she gives birth? Currently there are very few practitioners who
affirm a woman's ability to carry twins to term. In my case I gave
birth to two, three-kilogram babies at 40weeks, 1 day. With the
exception of my midwives everyone I spoke to would say"You won't go
full term' "You'll have these babies early' "No –one carries twins
to term'. Interestingly the women I spoke to who had birthed twins at
home or at least been cared for by an independent midwife all went
very close to term. Those who birthed in hospital had to fight off
the routine 38-week induction but with supportive care they all
achieved term babies at 39 to 40 weeks.

This was very welcome news. I told my babies daily that they would
grow to term. I did not give a thought to the fact that I would birth
premature babies. Living in rural NSW this would have been disastrous
for our family and myself. I would have been hours away from home and
our children. I was fortunate enough to read a fascinating book
called Pre-natal Parenting by US Neonatologist, Frederick Wirth.
After 35 years seeing the often tragic consequences of premature
birth, Dr Wirth researched how the mind affected the body. He makes a
compelling case for women to focus on positive and loving thoughts
throughout their pregnancy; Guiding families to address relationship
problems and potential fears to enable not only a healthy pregnancy
and birth but also an affirming start to bonding and parenting a new
human. He says:

"Prenatal visits help your healthcare provider recognize complications
during pregnancy, and they do an excellent job, but too many patients
believe that their pregnancy outcome depends solely on the quality of
their medical care. The success of your pregnancy also depends on the
psychological and spiritual content of your life.'

I was intrigued; Dr Wirth must be supportive of midwifery care and the
option of homebirth (due to the very model of care being holistic
blending health care into the social fabric of our lives). Dr Wirth
in fact described the first homebirth he attended as the most
beautiful, despite witnessing hundreds in the hospital system. He
felt like an intruder and wanted to leave the couple to do what they
were doing so beautifully, creating a safe and loving environment to
welcome new life.

I was buoyed by what I read. I progressed full steam with confidence
that the only place to have my babies was at home full term.
Instinctively I knew that home was the safest place to give birth (in
the absence of medical complications or conditions). Importantly I
had also proven clinically that it was also much safer for me to be
cared for by midwives at home.

How could my babies be safer with a routine induction at 38 weeks,
when they were more likely to need resuscitation and medical care?
How would constant foetal monitoring assist when studies have shown
it's routine use has seen no improvement in outcomes only an increase
in caesarean section? How would my babies or I be safer with an
epidural that would prevent me being upright, the proven best
physiological position for normal birth? How would I be safer being
denied deep water for pain relief? (Do you know of a hospital that
will enable a woman birthing twins to use a birth pool for pain relief
in labour and to give birth if she wishes?).

As my pregnancy progressed I remained healthy and happy. I had
decided to have 3 ultrasounds one at 20 weeks (soon after I realised I
was carrying twins) one at 28 weeks and another at 34 weeks. All
these scans revealed healthy babies of a good size. I was carrying
fraternal twins (in all likelihood) I had a single placenta that had
probably fused. One baby was head down the other breech. This is the
only interaction I had with obstetrics. I used technology in a
limited way to keep my home birth plans alive.

Like many women in a way I would of liked to have given birth at
around 38 weeks, I felt pretty heavy. Although at 39 weeks I felt
excellent (even had a spring in my stride). My midwives said I looked
'too good' to be close to birth!

At 40 weeks I decided it was really time to meet my babies and they
must have agreed. My midwives and doula were with me. On the last
day we enjoyed time together with the kids, had a nice meal together
and all went to bed. At 1.30am my waters broke with a huge gush. By
2 am I had strong contractions. I then woke my midwives and doula, as
I was conscious the pool needed to be filled. My labour progressed
furiously. I could feel twin 1 moving down. I entered the pool with
the water level a little low. The pain relief was instant and
considerable. Our digital camera revealed I was only in the pool for
7 minutes before our first baby was born. The water was just deep
enough! Amazingly I put my hand on her head and felt her shoulders
rotate as she was born. I also caught her and drew her close to me
revealing her gender. It was an awesome feeling to catch my own child
(something I had been previously unable to manoeuvre).

My husband entered the pool at this stage. Contractions started
again, 6 minutes after our first baby was born. I was very uneasy
holding our first baby with a contraction winding up. Paul held her
as I got on with birthing our second baby. The cord had stopped
pulsing with baby 1 and I asked that it be cut. Although this would
not have been by preference the cord was not overly long and I felt
very uneasy still being connected and contracting. The midwives later
said they were happy to hear me quite anxious about all of this, as it
was a clear sign that baby 2 was very near.

My midwife announced there was "a foot' and I very clearly thought "OK
here's our little breech babe, just remember her head will be last,
brace yourself! I had no fear about her being breech. Her birth was
easy. I do concede however, that she was a twin with a smaller head
than most (33cm) and I had just birthed a baby. My midwives were
remarkable. One simply gave baby 2 a gentle push back towards me (as
the weight of her head prompted her to move up towards my back rather
than the front). Both Paul and I then welcomed our 2 girls in the warm
pool. Both babies were born with APGAR's of 9 and 9. I had a slight
graze. I had a physiological 3rd stage, birthing a vary large and
healthy placenta 45 minutes later. I had minimal blood loss and
recovered beautifully

The photo on the front cover was taken 8 minutes after our second baby
was born. I guess it says it all really. Our baby's entrance into
the world was sacred and safe. In comparison they could have been cut
or pulled from me before they were ready most likely with worse
results. The irony is that the latter choice is seen to be 'safer'.

It is time to re-think risk. I have explored twin birth through my
own experience. VBAC and single vaginal breech birth are other 'risk'
categories that need to be examined. The fear that surrounds VBAC is
totally unwarranted. I believe the majority of women attempting VBAC
are set up to fail, vaginal breech is so rare in the hospital system
that I believe it is unsafe. Not unsafe itself but unsafe due to
totally inexperienced practitioners. Other than independent midwives
I know of one Obstetrician experienced in breech birth with a gentle
'hands-off' approach.

In relaying this story I do not believe that all twins, some VBAC's or
breech babies can or should be born at home. What I have learnt via
research and through practical experience is that 'risk' is a
conjecture from practitioners who have little if any understanding or
faith in normal birth. Unfortunately birth in Australia is dominated
by medical practitioners. These practitioners create labels of 'risk'
often with little regard for research evidence. On the whole these
practitioners only believe in the safety of birth after the event. To
me this is most telling and explains our huge rates of intervention,
and resultant morbidity.

If the pilot responsible for flying the plane you travelled on was
only convinced air travel was safe after he had safely landed the
plane what would you think? Would you doubt his competence as a pilot?
Think perhaps he should get another job. Would you doubt the safety of
the actual aircraft? Sadly most women do the latter, they allow
medical practitioners to convince them that their body is faulty. Why
not question the practitioner? After all most Obstetricians are male
with no real way of truly understanding pregnancy and birth.

Post Script: As I write this our twins are 7 weeks old. I am happily
breastfeeding them, they have grown beautifully 1.2 and 1.3 kg since
birth! Raising twins is certainly hard work but the support I
received from my midwives gave me such a huge head start. Thank you
to Betty Vella, Robyn Gasparotto and Margie Perkins for your courage
and commitment.

Justine Caines