Episode 131 - Myth Busting - big baby, homebirth, postdates, CPD
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey. This is an interview that I was on another podcast, a doula named Angela, whose podcast is Guardian Doula's Diary, and she interviewed me about a few myth-busting questions, and so we engaged in a truth-telling conversation about lots of different topics.
Angela:
[0:44] It'll be really, really cool to chat through some of the things that there are myths around when it comes to birth. There are so many. When we were emailing back and forth, I actually sat there and I was like, oh my gosh, it's going to be really hard to just pick a few to focus on because there are so many. But should we just dive straight into the like myth busting? Did you want to go over anything else or mention anything else?
Mel:
[1:06] No, let's do some myth busting. That's my favorite. And I call it truth telling. People are like, what do you do on the podcast? So I'm like, you know what? I try and tell the truth as much as possible.
Mel:
[1:20] Let's today focus on what's the truth. I love that. Yeah.
Angela:
[1:26] Why don't we start with home birth? I feel like this is a massive one. Tell us all about home birth. Is it dangerous? Is it only for hippies?
Mel:
[1:37] No, it's not only for hippies. I can attest that there's a full scope of people who choose home birth. And actually, when you look at the demographic of women who choose home birth, they are usually more highly educated than the rest of the population, sort of on a statistical level. If you have a look at how many of them have university degrees and higher incomes, that's the demographic of women who usually choose home birth. There's obviously a full spectrum, but if you look overall, that's the group of women. So home birth, I'm a private home birth midwife. So obviously I'm in this line of work because I do believe it's a genuine and reasonable option for women. And now we're in Australia and unfortunately here the idea of home birth is not really ingrained in our maternity care system so there's under one percent of women here in Australia will give birth at home so it's not a very widespread choice but there's lots of barriers to accessing it. One of the big ones is the social messaging around childbirth and what we've been led to believe as women what we've been told about birth and how dangerous or safe it is.
Mel:
[2:53] And so society and the medical system would love for everybody to believe that childbirth and pregnancy is a time of profound risk and danger, and that it's a time that women need lots of supervision by an expert, lots of testing and surveillance to make sure that nothing's going wrong. And so society generally looks at pregnancy that way and is very cautious around pregnant women because we think that they're existing in a, like as a ticking time bomb and just waiting and watching for something to go wrong.
Mel:
[3:31] And so when women believe that, their mindset is set to also then be fearful that it's going to happen to them. And so it makes sense when society says, look, we can keep you safe from all the dangers if you hire a doctor or if you come to the hospital or if you accept medical management of your birth, we can keep you safe from this dangerous situation. So that's the social messaging. And home birth goes against that because it is not in a hospital. I mean, it is with midwives. But we also have been subliminally messaged to believe that midwives aren't really skilled. Or in fact, we're highly skilled. We're highly trained. Our job is to be with women all through their pregnancy, birth and postpartum.
Mel:
[4:23] We're considered, I guess, I don't want to say the experts, but we are the profession that is tasked with caring for women during this time. And we care for women as an approach, more like a wellness approach. So this is a well woman who happens to be pregnant and our job is to nurture them through this period of their lives. We do keep an eye on women clinically in a sense that we can help identify if there's a complication developing in their pregnancy, and then we can either manage it with our own skill set, or we can recommend another person to be involved in their care who might be more specialized and might have something that we need that I don't have as a midwife. Home birth comes into it then.
Mel:
[5:11] It's a bit of an uphill battle because already people are thinking home birth, Therefore, it must be dangerous because usually everyone goes to the hospital.
Mel:
[5:21] But when you look at the research, you know, we've done home birth research right to the eyeballs and everything has come back showing that if you're cared for by a midwife who's suitably trained and works within her scope and is well connected in with other healthcare professionals and other services, and you're not experiencing a high level of complexity in your pregnancy, then actually your outcomes with that midwife at home are equivalent or better. And certainly that's the case for babies. And then when you look at the outcomes for mothers, actually women do much better having been at home in terms of their physical, emotional, social, psychological well-being. We've asked the question a lot in research, is home birth safe? And the answer is yes, most of the time with a well-trained clinician, a midwife and a woman who has been appropriately kind of
Mel:
[6:27] And this is a tricky one because midwives are highly skilled to care for women who have risk factors. But if there's certain complexities that are present, you know, it's our job to work out, is this still a reasonable situation for me to be caring for this woman? Or do I need to involve other people? Yeah. And does the location need to change? Yeah. So I think the better question to be asking and what we are asking now is not, is home birth safe? We need to be asking, is hospital birth dangerous?
Mel:
[6:57] Yeah, yeah. And this is the question that's now, I mean, we are asking it in a roundabout way. We're asking about childbirth trauma and the impact of unnecessary interventions on women's health and well-being and baby's health and well-being in the long run. So there's lots of sort of roundabout research being done that's starting to point to the very real possibility that we've got it wrong in terms of sending the majority of women to hospital for childbirth. Now we're in the process of reversing a lot of the social messaging that's developed around childbirth to make it more truthful and make it more in line with what the research is finding.
Angela:
[7:36] I love what you touched on before about how, you know, there's this misconception, I think, around midwives and how like skilled they are. Like, I think, yeah, it's one of the things that I actually had down to kind of talk about was the difference between obstetricians and midwives and the reality that, you know, if you are a healthy woman, like you said, like a healthy woman who happens to be pregnant, like you're not sick because you're pregnant.
Angela:
[8:04] It's a normal thing to go through. And so often I'll hear this idea, you know, women will say, oh, I'm really keen to go as natural as possible. I really want to experience birth for what it is. And I want this rite of passage and I just can't wait. And so I'm keen to go natural, you know, and have no interventions or as little as possible, but I'm going to be looked after by an obstetrician because they are just, you know, they're, the experts. They're better trained. They're more qualified.
Angela:
[8:33] And I just think it's such an unfortunate misconception, I guess, because midwives are the experts in normal birth. You know, obstetricians are surgeons essentially, and their skill set is different. And I love what you were saying about how there is a place for both. You know, we can't just sit here and say, like, absolutely every woman needs a midwife. No one needs an obstetrician. Like the profession is pointless like of course not there's certainly a disproportionate amount of women out there in the community who are being seen by obstetricians especially if like you know if you don't really mind about interventions and you don't really care then great like that's i suppose that's a different conversation but when it comes to women who really feel very strongly that they want this natural birth and that they really want it to be treated as this like sacred normal experience i I always am so confused and you're right. There's so much conditioning that goes on. And like, since you're this big, you're a tiny little girl. This fear is put into you around birth and how dangerous it is. And we have this Hollywood perception of birth. And, but I love what you were saying about, you know, midwives are experts.
Mel:
[9:43] Yeah. And you touched on, you know, the idea behind getting the type of birth that you want is about choosing the location and the care provider that matches your needs. Yeah. So, midwives are trained to care for well women, but also... There's a lot of research around the impact and benefit of having, of basically every woman, regardless of risk factor and regardless of complexity, having a midwife and some people also need a doctor. Yeah. And so, you know, the very most standard basic care that women should have access to is their own midwife. And then adding, adding the other people that are needed to suit her particular needs. You know, is she diabetic? okay, she might need an endocrinologist involved. Has she got a complex, you know, other needs? She might need a hematologist or an immunologist or whoever it is we need to add. And an obstetrician is a specialty like that to help deal with pathology. So they are doctors, you know, they're trained with a medical mindset. And so they're always going to approach birth with a medical mindset, but pregnancy and birth aren't a medical event.
Mel:
[11:00] Unless there's something going wrong. And that doesn't happen as often as we think. For women who, you know, the scenario that you gave, you know, they want to have a normal physiological birth with very few interventions. There's certainly a proportion, you know, you can handpick some obstetricians around the country who you could trust to care for you in a physiological way.
Mel:
[11:24] But that is counterintuitive to their training. They've done their own work to actually equip themselves to care for women in a way that honours their physiology instead of viewing every scenario as a medical event. Yeah. So they're more rare. So yes, I think some women, if you hand-selected the right obstetrician who suits your philosophy and your needs, but it's for the women who aren't aware that they've made that decision and they just choose any obstetrician hoping that their requests will be honoured because As we know, the research shows that in private hospitals with private obstetricians, that's the most likely chance you're going to be exposed to interventions. Obviously, choosing a lower medically inclined care option like midwives or home birth and birth centers, there you're less likely to get intervention. And that's not led by the needs of the women. That's kind of clinician-led interventions. Yeah. And so it's just, you know, if women choose an obstetrician that they believe is going to really suit what they're choosing, then that's, that's great.
Mel:
[12:33] I think more of the issue is that women don't realize there's a difference and that they're inadvertently putting themselves on a path that doesn't match where they want to go.
Angela:
[12:44] Yeah, that's such a good point. It's so true. It's so important to be having those conversations around what their philosophy is on birth and what is your approach. Like if X, Y, Z happened, what would your response be and how do you go about these things? And I think something that I noticed that women do really, really well when it comes to choosing a doula is that they will, they'll talk to a few, which I think is so crucial. Like you really need to talk to a few. You need to know that this person that you are inviting into this experience and into this moment is someone who is the best possible person for you and who lines up really well with what you want and even just your personalities. Like it's a really vulnerable experience that a woman goes through, you know? So it's huge. And I think women are so good at being very intentional about which doula they pick, which is fantastic. But I do wish that they were also really intentional about the other pieces of the puzzle too. Yeah.
Mel:
[13:37] And the other challenge with that is that women will always have a choice over which doula they hire. The issue is a lot of women don't have a choice over who's going to care for them in birth, which is insane, but we're currently in a medical model that doesn't value continuity of care.
Mel:
[13:57] And so most women will either only have access to or can only afford a publicly funded model, which basically means you'll see a different midwife every appointment, a different person will be at your birth, and your postnatal care will be in a completely different scenario again. So there's only about 30% of women who have access to or can afford to select their care provider. Like even, you know, there's this amazing variety and options available for women who are choosing doulas and they're committed to putting money into that, which is excellent. And then the challenge is, is if you want continuity of care, you either have to be a low risk woman near a hospital that has a midwifery group practice model. Yeah. Because often those group practices won't accept women with any risk factors or a home birth, publicly funded home birth model. Or you have to have the money to afford to pay for a private midwife to have a home birth or enough to have private insurance to hire a private obstetrician. So if you want continuity, there's all these real challenges to accessing that. And usually the women who need continuity of care with a midwife or an obstetrician the most are the least resourced. They don't have the money or they don't live in the location where those services are offered.
Mel:
[15:17] So it's a real challenge. it's hard for women to interview people who they want to care for them because there's simply not even that option
Angela:
[15:25] And even like you touched on the mgp being one of the only ways that you kind of can access a consistent midwife throughout your pregnancy and have that continuity of care, but the amount of times that women will get into let's say they do get into the mgp program and they're so excited but then like that midwife may not be on call the day that you go into labor And so it's almost like a false sense of security, which is really unfortunate to say, but the amount of times that this has happened, like just with my own clients. So I know it's, you know, I actually don't have the stats on this, but just in my own kind of anecdotal experience with clients, it's quite common that you'll go into labor, you know, one of the days that your MGP midwife isn't on call. And then it's like, well, there goes your continuity of care. And exactly what you were saying, the women who, are getting continuity under the current sort of way that the system works are the low-risk women. And that's great that low-risk women have more access. I mean, we definitely need more, but it's great that they have access to that. But you're so right. It's the women who need it the most. Like if you have a relatively complex pregnancy, sure you need more continuity because you're going to be really stressed. Like there's so much value and the research shows like building trust with your care providers and with your team is so huge. And if you are high risk, like that is just all the more crucial, isn't it?
Mel:
[16:48] Well, it just means that less is missed. And so even if other people are involved in your care, the midwife is kind of making sure nothing's been missed for that woman, that she's getting the care that she needs, that there's no gaps. You know, she's getting all the education that she needs to make her own decisions. You know, the dream model is to give every woman the midwife of their choice and then adding all the other elements and care providers as needed. It's the partnership that's existed forever. You know, through history, when you look at birth sort of from an anthropological and historical perspective, midwives and women have always partnered together. They've been part of the community and selected by the community and trained over time in apprenticeships. And, you know, this was just always the way. And so we've moved away from that over the last few hundred years. It's this real breakdown in understanding the role and place of a midwife in birth. It's a sad state, but that's what we're all here for, isn't it? I'm sure that's what your work is about. That's what my work's about, you know, in so many elements. Yeah.
Angela:
[17:59] So true. Should we chat about going past your due date?
Mel:
[18:04] Yes. Okay. Wonderful. So new dates. And actually the podcast episode that I did on this, on the Great Birth Rebellion, I think it's been one of the most popular ones. It's episode three of the great man's rebellion we attacked it early yeah so due date so you know women are given a due date for when their baby is due but it's an estimated due date it's not accurate and but it proposes to put a pin in week 40 of your pregnancy so okay you're 40 weeks pregnant that's your due date I'm saying I'm doing that in inverted commas but actually a healthy and normal gestation for pregnancy is up to 42 weeks and And certainly, that's been my experience in private practice is that a lot of women will give birth after 40 weeks. It's kind of a bit of a surprise and a bit of an anecdote if somebody is before 40 weeks and has their baby. I'm like, oh, wow, that's a bit of a surprise. Somebody's 39 weeks. Okay.
Mel:
[19:09] And so, there's a few issues with it in that, you know, dating scans, for example, that give you, that often are sort of held as the most authoritative way to work out your due date. They can be around six days out. And again, if you're going to go by estimated due date by calculating it from your period, again, it assumes that you ovulate around day 14 because it goes from the start of your last period. But some women ovulate day 13 and some maybe day 18 or 21. And that's when you get pregnant. And so if we use the first day of the last period as estimated to use to estimate your due date, again, it could be inaccurate by another week if you ovulate at a different time. And again, if your cycle's longer, it can change. You know, there's lots of variability. But in hospitals, if you are 40 weeks and 10 days, that's the most general way that they calculate it, they'll recommend that you get induced, that your labor be induced. Yeah. And the reason they do that is from 37 weeks, there is a gradual statistical increase in the chances of a baby being stillborn.
Mel:
[20:34] And some genius has calculated the period at which, you know, you have, if you bring every baby out at 37 weeks, then you introduce new risks, like the risk of prematurity and there's actually poorer outcomes for the babies. Yeah. So they've kind of worked out where there's this cross section, if the babies are born at 39 weeks. Then you reduce the risk of stillbirth because you take away the last three weeks of pregnancy and you counteract the impact of prematurity in the baby if they're born at 39 weeks. So logically, they're saying, you know, there are papers, there are some research papers that suggest that the optimal time to get a baby out is 39 weeks. And some clinicians will induce women in order to meet that sort of timeframe.
Angela:
[21:24] I'm so glad you've brought this up. This is so good. Yeah.
Mel:
[21:27] And so, I mean, it's a very problematic thinking because it doesn't value the woman and baby's individual situation. Some babies are ready at 39 weeks. Some babies need three more weeks of gestating before their brain and body and lungs and reflexes are ready to be born. And we don't know which ones of those babies your baby is. But let's have a look at, you know, they all propose that the reason they do this is to reduce stillbirth. I'm clutching at the stats. The episode, the due dates episode gives very accurate stats. And also there's a resource folder that people can use to actually get the studies that I'm talking about. Great. But the stillbirth rate at 41 weeks is about six or seven babies in 10,000.
Mel:
[22:21] If you add another week of pregnancy up to 42 weeks, it's about 11 or 12 babies per 10,000. So women are told that each week you're pregnant, your risk of stillbirth doubles. And that's not untrue. I mean, yeah, it goes up from 6 or 7 to 11 or 12 within that week in 10,000 babies. Of 10,000 pregnancies. So really, instead of saying to women, you've got a 50% increase in the chance of stillbirth, which is terrifying to hear as a pregnant woman. And you think, well, I am 41 weeks. So, you know, I would very much like to reduce my risk of the risk of a baby being stillborn. I can understand why women make that decision.
Mel:
[23:06] But to know the actual numbers might be more helpful for women as they make their decisions. If you really don't want an induction and you are and every woman is deeply invested in the safety of their baby then with those numbers they can actually make a decision for themselves as to which risks they'd like to take
Mel:
[23:25] and which they don't because being pregnant has this additional risk of additional chance of stillbirth the small increased chance but induction also carries a risk and so now women have to decide, do I want to accept the risk of an induction or do I want to accept the risk of being pregnant for potentially a whole other week? And so that's not a decision for us to make as clinicians. That's a decision for the woman to make. Yeah. And then there's research that shows if you adequately supervise and nurture a woman to 42 weeks and beyond, there are things that we can do to identify which babies are at risk of stillbirth and which ones aren't. And the challenge is, is that clinicians aren't familiar with how to care for women who are post-dates, who are beyond 42 weeks, except to say that they're frightened and to keep recommending induction.
Mel:
[24:21] Whereas if we do things like monitor placental function and the amniotic fluid volume, and we're being really careful about monitoring for the movements of the baby, and the woman's feeling well and she's chapped in intuitively, then there's a lot that we can still do to supervise and monitor these pregnancies that go over 42 weeks because we are in an unusual situation.
Mel:
[24:45] Then potentially we can help reduce those stats with continuity of care, with midwifery care, with adequate supervision, you know, when you're tapped into services that you might need, but also realizing that your dates might not have even been accurately, correctly kind of pinned anyway. So when you're 42 weeks, you could be 41 weeks quite reasonably, even if you've got due dates and ultrasounds. So, it's a really shady kind of area and I don't think that inducing every woman at 40 weeks and 10 days is an appropriate response because we just are still yet to be able to even predict which babies are in danger of being stillborn.
Angela:
[25:33] What you were saying about the risk of stillbirth being described to the women as, you know, your chances double every week, like it's so common and I think it's very rare. Well, of course, it's common because it's true what you were saying. It's true. Like your risk does go up. But I think what is unfortunately so rare is care providers giving women the actual numbers. Like, of course, women care about this. And if you tell the woman, you know, the chance that you're going to have a stillbirth doubles every week. Of course, that's going to cause serious panic. You're going to say like, oh my gosh, induce me right now then. Like induce me yesterday. Of course, you're going to have that reaction. But if you are given the proper, the numbers, for a lot of women, that would be very reassuring. And I love what you were saying about choosing your risk because there's a risk to induction, just like there's a risk to being pregnant, just like there's a risk to taking a walk around the block. Like you might get hit by a car. It's unlikely, but you might. Like there's risk to everything and it's choosing your risk and choosing what you're comfortable with. And, you know, for some people, maybe... Let's say seven in every 10,000 babies, maybe that's really high. And they go, that is, I just cannot take that risk and I'd rather do the induction. And then other families might hear that number and go, oh my gosh, what are we panicking about then? Seven in 10,000? Let's just, as you said, keep an eye on the fluid, keep an eye on the placenta function, keep an eye on baby's movements. Yeah. It's so nuanced, isn't it?
Mel:
[26:56] Yeah. And I think we have gotten to the point in maternity care where the care providers are being allowed to decide what they believe is high risk and what's low risk and what risk they're willing to take and what risk they're not willing to take. But we've forgotten that actually that choice lies with the woman. And our job is to actually firstly have the information ourselves so that we can satisfy our own fears. Yeah. And then pass all of that information onto the woman. But what happens is, is care providers will often select the pieces of information that they want to give the woman that will direct the woman into making the decision that her care provider wants her to make. Yes. And really what we should be doing is giving women all the information, regardless of what we think she should do, and so that she can make her own decision. And then it's the woman's role to make the decision and then take responsibility for that decision. But if I make a decision for the woman and
Mel:
[28:02] I think the outcome and the responsibility of the outcome lays on the clinician. And this is where I think we get into these real legal kind of battles of, you know, it's not so much here in Australia, I don't think, but definitely in the US is a big blame culture.
Mel:
[28:20] But if you're making a decision for a woman saying, you know, we think it's better for you to have an induction and then something goes wrong with that induction and the woman's only decided that because she's been kind of groomed to make that decision by her care provider, then is she responsible? Should she bear that consequence on her own or is somebody else responsible for whatever outcome happens, especially because the research is not very conclusive about the benefits of induction over weighting?
Mel:
[28:54] So it's a really complex issue, but I think as clinicians, we should let go of the decision making and just see our role as information givers. And definitely, you know, sometimes I will give women a recommendation, you know, based on our experience, but she needs to know that you're only recommending it because it's based on your experience. And maybe I could even be even more vulnerable and say to a woman, I'm really frightened of this scenario because I've had this experience in the past.
Mel:
[29:26] And so I'm going to bring my colleague into this scenario who's more experienced and less frightened. For example, and that's, you know, us being vulnerable and honest with our humanness and our fears, but then recognizing that we shouldn't be letting that impact on the recommendations that we make for the women, because then we're just letting our own fears govern the type of care that we give and that's not evidence-based
Angela:
[29:55] Or appropriate that's amazing I think that's so if we could like just imagine a world where that is normal acknowledging okay I think I'm feeling really scared here I've had whatever experience that is likely a very very valid experience like I can only imagine if you're a care provider and you have experienced a really adverse outcome because of whatever inducing or not inducing or whatever it might be it would be seriously scary sitting in that same position again and feeling like oh my goodness history is repeating itself in front of me and I just am so terrified that what has happened before might happen again like I can totally empathize that would be horrendous like but and imagine how beautiful the world would be if in those moments we were vulnerable and honest with ourselves and even like secure enough in ourselves to go hang on I'm gonna rely on some other you know another a colleague or whatever it might be yeah like you described like I think, gosh, imagine how incredible the whole world would be and imagine how amazing the system would be if it worked like that, just to like dream for a second.
Mel:
[30:58] I know. Well, and it's challenging too because, you know, hospitals are short-staffed and clinicians don't always have someone they can defer to. And then there's, you know, there's the workplace hostility. Like if you turned around and said, hey, mate, this person wants this. I'm really frightened because I've done this one time before and this happened and I'm not confident.
Mel:
[31:22] And, you know, that might be looked down upon in the system, you know, if people are busy or if someone's not there or they'd be like, you know, just tell her to have a cesarean or something. You know, really, this is a real challenge. It's not pinning this on individual practitioners because just like women become the victims of sort of a poorly set up and poorly resourced system, so too are the clinicians. So there's a lot of complexity. Women are sometimes put in situations where they have to make decisions because of the pitfalls of the system. Yeah. And they're not less legitimate decisions. You know, I've had obstetricians walk into my client's room, you know, if they're having a complexity and saying, you know, like basically all the experienced staff are leaving at five. So we need you to make a decision. Otherwise, you are going to be left in the care of the less skilled night shift. And you know that's a reasonable thing for a woman who's having quite a large level of complexity to be thinking do I want to just submit to this now knowing that there's more experienced care or am I willing to wait till tomorrow and hope that it'll all be fine or you know it's a real challenge it's not just you know making decisions is not just about what do you need as a woman but And it's like, what resources and clinicians do you have access to?
Angela:
[32:50] Yeah.
Mel:
[32:50] Yeah.
Angela:
[32:51] It's so true. It's so true. And midwives and obstetricians, everyone, all of these care providers who are working in the hospital system, as you said, that is so understaffed and so underfunded and so under everything, like they have a really, really hard job. Like it's really hard. Even if you have the purest of intentions and you are so wildly passionate about giving women the best possible experience and giving them the best care and, You can set out on that mission, but you're on a really, really difficult playing field. So even just to call out for those midwives who are working in a really tough system, you know, and they're doing their best. And like, I have friends who are midwives who sometimes say to me, oh my goodness, I feel like I just failed my women today because I was so rushed because there just weren't enough of us on shift. I just couldn't provide what those women needed today. And I feel like I failed them. And that's a really heavy burden to be carrying around. Yeah, I've got so much compassion for those people that work in a system that is so hard to navigate and so, yeah, yeah.
Mel:
[33:56] Well, there's terminology for it. You know, there's new research coming out now. It's called, you know, we are acknowledging and realising that midwives are working a lot of the time under a state of what we call moral distress.
Angela:
[34:08] Yeah.
Mel:
[34:08] And that's that feeling that you described of like they know the type of care and the type of midwife they want to be. but because of the limitations of the system and the requirements of their workplace, they can't work that way. They have to compromise on the type of care that they're giving and then that distresses them because they know they haven't done the best job that they possibly can and then that layers day after day after day and then midwives burn out. And so there's this desire to have an allegiance with the woman but then we're pulled towards our requirements as employees knowing that we can't give the women like what they need we can do our very very best but at the end of the day we still feel like we haven't done a good enough job and then that gets layered if there's been a poor outcome for a woman and she's upset you think oh my gosh you know she's absolutely she should be upset and then we bear you know that responsibility knowing maybe if things were different I could have done something different but then oh it's it's so hard and so I give midwives and maternity care workers just so much compassion knowing that just like women are trying to navigate a way to get the best birth they possibly can, hair providers are trying to navigate a way to give the best possible care they can under these impossible circumstances.
Mel:
[35:34] And so, yeah, if we just realize that we're all fighting against the social pull away from giving women what they fundamentally need in labor and birth, then we can just kind of have a bit more compassion for each other.
Angela:
[35:47] I love that. It's so true. It's so true.
Angela:
[35:50] I love when I, you know, am at a birth and it's a team effort and there is that real sense of like, we are in this together. We're all working together because we want this woman to have the best possible experience and, you know, we just want to see her and her baby thrive. There's something so special about that like it actually just gives me goosebumps even just thinking about it should we should we get back to our truth speaking and chat about do you want to go over I guess the idea that if your baby's big you have to be induced before they get even bigger and even to to chat around like growth scans and how you know we're aware that they are notoriously inaccurate um yeah yeah.
Mel:
[36:34] I guess and I guess that's the place to start, isn't it? So if someone said, you know, we want to induce you because your baby's big. They can't know your baby's big. They can have done everything they possibly can to try and work out if your baby's big.
Angela:
[36:52] Yeah.
Mel:
[36:53] But there's no way to accurately tell if your baby is actually big or too big to be born because that's the bigger issue. I don't think that big babies are an issue.
Angela:
[37:06] Yeah.
Mel:
[37:06] But is the baby too big to be born? And we start to see issues with babies being too big to be born in times, for example, of uncontrolled gestational diabetes, where the babies do get bigger than they should for the woman's body, whereas some women are so capable of having these huge babies, and they'll fit through their pelvis, and they don't get stuck, and there's no issue, and these are perfectly well-healthy women who just happen to make bigger babies. You know, the challenge firstly is we can't, as clinicians, really accurately diagnose whose baby is very big and whose is a normal size and if that baby is going to come out or not. And so, you know, growth scans can be wrong by, well, not wrong. They're still considered accurate if they can estimate the weight of your baby 10% above or below its actual weight.
Angela:
[38:09] It's crazy, isn't it? Because that's not super accurate. Like if the scan says baby's four kilos.
Mel:
[38:15] 10% could be 3.6 kilos or it could be 4.4 kilos. But that's 70% of the time they can predict with that level of accuracy. So the other 30% of the time they're more wrong. Right. Than 10%.
Angela:
[38:36] Right. Is it 15%?
Mel:
[38:39] Some, it depends on the facility. So they'll tell you, they usually tell you on the scan, they'll say, this is the estimated weight of the baby on the report. And then in brackets, they'll have plus or minus a certain percentage. So, you know, there's some more specialist units that will give more accurate, higher quality ultrasounds. And then there is some kind of, you know, they're not all ultrasound places and all sonographers are the same. Yeah. There's definitely a sliding scale of skill and certainly ultrasound is something that relies heavily on user skill and user error. And so, you know, there are some places, certainly if you're concerned about a larger baby as a clinician, I personally will choose one sonographer over another knowing their skill level and sort of the quality of their service over some others.
Angela:
[39:34] Yeah.
Mel:
[39:34] Not all ultrasounds are created equal, but we really cannot tell you how big your baby is. I've had scenarios where, you know, as midwives, we measure what we call the fundal height. So the measurement from the woman's pubic bone to the top of her uterus, it's considered only 50% accurate if you don't have continuity of midwifery care. So if somebody different is doing it every time, it's about 50% accurate. If you have your own midwife and it's the same person doing those measurements every time, then the accuracy increases up more towards 80%.
Mel:
[40:13] But even then, that's not about telling the size of your baby of like your baby's now three kilos and now it's three and a half kilos. And that's about monitoring the pace of your baby's growth. And so if I've been measuring one of my client's bellies from 28 weeks and every time I measure her, the increments of growth are pretty consistent week to week. If, and this has happened to me, if I measure a client at 32 weeks and then she comes back at 34 weeks and there's been a six or eight centimetre growth in the fundus, I think, whoa, that is terribly unusual. Something is going on. What could it be? And it could be that the baby's suddenly grown exponentially. It could be that there's suddenly a stachymal amniotic fluid. There's babies who, for example, can suddenly have growths within their body, pathological growths. There's all kinds of things that we can tell from measuring the woman's belly size, but it's less about the size of the baby and more about tracking an inconsistency in growth. And now what are we going to do with this information?
Mel:
[41:26] Some people will say we should induce women whose babies are over you know the 95th centile or something this is how they will will report this in an ultrasound is saying you know your baby is bigger than 95 percent of other babies and so it's on the really top of the scale and we're concerned that if your baby gets any bigger that there could be a complication at your birth and the most likely complication that they're worried about is things like shoulder dystocia Yeah. What we should be less worried about is, you know, when people say, oh, the baby's too big to come out. Well, you'll discover that in labor, actually. You'll be laboring and you'll probably get to fully dilated and your baby just won't come down in your pelvis and it will become obvious over time, either because the baby's distressed or, you know, labor just doesn't progress and, you know, maybe the pushing efforts from the mom have been ineffective and the baby's just not coming down. Okay, now we can diagnose maybe your baby's too big to come through your pelvis. Maybe that's the reason. It could be a whole lot of other things.
Mel:
[42:33] But then we have the wonderful invention of cesarean sections. You know, I've had women suggested to have a cesarean section because their doctor or clinician just believes that their baby's not going to come out because it's too big. And so they do like this prophylactic, preventative cesarean section. And then forever the woman believes that babies don't fit through her pelvis. Whereas if she'd gone into labor and attempted labor, the most likely thing that would have happened is that her baby would have come out her vagina and maybe she would have needed the caesarean section, in which case everybody involved in that scenario, including the woman, It feels a little bit more confident that, yeah, maybe I needed that. Whereas if you give a woman a cesarean section for a bigger baby, there could be a point down the track where she's like, did I really, really need that? And then women want answers to that question. Yeah. And then they'll try for a VBAC, right? Yeah. Yeah. The bigger problem with, you know, with bigger babies is that we actually can't really work out which babies are too big because we don't know what the capacity of the woman's pelvis is. Yeah. But also we don't have a proper technique for accurately measuring babies. Yeah.
Angela:
[43:54] This is so cool that you brought up about the idea that sometimes clinicians will base this advice around like, you know, I just don't think this baby's going to fit through your pelvis. Let's just do a cesarean just in case. And then as you said, it creates this doubt and this lack of confidence in the woman because She goes, oh, my gosh, like maybe my body's not capable or whatever.
Angela:
[44:14] Do you want to just really quickly touch on – so I always am so fascinated because I think this thing is so hugely common in the community. Like whenever I'm out in the world going about my life, the amount of women that tell me, oh, you know, my doctor said I had to have a caesarean because there's no way that baby would have fit through my pelvis –, Let's just talk about this for a second because, so cephalopelvic disproportion, am I saying that right? Yeah, CPD. Yeah, CPD. But CPD, the true mismatch in size between the baby and the woman's pelvis, it's one in 250, isn't it? And even then, like, it's quite hard to diagnose.
Mel:
[44:52] Yeah, very hard to diagnose. I've been a midwife for 16 years and probably there's been two scenarios where I've said to my colleagues you know if I had to give it a name as to what happened with this client I think this was true cephalopelvic disproportion.
Angela:
[45:13] Do you say it like cephalopelvic? That's so funny.
Mel:
[45:18] It doesn't you know who it doesn't matter it's you know some people say cephalo some people say kephalo kephalo is like you know kephalic like the head i'm
Angela:
[45:27] So glad that we discovered this.
Mel:
[45:29] Yeah so you know if your baby's coming head down we say it's kephalic it's coming head first i
Angela:
[45:34] Feel like it's definitely how you say it love it right now.
Mel:
[45:37] I think we can't we can't measure a woman's pelvis and we like internal the internal part of the pelvis where the baby comes down
Mel:
[45:49] We also can't accurately measure the size of the baby's head and we can't predict what the woman's pelvis is going to do during labor because during pregnancy, we have this hormone relaxant that actually makes our pelvis a lot more mobile. And also when we change positions in labor, we can also change the shape and diameter of the internal part of the pelvis to help accommodate the baby. And as the baby comes down, if we're in upright sort of more physiological positioning, The woman's tailbone will move position depending on how she moves her legs. She can expand or restrict the internal capacity and the internal space where the baby's going to come out. So there's no way to accurately measure those things. So how on earth can we say to a woman, your baby will not come out that space unless, for example, there's this very rare circumstances where the babies have like a neck growth or something. There's extra parts of the baby that, you know, will not fit through. Okay. Like I think, okay, we could make some very clinical educated decisions about that. But I think kefala pelvic disproportion can only be diagnosed in retrospect. So after all the events have unfolded and you kind of go through a systematic elimination of all the other options, like, no, it wasn't that.
Mel:
[47:17] No, Possibly what it was is cephalopelvic disproportion, but we can't really fully know, I don't think. There are some symptoms that you can put together that might say, I don't think that baby fit through. But even then, I don't know that that's helpful information to a woman because even if a woman has had the situation of cephalopelvic disproportion, I personally would tell her in her next pregnancy, there's no harm in trying again.
Mel:
[47:47] Because what's going to happen in that true scenario is that your baby just won't come down and out. The head's not going to be born. It's not like you're going to be in the scenario where the head's born and the rest of the baby can't come. That's different. That's shoulder dystocia. That's not the same scenario as kefalo-pelvitism proportion. The scenario will be that labor goes on and on and on, that your body works hard and harder and harder to try and push the baby down and it won't go through your pelvis or through part of your pelvis and then the baby gets distress and then we say well the baby's not coping with this situation anymore we think maybe a cesarean's necessary okay so this is the usual trajectory the other thing that can cause that is is maybe the baby's head has come down to the pelvis in what we call an asynclitic way so it's tilting to one side that's different again that's not careful the pelvic disproportion. That's kind of an interruption in the baby's progress through the pelvis based on its own positioning, not because of a mismatch in the shape.
Angela:
[48:51] I love, there's this analogy that I always use with my clients. I feel like it's so helpful to wrap your head around this stuff. But if you picture like a shape sorter, like you know, the little shape sorting things that babies play with. And you might have a circle that's perfectly, you know, the right size for the circle shape to fit through. But if you've tilted that circle shape, the circle shape being the baby, if you tilt it a little bit funny, it's going to feel like there's a mismatch, you know? So it's, yeah, so good to call out what you were saying about that kind of asynclitic presentation. Like, of course, that's going to then create a challenge.
Mel:
[49:24] Yes. Yeah, and it's about working out, is this baby asynclitic or is it genuinely not fitting? And usually, you know, a skilled clinician could tell the difference. Like, yeah, from what I've seen with the labours where I suspected kefalo-pelvic disproportion, the presentation, you know, if I, yeah, I don't want to give away too sort of many like symptom pictures because it's not necessarily going to happen for everybody. But definitely my inclination with asynclitic babies is you can tell the difference based on the pattern of the labor and of the situation like the state of the baby usually the baby's still well if it's asynclitic and the contraction pattern's a bit different and the woman's got some you know different sensations whereas with with kefla pelvic disproportion the end point that I've experienced is usually distress in the baby and meconium stained lycor and the woman is just getting really lots of strong contractions that aren't progressing things in any way yeah I think it's different but I do think it can only be diagnosed in retrospect yeah
Angela:
[50:34] Which is huge because you know then you wonder and you go oh you know was it what was it was it a true like is my pelvis It's just completely, you know, is it me? Like there's this whole almost like turmoil that would happen afterwards because you just can't help but wonder, like, what was that? What's going to happen next time? Like it's huge.
Mel:
[50:59] Yeah. And there's lots that women can do. If this is the story they've been given, you know, that your baby couldn't come out for whatever reason, then I think there's no harm in trying again because if you're in a facility that can assist you in an emergency, then you're in the right place. But there's lots of things you can do to prepare. So I always recommend to any woman, but even more so for women who've got this story, is how about we engage with some care providers like body workers, osteopaths or chiropractors, for example, sometimes physiotherapy or somebody who can do sort of internal pelvic floor release, pelvic bowl release. There's so many muscles and bones and ligaments and fascia that are involved. In shaping the area where your baby's going to come down, that if in your mind you can tick off, like I've ticked off everything that's within my own control. Yeah. My pelvis is aligned. I'm muscularly balanced. My pelvic floor hasn't got any tension. You know, all these little things that we can do, staying active in labor, making sure there's enough movement in your pelvis where your baby could navigate that. But, you know, if it's been that you've had diabetes last time, you know, working really hard to keep your blood sugars controlled so that the size of your baby mimics what it would normally be.
Mel:
[52:28] Then women can mentally say, I've done all I can to control this scenario. And it's not necessarily that it's the woman's fault, but there's elements that are within our control. And so now anything that happens is out of my control. And women start to feel kind of better with whatever plays out the next time. Maybe all of that work did the trick to solving whatever happened last time. But if it doesn't, they can say, you know, they can start to just resolve things in their own mind as well. But I did everything. So this was always how it was going to end up. So, but again, this is where the value and continuity of care is, where women and midwives can work together to sort of navigate and come to terms with these certain situations.
Angela:
[53:19] This is such a good little note to finish off on because I think it's so important that we challenge the idea that is so prevalent out there around how birth is this like completely out of our control thing. But you can control what your model of care is. You can control where you give birth. You can control how you eat, whether you hire a doula, whether you do really good, you know, education around birth and you really understand your options, you can control, like there's so much that you can control. And exactly what you were saying, if you do all the things to give yourself the best possible shot at the birth that you do hope to have, and it doesn't go that way, then, you know, at least if you do find yourself in that scenario, at least you are so well supported, you've put all the things in place. And exactly what you were saying, Mel, like you, you just, you know, that you're, you, And it's almost like it wasn't going to be different. Like you're not going to always be wondering, you know, what if I had done this or what if I had done that? Like, I think it takes the pressure off a little bit because you go, do you know what? Like, that's just how it happened. I did everything that was in my power. And then it's so much easier to make peace with whatever that ends up as.
Mel:
[54:34] Yes. And you make a point of, you know, how women feel about their birth at the end of the day. It's not usually about the events that unfolded. For some, it is. But usually the thing that makes a difference is did they feel like they had choices? Were they given respect and autonomy in their care? And then did they feel like they did everything they could? Did they leave no stone unturned? And I think back to a client of mine who'd had a very traumatic previous cesarean section and she came to me planning a V back at home. And she went to 42 weeks and she labored for sort of six or seven days and things were really, you know, really going on. You know, it was a lot of early labor, but she was incredibly exhausted. And, you know, her and her baby were well, but, you know, she said to me on the last day, Mel,
Mel:
[55:27] I'm ready for another cesarean section. And I said, absolutely, I will make this happen for you. She had her cesarean. And when, you know, postnatally, I care for my clients till they're six weeks postpartum. And so we had a lot of time together after that. And even day one or two afterwards, she said, I'm so happy with how everything went. Even though she had a cesarean both times, She said, this time I got to take it all the way to the end. I went all the way to 42 weeks. I labored that whole time. The whole time I was given all of the options and I did, I had control over every single decision. And so she was fine with having had a cesarean section, actually still as blissful and elated as a woman who'd gotten every item on her request list. And so it just reminds me so much of the importance of nurturing a woman with what she needs.
Mel:
[56:33] And at the end of the day, if she doesn't get what she'd hoped for, she's still emotionally and socially and mentally intact, knowing that she explored every option. And yeah, so it's often not the outcome that causes women to be disappointed. It's when their decision making is taken from them and where they didn't have enough information and they have questions that are left if they feel like they didn't explore every option.
Angela:
[57:02] Yeah, it's really true. I found the exact same thing. And even in my own births, I feel like that's been the case. Massive.
Mel:
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