The Having a Baby in Queensland Book Dec 2010 v1.0

AcknowledgementsOrganisationsIndividualsAustralian College of Midwives(ACM)Caboolture HospitalCentral Maternity &Neonatal Clinical NetworkEthnic CommunitiesCouncil of QueenslandFriends of the Birth CentreQueensland Association IncGeneral Practice QueenslandGriffith UniversityHerston Multimedia UnitMater Mothers’ HospitalMaternity CoalitionMaternity Unit, Primary,Community and Extended CareBranch, Queensland HealthMidwives Information &Resource Service (MIDIRS), UKMidwifery Advisory Committee,Office of the Chief NursingOfficer, Queensland HealthMidwifery Advisor,Queensland HealthNorthern Queensland Maternity& Neonatal Clinical NetworkPreventative Health,Queensland HealthQueensland Maternal andPerinatal Quality CouncilRoyal Australian and NewZealand College of Obstetriciansand Gynaecologists (RANZCOG)Redland HospitalSexual Health and HIV ServiceSouthern Queensland Maternity& Neonatal Clinical NetworkStatewide Maternity &Neonatal Clinical NetworkStillbirth and Neonatal DeathSupport (SANDS) NetworkThe University of QueenslandLana BellDr Wendy BrodribbDeirdrie CullenRachel FordDr Glenn GardenerProfessor Geoffrey MitchellRosalie PotterDr Camille Raynes-GreenowAssoc. Professor Allison ShortenHayley ThompsonAssoc. Professor Lyndal TrevenaThe Queensland Centre for Mothers & Babies would also like to acknowledge the families in Queensland for their generosity in contributing many of the beautiful photos contained in this book.The Having a Baby in Queensland book was developed by researchers at the Queensland Centre for Mothers & Babies. The Centre is an independent research centre based at The University ofQueensland and funded by Queensland Health. The Centre does not stand to gain or lose anything by the choices you make after reading this book. The decision aids contained in this book havebeen developed to be consistent with the International Patient Decision Aid Standards criteria for quality decision aids wherever possible.The University of Queensland, its employees and affiliates have made reasonable efforts to ensure the content provided is up to date and accurate. However, it does not guarantee and acceptsno liability or responsibility for the accuracy, currency or completeness of the information contained in this book. To the extent permitted by law, The University of Queensland its employees andaffiliates exclude all liability including negligence for any injury, loss or damage caused by or arising out of any reliance on the content contained in this book.Unless otherwise indicated, the content of this book is the property of The University of Queensland. All content is protected by Australian copyright law and, by virtue of international treaties,equivalent copyright laws in other countries. No material contained within this book may be reproduced or copied in any way without the prior written permission of The University of Queensland.Last updated: March 2010Next update: March 2012© 2010 The University of Queensland, Brisbane Australia. ABN 63942912 684, CRICOS Provider No. 00025B Web Version v1.5Cover Photos:Left courtesy of Little Posers Photography, centre courtesy of Andrea and Hannah Sunderland and right courtesy of Herston Multimedia Unit.

AboutthisbookThe aims of the Having a Baby in Queensland book are to:» Give you information that is consistent, clear and trustworthy» Support you to know what to expect from your care duringpregnancy, labour and/or birth» Give you ‘tools’ to help you to understand the decisionsthat you can be involved in, what your options are, andwhich options may best suit your needs and preferences» Support you to communicate your needs and preferencesto your care provider/s (midwife, doctor and/or obstetrician)and ask questions» Increase your satisfaction with your pregnancy, labourand/or birth experienceThe Having a Baby in Queensland book is not meant to give youmedical advice or recommend a course of treatment. You should notrely on it to provide you with a recommended course of treatment. Itis not intended and should not be used to replace the advice or careprovided by your midwife, doctor and/or obstetrician. You shouldask about and discuss your treatment options with your midwife,doctor and/or obstetrician before making any treatment decisions.This book aims to help you to make informed decisions aboutyour maternity care options. Making an informed decision involvesthinking about different options, getting enough information toknow what happens if you choose different options and thenpicking the best option for you. If you have trouble understandingany of the information in this book you may like to speak with yourcare provider/s. Your care provider/s should be able to give youone-on-one support to understand the information in this book.We hope that this book is useful and supports you to access to thetype of maternity care that meets your needs and your preferences.We use this symbol when thereis something you might like to askyour care provider about.The information in these decisionaids are from the best studiesavailable. When you’re reading, youwill see small numbers at the end ofsentences, eg [5]. The numbers showthat the information is backed up bythe results of a study/studies.Some of the studies that we talkabout are better quality than others.Whenever we talk about the resultsof a study, we give you some idea ofits quality, using the following rating:An is given to studies that arehigh quality. level studies tellus we can be very confident thatchoosing to do something causessomething else to happen.studies are the very highest qualityof studies.A is given to studies that aremedium quality. level studiescan tell us we can be moderatelyconfident that choosing to dosomething causes something elseto happen.A is given to studies that are lowquality. level studies can tell uswhen things tend to happen at thesame time. But level studies can’ttell us that choosing to do somethingcauses something else to happen.2

Eachdecision aidin this bookFor each topic in this book, we have developed a decision aid.A decision aid is a tool designed to give you information about youroptions. Each decision aid in this book:»»Gives you information about the decision and what youroptions might be»»Aims to answer your questions about what might happen if youchoose different options, including the option of doing nothing»»Aims to help you think about how your values and preferencesmay play a role in making these decisions»»Aims to help you think about what options might be best for youand your baby»»Gives examples of questions you might ask your care providerto find out more»»Includes room for you to make notes or write down yourthoughts or questionsThis book has been written about pregnancy, labour and birth.Many different aspects of these experiences are discussed indetail. This book includes photographs of women before, duringand after birth, including naked women and women undergoingmedical procedures. This book also includes diagrams anddrawings of women’s bodies, including the organs inside theirbodies. You are free to choose whether you read this book, andwho you show this book to.3

How can I makethe decisionthat’s best for me?At the Queensland Centre for Mothers & Babies, we understand that the right decision for you may not be the right decision for others.When making decisions about their maternity care, some women prefer to get the information and make decisions by themselves or with theirfamilies. Other women like to make decisions as a team with their care providers and some women like their care providers to make decisions forthem. This decision is yours to make. You might change your mind about previous decisions if you get more information, if your circumstanceschange or your preferences change. For all decisions before, during and after your birth, you are entitled to know your different options, knowwhat happens if you choose different options and choose the option that is best for you.Think about the reasons forchoosing each optionWhen making a decision about which option is best for you, it can be helpful to think about the reasonsthat you personally might choose each option. We have included a table in each decision aid in the bookwhere you can write down both the reasons you might and might not choose each option. You might havecome up with your own ideas, or have found information somewhere else.Think about which reasonsmatter to you the mostSome reasons might matter more to you than others and you might want to give these reasons extrathought when making a decision. There is room in each decision aid for you to mark how much eachreason matters to you in a box. Doing this can also help you talk to other people about what matters toyou. You might like to use a simple star rating like this to mark how important each reason is:Matters to me a little Matters to me quite a bit Matters to me a lotThink about whether you’releaning towards one option orthe otherOnce you’ve thought about the reasons for choosing each option and how much each reason matters toyou, you might feel that one option is better for you. Or, you might still be unsure and want to think aboutit some more or ask questions. There is a place to mark what you feel about your options within eachdecision aid. You can also show this table to your care provider to help you make decisions as a team.4

Using theinformationin this bookWhat wehaven’t coveredin this bookHow you use the information in this book is entirely up to you. Ifyou want to be involved in making decisions about your pregnancy,labour and birth, this information will support you to do so. If youdon’t want to be involved in decision-making, this information mayhelp you to know what to expect during your maternity care.The list of studies we refer to in this book can be found in theonline versions of each decision aid (www.havingababy.org.au).In time, the technical reports for the development of each of thedecision aids in the book will also be available online. Technicalreports are a record of the decisions the researchers made whenconsidering which studies to include and exclude in each of thedecision aids.We are aware the information in this book is only the ‘tip of theiceberg’ when it comes to information about your maternity care.Unfortunately there are lots of topics we haven’t been able to cover,that women said they wanted more information about. For example,women told us they wanted clear, consistent and trustworthyinformation about immunisation, postnatal depression, sleeping andsettling newborns, breastfeeding, stillborn babies and miscarriage.We have done our best to put topics into this book that women havesaid were most important. In time, our website will be able to provideyou with more clear, consistent and trustworthy information aboutmaternity care.Studies can’t say for sure what would happen if you choose oneoption or another. However, the results of studies might give youan idea of the possible outcomes of each option. The studies weuse in this book give you the best possible estimates of how likelydifferent things are to happen.In the decision aids in this book, we talk a lot about the chance ofdifferent things happening. To put the numbers we have includedinto some context, it might be useful to know that each year inAustralia:»»5 out of every 1000 people are injured in a car accident»»2 out of every 100 people have vomiting or diarrhoea fromfood poisoning»»30 out of every 100 people catch a cold or flu»»45 out of every 100 people get sunburntThe information in this book can be used with Queensland Health’sPregnancy Health Record (pictured right). You might like to ask yourcare provider about this record.5

Your carechoicesChoosing your modelof care: A decision aidfor pregnant womenchoosing their maternitycare provider7

The research and development of this decision aid was conducted by Liz Wilkes, aresearcher and midwife contracted to complete this work for the Queensland Centrefor Mothers & Babies.What is this decision aid about?This decision aid has been written to support women to know whatto expect and to have a say in making decisions about their careduring pregnancy, labour, birth and after birth.This decision aid provides information about four options:1. Shared care2. Public midwifery models of care3. Private obstetric care4. Private midwifery careThis decision aid will answer the following questions:» What is maternity care?» What is a model of care?» Who can provide my maternity care?» What are my options for maternity care?» Will I always be able to choose?» How might I choose my model of care?» What are the differences between midwifery modelsof care and other models of care?» What are the differences between birth centre modelsof care and other models of care?» What are the differences between public models of careand private obstetric care?This decision aid is not meant to give you medical advice or recommend a course oftreatment and you should not rely on it to provide you with a recommended course oftreatment. It is not intended and should not be used to replace the advice or care providedby your midwife, your doctor and/or your obstetrician. You should consult and discussyour treatment options with your midwife, your doctor and/or your obstetrician beforemaking any treatment decisions.» What are the differences between private midwifery carefor a planned homebirth and hospital models of care forbirths in hospital?» What are my options in each model of care?» How can I make the decision that’s best for me?» How can I ask questions to get more information?8

What ismaternitycare?What isa modelof care?Maternity care is the process of regularly checking on the wellbeingof you and your baby and providing care and support. Maternitycare can be provided to you from the time you find out youare pregnant until your baby is around six-weeks-old. Prenatalor antenatal care is care you may receive during pregnancy.Intrapartum care is the care you may receive during labour andbirth. Postnatal care is the care you may receive after birth.The words model of care or model of maternity care mean the wayyour care is organised, who is providing your care and how they areproviding it.Photo courtesy of Little Posers Photography9

Who canprovide mymaternity care?A midwifeA midwife is a person who has been educated to care for womenduring pregnancy, labour and birth and the post birth period.Midwives are registered to provide care to a woman and her babyin a normal pregnancy. Midwives are also registered to provide carefor women with more complicated pregnancies by working togetherwith doctors and other health care providers. Midwives can work inprivate practice (self employed) and can work in public and privatehospitals. Midwives work in all areas in Queensland including ruraland remote areas.An obstetricianAn obstetrician is a medical doctor who has been educated inobstetric care, including surgery like caesarean sections, after theyfinish a medical degree. Obstetricians are specialists in caring forwomen with complicated pregnancies or special circumstances.Obstetricians can work in private practice and can work in publicand private hospitals. Most obstetricians are located in largeregional centres or cities.A general practitionerSome general practitioners (or GPs) have completed additionalqualifications in obstetrics or maternity care, while others have not.GPs who haven’t completed additional qualifications in obstetricsor maternity care are still able to care for women during pregnancyand after birth. Most GPs don’t provide birth care, except in somerural areas where they may work in rural hospitals. A GP whoprovides birth care is usually called a GP obstetrician.What is a doula?A doula is a trained birth support person who provides emotionalsupport to women during their pregnancy, labour and birth. A douladoes not provide maternity care. In all models of care you maybe able to have a doula support you in your pregnancy, birth andpostnatal period.What is a child health nurse?A child health nurse is a trained registered nurse who has additionalqualifications in infant and child health.A child health nurse is not usually involved in your pregnancy andbirth care. However sometimes in rural and remote areas childhealth nurses may also be qualified midwives. Child health nursesand midwives may work together to provide care after birth.Child health nurses provide postnatal advice and support in acommunity setting. Some child health nurses are also qualifiedlactation consultants.10

What are myoptions for mymaternity care?There are four options for how to be cared for during pregnancy:This decision aid is not designed to help you make decisions asto whether or not to choose a maternity care provider. The optionnot to have a care provider at all during pregnancy and/or birth isreferred to as a free birth.PubliccareOption 1SharedcareOption 2Midwiferymodels of carePrivatecareOption 3Privateobstetric careOption 4Privatemidwifery carePhoto courtesy of Deirdrie Cullen11

Will I alwaysbe ableto choose?How mightI choose mymodel of care?While you always have a choice in your care, there may be thingsto do with your situation and pregnancy that may impact onyour decision. Not all models of care are available in all areas.Some models of care do not cater for women who have certaincomplications in their pregnancy.In some situations, your care provider might suggest oneoption instead of the other. If this happens, you can ask yourcare provider about the reasons for their suggestion and makedecisions as a team. You can choose to follow their suggestion orchoose to say no. Some care providers choose not to offer, or arenot comfortable offering, all options to women. If you are not ableto be offered all options, or the options you prefer, you can ask tohave another care provider.Women are more likely to feel positively about their birth experienceif they felt supported from their care providers, had a strongrelationship with their care providers and felt involved in thedecisions about their care during pregnancy and birth [4] . Youmight like to consider this when choosing your model of care.A number of studies have looked at what happens when womenhave different models of care. We have included some of the resultsof these studies in the next few pages.Will the results of these studies apply to me?Most of the studies we’ve included are studies of women who weredescribed as low or moderate risk (eg women who did not haveserious health issues prior to pregnancy). However, every woman’spregnancy is different, so the possible outcomes of each optionmight be different for you. You might like to talk to the care providersyou are thinking of selecting who can give you extra information thatis suited to your unique pregnancy.Photo courtesy of Little Posers Photography12

Public careOption 1What happens if Ichoose shared care?What is shared care?In shared care, your care during pregnancy is shared between yourGP and the hospital midwives and doctors. Labour, birth and afterbirth care is usually provided by the hospital midwives and nurses. Ifyou need extra medical support, the hospital doctors may becomeinvolved in your care.How do I access this care?GP shared care: To access GP shared care, you will need to find aGP who does maternity shared care and get a referral to the nearestpublic hospital. Not all GPs offer maternity shared care, so you mightwant to check with your GP about whether they offer shared care.You or your GP contact the hospital and organise a booking visit. Abooking visit is the first pregnancy check-up at your planned placeof birth. Usually the booking visit is between 12 and 18 weeks ofpregnancy depending on your preferences and the availability ofappointments at your hospital.Public hospital midwife shared care: To access midwifery sharedcare you will need to find a public hospital that has a midwives’clinic. You might like to ask for midwifery shared care at yourbooking visit.Who are my care providers?In shared care you will usually see your GP or a midwife for mostof your pregnancy check-ups and you will see the hospital doctorsand antenatal clinic midwives for the booking visit and for checkupslater in your pregnancy. You will usually go to the hospital whenyou are in labour and will usually be cared for by midwives anddoctors who work in the birth suite (birthing rooms) and are on dutyat the time. These midwives and doctors may be caring for multiplewomen at the same time. After your baby is born, the midwives,nurses and doctors who work on the postnatal ward (rooms forwomen after birth) will usually work together to look after you andyour baby while you are in hospital.What if I have complications?If you have, or develop, pregnancy complications, your GP or thehospital clinic may organise for a hospital obstetrician to see you forsome or all of your pregnancy check-ups.If your baby needs extra medical care after birth, he or she willusually be cared for by the hospital paediatricians andneonatologists (doctors who are child and baby specialists). Yourbaby may go to a Special Care Nursery or a Neonatal IntensiveCare Unit (NICU) in the hospital, which is for babies who need ahigh level of special medical care.How will I be cared for after birth?Immediately after the birth of your baby, you and your baby will becared for in the hospital by the hospital midwives, nurses anddoctors. Once you leave the hospital, you can visit your GP orother health care providers for ongoing health care. Your hospitalmay also offer postnatal midwifery services, where a midwifecan visit you at home or where you can come to the hospital oranother location to see a midwife. In-home services are availablein some places, but not in others. In rural areas there is usuallyless opportunity for women to have care at home after their babyis born. Your care provider will refer you to child health nursingservices for ongoing assistance. Some hospitals have an earlydischarge program where you can be discharged (leave hospital)a few hours after birth. This option may include hospital midwivesvisiting you at home.What is the cost of this care?Shared care is usually free of charge however, there may be someadditional costs like parking or transport. Visits to your GP maynot be free of charge. Whether you have to pay for visits to yourGP depends on whether or not your GP bulk bills. Ultrasoundscans and blood tests in the hospital will usually be free of charge.However, if you have these privately, they may not be free of charge.13

Public care Continued...Option 2What happens if I choosemidwifery models of care?What are midwifery models of care?Midwifery models of care refer to models of care where a midwifeis the main person providing your care. Usually in these models,the same midwife or group of midwives provides your care.Midwifery models of care can have different names which aredescribed below.How do I access this care?Midwifery models of care are available in some public hospitals.To access a hospital based midwifery model of care you willusually need to be referred to the hospital by your GP. You mightlike to phone your local hospital to see if a hospital midwiferymodel is available. Contact details for maternity hospitals inQueensland can be found at www.havingababy.org.au. Midwiferymodels of care are quite popular in Queensland, so sometimes itmight take a while before you find out if you have a place. If youare able to get a place, a midwife will contact you and let youknow what happens next. Midwifery models of care usually startat around 12–16 weeks of pregnancy. However, some midwiferymodels don’t start until around 20 weeks of pregnancy.Who are my care providers?There are different types of midwifery models of care—MidwiferyGroup Practice (MGP or Caseload midwifery), team midwiferycare and birth centre care.Midwifery Group Practice (MGP or Caseload midwifery)If you choose to be cared for by a midwife who works in aMidwifery Group Practice model, you will be cared for by onemidwife throughout your pregnancy, labour and birth andsometimes after birth. This is known as continuity of care.On your midwife’s days off, one or more back-up midwives willbe available. This may include when you are in labour. You willnormally meet the back-up midwives at some stage during yourpregnancy. Your postnatal care is provided by your midwife.Team midwifery careTeam midwifery care is similar to Midwifery Group Practice.However, instead of having one midwife caring for you, youhave a team of up to eight midwives who care for you duringpregnancy, labour, birth and after birth.Birth centre careBirth centre care is when you are cared for by one midwife ora team of midwives and birth in a birth centre. Therefore, duringyour pregnancy, labour and birth you can either have a teammidwifery or midwifery group practice model of care. In Queensland,birth centres are attached to a public hospital and set up to be likea home environment.In all midwifery models of care you have your appointments inpregnancy with midwives. When you are in labour you can phoneyour midwife (or back-up midwife) and they can go with you to thehospital to care for you in labour. You might like to look for hospitalswith birth centres at www.havingababy.org.au/birthplaceWhat if I have complications?If you have or develop pregnancy complications at any time duringyour care, your midwife will work together with the hospital doctorsor your GP.Your midwife may be able to continue to provide your midwiferycare working in partnership with a hospital obstetrician. Sometimes,women who have pregnancy complications aren’t able to access amidwifery model of care.If your baby needs extra medical care after birth, he or she will becared for by the hospital paediatricians or neonatologists and may14

go to a special care nursery or Neonatal Intensive Care Unit (NICU)(a unit in the hospital for babies who need a high level of medicalcare).How will I be cared for after birth?In most midwifery models of care the length of stay after birth isshorter than in other models (as early as 6 hours and usually withinthe first 24 hours). After you have gone home from the hospital, yourmidwife will be available to you 24 hours-a-day by phone. A midwifewill usually visit you once a day in the first week to provide care andsupport. You will usually be able to receive care from your midwifein this model up until six weeks after your birth when you will bereferred to child health nurses and your GP.What is the cost of this care?Midwifery models of care are usually free of charge although theremay be costs such as parking or transport. Visits to your GP may befree of charge. However it depends on whether or not your GP bulkbills. Ultrasound scans and blood tests in the hospital will usually befree of charge, however if you have these privately, they may not befree of charge.Photo courtesy of Little Posers Photography15

What are the differences between midwiferymodels of care and other models of care?Studies have found thereis a difference betweenmidwifery models of careand other models of carein:The chance of havingan episiotomy (a cut made toincrease the size of the opening of thevagina) [7]Women who had midwiferymodels of care...21 out of every 100 womenhad an episiotomyWomen who had othermodels of care...25 out of every 100 womenhad an episiotomyWomen who hadan episiotomyWomen who did nothave an episiotomyThe chance of going tohospital during pregnancy[3]24 out of every 100 womenwent to hospital duringpregnancy26 out of every 100 womenwent to hospital duringpregnancyWomen who went tohospital during pregnancyWomen who did not go tohospital during pregnancyThe chance of havinga vaginal birth withoutintervention [8]75 out of every 100 womenhad a vaginal birth withoutintervention71 out of every 100 womenhad a vaginal birth withoutinterventionWomen who had a vaginalbirth without interventionWomen who did not have avaginal birth without intervention16

Women who had midwiferymodels of care...Women who had othermodels of care...The chance of startingbreastfeeding [10]40 out of every 100 womenstarted breastfeeding30 out of every 100 womenstarted breastfeedingWomen who startedbreastfeedingWomen who did notstart breastfeedingThe chance of a babydying before 24 weekspregnancy [8]3 out of every 100 babies diedbefore 24 weeks pregnancy4 out of every 100 babies diedbefore 24 weeks pregnancyBabies who died before24 weeks pregnancyBabies who did not die24 weeks pregnancyThe chance of having anepidural or spinal block[3]19 out of every 100 womenhad an epidural or spinal block24 out of every 100 womenhad an epidural or spinal blockWomen who had anepidural or spinal blockWomen who did not havean epidural or spinal block17

What are the differences between midwiferymodels of care and other models of care? Continued...Studies have found thereis a difference betweenmidwifery models of careand other modelsof care in:Continued...The chance a woman willbe supported in labour bya midwife she knows [3]Women who had midwiferymodels of care...69 out of every 100 womenknew the midwife at her birthWomen who had othermodels of care...9 out of every 100 womenknew the midwife at her birthWomen who were supportedby a known midwife in labourWomen who weren’t supportedby a known midwife in labourThe chance of having aninstrumental birth (whereforceps (tongs) and/or a vacuum(suction) cap is used to help pullthe baby out of the vagina) [7]10 out of every 100 womenhad an instrumental birth12 out of every 100 womenhad an instrumental birthWomen who had aninstrumental birthWomen who did not havean instrumental birthThe chance of feeling incontrol during labour andbirth [3]42 out of every 100 womenfelt in control during theirlabour and birth24 out of every 100 womenfelt in control during theirlabour and birthWomen who felt in controlduring labour and birthWomen who did not feel incontrol during labour and birth18

Studies have foundno difference betweenmidwifery models ofcare and other modelsof care in:The chance of having antepartum haemorrhage (bleeding from your vagina during pregnancy) [3]The chance of a baby dying before, during and after pregnancy [8]The chance of having your labour augmented (using artificial oxytocins during labour) [8]The chance that a women will have her labour induced (trying to start labour artificially) [8]The chance of having analgesia/anaesthesia [8]The chance of having a caesarean section [8]The chance of having tears or cuts in or around your vagina [3]The chance of having a postpartum haemorrhage (losing more than 500ml of blood after birth) [8]The average length of time a woman stays in hospital after birth [8]The chance of having a baby with a low birth weight (less than 2500g) [8]The chance of having a baby born prematurely (before 37 weeks pregnancy) [8]The chance of the baby having a low APGAR score (A score to assess a baby’swell-being after birth, a score lower than 7 means that a baby might need help breathing) [3]The chance of the baby having convulsions (fits) [8]The chance of having postnatal depression [8]The average length of a woman’s labour [8]The chance that a women will have her membranes artificially ruptured (when your careprovider makes a small hole in the amniotic sac that holds your baby and the amniotic fluid around your baby) [4]The chance that the baby will be admitted to the special care nursery or NeonatalIntensive Care Unit (NICU) (a unit in the hospital for babies who need a high level of special medical care) [3]Studies are not clearabout whether there isany difference betweenmidwifery models ofcare and other modelsof care in:The average length of time a baby stays in hospital after birth [4]19

What are the differences between birth centre modelsof care and public hospital models of care? .Studies have found thereis a difference betweenbirth centre models ofcare and public hospitalmodels of care in:The chance that a woman’slabour will start by itself[9]Women who had birthcentre models of care...80 out of every 100 womenhad a labour that startedby itselfWomen who had publichospital models of care...64 out of every 100 womenhad a labour that startedby itselfWomen who had a labourthat started by itselfWomen who did not havea labour that started by itselfThe chance a baby willgo to the special carenursery [9]6 out of every 100 babieswent to the special carenursery10 out of every 100 babieswent to the special carenurseryBabies who went to thespecial care nurseryBabies who did not go tothe special care nurseryThe chance of having aninstrumental birth (whereforceps (tongs) and/or a vacuum(suction) cap is used to help pull thebaby out of the vagina) [9]8 out of every 100 womenhad an instrumental birth13 out of every 100 womenhad an instrumental birthWomen who hadan instrumental birthWomen who did not havean instrumental birth20

Studies have found there isa difference between birthcentre models of care andpublic hospital models ofcare in:Continued...The chance of having anepidural [9]Women who had birth centremodels of care...16 out of every 100women had an epiduralWomen who had publichospital models of care...32 out of every 100women had an epiduralWomen whohad an epiduralWomen who did nothave an epiduralStudies have found nodifference between thebirth centre models ofcare and public hospitalmodels of care in:The chance that a woman will not have any tears or cuts in or around the vagina [9]The chance that a woman will die as a result of her pregnancy or birth [9]The chance that a baby will die during pregnancy or soon after birth [9]21

Private careOption 3What happens if I chooseprivate obstetric care?What is private obstetric care?Women can choose to be cared for by a private obstetrician andbirth in a hospital at which the obstetrician practices. This is usuallya private hospital but may be a public hospital. This model of caremay not be available in all parts of Queensland as it relies on havinga private obstetrician available. In this model, your doctor will beemployed by you and not by a hospital. You can choose who thisdoctor will be.How do I access this care?If you choose to be cared for by a private obstetrician you will needa referral to an obstetrician from your GP. You might like to ask yourfriends, family or your GP about the obstetricians in your local area.Your maternity care will start from the time when you get your firstappointment with your obstetrician, which is usually between 9 and12 weeks of pregnancy.What happens if I have complications?If a complication arises during your pregnancy, labour or birth, yourobstetrician will continue to provide your maternity care.What is the cost of this care?Private obstetricians usually bill you through Medicare for your careduring pregnancy. For your care during birth, you will usually bebilled through private health insurance if you have it. There is usuallya gap in these payments, even if you have private health insurance,which can be between $1000 and $10,000, depending on yourprivate health insurance and your private obstetricians individualfees. You might like to ask your obstetrician about the costs involvedwith your care at the beginning of your pregnancy.Who are my care providers?During your pregnancy you will see your private obstetrician, whomay work in a group with other obstetricians. Your obstetrician andhospital midwives will care for you during labour and birth. If yourobstetrician is not available when you are having your baby, a backupobstetrician will be available at the hospital. You may or may nothave a chance to meet the back-up obstetrician. You might liketo ask your obstetrician if you can meet your back-up obstetricianbefore your birth.How am I cared for after birth?After your baby is born you will be looked after by hospital midwives.You will usually see your obstetrician at six weeks after your birth fora check-up.22

What are the differences between publicmodels of care and private obstetric care?Studies have found thereis a difference betweenpublic models of care andprivate obstetric care in:Women in publicmodels of care...Women in privateobstetric care...The chance that a womanwill have an induction oflabour [10]38 out of every 100 womenhad an induction of labour45 out of every 100 womenhad an induction of labourWomen who had aninduction of labourWomen who did not havean induction of labourThe chance that a womanwill have an epidural [10]10 out of every 100women had an epidural21 out of every 100women had an epiduralWomen whohad an epiduralWomen who didnot have an epiduralThe chance that a womanwill have an episiotomy[11]17 out of every 100 womenhad an episiotomy33 out of every 100women had an episiotomyWomen who hadan episiotomyWomen who did nothave an episiotomy23

What are the differences between privatemidwifery care for a planned homebirth andhospital models of care for births in hospital?Studies have found thereis a difference betweenprivate midwifery care fora planned homebirth andhospital models of care forbirths in hospital in:Women’s perceptions of painduring labour and birth [12]Women who had privatemidwifery care for a plannedhomebirth...Women rated their experienceof pain as 6 out of 10Women who had hospitalmodels of care for births inhospital...Women rated their experienceof pain as 7 out of 10The chance a woman willhave drugs for pain relief [12]8 out of every 100 womenhad drugs for pain relief22 out of every 100 womenhad drugs for pain reliefWomen who haddrugs for pain reliefWomen who did nothave drugs for pain reliefThe chance that a woman willhave an episiotomy [13]2 out of every 100 womenhad an episiotomy33 out of every 100 womenhad an episiotomyWomen who hadan episiotomyWomen who did nothave an episiotomyStudies have found nodifference between privatemidwifery care for aplanned homebirth andhospital models of carefor births in hospital in:The chance that a woman will die as a result of her pregnancy or birth [13]The chance that a baby will die during or soon after birth [13]25

What are my options ineach model of care?Option 1:Publicshared careOption 2:Publicmidwifery modelsAvailability of water immersion in labourAvailability of water immersion in birthAvailability of an epiduralOther drugs for pain reliefFreedom to eat & drink during labourWear own clothes during labour & birthFlexibility in the number of support people allowedSiblings allowed to attend birthFreedom to move around during labourChoice of birth positionElective caesarean birth (not medically indicated)26

Option 3:Privateobstetric careOption 4:Privatemidwifery modelsKeyAlwaysUsuallyNot usually, discuss with your care providerFew locationsNot all locationsProbably not in a birth centreNot in all circumstancesOnly if pre-arrangedDiscuss with your care providerDrugs such as Panadol ® and Panadeine ®27

How can I makethe decision that’sbest for me?Reasons I might chooseshared care...Reasons I might choosepublic midwifery models of care...At the moment, I am leaning towards…Not having shared careI’m unsureHaving shared careNot having public midwifery models of careI’m unsureHaving public midwifery models of care28

Reasons I might chooseprivate obstetric care...Reasons I might chooseprivate midwifery care...Not having private obstetric careI’m unsureHaving private obstetric careNot having private midwifery careI’m unsureHaving private midwifery care29

How can I askquestions to getmore information?Asking your care provider questions can help you get the information you want and need. Below are some questions you might wantto ask your care provider to get more information early in your pregnancy:Where do you usually provide care to women during pregnancy? During birth?Do you provide care at a particular hospital for birth?Do you provide birth care anywhere other than hospital, eg birth centre or home?Do you usually offer care after birth?How often do you usually provide care after birth?How long after the birth of my baby do you provide care?What happens if my baby and I need more care after this time?Will someone be available to provide me with in-home after birth care?Would you do (insert anything you would like to ask, eg induction of labour for prolonged pregnancy) if I asked for one?How would you feel if I refused any aspect of care that you suggest?Do you support (insert anything you would like to ask, eg vaginal birth after caesarean)?What is the chance that I will have you caring for me in labour?30

Myquestionsand notes31

Where hasthis informationcome from?The information in this decision aid has come from the best scientific studies available to us. A list of these studies is included below:[3] Hodnett, E.D., Pain and women's satisfaction with the experience of childbirth: A systematic review. American Journal of Obstetrics andGynecology, 2002. 186(5, Supplement 1): p. S160-S172.[4] Hatem, M., et al., Midwife-led versus other models of care for childbearing women. Cochrane Database Syst Rev, 2008(4): p. CD004667.[7] Harvey, S., et al., Evaluation of satisfaction with midwifery care. Midwifery, 2002. 18(4): p. 260-267.[8] Biro, M.A., U. Waldenstrom, and J.H. Pannifex, Team midwifery care in a tertiary level obstetric service: a randomized controlled trial. Birth,2000. 27(3): p. 168-73.[9] Homer, C.S.E., et al., Collaboration in maternity care: a randomised controlled trial comparing community-based continuity of care withstandard hospital care. BJOG: An International Journal of Obstetrics & Gynaecology, 2001. 108(1): p. 16-22.[10] Ryan, M. and C. Roberts, A retrospective cohort study comparing the clinical outcomes of a birth centre and labour ward in the same hospital.Australian Midwifery, 2005. 18(2): p. 17-21.[11] Shorten, A. and B. Shorten, What happens when a private hospital comes to town? The impact of the 'public' to 'private' hospital shift onregional birthing outcomes. Women Birth, 2007. 20(2): p. 49-55.[12] Roberts, C.L., S. Tracy, and B. Peat, Rates for obstetric intervention among private and public patients in Australia: population baseddescriptive study. BMJ, 2000. 321(7254): p. 137-41.[13] Borquez, H.A. and T.A. Wiegers, A comparison of labour and birth experiences of women delivering in a birthing centre and at home in theNetherlands. Midwifery, 2006. 22(4): p. 339-347.[16] AIHW, 2009.32

Your scansand testsChoices about firsttrimester ultrasoundscans: A decision aidfor pregnant women33

The research and development of this decision aid was conducted by Natasha Hayes,a health researcher, and Rachel Thompson, a health psychology researcher, at theQueensland Centre for Mothers & Babies.What is this decision aid about?This decision aid has been written to support pregnant women toknow what to expect and to have a say in making decisions aboutfirst trimester ultrasound scans. An ultrasound scan is when a smallhandheld device is used to create a picture of a woman’s uterus(womb) and baby during pregnancy. A first trimester ultrasound scanis an ultrasound scan done in a woman’s first trimester of pregnancy(the first 14 weeks of a woman’s pregnancy).This decision aid provides information about two options:1. Not having a first trimester ultrasound scan2. Having first trimester ultrasound scanThis decision aid will answer the following questions:» What is an ultrasound scan?» Why might a first trimester ultrasound scan be offered?» What are my options?» Will I always be able to choose?» How might I choose between not having and havinga first trimester ultrasound scan?» What are the differences between not having andhaving a first trimester ultrasound scan?» How can I make the decision that’s best for me?» How can I ask questions to get more information?This decision aid is not meant to give you medical advice or recommend a course oftreatment and you should not rely on it to provide you with a recommended course oftreatment. It is not intended and should not be used to replace the advice or care providedby your midwife, your doctor and/or your obstetrician. You should consult and discussyour treatment options with your midwife, your doctor and/or your obstetrician beforemaking any treatment decisions.Women may also be offered an ultrasound scan at other timesin pregnancy. This decision aid provides information only aboutultrasound scans in the first trimester of pregnancy. You might like toask your care provider about ultrasound scans at other times.34

What is anultrasoundscan?Why might a firsttrimester ultrasoundscan be offered?An ultrasound scan is when a midwife, a doctor or a sonographer(a person trained to do ultrasound scans) uses a transducer (asmall handheld device) to create a picture of a woman’s uterusand baby during pregnancy.The transducer is usually moved across the woman’s abdomen(stomach) and sends out soundwaves to create the picture of theuterus and baby on a computer screen. This type of ultrasoundscan is also called a transabdominal ultrasound scan.Another type of ultrasound scan is a transvaginal ultrasound scan.A transvaginal ultrasound scan is when a midwife, a doctor or asonographer inserts a long and narrow transducer into a woman’svagina to do the ultrasound scan. This type of ultrasound scanallows your care provider to get closer to the uterus and may beused to get a clearer picture of the uterus and baby.Ultrasound scans can be 2-D (two-dimensional), 3-D (threedimensional),or 4-D (four-dimensional). A 2-D ultrasound scangives a still black and white picture showing the outline of thebaby in the woman’s uterus. A 3-D ultrasound scan gives a stillbrown picture showing the baby in the woman’s uterus in threedimensions. A 4-D ultrasound scan gives a moving brown pictureshowing the baby in the woman’s uterus in three dimensions.A first trimester ultrasound scan creates a picture of the pregnantwoman’s uterus and baby that can give the woman and her careprovider information about her pregnancy.First trimester ultrasound scans don’t always provide informationthat is accurate. The accuracy of the information from the ultrasoundscan depends on different things including the timing of the scan, theposition of the baby, the skill of the person who does the ultrasoundscan, and the skill of the person who looks at the pictures from theultrasound scan and prepares the report on the results [1,2].The most common types of information that can be found out from afirst trimester ultrasound scan are explained below. Different womenlike to know different things about their pregnancies and somewomen prefer to not know any of these things. For each type ofinformation given, we have included space for you to tick whetherthe information is important to you. Ticking these boxes might helpyou to make decisions about whether to not have, or have a firsttrimester ultrasound scan. If you choose to have a first trimesterultrasound scan ticking these boxes might also help you to makedecisions about what information to find out from the ultrasound scan.Ultrasound scans can be done at different times in pregnancy—during the first trimester (up to 14 weeks of pregnancy), duringthe second trimester (from 14 weeks to 26 weeks of pregnancy),or during the third trimester of pregnancy (from 26 weeks ofpregnancy onwards). This decision aid is about ultrasounds doneduring the first trimester.35

Why might a firsttrimester ultrasoundscan be offered? Continued...1. To see whether a woman’s pregnancy is viableA first trimester ultrasound scan can be a way of confirming awoman’s pregnancy and finding out in some circumstances whether itis viable (will continue). For example, a first trimester ultrasound scancan be used to check whether the woman has an ectopic pregnancy.An ectopic pregnancy is when a fertilised egg implants and growsoutside of the uterus rather than inside the uterus. In most cases, anectopic pregnancy is not viable.A first trimester ultrasound scan cannot always confirm whether awoman’s pregnancy is viable. You might like to ask your care providermore about the accuracy of first trimester scans and other methodsfor finding out whether a woman’s pregnancy is viable.You might also like to ask your care provider for more informationabout your options if you have a first trimester ultrasound scan andfind out that your pregnancy is not viable. These options caninclude counselling to give you support and help you make decisionsabout your options.Important to you? Yes No Unsure2. To see how many weeks pregnant a woman isA first trimester ultrasound scan can be a way of estimating howmany weeks pregnant a woman is, that is, how long she has beenpregnant. Care providers estimate how many weeks pregnant awoman is by looking at the size and development of the baby. Forexample, care providers can look at the baby’s crown-rump length.The crown-rump length is a measure of the distance in centimetresfrom the baby’s crown (the top of the head) to the baby’s rump(the bottom of the buttocks).The estimate of how long a woman has been pregnant is used towork out her baby’s estimated due date (EDD). The estimated duedate is the date when it is thought that a woman will be 40 weekspregnant. However, it is very common for babies to be born beforeor after the estimated due date. A baby born when a woman isanywhere between 37 and 42 weeks pregnant is said to be full term [3].The estimate of how long a woman has been pregnant is alsoused to work out when best to schedule any other tests or scansa woman chooses to have during pregnancy. Some tests and scansoffered to women can only be done at specific times in pregnancy [1].The estimate of how long a woman has been pregnant is alsoused later to work out whether she has a prolonged pregnancy. Aprolonged pregnancy is a pregnancy when the woman has not hadher baby by the time she is 42 weeks pregnant. Women with aprolonged pregnancy often have different considerations and decisionsthan women who have their baby before 42 weeks. A more accurateestimate of how many weeks pregnant a woman is results in a moreaccurate estimate of whether or not she has a prolonged pregnancy.More information for women who have a prolonged pregnancy isprovided in ‘Choosing how your labour will start: A decision aid forwomen with a prolonged pregnancy’.You can also find out how many weeks pregnant you are by countingforward the number of weeks since the first day of your last menstrualperiod (LMP) or by having an ultrasound scan later in pregnancy.You might like to ask your care provider about the accuracy of thesedifferent ways of finding out how many weeks pregnant you are.More information about the whether there are differences betweenwomen who don’t have, and women who have, a first trimesterultrasound scan (eg the chance of having other pregnancy tests andscans at the right time, the chance of being told you have a prolongedpregnancy, the timing of the baby’s birth) is provided on pages 42–44.Important to you? Yes No Unsure36

3. To see what position a woman’s placenta is inWhile it is not usually offered for this reason, a first trimesterultrasound scan can be a way of finding out the position of awoman’s placenta. The placenta is an organ that connects tothe wall of the uterus and is also connected to the baby by theumbilical cord.For some women, the placenta is down low in the uterus and isnear to or covering the cervix. When a woman has a placentathat is near to or covering the cervix, she is said to have placentapraevia. When a woman has placenta praevia, the placenta canblock the baby coming out of the vagina during birth. Womenwith placenta praevia often have different considerations anddecisions than women who do not. If a care provider knows thata woman has placenta praevia, he or she can give the womaninformation and care more suited to her unique pregnancy.Frequently, a placenta that is down low in the uterus in thefirst trimester can change positions and move away from thecervix as the uterus grows during pregnancy. If a first trimesterultrasound scan shows that your placenta is low in the uterus,near to or covering your cervix, you may be offered anotherultrasound scan later in pregnancy to see if your placenta haschanged positions [4].4. To see whether a woman has a multiple pregnancyA first trimester ultrasound scan can be a way of finding out if awoman has a multiple pregnancy. A multiple pregnancy is whena woman is carrying twins, triplets or more babies. Women with amultiple pregnancy often have different considerations and decisionsthan women who are carrying one baby. If a care provider knowsthat a woman has a multiple pregnancy, he or she can give thewoman information and care more suited to her unique pregnancy.You may be able to find out whether you have a multiple pregnancyin other ways. For example, if your care provider listens to yourbaby’s heart beat during pregnancy, more than one heart beat maybe able to be heard. You might like to ask your care provider aboutthe accuracy of a first trimester ultrasound scan and other ways offinding out whether a woman has a multiple pregnancy.Important to you? Yes No UnsureYou can find out what position your placenta is in by having anultrasound scan later in pregnancy. You might like to ask yourcare provider about the accuracy of ultrasound scans done atdifferent times during pregnancy. You might also like to askyour care provider about your options if you find out that youhave placenta praevia.Important to you? Yes No UnsurePhoto courtesy of Little Posers Photography37

Whatare myoptions?When thinking about first trimester ultrasound scans, thereare two options:Option 1Not having a first trimesterultrasound scanOption 2Having a first trimesterultrasound scan39

What happens if I choose not to have aOption 1 first trimester ultrasound scan? Option 2What happens if I choose to havea first trimester ultrasound scan?If you choose not to have a first trimester ultrasound scan, you willprogress through your first trimester without having an ultrasoundscan. You can still choose to have an ultrasound scan later inpregnancy.If you choose not to have a first trimester ultrasound but areinterested in some of the information described previously (eg howmany weeks pregnant you are), you might like to ask your careprovider how else you might find out this information.If you choose to have a first trimester ultrasound scan, theultrasound scan might be done at the place where you arereceiving your pregnancy care (eg at a clinic or hospital) or mightbe done somewhere else (eg at a special ultrasound clinic). Youcan usually bring a support person or people with you to a firsttrimester ultrasound scan.If you are having a transabdominal ultrasound scan, your careprovider might ask you to drink a large amount of water and/orfast (not eat) for several hours before the time of your scan. Thisis so you have a full bladder and/or no food in your stomachduring your ultrasound scan.During the ultrasound scan, your care provider puts a smallamount of gel on your abdomen and moves the transduceracross the gel on your skin. A picture of your uterus and yourbaby then appears on the computer screen. Some women liketo ask to look at the screen to see the picture while they arehaving the ultrasound scan. It is sometimes possible for theultrasound picture to be printed out as a photo for you to keep,but not all places offer this.If you are having a transvaginal ultrasound scan, your careprovider will not usually ask you to drink a large amount of waterbefore your scan. During the scan, your care provider will askyou to remove your underwear and will cover you with a sheet.Your care provider will then cover the long, narrow transducerin plastic (like a condom) and insert it in your vagina. A pictureof your uterus and your baby will then appear on the computerscreen.When you have a first trimester ultrasound scan, the results areusually ready straight away. Sometimes, the pictures of youruterus and your baby are examined by a radiologist (a specialistdoctor) after the ultrasound scan. The radiologist then interpretsthe ultrasound pictures and prepares the results report for youand your care provider.There may be a cost involved in having a first trimesterultrasound scan. You might like to ask your care providerfor more information about whether there is a cost for a firsttrimester ultrasound scan, how long the scan will take, how youcan prepare for your ultrasound scan and what to expect.40

Will I alwaysbe ableto choose?How might I choosebetween not having &having a first trimesterultrasound scan?During your pregnancy, your care provider might suggest that youhave a first trimester ultrasound scan. If this happens, you can askyour care provider about the reasons for their suggestion and makedecisions as a team. You can choose to follow their suggestion oryou can choose to say no.You will usually be able to choose to have a first trimester ultrasoundscan.You can also choose what you would like to find out from theultrasound. For example, you can choose to find out some things,and choose not to find out other things. It may not be possible foryour care provider not to find out something during an ultrasoundscan (eg whether you have a multiple pregnancy). However, youmight be able to ask them not to tell you, if you would prefer not toknow. You might like to talk to your care provider in advance if thereare some things you would prefer not to know.Some care providers choose not to offer or are not comfortableoffering all options to women. If you are not able to be offered alloptions or the option you prefer, you can ask to have another careprovider.When choosing between not having and having a first trimesterultrasound scan, you might like to consider how important it is toyou to know the things that can be found out from the scan, asdescribed on pages 36–38. You might also like to consider howyou may feel if you find out certain things from the first trimesterultrasound scans (eg if you find out that your baby is not developingin the usual way).A number of studies have also looked at what happens whenwomen don’t have a first trimester ultrasound scan compared towhen women do have a first trimester ultrasound scan regardlessof whether they have an ultrasound scan later in pregnancy. Wehave included some of the results of these studies in the next fewpages. Only high quality studies have been included in this decisionaid. More information about the quality of studies is provided on theback flap of this book.Will the results of these studies apply to me?The studies we’ve included are studies of women who weredescribed as low risk (eg women who were not thought to haveany complications with their pregnancy). However, every woman’spregnancy is different, so the possible outcomes of each optionmight be different for you. You might like to talk to your care providerwho can give you extra information that is suited to your uniquepregnancy.41

What are the differences between not havingand having a first trimester ultrasound scan?Studies have found thereis a difference betweennot having a first trimesterultrasound scan andhaving a first trimesterultrasound scan in:The chance of feeling worriedabout the pregnancy [1]Women who don’t have a 1 sttrimester ultrasound scan40 out of every 100 womenwere worried about theirpregnancyWomen who have a 1 sttrimester ultrasound scan32 out of every 100 womenwere worried about theirpregnancyWomen who were worriedabout their pregnancyWomen who were not worriedabout their pregnancyThe chance of being told youhave a prolonged pregnancy[6]16 out of every 100 womenwere told they had aprolonged pregnancy7 out of every 100 womenwere told they had aprolonged pregnancyWomen who were told theyhad a prolonged pregnancyWomen who were not told theyhad a prolonged pregnancy42

Studies have found nodifference between nothaving a first trimesterultrasound scan andhaving a first trimesterultrasound scan in:The chance of feeling excited about one’s pregnancy [7]The chance of having other pregnancy tests and scans at the right time [1]The chance of the baby dying before, during or soon after birth [1]How many weeks pregnant a woman is at birth [7]The chance of having an induction of labour (when labour is started off artificially) [1,7]The chance of having a caesarean section [1,6,7]The chance of having a caesarean section before labour starts [7,8]The chance of having an instrumental birth (where forceps (tongs) and/or a vacuum (suction)cap is used to help pull the baby out of the vagina) [7,8]The chance of the baby having a low birthweight (weighing less than 2500g) [1]The baby’s birthweight [7]The chance of the baby having a low APGAR score (a score to assess a baby’s well-being afterbirth, a score lower than 7 means that a baby might need help breathing) five minutes after birth [1]The chance of the baby going into to the Special Care Nursery (a unit in the hospitalfor babies who need special medical care) [7]The chance of the baby going into to the Neonatal Intensive Care Unit (NICU) (a unitin the hospital for babies who need a high level of special medical care) for three days or more [9]43

What are the differences between not having andhaving a first trimester ultrasound scan? ContinuedStudies are not clearabout whether there is adifference between nothaving a first trimesterultrasound scan andhaving a first trimesterultrasound scan in:The chance of having an induction of labour because of a prolonged pregnancy [6,8,9]Studies haven’t lookedat whether there is adifference between nothaving a first trimesterultrasound scan andhaving a first trimesterultrasound scan in:The chance of finding out that a woman has a non-viable pregnancy before she has symptomsThe chance of finding out that a woman has an ectopic pregnancy before she has symptomsThe chance of finding out that a woman has a multiple pregnancy before birthThe chance of finding out that a woman has placenta praevia before birthThe chance of finding out that a baby has an abnormality before birthThe chance of having a postpartum haemorrhage (losing more than 500ml of blood after birth)The chance of the baby having development problems or disabilities in childhoodThe chance of the baby having difficulties with vision during childhoodThe chance of the baby having difficulties with hearing during childhoodHow satisfied women are with their pregnancy care44

How can I makethe decision that’sbest for me?Reasons I might choose not to havea first trimester ultrasound scan...Reasons I might choose to havea first trimester ultrasound scan...At the moment, I am leaning towards…Not having a first trimesterultrasound scanI’munsureHaving a first trimesterultrasound scan45

How can I askquestions to getmore information?Asking your care provider questions can help you get the information you want and need. Below are some questions you might want to askyour care provider to get more information before you are offered a first trimester ultrasound scan.When would you normally offer a woman a first trimester ultrasound scan?Would you do a first trimester ultrasound scan if I asked for one?How would you feel if I declined a first trimester ultrasound scan if it was offered to me?Below are some questions you might ask your care provider to get more information if you are offered a first trimester ultrasound scan.How long do I have to think about this decision?What are the possible outcomes in my unique pregnancy if I choose not to have a first trimester ultrasound scan?What are the possible outcomes in my unique pregnancy if I choose to have a first trimester ultrasound scan?When, where and how would the first trimester ultrasound scan be done?What could I find out from this ultrasound scan?Could I choose to find some things out and not find other things out during this ultrasound scan?Is there a cost involved in having a first trimester ultrasound scan?Below are some questions you might like to ask if you choose to have a first trimester ultrasound scan.How can I prepare for my ultrasound scan?Can I bring support people with me to my ultrasound scan?Is it possible to have a print out or DVD of my ultrasound scan afterward?46

Myquestionsand notes47

Where hasthis informationcome from?The information in this decision aid has come from the best scientific studies available to us. A list of these studies is included below:[1] Whitworth, M., et al., Ultrasound for fetal assessment in early pregnancy. Cochrane Database of Systematic Reviews, 2010. 4: p.Art. No.: CD007058.[2] Efrat, Z., O.O. Akinfenwa, and K.H. Nicolaides, First-trimester determination of fetal gender by ultrasound. Ultrasound in Obstetricsand Gynecology, 1999. 13: p. 305-307.[3] National Collaborating Centre for Women's and Children's Health, Induction of labour. 2008.[4] National Collaborating Centre for Women's and Children's Health (NCCWCH), Antenatal care: Routine care for the healthypregnant woman. 2008, RCOG Press: London.[5] Nicolaides, K.H., M.L. Brizot, and R.J.M. Snijders, Fetal nuchal translucency: ultrasound screening for fetal trisomy in the firsttrimester of pregnancy. British Journal of Obstetrics & Gynaecology, 1994. 101(9): p. 782-786.[6] Bennett, K.A., et al., First trimester ultrasound screening is effective in reducing postterm labor induction rates: A ra ndomizedcontrolled trial. American Journal of Obstetrics and Gynaecology, 2004. 190: p. 1077-1081.[7] Crowther, C.A., et al., Is an ultrasound assessment of gestational age at the first antenatal visit of value? A randomised clinical trial.British Journal of Obstetrics & Gynaecology, 1999. 106(12): p. 1273-1279.[8] Harrington, D.J., et al., Does a first trimester dating scan using crown rump length measurement reduce the rate of induction oflabour for prolonged pregnancy? An uncompleted randomised controlled trial of 463 women. BJOG, 2006. 113: p. 171-176.[9] Ewigman, B., M. LeFevre, and J. Hesser, A randomized trial of routine prenatal ultrasound. Obstetrics and Gynaecology, 1990.76(2): p. 189-194.48

YourbirthingoptionsChoosing how tobirth your baby:A decision aidfor womenwithout a previouscaesarean sectionA decision aidfor womenwith a previouscaesarean section49

Your birthingoptionsChoosing how to birthyour baby: A decisionaid for womenwithout a previouscaesarean section50

The research and development of this decision aid was conducted by Aimée Dane, ahealth psychology researcher at the Queensland Centre for Mothers & Babies.What is this decision aid about?This decision aid has been written to support women to know whatto expect and have a say in making decisions about how to birth.This decision aid provides information about two options:1. Choose to have a vaginal birth2. Choose to have a planned caesarean sectionThis decision aid will answer the following questions:» What are my options for how to birth my baby?» Will I always be able to choose?» How might I choose between a vaginal birth anda planned caesarean section?» What are the differences between having a vaginalbirth and having a caesarean section?» How can I make the decision that’s best for me?» How can I ask more questions to get more information?This decision aid is not meant to give you medical advice or recommend a course oftreatment and you should not rely on it to provide you with a recommended course oftreatment. It is not intended and should not be used to replace the advice or care providedby your midwife, your doctor and/or your obstetrician. You should consult and discussyour treatment options with your midwife, your doctor and/or your obstetrician beforemaking any treatment decisions.51

What are myoptions for howto birth my baby?There are two options that you choose:Option 1Choose to have a vaginal birthOption 2Choose to have a plannedcaesarean sectionPhoto courtesy of Gemma-Rose Turnbull52

Option 1What happens if I choose tohave a vaginal birth?If you choose to have a vaginal birth you will usually wait foryour body to go into labour. Going into labour is brought on by anumber of changes in your body, including changes in your uterus(womb) and your cervix (the bottom part of your uterus at theinside end of your vagina). Towards the end of pregnancy, yourcervix changes from being long, closed and hard to being short,soft and thinned (also called effaced). Changes to the cervix arecalled cervical ripening. A ripe cervix means your body is ready forlabour. A cervix that is not ripe (and not ready for labour) is calledunripe. Your uterus also changes towards the end of pregnancy,becoming more active and starting to contract (tighten).If it looks like you might not go into labour by 42 weeks, you andyour care provider might talk about what your options are. Moreinformation about your choices in longer pregnancy is provided inthe ‘Choosing how your labour will start: A decision aid for womenwith a prolonged pregnancy’ chapter of this book.What can I expect in labour?Labour usually happens in three stages: first stage labour, secondstage labour and third stage labour.What is first stage labour?The progress of first stage labour is measured by how dilated(open) your cervix is in centimetres. First stage labour is from whenyour cervix starts to dilate to when it has fully dilated to 10cm. Thedilation (opening) of the cervix allows your baby to move from theuterus into the birth canal (the passage from the uterus to outsidethe vagina).First stage labour includes three phases: early, active and late.» Early phase of labour is from when the cervix startsto dilate to 4cm» Active phase of labour is from 4cm dilation to about8cm or 9cm. Women say that the pain of contractionsnormally becomes more painful from the active phaseof labour onwards» Late (or transitional) phase of labour is from about8cm or 9cm to 10cm dilationAugmentation is the process of artificially speeding up your labourafter it has already started. Augmentation may be offered towomen if it is thought that labour is not progressing. You may wantto discuss this with your care provider during pregnancy.During first stage labour, your uterus contracts to slowly open upyour cervix, preparing for the birth of your baby. Some women saythat these contractions feel like a tightening of the stomach. Thecontractions in the early part of first stage labour may be irregularand quite far apart. Women usually say that the contractionsin the early part of first stage labour are not as painful as thecontractions later in labour. As you get closer to second stagelabour your contractions will usually become more regular, longerlasting, stronger and close together [1]. You may feel stronger painthrough the contractions, however this will usually lessen betweencontractions. Women usually say that as they get closer tosecond stage labour, their contractions become more painful. Thelength of first stage labour is different for every woman. For somewomen, this stage can last less than an hour, for others it may lastup to a few days.53

Option 1What happens if I chooseto have a vaginal birth? Continued...What is second stage labour?Second stage labour is from the complete dilation of the cervix(10cm) to the birth of your baby. Your contractions during secondstage labour will push your baby from your uterus into your birthcanal. When your baby is in the birth canal you will usually feel theurge to push your baby out. At this stage, you might like to pushwhen you feel the urge to push (called spontaneous pushing) or yourcare provider can tell you when to push (called coached pushing).You might like to ask your care provider about the differencesbetween spontaneous and coached pushing. If you have had anepidural (a type of pain management where drugs are used to numbthe lower half of the body) you may not feel this urge to push.During second stage labour, your baby usually moves head first downthe birth canal and the top of his or her head can be seen at theopening of your vagina. When your baby’s head reaches the openingof your vagina you may feel a hot, stinging sensation as the openingof your vagina stretches. Some women reach down with their handand feel their baby’s head as it comes out of their vagina or hold amirror to see their baby’s head. After your baby’s head has come outof your vagina, his or her shoulders and body will usually follow withinthe next couple of contractions. Some women choose to catch theirbaby themselves. Other women ask their care provider to catch theirbaby when he or she is born. The length of second stage labour isdifferent for every woman. For some women this stage can last for afew minutes, for others it may last over an hour.Sometimes a woman can have a tear in the skin or muscles aroundher vagina, in her labia (the flaps around the vagina), or in herperineum. The perineum is the area between the vagina and theanus (back passage). If a tear happens, it usually happens at the timethat the baby’s head passes through the vagina. More informationabout the chance of tearing and things that can affect your chance oftearing is provided in ‘Choices about episiotomy: A decision aid forwomen having a vaginal birth’.What is third stage labour?Third stage labour is from the birth of your baby to the birth ofyour placenta. The placenta is an organ that connects to thewall of a pregnant woman’s uterus. The baby is connected tothe placenta by the umbilical cord. The umbilical cord allowsnutrients (eg vitamins and minerals) and oxygen from thewoman to be carried to her baby.The contractions that you experience through first and secondstage labour will continue, however women often say that theseare not usually as intense in third stage labour. Contractionsduring third stage labour allow your placenta to separate fromthe inside wall of your uterus and also control any excessivebleeding.The length of third stage labour is different for every woman.For some this stage can last for less than 30 minutes, for othersit can last over an hour [2]. More information about third stagelabour is provided in ‘Choosing how to birth your placenta: Adecision aid for women having a vaginal birth’.What can I expect after the birth of my baby andmy placenta?After the birth of your baby and your placenta you will be ableto rest and recover. You might also be offered something to eatand drink. Women who have had a vaginal birth in Queenslandusually stay in hospital for about two days, however this can bedifferent for every woman [3].Many women experience afterpains (pains from the uteruscontracting after birth). Afterpains can be quite painful andoften become more painful with breastfeeding. You might liketo ask your care provider about pain management options ifyou experience this.Many women choose to have skin-to-skin with their baby immediatelyafter birth. Skin-to-skin is having your baby against your chest,without any clothing in between. You might like to ask your careprovider about the differences between having and not having skinto-skinon the health of you and your baby. You might also like todiscuss your preferences for skin-to-skin with your care provider.54

What if there are complications?Sometimes women who choose a vaginal birth may havecomplications during labour and birth. For example, labourmay take longer than usual or the baby may becomedistressed. If there are complications during labour or birth,your care provider might offer you an instrumental birth (whereforceps (tongs) and/or a vacuum (suction) cap is used to helppull the baby out of the vagina) or an emergency caesareansection (when a woman has a caesarean section to birth herbaby but doesn’t arrange it in advance).Therefore, when making a decision about how to birth, youmay like to consider that, for some women, things don’t goto plan. You might also like to ask your care provider aboutcomplications that may occur during labour and birth.It might be helpful to know that in Queensland, for every100 women who planned a vaginal birth [4]:Vaginal birth (73)Instrumental birth (11)Emergency caesareansection (16)55

Option 2What happens if I choose to have aplanned caesarean section?A planned caesarean section (also called an elective caesareansection) is when a woman arranges in advance to birth her baby bycaesarean section. A caesarean section is when an incision (cut) ismade in a woman’s abdomen and uterus to take her baby out.Different women plan to have a caesarean section for differentreasons. Some women plan to have a caesarean section for medicalreasons, while other women plan to have a caesarean sectionbecause it is their preferred option.There are differences in health outcomes depending on the timingof a caesarean section. You might like to talk to your care providerabout the timing of your caesarean section as well as how the timingof your caesarean section might affect the health outcomes for youand your baby.What can I expect if I plan a caesarean section?When you arrive at hospital on the day of your caesarean section,you will be taken to theatre (the operating room) to meet the doctorsperforming your caesarean section. Sometimes women can bringtheir partner or support person into theatre. You might like to askyour care provider about whether your partner or support person canbe at your caesarean section.Once you’re in the operating theatre, you will usually be given anepidural or spinal block (drugs that numb the lower half of the body)to stop the feeling of pain from the abdomen down. If you are givenan epidural or spinal block, an anaesthetist will give you a needlein your back with a local anaesthetic to firstly numb the skin. Theanaesthetist will then insert a needle into your lower back. A catheter(thin tube) will then replace the needle so more of the drug can begiven easily without another injection. You may feel pressure andtugging in your abdomen during your caesarean section but youusually won’t feel pain.Some women are offered a general anaesthetic (a drug that putsthe entire body to sleep) for their caesarean section. A generalanaesthetic means that you won’t be awake during your caesareansection. If you are given a general anaesthetic, this will usually bethrough an intravenous (IV) drip (a bag of liquid that enters your bodythrough a tube inserted into your hand or arm). You may like to talk toyour care provider about anaesthetics for your caesarean section.Either before or after you are given an anaesthetic, your doctor or amidwife will put a catheter into your bladder so that your urine will bedrained out during your caesarean section.Before the incision in your abdomen is made, a curtain is usually putup so that you won’t see your surgery happening. Your doctor willthen make an incision in your abdomen through to your uterus, justabove your pubic hair line. Sometimes accidental cuts can occurto you or your baby during the caesarean section. For example,there can be an accidental cut to your bladder. About 3 out of every1000 women who have a caesarean section have an accidentalcut to their bladder [5] . There can also be an accidental cut yourbaby. Between 1 and 3 out of every 100 babies who are born bycaesarean section are accidentally cut [6–11] .The doctor will then put his or her hand into your uterus and lift outyour baby’s head. Your doctor pushes gently on the top of yourabdomen to push your baby out. Sometimes doctors may pull downthe curtain during this stage so that you can see your baby comingout of your abdomen. You may like to ask your care provider if youcan watch your baby coming out of your abdomen.Often, after your baby is born, he or she is quickly checked over bya midwife or doctor in a well lit area of the theatre. Some womenask that their baby is checked over, while having skin-to-skin withtheir baby on their chest. You might like to talk to your care providerabout your preferences for immediately after birth. If you have ageneral anaesthetic, your baby is sometimes kept in the nursery untilyou wake up or can sometimes be held by your partner or supportperson in the time before you wake up.After your baby is born, your doctor will take out your placentathrough the same incision in your abdomen. Information aboutyour options for taking out your placenta in a caesarean section isavailable on our website www.havingababy.org.auAt the end of your surgery, your doctor will stitch up the layers ofyour uterus and abdomen. The length of the surgery varies widely,however is usually between 30 to 60 minutes.56

What can I expect after my caesarean section?After your caesarean section you will be taken to your bed to restand recover. You might also be offered something to eat and drink.If you were given an epidural or spinal block for your surgery, itwill eventually wear off. You will usually be offered further painmanagement options when this happens. Some epidurals andspinal blocks wear off quite quickly, while others may last up to aday. If you were given a general anaesthetic, it will not provide anypain relief once you wake up. Therefore you will usually be offeredfurther pain management options when you wake up.You will usually be encouraged to get out of bed and walk aroundafter your birth or encouraged to wear tight pressure stockings toreduce your chance of having deep vein thrombosis (a blood clotthat forms in the legs or sometimes the pelvis or arms).Women who have had a caesarean section in Queensland usuallystay in hospital for about four days, however this can be different forevery woman [3].What happens if I go into labour before a planned caesareansection?Some women go into labour before the date of their caesareansection. If this occurs close to the date of your caesarean sectionyou can choose to have a caesarean section or choose to continuewith a vaginal birth. You might like to discuss the possibility of goinginto labour before the date of your caesarean section with your careprovider, as well as your choices if this situation occurs.57

Will I alwaysbe ableto choose?How might I choosebetween a vaginalbirth and plannedcaesarean section?It is always your choice about how you would like to birth, howeversome hospitals and care providers have guidelines about vaginalbirths and planned caesarean sections. For example, some publichospitals don’t offer a planned caesarean section unless there aremedical reasons.In some situations, your care provider might suggest one optioninstead of the other. If this happens, you can ask your care providerquestions about why and make decisions as a team. If one optionis suggested by your care provider, you can always choose to sayno. Some care providers choose not to offer, or are not comfortableoffering, all options to women. In this situation you might like to askto see another care provider.A number of studies have looked at what happens when womenhave a vaginal birth compared to women who have a caesareansection. We have included some of the results of these studies inthe next few pages.The studies talked about in the next few pages are levelstudies. level studies can tell us when things tend to happenat the same time, however can’t tell us that choosing to dosomething causes something else to happen. For example, you’llsee below that we have talked about the chance of a baby havingpersistent pulmonary hypertension. This study shows that babiesborn by caesarean section are more likely to have persistentpulmonary hypertension. Because this study is a level study,we can’t be confident that a caesarean section causes a baby tohave persistent pulmonary hypertension. Instead, we can say withconfidence that these things tend to happen at the same time.Will the results of these studies apply to me?Most of the studies we’ve included are studies of women whowere described as low risk (eg women who were not pregnantwith twins or had a breech baby—that is a baby who is feet downin the womb rather than head down). Also, most of the studieswe’ve included are of women who had a vaginal birth comparedto women who had a caesarean section. This means that some ofthe women who had a caesarean section may have tried to havea vaginal birth but ended up having a caesarean section. Everywoman’s pregnancy is different, so the possible consequences ofeach option might be different for you. You might like to talk to yourcare provider who can give you extra information that is suited toyour unique pregnancy.58

What are the differences between having avaginal birth and having a caesarean section?Studies have found thereis a difference betweenhaving a vaginal birthand having a caesareansection in:The chance of havinga hysterectomy (when theuterus and sometimes the ovariesare removed) during or soonafter birth [12–14]Women who hada vaginal birth...3 out of every 10,000women had a hysterectomyWomen who had acaesarean section...23 out of every 10,000women had a hysterectomyThe chance of havingendometritis (infectionof the uterus) [15]6 out of every 1000women had endometritis62 out of every 1000women had endometritisThe chance of thebaby having persistentpulmonary hypertension(when the baby’s circulation systemdoesn’t adapt to breathing outsidethe uterus) [16]8 out of every 10,000 babieshad persistent pulmonaryhypertension40 out of every 10,000 babieshad persistent pulmonaryhypertension59

What are the differences between having avaginal birth and having a caesarean section? Continued...Studies have found thereis a difference betweenhaving a vaginal birthand having a caesareansection in:Continued...The chance of thebaby having transienttachypnoea (when the babyis born with fluid on their lungs)[16]Women who hada vaginal birth...1 out of every 100 babieshad transient tachypnoeaWomen who had acaesarean section...4 out of every 100 babieshad transient tachypnoeaBabies who hadtransient tachypnoeaBabies who did not havetransient tachypnoeaThe chance of thebaby having respiratorydistress syndrome (whenthe baby’s lungs don’t work properlybecause they lack a wetting agent)[16]16 out of every 10,000babies had respiratorydistress syndrome47 out of every 10,000babies had respiratorydistress syndromeThe ease of breastfeedingafter birth [17]Women were given a scoreof 9 out of 10 for ease ofbreastfeeding in their firstthree breastfeeding sessionsWomen were given a scoreof 8 out of 10 for ease ofbreastfeeding in their firstthree breastfeeding sessions60

Women who hada vaginal birth...Women who had acaesarean section...The chance of the babydying within four weeksof birth [18, 19]6 out of every 10,000 babiesdied within four weeks of birth17 out of every 10,000 babiesdied within four weeks of birthThe chance of gettingsepsis (whole body infection) atthe time of birth [20]4 out of every 1000 womengot sepsis at the time of birth14 out of every 1000 womengot sepsis at the time of birthThe chance of having pain(in the birth canal area or at the site ofthe caesarean section wound) oneyear after birth [21]10 out of every 100 womenexperienced pain one yearafter birth18 out of every 100 womenexperienced pain one yearafter birthWomen who had painone year after birthWomen who did not havepain one year after birthThe chance of having stressurinary incontinence (losing controlof urine when coughing, sneezing, laughing,exercising, etc) one year after birth[22]Women who had stressurinary incontinenceWomen who did not havestress urinary incontinence23 out of every 100 womenhad stress urinary incontinence10 out of every 100 womenhad stress urinary incontinence61

What are the differences between having avaginal birth and having a caesarean section? Continued...Studies have found thereis a difference betweenhaving a vaginal birthand having a caesareansection in:The chance of havingplacental abruption(when the placenta detachesfrom the wall of the uterus tooearly) [23, 24]Women who hada vaginal birth...6 out of every 1000women had placentalabruption in one oftheir pregnancies ifthey have never hada caesarean sectionWomen who had acaesarean section...8 out of every 1000women had placentalabruption in one oftheir pregnancies ifthey had one or morecaesarean sectionsThe chance of havingplacenta praevia (whenthe placenta attaches close toor covering the cervix) [24]9 out of every 1000women had placentapraevia in one of theirpregnancies if theyhave never had acaesarean section12 out of every 1000women had placentapraevia in one of theirpregnancies if theyhad one or morecaesarean sectionsThe chance of havingplacenta accreta (whenthe placenta is attached toodeeply into the wall of the uterus,the treatment is a hysterectomy)[24]4 out of every 10,000women had placentaaccreta in one of theirpregnancies if theyhave never had acaesarean section20 out of every 10,000women had placentaaccreta in one of theirpregnancies if theyhad one or morecaesarean sections62

Studies have foundno difference betweenhaving a vaginal birthand having a caesareansection in:The chance of having anal incontinence (losing control of the bowel) [25,26]The chance of having urge incontinence (when there is an intense urge to urinate and an uncontrollableleakage of urine before reaching a toilet) [22,25]Studies are not clearabout whether there isany difference betweenhaving a vaginal birthand having a caesareansection in:The chance of having a uterine rupture without a previous caesarean section [24,27,28]The chance of having a wound infection (tear, caesarean or episiotomy wound) [29]The chance of having a blood transfusion (being given blood) [15,29]The chance of the woman dying during birth [30,31]The chance of having pain during sex [21,32]The chance of having an ectopic pregnancy (when a fertilised egg grows outside the uterus, such as the ovary,abdomen, or the cervix) [33,34]The chance of becoming pregnant again [35,36]The chance of having a miscarriage [37]The chance of having deep vein thrombosis (a blood clot that forms in the legs or sometimes the pelvis or arms) [38]Studies have not lookedat whether there is adifference between havinga vaginal birth and havinga caesarean section in:The chance of having depressionThe chance of having anxiety63

How can I makethe decision that’sbest for me?Reasons I might choosea vaginal birth...Reasons I might choosea caesarean section...At the moment, I am leaning towards…A vaginalbirthI’munsureA caesareansection64

How can I askquestions to getmore information?Asking your care provider questions can help you get the information you want and need. Below are some questionsyou might want to ask your care provider to get more information during your pregnancy.How often do you perform a caesarean section?How often do you care for women having a vaginal birth?Are there rules at my planned place of birth about having a vaginal birth?Are there rules at my planned place of birth about having a caesarean section?Would you perform a caesarean section if I asked you to?Would you agree with my decision to have a vaginal birth if I asked?How would you feel if I refused a caesarean section if it was offered to me?Are there things I can do during my pregnancy to increase my chance of a vaginal birth?If I have a caesarean section, can I still choose how to birth if I have another baby?If I plan a vaginal birth, can I change my mind during labour?What happens if I go into spontaneous labour before the date of my caesarean section?How long do I have to think about this decision?65

Myquestionsand notes66

Where hasthis informationcome from?The information in this decision aid has come from the best scientific studies available to us. A list of these studies is included below:[1] Lowe, N.K., The nature of labor pain. American Journal of Obstetrics and Gynecology, 2002. 186(5, Supplement 1): p. S16-S24.[2] National Collaborating Centre for Women's and Children's Health, Intrapartum care: Care of healthy women and their babies during childbirth.September 2007.[3] Queensland Health, Perinatal statistics; Queensland 2007. 2009.[4] Laws, P. and E.A. Sullivan, Australia's mothers and babies 2007. Perinatal statistics series no. 23. Cat. no. PER 48. 2009, AIWH NationalPerinatal Statistics Unit: Sydney.[5] Phipps, M.G., et al., Risk factors for bladder injury during cesarean delivery. Obstetrics & Gynecology, 2005. 105(1): p. 156-160.[6] Haas, D.M. and A.W. Ayres, Laceration injury at cesarean section. Journal of Maternal-Fetal Neonatal Medicine, 2002. 11(3): p. 196-8.[7] Smith, J.F., C. Hernandez, and J.R. Wax, Fetal laceration injury at cesarean delivery. Obstetrics and Gynecology, 1997. 90(3): p. 344-346.[8] Alexander, J.M., et al., Fetal injury associated with Cesarean delivery. Obstetrics and Gynecology, 2006. 108(4): p. 885-890.[9] Silver, R.M., et al., Maternal morbidity associated with multiple repeat cesarean deliveries. Obstetrics and Gynecology, 2006. 107(6): p. 1226-1232.[10] Dessole, S., et al., Accidental fetal lacerations during cesarean delivery: Experience in an Italian level III university hospital. American Journal ofObstetrics and Gynecology, 2004. 191(5): p. 1673-1677.[11] Wiener, J.J. and J. Westwood, Fetal lacerations at caesarean section. Journal of Obstetrics and Gynaecology, 2002. 22(1): p. 23-4.[12] Stivanello, E., et al., Peripartum hysterectomy and cesarean delivery: A population-based study. Acta Obstetricia et Gynecologica, 2010. 89(3):p. 321-327.[13] Roopnarinesingh, R., L. Fay, and P. McKenna, A 27-year review of obstetric hysterectomy. J Obstet Gynaecol, 2003. 23(3): p. 252-4.[14] Daskalakis, G., et al., Emergency obstetric hysterectomy. Acta Obstetricia Et Gynecologica Scandinavica, 2007. 86(2): p. 223-227.[15] Burrows, L. J., L. A., Meyn, and A.M. Weber, Maternal morbidity associated with vaginal versus cesarean delivery. Obstetrics & Gynecology,2004. 103(5): p. 907-912.[16] Levine, E.M., et al., Mode of delivery and risk of respiratory diseases in newborns. Obstetrics & Gynecology, 2001. 97(3): p. 439-442.[17] Cakmak, H. and S. Kuguoglu, Comparison of the breastfeeding patterns of mothers who delivered their babies per vagina and via cesareansection: A observational study using the LATCH breastfeeding charting system. International Journal of Nursing Studies, 2007. 44(7): p. 1128-1137[18] MacDorman, M.F., et al., Neonatal mortality for primary cesarean and vaginal births to low-risk women: Application of an ‘‘intention-to-treat’’model. Birth, 2008. 35(1): p. 3-8.[19] MacDorman, M.F., et al., Infant and neonatal mortality for primary cesarean and vaginal births to women with “no indicated risk,” United States,1998-2001 birth cohorts. Birth, 2006. 33(3): p. 175-182.[20] Howell, S., Sepsis in mothers having a vaginal birth or casearean section in Queensland 2007/2008. 2009, Unpublished raw data. HealthStatistics Centre, Queensland Health.67

Where hasthis informationcome from?Continued...[21] Kainu, J.P., et al., Persistent pain after caesarean section and vaginal birth: A cohort study. International Journal of Obstetric Anesthesia, 2010.19(1): p. 4-9.[22] Press, J.Z., et al., Does cesarean section reduce postpartum urinary incontinence? A systematic review. Birth, 2007. 34(3): p. 228-237.[23] Rasmussen, S.L., M. Irgens, and K. Dalaker, A history of placental disfunction and risk of placental abruption. Paediatric and PerinatalEpidemiology, 1999. 13(1): p. 9-21.[24] Wills, R., S. MacLeod, and T. Johnston, Select adverse maternal outcomes following a previous caesarean section in Queensland. 2010,Health Statistics Centre, Queensland Health.[25] Nelson, R.L., et al., Cesarean delivery for the prevention of anal incontinence. Cochrane Database of Systematic Reviews, 2010(2): p. 1-31.[26] Solans-Domenech, M., E. Sanchez, and M. Espuna-Pons, Urinary and anal incontinence during pregnancy and postpartum: Incidence, severity,and risk factors. Obstetrics & Gynecology, 2010. 115(3): p. 618-628.[27] Garnett, J.D., Uterine rupture during pregnancy: Analysis of 133 patients. Obstetrics and Gynaecology, 1964. 23(6): p. 898-905.[28] Douglas, R.G. and W.B. Stromme, Operative Obstetrics. 1956, New York: Appleton Century Crofts.[29] Allen, V.M., et al., Maternal morbidity associated with cesarean delivery without labor compared with spontaneous onset of labor at term. Obstetricsand Gynecology, 2003. 102(3): p. 477-482.[30] Clark, S.L., et al., Maternal death in the 21st century: Causes, prevention, and relationship to cesarean delivery. American Journal of Obstetricsand Gynecology, 2008. 199(1): p. 1-5.[31] Vadnais, M. and B. Sachs, Maternal mortality with cesarean delivery: A literature review. Seminars in Perinatology, 2006. 30(5): p. 242-246.[32] Griffiths, A., et al., Female genital tract morbidity and sexual function following vaginal delivery or lower segment caesarean section. Journal ofObstetrics and Gynaecology, 2006. 26(7): p. 645-9.[33] Barnhart, K.T., et al., Risk factors for ectopic pregnancy in women with symptomatic first-trimester pregnancies. Fertility and Sterility, 2006. 86(1):p. 36-43.[34] Kendrick, J.S., et al., Previous cesarean delivery and the risk of ectopic pregnancy. Obstetrics & Gynecology, 1996. 87(2): p. 297-301.[35] Bhattacharya, S., et al., Absence of conception after caesarean section: voluntary or involuntary? BJOG: An International Journal of Obstetrics andGynaecology, 2006. 113(3): p. 268-275.[36] Murphy, D.J., et al., The relationship between Caesarean section and subfertility in a population-based sample of 14,541 pregnancies. HumanReproduction, 2002. 17(7): p. 1914-1917.[37] Hall, M.H., et al., Mode of delivery and future fertility. British Journal of Obstetrics and Gynaecology, 1989. 96(11): p. 1297-1303.can Medical Association,[38] Lydon-Rochelle, M., et al., Association between method of delivery and maternal rehospitalization. Journal of the Ameri2000. 283(18):p. 2411-2416.68

Your birthingoptionsChoosing how to birthyour baby: A decisionaid for womenwith a previouscaesarean section69

The research and development of this decision aid was conducted by Aimée Dane, ahealth psychology researcher at the Queensland Centre for Mothers & Babies.We would like to acknowledge Associate Professor Allison Shorten’s publication “BirthChoices: What is best for you... vaginal or caesarean birth?”. We would like to thankAllison for her contribution to and support of this decision aid.What is this decision aid about?This decision aid has been written to support women who have hadone or more previous caesareans, to know what to expect and havea say in making decisions about the way they would like to birth.This decision aid provides information about two options:1 Choose to have a vaginal birth after caesarean (VBAC)2 Choose to have a planned repeat caesarean sectionThis decision aid will answer the following questions:» What are my options when choosing to birth my baby aftera previous caesarean section?» Will I always be able to choose?» How might I choose between a VBAC and a planned repeatcaesarean section?» What are the differences between having a VBAC and havinga repeat caesarean section?» How can I make the decision that’s best for me?» How can I ask more questions to get more information?This decision aid is not meant to give you medical advice or recommend a course oftreatment and you should not rely on it to provide you with a recommended course oftreatment. It is not intended and should not be used to replace the advice or care providedby your midwife, your doctor and/or your obstetrician. You should consult and discussyour treatment options with your midwife, your doctor and/or your obstetrician beforemaking any treatment decisions.70

What are my options whenchoosing to birth my baby aftera previous caesarean section?There are two options that you can choose from:Option 1Choose to have a vaginal birthafter caesarean (VBAC)Option 2Choose to have a plannedrepeat caesarean sectionPhoto courtesy of Hayley Thompson71

What happens if I choose to haveOption 1 a vaginal birth after caesarean? Option 2What happens if I choose to have aplanned repeat caesarean section?A vaginal birth after caesarean (VBAC or trial of labour) is whena woman has a vaginal birth, after having one or more previouscaesarean sections.Information about what to expect in a vaginal birth is providedin ‘Choosing how to birth your baby: A decision aid for womenwithout a previous caesarean section’.What increases my chance of having a VBAC?The chance of having a VBAC depends on many things butcan vary between 50% to 90% [4]. This means that between10% to 50% of women have an emergency caesarean sectionafter trying a VBAC.A planned repeat caesarean section is when a woman who has hadone or more previous caesarean sections plans to have anothercaesarean section to birth her baby.Different women plan to have a repeat caesarean section fordifferent reasons. Some women plan to have a repeat caesareansection for medical reasons, while other women plan to have arepeat caesarean section because it is their preferred option.Information about what to expect during a caesarean section isprovided in ‘Choosing how to birth your baby: A decision aid forwomen without a previous caesarean section’.You are more likely to have a VBAC if:»»You have ever had a vaginal birth [4]»»Your baby weighs less than 4kg [4]»»You don’t have an induction (trying to start labourartificially) or augmentation of labour (trying toartificially speed up your labour) [4]There are also many things that can affect your chanceof having a VBAC, these include:»»The reason for your previous caesarean section»»Your care provider’s thoughts about trying a VBAC(eg do they support you or not?)»»The guidelines about VBAC at your birth place(eg how long is it considered safe for you to be in labour?)You might like to ask your care provider more about the thingsthat can affect your chance of having a VBAC.72

Will I alwaysbe ableto choose?How might I choosebetween a VBAC anda planned repeatcaesarean section?It is always your choice about how you would like to birth, howeversome hospitals and care providers have guidelines about when aVBAC and planned repeat caesarean section can be performed. Youmight like to ask your care provider about these guidelines at yourplanned place of birth.In some situations, your care provider might suggest one optioninstead of the other. If this happens, you can ask your care providerquestions about why and make decisions as a team. If one optionis suggested by your care provider, you can always choose to sayno. Some care providers choose not to offer, or are not comfortableoffering, all options to women. In this situation you might like to askto see another care provider.There are many reasons why women have had a previous caesareansection. The reasons for and procedures of your previous caesareansection/s can affect your decisions about how to birth. You mightlike to talk to your care provider about how your previous caesareansection/s may affect your decision about how to birth.A number of studies have looked at what happens when womenhave a VBAC compared to women who have a repeat caesareansection. We have included some of the results of these studies in thenext few pages.The studies talked about in the next few pages are level studies.level studies can tell us when things tend to happen at the sametime, however can’t tell us that choosing to do something causessomething else to happen. For example, you’ll see below that wehave talked about the chance of having a uterine rupture (tearthrough the wall of the uterus – this tear could be small or large insize). This study shows that women who had a VBAC were morelikely to have a uterine rupture than women who had a plannedrepeat caesarean section. Because this study is a level study, wecan’t be confident that a VBAC causes a woman to have a uterinerupture. Instead, we can be confident that these things tend tohappen at the same time.Will the results of these studies apply to me?Most of the studies we’ve included are studies of women whowere described as low risk (eg women who were not pregnant withtwins or had a breech baby—that is a baby who is feet down inthe womb rather than head down). Also, most of the studies we’veincluded are of women trying a VBAC compared to women whohave a repeat caesarean. This means that the women who tried aVBAC may have ended up having a vaginal birth or a caesareansection. Every woman’s pregnancy is different, so the possibleconsequences of each option might be different for you. You mightlike to talk to your care provider who can give you extra informationthat is suited to your unique pregnancy.73

What are the differences between having aVBAC and having a repeat caesarean section?Studies have found thereis a difference betweenhaving a vaginal birth aftercaesarean and having arepeat caesarean sectionin:The chance of havinga uterine rupture (A tearthrough the wall of the uterus – thistear could be small or large in size)[5–9]Women who hada VBAC...50 out of every 10,000women had a uterine ruptureWomen who had a repeatcaesarean section...2 out of every 10,000women had a uterine ruptureThe chance of having afever (increased body temperature)[4]65 out of every 1000women had a fever72 out of every 1000women had a feverThe length of time spent inhospital after giving birth[4]Women stayed in hospitalfor an average of 2.6 daysWomen stayed in hospitalfor an average of 3.9 daysThe chance of dying duringbirth [4]4 out of every 100,000women died during birth13 out of every 100,000women died during birthThe chance of the babydying between 20 weeksgestation (amount of time in theuterus) and four weeks afterbirth [4]13 out of every 10,000babies died between 20weeks gestation and fourweeks after birth5 out of every 10,000babies died between 20weeks gestation and fourweeks after birth74

What are the differences between having aVBAC and having a repeat caesarean section? Continued...Studies have found thereis a difference in healthoutcomes depending onthe number of previouscaesarean sections in:Continued...The chance of havingplacenta praevia (whenthe placenta attaches close to orcovering the cervix) [4,10,11]Womenwho had...1 previouscaesarean section2 previouscaesarean sections4 out of every 1000 womenhad placenta praevia12 out of every 1000 womenhad placenta praevia3 previouscaesarean sections19 out of every 1000 womenhad placenta praeviaStudies have foundno difference betweenhaving a VBAC andhaving a repeatcaesarean section in:The chance of having a hysterectomy (when the uterus and sometimes the ovaries are removed) [4]The chance of having a blood transfusion (being given blood) [4]The chance of having anxiety during pregnancy [12]The chance of having depression during pregnancy or after birth [12]Women’s reported satisfaction with their birth [12]Women’s reported psychological wellbeing during pregnancy and after birth [12]The chance of the baby having a low APGAR score five minutes after birth (a score to assessa baby’s well-being after birth, a score lower than 7 means that a baby might need help breathing) [4]75

Studies are not clearabout whether thereis any differencebetween having a VBACand having a repeatcaesarean section in:The chance of having endometritis (infection of the uterus) [4]The chance of having a wound infection (tear, caesarean or episiotomy wound) [4]The chance of having a haemorrhage (excessive bleeding) [4]The chance of having deep vein thrombosis (a blood clot that forms in the legsor sometimes the pelvis or arms) [4]The chance of having placental abruption (when the placenta detaches from thewall of the uterus too early) [4]The chance of having placenta accreta (when the placenta is attached too deeplyinto the wall of the uterus, the treatment is a hysterectomy) [4]The chance of the baby going into the Neonatal Intensive Care Unit (NICU)(a unit in the hospital for babies who need a high level of special medical care) [4]The chance of the baby having breathing problems at birth [4]The chance of the baby having brain damage [4]The chance of the baby having sepsis (infection of the whole body) [4]Studies haven’t looked atthe differences betweenhaving a VBAC andhaving a planned repeatcaesarean section in:The chance of or length of time breastfeeding [4]The chance of having urinary incontinence (losing control of the bladder) [4]The chance of having anal incontinence (losing control of the bowel) [4]The chance of becoming pregnant again [4]76

How can I makethe decision that’sbest for me?Reasons I might choosea VBAC...Reasons I might choosea repeat caesarean section...At the moment, I am leaning towards…AVBACI’munsureA repeatcaesarean section77

How can I askquestions to getmore information?Asking your care provider questions can help you get the information you want and need. Below are some questions you might wantto ask your care provider to get more information during your pregnancy.Are there guidelines at my planned place of birth about having a VBAC (eg guidelines about labour or guidelines about birth)?Are there guidelines at my planned place of birth about having a planned repeat caesarean section?Do you care for women who have a planned repeat caesarean section?Do you care for women who have a VBAC?How often?How often do women you care for have a VBAC without having an emergency caesarean section?Would you do a repeat caesarean section if I asked you to?Would you support me in my choice to have a VBAC?How would you feel if I refused a repeat caesarean section if it was offered to me?How would you feel if I refused a VBAC if it was offered to me?Are there things I can do during my pregnancy to increase my chance of having a VBAC?How long do I have to think about this decision?What would happen if I chose a VBAC?What are my options if my labour doesn’t progress?What would happen if I chose a repeat caesarean section?What happens if I go into labour before my planned caesarean section?78

Myquestionsand notes79

Where hasthis informationcome from?The information in this decision aid has come from the best scientific studies available to us. A list of these studies is included below:[4] Guise, J., et al., Vaginal birth after cesarean: New insights. Evidence report/Technology Assessment No.191. (Prepared by the Oregon Health &Science University Evidence-based Practice Center under Contract No. 290-2007-10057-I). AHRQ Publication No. 10-E003. March 2010,Agency for Healthcare Research and Quality: Rockville, MD.[5] Dekker, G.A., et al., Risk of uterine rupture in Australian women attempting vaginal birth after one prior caesarean section: A retrospectivepopulation-based cohort study. BJOG, 2010. 117(11): p. 1358-1365.[6] Spong, C.Y., et al., Risk of uterine rupture and adverse perinatal outcome at term after cesarean delivery. Obstetrics & Gynecology, 2007.110(4): p. 801-807.[7] Cahill, A., et al., Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? American Journalof Obstetrics and Gynecology, 2006. 195(4): p. 1143-1147.[8] Loebel, G., et al., Maternal and neonatal morbidity after lective repeat cesarean delivery versus a trial of labor after previous cesaren delivery in acommunity teaching hospital. Journal of Fetal and Neonatal Medicine, 2004. 15(4): p. 243-246.[9] McMahon, M.J., et al., Comparison of trial of labor with an elective second cesarean section. New England Journal of Medicine, 1996. 335(10):p. 689-695.[10] Shorten, A. Weighing the pros and cons of planned vaginal birth after cesarean and repeat cesarean section. 2010 [cited 23 September 2010];Available from: http://givingbirthwithconfidence.org/birth/a-womans-guide-to-vbac/weighing-the-pros-and-cons/.[11] Silver, R.M., et al., Maternal morbidity associated with multiple repeat cesarean deliveries. Obstetrics and Gynecology, 2006. 107(6): p. 1226-1232.[12] Law, L.W., et al., Randomised trial of assigned mode of delivery after a previous caesarean section - Impact on maternal psychological dynamics.Journal of Maternal-Fetal and Neonatal Medicine, 2010. 23(10): p. 1106-1113.80

Your choicesin longerpregnancyChoosing how your labour willstart: A decision aid for womenwith a prolonged pregnancy81

The research and development of this decision aid was conducted by Rachel Thompson,a health psychology researcher at the Queensland Centre for Mothers & Babies.What is this decision aid about?This decision aid has been written to support women who mighthave a prolonged pregnancy (a pregnancy that continues beyond42 weeks) to know what to expect and to have a say in makingdecisions about how their labour will start.This decision aid provides information about two options:1. Choosing to wait for labour to start by itself2. Choosing to have an induction of labour(starting labour artificially)This decision aid will answer the following questions:» How long is pregnancy?» What is labour?» What may help me to go into labour by 42 weeks?» What if it looks like I might not go into labour by 42 weeks?» Will I always be able to choose?» How might I choose between waiting for labourto start and having an induction of labour?» What are the differences between waiting forlabour to start and having an induction of labour?» How can I make the decision that’s best for me?» How can I ask questions to get more information?This decision aid is not meant to give you medical advice or recommend a course oftreatment and you should not rely on it to provide you with a recommended course oftreatment. It is not intended and should not be used to replace the advice or care providedby your midwife, your doctor and/or your obstetrician. You should consult and discussyour treatment options with your midwife, your doctor and/or your obstetrician beforemaking any treatment decisions.Women may also be offered an induction of labour for reasonsother than a prolonged pregnancy, including if a woman has aprelabour rupture of membranes (when a woman’s waters breakand she doesn’t go into labour) or if it is believed that a woman’sbaby is growing more or less than expected. This decision aidprovides information only about induction of labour for prolongedpregnancy, not for other reasons. You might like to ask yourcare provider about the different reasons women are offered aninduction of labour.82

Howlong ispregnancy?The length of a pregnancy is usually counted in weeks. You, or yourcare provider, can estimate how many weeks pregnant you areby either counting forward from the first day of your last menstrualperiod (LMP), or by checking the size of your baby if you had anearly ultrasound scan (dating scan) during your pregnancy. But, thisnumber is only an estimate and may not be accurate. Also, everywoman’s pregnancy is different and it is normal for different womento have shorter or longer pregnancies.A pregnancy is said to be full term (the normal length) if the babyis born anytime between 37 and 42 weeks of pregnancy [1]. Yourestimated due date is in the middle of this range of time, and isusually the date when it is estimated that you will be 40 weekspregnant. However, it is very common for babies to be born beforeor after the estimated due date.A prolonged pregnancy is a pregnancy when the woman has nothad her baby by 42 weeks [1]. A prolonged pregnancy is alsosometimes called being ‘post-dates’ or ‘post-term’. It is unclearexactly how many women have a prolonged pregnancy, but it isthought that it could be anywhere from less than 5% to almost 15%of women [2].In Queensland, prolonged pregnancy is the most common reasonfor a woman to have an induction of labour [3]. An induction oflabour is when a care provider tries to artificially ‘start off’ a woman’slabour. An induction of labour is different to a spontaneous labour,which is when labour starts by itself. The main reason that aninduction of labour for prolonged pregnancy is offered to womenis that health problems for the baby are more common for womenwho have a prolonged pregnancy than for women who go intospontaneous labour by 42 weeks [3]. More information aboutwhether induction of labour helps to reduce the chance of thesehealth problems is provided later.83

Whatislabour?Labour is the process your body goes through when your baby is born.Going into labour is brought on by a number of changes in your body,including changes in your uterus (womb) and your cervix (the bottompart of your uterus at the inside end of your vagina).Towards the endof pregnancy, your cervix changes from being long, closed and hardto being short, soft and thinned (also called effaced). Changes to thecervix are called cervical ripening. A ripe cervix means your body isready for labour. A cervix that is not ripe and not ready for labour iscalled unripe. Your uterus also changes towards the end of pregnancy,becoming more active and starting to contract (tighten).The changes in the cervix and the uterus that start labour are slowand take several weeks. Substances produced naturally in your body,including hormones called prostaglandin and oxytocin, are involved inlabour starting. These hormones are thought to help ripen the cervixand start contractions in the uterus.Most women have a spontaneous labour. You might like to ask yourcare provider to give you information about what to look out for andwhat to expect when labour starts.UterusAmniotic SacCervixBladderVaginaLabiaUmbilical CordAnusPerineumAmnioticFluidPhoto courtesy of Little Posers Photography84

What may help meto go into labourby 42 weeks?What if it looks likeI might not go intolabour by 42 weeks?There are some things that may help you to go into labour before 42weeks. When you reach 41 weeks of pregnancy, your care providermight offer you a membrane sweep (also called a stretch andsweep or a strip and stretch). A membrane sweep is done duringa vaginal examination (internal examination). A membrane sweepis when your care provider makes circular movements around yourcervix with his or her finger to try and separate the amniotic sac (thesac around the baby) from the cervix. A membrane sweep is notdone to make a hole in the amniotic sac (break your waters).A membrane sweep is not usually thought of as an official way ofhaving an induction of labour, but it can increase your chance ofgoing into spontaneous labour [4]. A membrane sweep can beuncomfortable and it is normal to have a small amount of bleedingfrom your vagina for a brief time after the membrane sweep. Amembrane sweep can be done during a pregnancy check-up andyou can usually go home afterwards.You might like to ask your care provider about things like amembrane sweep, that can help you go into labour before 42weeks.Most women go into spontaneous labour by the time they are 42weeks pregnant [1]. If it looks like you might not go into labour by42 weeks, you and your care provider might talk about your options.There are two options:Option 1Choose to waitfor labour to startOption 2Choose to have aninduction of labourPhoto courtesy of Deirdrie Cullen85

Option 1What happens if I choose towait for labour to start?Option 2What happens if I choose to havean induction of labour?If you choose to wait for labour to start, your care provider mightoffer you extra check-ups. These check-ups are to see how yourpregnancy is going and to check the health of you and your babywhile you wait for labour to start.Check-ups usually include your care provider checking on yourbaby’s heart beat. Your baby’s heart beat might be checked using acardiotocograph (also called a CTG machine). A cardiotocograph isa machine that connects to small plastic sensors on a belt aroundyour abdomen (stomach). The cardiotocograph records your baby’sheart beat and any contractions of your uterus. Your baby’s heartbeat may also be checked in other ways, for example, using aDoppler (a handheld device which allows you to listen to the baby’sheart beat).Your care provider might also offer to do an ultrasound scan (wherea handheld instrument is used to look inside your uterus) to measurehow much amniotic fluid you have. Amniotic fluid is the liquid thatsurrounds your baby in the uterus (also called waters). If you areoffered these check-ups, you can ask your care provider what thecheck-ups will tell you.If you choose to wait for labour to start, you can still choose to havean induction of labour later on if you wish.Induction of labour, or being induced, is when a care provider triesto artificially start off a woman’s labour.If you choose to have an induction of labour, a date will be set forthe induction. An induction of labour is often planned for sometime after a woman is estimated to be 41 weeks pregnant. Youmight choose to have an induction of labour at this time, or youmight choose to wait until after 42 weeks, that is, until you have aprolonged pregnancy.Having an induction of labour usually requires having a vaginalexamination first. During a vaginal examination, your care providerwill check on how ready your cervix is for labour, that is, how ripe itis. You will also be offered a check of your baby’s heart beat, usuallyusing a cardiotocograph.An induction of labour is normally done in a hospital and usuallyyou then stay there until after the baby is born. An induction oflabour does not always work. You might like to ask your careprovider about what might happen if you choose to have aninduction of labour and it doesn’t work.There are three main ways of doing an induction of labour:1 giving you synthetic prostaglandin,2 breaking your waters, and3 giving you a Syntocinon ® infusion.These ways of doing an induction of labour are described in thenext section.Your care provider might offer one way for your induction of labour(eg giving you synthetic prostaglandin) or offer a combinationof ways (eg breaking your waters and giving you a Syntocinon ®infusion). The way offered to you depends on different things,including how ready your cervix is for labour. You might like toask your care provider when he or she would usually offer thedifferent types of induction of labour.86

1. What happens if I am given synthetic prostaglandin?Prostaglandin is a natural hormone that helps women go intospontaneous labour. Synthetic prostaglandin is not prostaglandin, butis a drug made to copy prostaglandin as closely as possible. Syntheticprostaglandin can be given in a gel, tablet or pessary (like a tampon),which is put into your vagina and releases the drug slowly.If you have the gel or the tablet, it is common to have one dose thenwait for around 6 hours. If contractions haven’t started, you mightbe offered a second dose and then usually wait another 6 hours andmaybe a third dose. If contractions still don’t start, your care providermight offer another way of having an induction of labour or might offeryou a caesarean section to birth your baby.If you have the pessary, it is normal to wait around 24 hours to see ifcontractions start. If contractions still haven’t started after 24 hours,your care provider might offer another way of having an induction oflabour or offer you a caesarean section to birth your baby.Different facilities might have different guidelines for how syntheticprostaglandin is given. You might like to ask your care provider howsynthetic prostaglandin is given at your planned place of birth.2. What happens if my care provider tries to break my waters?Breaking your waters is when your care provider makes a small holein the amniotic sac that holds your baby and the amniotic fluid aroundyour baby. Breaking your waters is also called an artificial rupture ofmembranes (ARM) or an amniotomy. Breaking your waters can onlybe done if your cervix is ripe enough.Your care provider usually breaks your waters by inserting a long thininstrument with a hook on the end into your vagina and through yourcervix, then making a hole in the amniotic sac. Your care provider canalso break your waters using a special glove with a sharp tip on oneof the fingers. After breaking your waters, the amniotic fluid will drainout through your vagina. The amniotic fluid might drain out in a slowtrickle or more of a gush.3. What happens if I am given a Syntocinon ® infusion?A Syntocinon ® infusion is when the drug Syntocinon ® is giventhrough an intravenous (IV) drip. An intravenous drip is a bag ofliquid that enters your body through a tube inserted into your handor arm. Syntocinon ® is a drug that has been made to copy oxytocinas closely as possible. Oxytocin is a natural hormone that helpswomen go into spontaneous labour. Often, breaking your watersand having a Syntocinon ® infusion are done together.Usually when a Syntocinon ® infusion is given, continuous electronicfetal monitoring is done. Continuous electronic fetal monitoring iswhen a cardiotocograph is used to record the contractions of youruterus and your baby’s heart beat. Usually, the cardiotocographconnects to small plastic sensors on a belt placed around yourabdomen. Sometimes, your baby’s heart beat may be monitored bya device inserted into your vagina and attached to your baby’s headwith a tiny screw. More information about continuous monitoring isprovided in ‘Monitoring your baby during labour: A decision aid forwomen having a vaginal brith’.In some places, if you are given a Syntocinon ® infusion, you will berestricted in how much you can move around and change positions.Your movement can be restricted because of the drip that will beattached to your hand or arm, as well as the cardiotocograph thatmay be attached to your body. You might be able to stand up orsit down, but you may be unable to move from room to room, orhave a shower or bath. You might like to ask your care provider howmuch you can move around if you having a Syntocinon ® infusion atyour planned place of birth.If labour contractions don’t start after you are given a Syntocinon ®infusion your care provider might offer you a Syntocinon ®infusion again the next day, or offer you a caesarean sectionto birth your baby. If labour contractions do start after you aregiven a Syntocinon ® infusion, you will usually continue to receiveSyntocinon ® through the drip during your labour.If labour contractions don’t start after your care provider breaks yourwaters, your care provider will usually offer you a Syntocinon ® infusion.87

Will I alwaysbe ableto choose?How might I choosebetween waiting forlabour to start & havingan induction of labour?In some situations, your care provider might suggest that youhave an induction of labour. If this happens, you can ask your careprovider about the reasons for their suggestion and make decisionsas a team. You can choose to follow their suggestion or you canchoose to say no.You may not always be able to choose to have an induction oflabour. Usually induction of labour is only discussed and offered toa woman when it is believed that waiting for labour to start mightcause problems for a woman and/or her baby. Some birthingfacilities also have guidelines about when an induction of labour isoffered. Different care providers might also vary in when or if theyusually offer an induction of labour. You can find more informationabout when an induction of labour might be offered by asking yourcare provider.Some birthing facilities are not able to do induction of labour. Forexample, if you are planning to birth in a birth centre, you will usuallybe unable to choose an induction of labour. If you are planning tobirth at home with a private practice midwife, breaking your watersis usually the only way that an induction of labour can be tried, asthe drugs needed for the other two ways of having an induction oflabour are not available. If you are planning to birth in a birth centreor at home, you might like to ask your care provider about what youroptions are if it looks like you might have a prolonged pregnancy.There are no tests which can tell you what will happen if you chooseto wait for labour to start or choose to have an induction of labour.However, a number of studies have looked at what happens whenwomen who were 41 weeks pregnant or more waited for labourto start compared to when women who were 41 weeks pregnantor more had an induction of labour. We have included some of theresults of these studies in the next few pages.Will the results of these studies apply to me?The studies we’ve included are studies of women who weredescribed as low risk (eg women who were not thought to haveany complications with their pregnancy). However, every woman’spregnancy is different so the possible outcomes of each optionmight be different for you. You might like to talk to your care providerwho can give you extra information that is suited to your uniquepregnancy.Some care providers choose not to offer or are not comfortableoffering all options to women. If you are not able to be offered alloptions or the option you prefer, you can ask to have another careprovider.Photo courtesy of Little Posers Photography88

What are the differences betweenwaiting for labour to start and havingan induction of labour?Studies have found thereis a difference betweenwaiting for labour andhaving an induction oflabour at 41 weeks orlater in:The chance of the babydying before, during or inthe first week after birth[5]Women who waitedfor labour to start…30 out of every 10,000 babiesdied before, during or soonafter birthWomen who tried aninduction of labour…3 out of every 10,000 babiesdied before, during or soonafter birthThe chance of having aprecipitate labour (a labour thatis unusually short and intense) [6]5 out of every 100 womenhad a precipitate labour13 out of every 100 womenhad a precipitate labourWomen who hada precipitate labourWomen who did nothave a precipitate labourThe chance of havingvery frequent contractionsduring labour [7]35 out of every 100 womenhad very frequent contractions46 out of every 100 womenhad very frequent contractionsWomen who had very frequentcontractions during labourWomen who did not have veryfrequent contractions during labour89

What are the differences between waiting for labourto start and having an induction of labour? Continued...Studies have found thereis a difference betweenwaiting for labour andhaving an induction oflabour at 41 weeks orlater in:The chance of having veryintense contractions duringlabour [6]Women who waitedfor labour to start…48 out of every 100 womenhad very intense contractionsWomen who tried aninduction of labour…63 out of every 100 womenhad very intense contractionsWomen who had very intensecontractions during labourWomen who did not have veryintense contractions during labourHow many women say theywould choose the sameoption again for their nextpregnancy [7]38 out of every 100 womenwould choose to wait for labourto start again next time74 out of every 100 womenwould choose an induction oflabour again next timeWomen who would choosethis option again next timeWomen who would not choosethis option again next time90

Studies have found nodifference betweenwaiting for labour to startand having an inductionof labour at 41 weeks orlater in:Women’s ratings of the amount of pain during labour [7]The chance of having an epidural (a type of pain management where drugs are used to numb the lower half of thebody) [8]The chance of having an instrumental birth (where forceps (tongs) and/or a vacuum (suction) cup is used to helppull the baby out of the vagina) [5,6]The chance of having a caesarean section [5,6]The chance of having a severe tear (a 3rd or 4th degree tear, or a tear involving the skin and muscles around thevagina and the anus) during birth [6]The chance of having a postpartum haemorrhage (losing more than 500ml of blood after birth) [5, 6]The chance of the baby becoming distressed during labour [6]The chance of the baby not getting enough oxygen during labour or birth [5,6]The chance of the baby being resuscitated (helped to breathe) after birth [6]The chance of the baby having a low APGAR score (being slow to breathe and respond) five minutesafter birth [5,6]The chance of the baby going into the Neonatal Intensive Care Unit or ‘NICU’(a unit in the hospital for babies who need a high level of special medical care) [5,6]Studies are not clearabout whether there isany difference betweenwaiting for labour to startand having an inductionof labour at 41 weeks orlater in:The chance of the baby having breathing difficulties caused by accidentally breathingin amniotic fluid containing meconium (sticky poo passed by the baby in the uterus) [5]The baby’s birthweight [5,6]91

How can I makethe decision that’sbest for me?Reasons I might choose to waitfor labour to start…Reasons I might choose to havean induction of labour…At the moment, I am leaning towards…Waiting forlabour to startI’munsureHaving an inductionof labour92

How can I askquestions to getmore information?Asking your care provider questions can help you get the information you want and need. Below are some questions you might want to ask yourcare provider to get more information during your pregnancy (that is, before an induction of labour for prolonged pregnancy is offered to you).When would you normally offer a woman an induction of labour for prolonged pregnancy?How often do you do an induction of labour for prolonged pregnancy?Are there guidelines at my planned place of birth about induction of labour for prolonged pregnancy?Would you do an induction of labour for prolonged pregnancy if I asked for one?How would you feel if I declined an induction of labour for prolonged pregnancy if it was offered to me?Are there things I can do during my pregnancy to increase my chance of labour starting by itself?Would you do a membrane sweep for me if I asked for one?Below are some questions you might ask your care provider to get more information if you are offered an induction of labour for prolonged pregnancy.How long do I have to think about this decision?What are the possible outcomes in my unique pregnancy if I wait for labour to start by itself?What are the possible outcomes in my unique pregnancy if I have an induction of labour?When, where and how would induction of labour be tried?What kind of support would be available if I chose to have an induction of labour?What is the chance that induction of labour would be successful in starting my labour?What would happen if induction of labour wasn’t successful?93

Myquestionsand notes94

Where hasthis informationcome from?The information in this decision aid has come from the best scientific studies available to us. A list of these studies is included below:[1] National Collaborating Centre for Women's and Children's Health, Induction of labour. 2008.[2] Shea, K.M., A.J. Wilcox, and R.E. Little, Postterm delivery: A challenge for epidemiological research. Epidemiology, 1998. 9(2): p. 199-204.[3] Queensland Health, Perinatal statistics, Queensland 2007. 2009, Health Statistics Centre, Queensland Health: Brisbane.[4] Boulvain, M., C.M. Stan, and O. Irion, Membrane sweeping for induction of labour. Cochrane Database of Systematic Reviews, 2005.[5] Gülmezoglu, A.M., C.A. Crowther, and P. Middleton, Induction of labour for improving birth outcomes for women at or beyond term. CochraneDatabase of Systematic Reviews, 2006.[6] Heimstad, R., et al., Induction of labor or serial antenatal fetal monitoring in postterm pregnancy: A randomized controlled trial. Obstetrics &Gynecology, 2007. 109: p. 609-617.[7] Heimstad, R., et al., Women's experiences and attitudes towards expectant management and induction of labor for post-term pregnancy. ActaObstetricia et Gynecologica Scandinavica, 2007. 86(8): p. 950-956.[8] Cardozo, L., J. Fysh, and J. Malcolm Pearce, Prolonged pregnancy: the management debate. British Medical Journal, 1986. 293: p. 1059-1063.95

Monitoringyour babyduring labourMonitoring your babyduring labour: A decisionaid for women havinga vaginal birth96

The research and development of this decision aid was conducted by Teresa Walsh, aresearch midwife consulting to the Queensland Centre for Mothers & BabiesWhat is this decision aid about?This decision aid has been written to support women planninga vaginal birth to know what to expect, and to have a say inmaking decisions about how their baby will be monitoredduring labour and birth.This decision aid provides information about two options:1. Choose to have intermittent monitoring2. Choose to have continuous monitoringThis decision aid will answer the following questions:» What is monitoring?» Why might my baby be monitored during labour?» How can my baby be monitored during labour?» How accurate is monitoring?» What are my options for monitoring my baby during labour?» Will I always be able to choose?» How might I choose between intermittent monitoring andcontinuous monitoring?» What are the differences between intermittent monitoring andcontinuous monitoring during labour?» How can I make the decision that’s best for me?» How can I ask questions to get more information?This decision aid is not meant to give you medical advice or recommend a course oftreatment and you should not rely on it to provide you with a recommended course oftreatment. It is not intended and should not be used to replace the advice or care providedby your midwife, your doctor and/or your obstetrician. You should consult and discussyour treatment options with your midwife, your doctor and/or your obstetrician beforemaking any treatment decisions.This decision aid does not provide information about choosingbetween not monitoring and monitoring your baby during labour.If you choose not to have your baby’s heartbeat checked at allduring labour, you and your care provider will not have as muchinformation about how your baby is reacting to your labour andbirth. No studies have looked at the health and other outcomesfor women and babies who haven’t been monitored during labourcompared to those who have been monitored.97

Whatismonitoring?Why might mybaby be monitoredduring labour?Monitoring your baby is when your care provider checks the physicalcondition of your baby. There are a few different ways that careproviders can monitor your baby.Care providers monitor your baby during labour to look for changesin the pattern of your baby’s heart beat. Changes in your baby’sheart rate might be a sign that your baby may be distressed or notreceiving enough oxygen.What might a change in heart rate mean?A change in a baby’s heart rate is sometimes a sign that the baby isnot receiving enough oxygen. Sometimes the heart rate returns tonormal quickly and this is thought to be due to temporary pressureon the baby’s cord inside your uterus. Sometimes changes canbe related to the care you are receiving [1,10]. For example, if youwere lying down resting on your back during labour your baby mayreceive less oxygen for a while and your baby’s heart rate may slowdown. Your care provider will keep you informed of your baby’scondition during labour and may suggest techniques that help youand also influence your baby’s heart rate, like changing your positionto improve the flow of blood and oxygen to the uterus. Monitoringyour baby’s heart rate can give you and your care providerinformation about how labour is progressing. Knowing how labouris progressing may influence the decisions you make throughout therest of your labour.Using a Pinard’s stethoscopeFor information on how labour mightprogress, please see your birthing options.98

How can mybaby be monitoredduring labour?There are different ways that your baby can be monitored duringlabour. Some are quite simple and others are more complicated:What you see and feel in early labourOne simple way of monitoring your baby in the early part of labouris noticing the way your baby is moving and kicking inside you. Youshould notice your baby’s movements as often as you usually do inthe final days of pregnancy even though the baby has less room tomove. This is one sign that your baby is well [10].Your care provider might also ask you to describe the colour ofany fluid that comes from your vagina if your waters (membranesaround the baby) break during labour. This fluid is usually clear incolour but if your baby passes meconium (bowel waste) insidethe uterus the fluid will sometimes be a darker green colour. Thiscan sometimes be a sign that the baby has been stressed beforeor during labour [10]. If you are concerned about your baby’smovements or if you are losing fluid from your vagina, you mightwant to discuss this with your care provider.Handheld DopplerA handheld doppler is a small battery operated device which canpick up your baby’s beating heart using ultrasound waves, and youcan hear a sound like the baby’s heart beat from the machine. Youmay have heard your baby’s heart beat during pregnancy checkupsif your care provider auscultated (or listened) with a handhelddoppler device. This is the most common way that care providersmonitor babies using intermittent monitoring during labour.same time. The machine prints a record on a paper strip and thisis stored as part of your records after the birth. A cardiotocographis also sometimes called electronic fetal monitoring. The machinemakes a sound which sounds like a heart beat whenever theheart rate is picked up and you will be able to hear this regularsound at the same rate as your baby’s heart beat.A cardiotocograph may also be used to record your baby’s heartbeat directly using electrocardiography (ECG). The thin cablewhich is used to monitor your baby can be inserted into yourvagina by your care provider during an examination of your vaginaand passed through the opening in your cervix and attached toyour baby’s scalp using a tiny wire screw also called a scalp clip.This method of monitoring may provide a clearer tracing of yourbaby’s heart rate.Fetoscope or Pinard’s stethoscopeYour care provider can listen to your baby’s heart beat directlythrough your abdomen using a fetoscope (a fetal stethoscope)or Pinard’s stethoscope. A Pinard’s stethoscope looks like a tinytrumpet. These methods of listening to the baby’s heart do notrequire the use of additional machines or technology.Cardiotocograph (CTG)Cardiotocograph is connected to two small plastic sensors held onyour abdomen by elastic belts. The sensors of the cardiotocographmachine detect your contractions and your baby’s heart beat at the99

Howaccurate ismonitoring?What are my optionsfor monitoring mybaby during labour?It is difficult to determine how accurate monitoring is. Studiesindicate that when monitoring shows a baby’s heart rate asreassuring or normal, this is mostly accurate and the baby is indeedcoping well [1,10]. However, when monitoring indicates that a baby’sheart beat shows signs of stress, the baby’s actual condition is lesseasy to predict and some of these babies are born with no signs ofdistress [1,9]. This means that sometimes monitoring can produce‘false negative results’ where monitoring suggests the baby isdistressed, when in reality the baby is coping well [11].Monitoring your baby during labour and birth is a skill that careproviders learn. However, not all care providers agree on whatdifferent heart rate patterns mean for a baby’s well-being [1,4,9].Your baby’s heart rate pattern changes naturally at differentstages of pregnancy and labour and this is normal [10]. There isdisagreement about what different heart rate patterns could meanfor an individual baby’s well being.There are two options for monitoring your baby during labour:Option 1Choose to have intermittent monitoringOption 2Choose to have continuous monitoringUsing a handheld doppler100

Option 1What happens if I choose intermittentmonitoring?Option 2What happens if I choose continuousmonitoring?If you choose to monitor you baby intermittently, your care providerwill usually offer to check your baby’s heart beat about every 15to 30 minutes in the first stage of labour. A hand held doppler isusually used but cardiotocograph with external ultrasound, Pinard’sstethoscope or fetoscope can also be used to monitor intermittently.During the second stage of labour your care provider will offer tocheck your baby’s heart rate more frequently, usually after eachcontraction and at least every 5 minutes until the birth of your baby.Your care provider will offer to also check your pulse (heart beat) atabout the same time as the baby’s heart beat is checked.Your care provider is usually able to monitor your baby’s heart beatin any position you are comfortable so you can move around freely.You may also like to take a bath or shower or go for a walk outside.If monitoring the baby’s heart beat is difficult in a particular position,your care provider may ask you to try a different position temporarilyso that this can be done.During normal labour when no complications are expected,intermittent monitoring of your baby’s heart is usually offered. Yourcare providers can offer to monitor your baby more closely if yourlabour begins normally and becomes more complicated later. Forexample, if the fluid around your baby begins to show signs ofcontaining meconium which could be a sign of fetal distress [10,12],or if you choose to use drugs to manage pain in labour.If you choose to monitor your baby continuously, your care providerwill use a cardiotocograph. The belts around your abdomen restrictyour ability to move around. You might also be asked to sit downor lie in bed to stop the pads moving around. This usually meansthat you can’t use water immersion while being monitored. If youwant to use the toilet or have a shower or bath, the belt and padscan be removed temporarily.In some hospitals your baby can be continuously monitored usinga machine similar to a cardiotocograph where the heart beat ispicked up by telemetry (wirelessly). This may mean that it is easierto walk and move around in labour.Until recently, it was widespread hospital policy to monitor allwomen with a cardiotocograph for 20 to 30 minutes when theyfirst arrived at their chosen place of birth in labour. Some hospitalsstill suggest that all women are monitored when they first arrivewhile others do not. Studies have shown that when care providersperform routine cardiotocograph on admission to hospital, womenwith low risk of complications have an increased chance of havinginterventions during labour, like an epidural, caesarean section,augmentation of labour and fetal blood sampling.[5,6].Photo courtesy of Herston Multimedia Unit101

Will I alwaysbe ableto choose?How might I choosebetween intermittentmonitoring andcontinuous monitoring?You can choose when and how your baby is monitored during labour.Hospitals or birth centres usually have guidelines for care providersabout when intermittent and continuous monitoring is used. Differentcare providers might also vary in their preferences for monitoring indifferent circumstances [7]. You might like to ask your care providerabout these guidelines at your chosen place of birth.In normal labour when no complications are expected, intermittentmonitoring of the baby’s heart is usually offered. You may notalways be able to choose to have continuous monitoring asstudies show that continuous monitoring can lead to increasedmedical intervention in labour, which is not necessarily associatedwith improved outcomes [4]. For this reason continuous monitoringis not usually offered for use in uncomplicated spontaneous labour. Ifyou are offered continuous monitoring by your care provider and youare experiencing normal labour you can always choose to say no.A number of studies have looked at women’s and babiesexperiences and outcomes of labour when different methodsof monitoring are used. Some studies compare different methodsincluding intermittent monitoring, continuous monitoring withcardiotocograph machine and other methods. We have includedsome of the results of these studies in the next few pages.Will the results of these studies apply to me?The studies we’ve included are studies of women who weredescribed as low risk (eg women who had term pregnancies(more than 37 weeks) and no complications in their pregnancies).However, every woman’s pregnancy is different so the possibleoutcomes of each option might be different for you. You might liketo talk to your care provider who can give you extra informationthat is suited to your unique pregnancy.In some situations, your care provider might recommend one optioninstead of the other. If this happens, you can ask your care providerquestions about why he or she has recommended one optioninstead of the other and make decisions as a team. Some careproviders choose not to offer all options to women and some careproviders are not comfortable with offering all options to women. Ineither of these circumstances, you might like to ask to see anothercare provider who can support you to make decisions that are bestfor you.Photo courtesy of Little Posers PhotographyCardiotocograph102

What are the differences between intermittentand continuous monitoring during labour?Studies have found thereis a difference betweenintermittent monitoringand continuous monitoringduring labour in:The chance of havinga planned vaginal birthwithout intervention [4]Women who hadintermittent monitoring...77 out of every 100 womenhad a planned vaginal birthwithout interventionWomen who hadcontinuous monitoring...69 out of every 100 womenhad a planned vaginal birthwithout interventionWomen who had a plannedvaginal birth without interventionWomen who had a plannedvaginal birth with interventionThe chance of a womanhaving a caesarean sectionfor abnormal fetal heart rateand/or low oxygen levels inthe baby’s blood [4]4 out of every 1000 womenhad caesarean section8 out of every 1000 womenhad caesarean sectionThe chance of baby goingto the Neonatal IntensiveCare Unit (also called NICU, a unit inthe hospital for babies who need specialmedical care) [4]8 out of every 1000 babieswent to the Neonatal IntensiveCare Unit after birth11 out of every 1000 babieswent to Neonatal IntensiveCare Unit after birthThe chance of the babyhaving a seizure (like a fit,sometimes caused by lack of oxygento the brain) after birth [4]18 out of every 10,000 babieshad a seizure after birth6 out of every 10,000 babieshad a seizure after birth103

Studies have found nodifference betweenintermittent andcontinuous monitoringduring labour in:The chance of having a stillborn baby or the baby dying in the first week of life [4]Studies are not clearabout whether there isany difference betweenintermittent andcontinuous monitoringduring labour in:The chance of accurately detecting babies who need special medical care [4]The chance of the baby developing cerebral palsy (a brain injury associated with lack of oxygen) [4]The chance of a woman using analgesia (drugs to relieve pain) in labour [4]The chance of a woman using epidural for pain relief during labour [4]The chance of detecting when a baby is not getting enough oxygen [4]The chance of baby having a low APGAR score (a score to assess a baby’s well-being after birth,a score lower than 7 means that a baby might need help breathing) [4]Studies haven’t lookedat whether there is adifference betweenintermittent andcontinuous monitoringduring labour in:Women’s satisfaction and dissatisfaction with labourThe ease of detecting the baby’s heart rate if a woman has a BMI over 40The chance of having a tear or a cut in or around the vaginaThe ability of the woman to adopt her preferred position in labourThe chance of a woman developing postnatal depression104

How can I makethe decision that’sbest for me?Reasons I might choose intermittentmonitoring during labour...Reasons I might choose continuous monitoringduring labour ...At the moment, I am leaning towards…IntermittentmonitoringI’munsureContinuousmonitoring105

How can I askquestions to getmore information?Asking your care provider questions can help you get the information you want and need. Below are some questionsyou might want to ask your care provider to get more information during your pregnancy.Are there any reasons (at the moment) why I might like to consider intermittently monitoring my baby?Are there any reasons (at the moment) why I might like to consider continuously monitoring my baby?What methods of intermittent monitoring are available at my planned place of birth?What methods of continuous monitoring are available at my planned place of birth?How often do you check my baby’s heart rate if I choose to use intermittent monitoring in labour?Are there guidelines at my planned place of birth about monitoring in labour?Does my planned place of birth have telemetry (wireless) monitoring in labour?Do the care providers who will monitor my baby in labour have regular training to update their skills?How would you feel if I declined continuous monitoring if it was offered to me?How would you feel if I declined intermittent monitoring if it was offered to me?How would you feel if I declined the use of a fetal scalp electrode to monitor my baby if it was offered to me?What things can I do to prevent my baby getting distressed during labour?Can I choose intermittent monitoring at any time during my labour?106

Myquestionsand notes107

Where hasthis informationcome from?The information in this decision aid has come from the best scientific studies available to us. A list of these studies is included below:[1] Bailey, R and Hinshaw, K. (updated August 2009 by Fetal Monitoring Working Group) Intrapartum Fetal Monitoring in Advanced Life SupportObstetrics. ALSO Asia-Pacific.[4] Alfirevic, Z., Devane, D., Gyte, G. M. L. (2007) Continuous cardiotocograph (CTG) as a form of electronic fetal monitoring (EFM) for fetalassessment during labour (Review). Cochrane database of systematic reviews 2006.[5] Blix, E. et al. (2005) Prognostic value of the labor admission test and its effectiveness compared with auscultation only: A systematicreview. British Journal of Obstetrics and Gynaecology, 112: 1595-1604.[6] East, E. E. et al. (2009) Fetal pulse oximetry for fetal assessment in labour. (Review). Cochrane database of systematic reviews 2007, Issue 2.[7] Glass, H.et al. (2009) Clinical neonatal siezures are independently associated with outcome in infants at risk for hypoxic-ischemic brain injury.Journal of Paediatrics: 155: 318-23.[9] Low, J. A., Victory, R., Derrick, E. J. (1999) Predictive value of electronic fetal monitoring for intrapartum fetal asphyxia with metabolic acidosis.Obstetrics and Gynaecolocy: 93; 285-91.[10] National Institute of Health and Clinical Excellence (2007) Intrapartum Care Clinical Guideline. Care of healthy women and their babiesduring childbirth. National Collaborating Centre for Women's and Children's Health, UK.[11] Nelson, K. B. et al. (1996) Uncertain value of electronic fetal monitoring in predicting cerebral palsy. New England Journal of Medicine. 334:10:613-8.[12] Queensland Health. (August 2010) Intrapartum fetal surveillance. Statewide Maternity and Neonatal Clinical Guideline. Queensland Government108

Your painmanagementduring birthChoosing your positionsduring labour and birth:A decision aid for womenhaving a vaginal birthChoices about epidural:A decision aid for womenhaving a vaginal birth109

What is labourand what mightit feel like?Many women describe the process of birthing as the most intensephysical feeling they have ever experienced [1]. Having informationabout what labour (the process your body goes through when yourbaby is born) might be like may help you make decisions aboutmanaging and working with your pain.Many women say labour pain can feel like period pain whichstrengthens as labour progresses [1]. Words such as ‘cramping,aching, tiring, troublesome, pressing, excruciating, throbbing,fearful and happy’ have been used to describe how women feelduring different stages of labour [2–4]. Each woman’s labour isdifferent and unique. Each woman also has a different threshold forhandling different sensations and pain.Labour usually happens in three stages: first stage labour, secondstage labour and third stage labour.What is first stage labour?The progress of first stage labour is measured by how dilated (open)your cervix is in centimetres. First stage labour is from when yourcervix starts to dilate to when it has fully dilated to 10cm. Thedilation (opening) of the cervix allows your baby to move from theuterus into the birth canal (the passage from the uterus to outsidethe vagina).During the early part of first stage labour, your uterus contracts(tightens) to slowly open up your cervix, preparing for the birth ofyour baby. Some women say that contractions feel like a tighteningof the stomach. These contractions may be irregular and quite farapart. Women usually say that these contractions are not as painfulas the contractions during later stages of labour. As you get closerto second stage labour your contractions will usually become moreregular, longer lasting, stronger and closer together [5]. You mayfeel stronger pain through the contractions however this will usuallylessen between contractions. Women usually say that as they getcloser to second stage labour, their contractions become morepainful. The length of first stage labour is different for every woman.For some women, this stage can last less than an hour, for others itmay last up to a few days.Some women also experience lower back pain through first stagelabour. It is thought that lower back pain may be associated witha posterior fetal position (when the baby’s back is lying against thewoman’s spine). However it is still unclear as to what causes lowerback pain during labour [5].First stage labour includes three phases: early, active and late.» Early phase of labour is from when the cervix starts to dilate to4cm dilation» Active phase of labour is from 4cm dilation to about 8cmor 9cm dilation. Women say that the pain of contractionsnormally becomes more painful from the active phase of labouronwards.» Late (or transitional) phase of labour is from about 8cm or 9cmto 10cm dilationPhoto courtesy of Rachel Ford110

What is second stage labour?Second stage labour is from the complete dilation of the cervix(10cm) to the birth of your baby. Your contractions during secondstage labour will push your baby from your uterus into your birthcanal. When your baby is in the birth canal you will usually feelthe urge to push your baby out. You may also feel the pressure ofyour baby’s head between your legs.During second stage labour, your baby usually moves head firstdown through the birth canal and shows his or her head throughthe opening of your vagina. When your baby’s head reaches theopening of your vagina you may feel a hot, stinging sensationas the opening of your vagina stretches. After your baby’s headhas come out of your vagina, his or her shoulders and body willusually follow within the next couple of contractions. The lengthof second stage labour is different for every woman. For somewomen this stage can last for a few minutes, for others it may lastover an hour.What is third stage labour?Third stage labour is from the birth of your baby to the birth of yourplacenta. The placenta is an organ that connects to the wall of apregnant woman’s uterus. The baby is connected to the placentaby the umbilical cord. The umbilical cord allows nutrients (egvitamins and minerals) and oxygen from the woman to be carriedto her baby.provided in ‘Choosing how to birth your placenta: A decision aid forwomen having a vaginal birth’.Many women experience afterpains (pains from the uteruscontracting after birth). Afterpains can be quite painful and oftenbecome more painful with breastfeeding. You might like to askyour care provider about pain management options if youexperience this.What are Braxton Hicks contractions?Before you go into labour you may experience Braxton Hickscontractions. Braxton Hicks contractions are a tightening ofthe uterus (womb) which occurs throughout pregnancy. Thesecontractions are not labour contractions. Not all women feel BraxtonHicks contractions in early pregnancy as they can be very subtle. Asyou get closer to giving birth you may experience more noticeable,intense and painful Braxton Hicks contractions. Sometimes it can behard to tell if the contractions experienced during late pregnancy areBraxton Hicks contractions or whether they are the early stages oflabour. This is because Braxton Hicks contractions and early labourcontractions can feel very similar. If you experience contractions thatyou are worried or confused about, your care provider can help youto work out which type of contractions you are experiencing.The contractions that you experience through first and secondstage labour will continue however are not usually as intense asin third stage labour. Contractions during third stage labour allowyour placenta to separate from the inside wall of your uterus andalso control any excessive bleeding.The length of third stage labour is different for every woman. Forsome this stage can last for less than 30 minutes, for others it canlast over an hour [6]. More information about third stage labour is111

What are my choicesfor managing andworking with pain?There are many different options for managing and working with pain.Often you can use different methods of pain management together.Some options however may only be used at certain points in labourand some can’t be used together.You might like to consider all your options for managing and workingwith pain before you go into labour so that you can be prepared. Itis okay to change your mind along the way. All women have differentbeliefs, values and preferences, so the method of pain managementfor one woman may not be the best for you. Therefore, when choosingwhich method of pain management is best for you, you might like tothink about the following:»»Your beliefs about whether pain should be managedor treated or if pain is a natural process»»The level of control you want over your body during labourand birth eg whether you want to feel everything or whetheryou don’t want to feel pain»»Some people classify pain differently:››Physiological pain can be seen as pain from thenatural effects of birth as a result of the musclesin the body moving and working to deliver the baby››Abnormal pain can be seen as pain fromcomplications of birth such as tearingNot all birth places can offer every method of pain management. Youmight like to talk to your care provider about what pain managementoptions will be available to you at your planned place of birth and whatmethods of pain management can and can’t be used together.Unfortunately, this book does not cover all methods of managing andworking with your pain. When deciding which methods to include inthe book, we talked with women about what was important to them,considered which methods women often use in Queensland andincluded some drug methods and some non-drug methods. Thischapter will discuss in detail two pain management options. These are:1. Positions in labour and birth2. Having an epiduralThe following methods of pain management have not beendiscussed in this chapter:»»Use of water in labour»»Touch and massage»»Support person»»Aromatherapy»»Acupuncture and acupressure»»Hypnosis»»TENS (Transcutaneous Electrical Nerve Stimulation)»»Psychological and breathing methods»»Heat packs»»Sterile water injections»»Pethidine»»Morphine»»Gas (Entonox ® or nitrous oxide)More details about the methods not discussed in this chapterwill be available on our website in time: www.havingababy.org.auAnalgesia: Pain management however you will still be conscious andhave sensationAnaesthesia: Total or partial loss of sensation. Anaesthesia can begiven to a certain area of the body (local anaesthetic) or to the wholebody for total loss of consciousness (general anaesthetic)112

Your painmanagementduring birthChoosing your positionsduring labour and birth:A decision aid for womenhaving a vaginal birth113

The research and development of this decision aid was conducted by Natasha Hayes,a health researcher at the Queensland Centre for Mothers & Babies.What is this decision aid about?This decision aid has been written to support women who areplanning a vaginal birth to know what to expect and to have asay in making decisions about positions in labour and birth.This decision aid provides information about two options:1. Being upright2 Lying downThis decision aid will also answer the following questions:» What are my options for positions in labour?» Will I always be able to choose?» How might I choose between an upright positionand a lying down position?» What are the differences between being uprightand lying down during first stage labour?» What are the differences between being uprightand lying down in second stage labour?» How can I make the decision that’s best for me?» How can I ask questions to get more information?This decision aid is not meant to give you medical advice or recommend a course oftreatment and you should not rely on it to provide you with a recommended course oftreatment. It is not intended and should not be used to replace the advice or care providedby your midwife, your doctor and/or your obstetrician. You should consult and discussyour treatment options with your midwife, your doctor and/or your obstetrician beforemaking any treatment decisions.114

What are myoptions forpositions in labour?During labour many women move around to find the positionsthat help them manage or work with their pain and allow themto feel most comfortable. There are many positions that can beused during labour and birth. These positions may also changethrough labour and birth. In the next few pages we talk aboutthe differences between being upright and lying down. We havediscussed first and second stage labour separately. All positions inlabour can be grouped into two options. These are:Option 1Being uprightOption 2Lying downPhoto courtesy of Little Posers Photography115

What happens if I chooseOption 1 an upright position?Option 2What happens if I choosea lying down position?Upright positions include any positions where the body is workingwith gravity to help the baby move through the birth canal or wherethe woman’s head is higher than her body. Some examples of uprightpositions are standing, kneeling, sitting, leaning, squatting or being onhands and knees. Upright positions can also include moving aroundsuch as walking or rocking.Lying down positions include when your body doesn’t use gravity tohelp the baby move through the birth canal and the woman’s headis not higher than the rest of the body. A lying down position couldbe on your back or on your side.Studies have shown that gravity can help your baby move throughthe passage of your pelvis [7]. Studies have also shown that squattingand kneeling opens up the pelvis which may help you birth your babymore easily [7].You may wish to have different furniture and birthing equipment available to help support you in different positions such as:» A birthing ball» A chair» A bench or bed for leaning, sitting or lying» A mat for the floor» CushionsPhoto courtesy of Little Posers Photography116

Will I alwaysbe ableto choose?How might I choosebetween an uprightposition or lyingdown position?You can choose which positions are most comfortable and leastpainful to you during labour. Some things can limit your positions, forexample, if your labour is being monitored with an elastic belt aroundyour abdomen (stomach) or if you have had an epidural. You might liketo talk to your care provider about what things might limit your ability touse all positions during your labour.In some situations, your care provider might suggest one optioninstead of the other. If this happens, you can ask your care providerabout the reasons for their suggestion and make decisions as a team.If one option is suggested by your care provider instead of another,you can choose to follow their suggestion or choose to say no. Somecare providers choose not to offer, or are not comfortable offering, alloptions to women. If you are not able to be offered all options, or theoption you prefer, you can ask to have another care provider.A number of studies have looked at what happens when women arein an upright position compared to being in a lying down position.We have included some of the results of these studies in the nextfew pages.Will the results of these studies apply to me?Every woman’s pregnancy is different, so the possible outcomes ofeach option might be different for you. You might like to talk to yourcare provider who can give you extra information that is suited toyour unique pregnancy.117

What are the differences between being uprightand lying down during first stage labour?Studies have found there isa difference between beingupright and lying downduring first stage labour in:Women who were inan upright position...Women who were ina lying down position...The length of firststage labour [7]On average, women’s labourlasted 5 hours and 42 minutesOn average, women’s labourlasted 6 hours and 29 minutesThe chance of having anepidural (a type of pain managementwhere drugs are used to numb the lowerhalf of the body) [7]27 out of every 100 womenhad an epidural32 out of every 100 womenhad an epiduralWomen whohad an epiduralWomen who did nothave an epiduralStudies have found thereis no difference betweenbeing upright and lyingdown during first stagelabour in:The chance of having an augmentation (process of artificially speeding up a woman’s labour after it has already started)using drugs [7]The chance of having an artificial rupture of membranes (also known as ‘breaking your waters’, when your careprovider makes a small hole in the amniotic sac that holds your baby and the amniotic fluid around your baby) [7]118

Studies have found thereis no difference betweenbeing upright and lyingdown during first stagelabour in:Continued...The chance of having opioids (drugs like morphine or pethidine) for pain management [7]The length of second stage labour [7]The chance of having an instrumental birth (where forceps (tongs) and/or a vacuum (suction) cap is used tohelp pull the baby out of the vagina) [7]The chance of having a caesarean section [7]The chance of having a postpartum haemorrhage (losing more than 500ml of blood after birth) [8]The chance of the baby having a low APGAR score (a score to assess a baby’s well-being after birth, ascore lower than 7 means that a baby might need help breathing) five minutes after birth [7]The chance of the baby going into the Neonatal Intensive Care Unit (a unit in the hospital forbabies who need a high level of special medical care) [9]Studies are not clearabout whether there isany difference betweenbeing upright and lyingdown during first stagelabour in:The chance of having a severe tear (a 3 rd or 4 th degree tear, or a tear involving the skin and musclesaround the vagina and the anus) during birthThe chance of having an episiotomy (a cut made to increase the size of the opening of the vagina)The chance of the baby dying between 20 weeks gestation (amount of time in the uterus) and4 weeks after birthStudies haven’t looked atthe differences betweenbeing upright and lyingdown during first stagelabour in:Women’s rating of the amount of pain during labour119

What are the differences between being uprightand lying down in second stage labour?Studies have found thereis a difference betweenbeing upright and lyingdown during second stagelabour in:The chance of having anepisiotomy (a cut made to increasethe size of the opening of the vagina)[10]Women who were inan upright position...33 out of every 100 womenhad an episiotomyWomen who were ina lying down position...39 out of every 100 womenhad an episiotomyWomen who hadan episiotomyWomen who did nothave an episiotomyThe chance of having apostpartum haemorrhage(losing more than 500ml of blood after birth)[10]7 out of every 100 women hada postpartum haemorrhage4 out of every 100 women hada postpartum haemorrhageWomen who had apostpartum haemorrhageWomen who did not have apostpartum haemorrhageThe chance of experiencingsevere pain at birth [11]36 out of every 100 womenexperienced severe pain atbirth49 out of every 100 womenexperienced severe pain atbirthWomen who experiencedsevere pain at birthWomen who did notexperience severe pain at birth120

Studies have found thereis a difference betweenbeing upright and lyingdown during second stagelabour in:Continued...The chance of having asecond degree tear (a tearinvolving the skin and muscles aroundthe vagina) [10]Women who were inan upright position...16 out of every 100 womenhad a second degree tearWomen who were ina lying down position...14 out of every 100 womenhad a second degree tearWomen who had asecond degree tearWomen who did not havea second degree tearStudies have found thereis no difference betweenbeing upright and lyingdown during secondstage labour in:The chance of having drugs for pain management (analgesia and anaesthetic) [10]The chance of having a caesarean section [10]The chance of having a severe tear (a 3 rd or 4 th degree tear) during birth [10]The frequency of contractions [12]Women’s reported satisfaction with second stage labour [11]The chance of feeling in control during first and second stage labour [13]Studies are not clearabout whether there isany difference betweenbeing upright and lyingdown during secondstage labour in:The length of second stage labourThe chance of having an instrumental birth (where forceps (tongs) and/or a vacuum (suction)cap is used to help pull the baby out of the vagina)121

How can I makethe decision that’sbest for me?Reasons I might choosean upright position...Reasons I might choosea lying down position...At the moment, I am leaning towards…An uprightpositionI’munsureA lying downposition122

How can I askquestions to getmore information?Asking your care provider questions can help you get the information you want and need. Below are some questions you might want to askyour care provider to get more information during your pregnancy:Are there guidelines at my planned place of birth for positioning during labour and birth?What are the possible outcomes in my unique pregnancy of being in an upright position?What are the possible outcomes in my unique pregnancy of being in a lying down position?Is there anything that will restrict my positioning and movement in first and second stage labour?123

Myquestionsand notes124

Where hasthis informationcome from?The information in this decision aid has come from the best scientific studies available to us. A list of these studies is included below:[1] Pregnancy info net. What is labour pain like (thread). 2010 [cited 13 September 2010]; Available from: http://www.pregnancy-info.net/forums/Labor_Questions/what_do_labor_pains_and_contractions_actually_feel_like_/.[2] Chang, M.Y., C.-H. Chen, and K.-F. Huang, A Comparison of Massage Effects on Labor Pain Using the McGill Pain Questionnaire. Journal ofNursing Research, 2006. 14(3): p. 190-197.[3] Brown, S.T., D. Campbell, and A. Kurtz, Characteristics of labor pain at two stages of cervical dilation. Pain, 1989. 39(3): p. 289-295.[4] Gaston-Johansson, f., G. Fridh, and K. Turner-Norvell, Progression of labor pain in primiparas and multiparas. Nursing Research, 1988. 37(2): p. 86-90.[5] Lowe, N.K., The nature of labor pain. American Journal of Obstetrics and Gynecology, 2002. 186(5, Supplement 1): p. S16-S24.[6] National Collaborating Centre for Women's and Children's Health, Intrapartum care: Care of healthy women and their babies during childbirth. September 2007.[7] Lawrence, A., et al., Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews, 2009. 2.[8] McManus, T.J. and A.A. Calder, Upright posture and the efficiency of labour. Lancet, 1978. 1(8055): p. 72-4.[9] MacLennon, A.H., C. Crowther, and R. Derham, Does the option to ambulate during spontaneous labour confer any advantage or disadvantage?Journal of Maternal-Fetal Medicine, 1994. 3: p. 43-8.[10] Gupta, J.K., G.J. Hofmeyr, and R.M.D. Smyth, Position in the second stage of labour for women without epidural anaesthesia. CochraneDatabase of Systematic Reviews, 2004. 1.[11] De Jong, P.R., et al., Randomised trial commparing the upright and supine positions for the second stage of labour. British Journal of Obstetricsand Gynaecology, 1997. 104: p. 567-71.[12] Suwanakam, S., et al., The effects of sitting position on second stage of labor. Journal of the Medical Association of Thailand, 1988. 71(Suppl 1): p. 72-5.[13] Crowley, P., et al., Delivery in an obstetric birth chair: a randomized controlled trial. British Journal of Obstetrics and Gynaecology, 1991. 98: p. 667-74.125

Your painmanagementduring birthChoices about epidural:A decision aid for womenhaving a vaginal birth126

The research and development of this decision aid was conducted by Natasha Hayes,a health researcher at the Queensland Centre for Mothers & Babies.What is this decision aid about?This decision aid has been written to support women who areplanning a vaginal birth to know what to expect and to have a sayin making decisions about an epidural.This decision aid provides information about two options:1. Choose not to have an epidural2. Choose to have an epiduralThis decision aid will also answer the following questions:» What is an epidural?» What are my options for having an epidural?» Will I always be able to choose?» How might I choose between not having an epiduraland having an epidural?» What are the differences between not having an epidural andhaving an epidural?» How can I make the decision that’s best for me?» How can I ask questions to get more information?This decision aid is not meant to give you medical advice or recommend a course oftreatment and you should not rely on it to provide you with a recommended course oftreatment. It is not intended and should not be used to replace the advice or care providedby your midwife, your doctor and/or your obstetrician. You should consult and discussyour treatment options with your midwife, your doctor and/or your obstetrician beforemaking any treatment decisions.127

What is anepidural?What are myoptions?An epidural is a procedure where an anaesthetic (a drug that givestotal or partial loss of sensation of the body) is injected into thesmall space near your spinal cord by an anaesthetist (a doctor whospecialises in giving anaesthetic). As well as being used to relievelabour pain, epidurals can be used as anaesthetic for caesareansections.There are two options you can choose:Option 1Choose not to have an epiduralOption 2Choose to have an epidural128

Option 1What happens if I choosenot to have an epidural?If you choose not to have an epidural your care during labourand birth will continue as usual.Option 2What happens if I chooseto have an epidural?If you choose to have an epidural you may be asked to sit down,bend over or lie on your side while an anaesthetist puts a needlein your back with local anaesthetic to firstly numb the skin. Theanaesthetist then inserts a needle into your lower back. A catheter(thin tube) will then replace the needle so that more of the drugcan be given easily without another injection.Epidurals usually take between 10 to 30 minutes before they beginto work.If you have an epidural, you will usually be numb from the waist down.Different doses of anaesthetic can be given to numb more or less ofyour legs. The degree of numbing will affect how you can move duringlabour and birth. In Queensland some hospitals are able to adjust thedose of the epidural so that you can still walk around or move arounda bit in bed or in a chair with assistance. Some hospitals have PatientControlled Epidural Analgesia (PCEA) where you are able to controlthe dose yourself with a programmed pump. You may like to speakwith your care provider about what your planned place of birth canprovide and how much mobility you would like in your labour.Epidurals can cause a fall in blood pressure, so you will usually havean intravenous drip (a bag of liquid that enters your body through atube) put into your arm or the back of your hand in case your bloodpressure drops.Usually when a woman chooses to have an epidural, continuousmonitoring is suggested. More information about continuousmonitoring is provided in ‘Monitoring your baby during labour: Adecision aid for women having a vaginal birth’.In some hospitals, if you have an epidural you may be restricted inhow much you can move around and change positions. This may bebecause of an intravenous drip, continuous monitoring or a catheter.You may be able to stand up or sit down, but you may be unable tomove from room to room, or have a shower or bath. You might liketo ask your care provider for more information about your restrictionof movement if you choose to have an epidural at your plannedplace of birth.The effects of an epidural may take a few hours to wear off afterbirth. You may like to ask your care provider for more informationabout the effects of an epidural after birth.An epidural may also limit your ability to use other pain managementmethods. You might like to discuss this with your care provider.As with all medical procedures, if you choose to have an epidural,you will be asked to sign a consent form. If you would like to look atthis form before you go into labour, you might like to ask your careprovider if he or she can provide you with a copy.You may also lose the ability to sense when you need to pass urine,so you may also be given a catheter which is inserted into yourbladder via your urethra (leads urine from the bladder to outsidethe body).129

Will I alwaysbe ableto choose?How might I choosebetween not having,and having an epidural?For medical reasons, sometimes epidurals aren’t always suitable forall women. You may like to talk to your care provider for more aboutwhy epidurals aren’t always suitable for all women.Epidurals are not always available at all places of birth. Availabilitydepends on your place of birth and the availability of trainedindividuals who give epidurals, at the time of your labour. You mightlike to ask your care provider about the availability of an epidural atyour planned place of birth.In some situations, your care provider might suggest one optioninstead of the other. If this happens, you can ask your care providerabout the reasons for their suggestion and make decisions as ateam. If one option is suggested by your care provider instead ofanother, you can choose to follow their suggestion or choose to sayno. Some care providers choose not to offer, or are not comfortableoffering, all options to women. If you are not able to be offered alloptions, or the option you prefer, you can ask to have another careprovider.A number of studies have looked at what happens when womendo not have an epidural compared to when women have anepidural. We have included some of the results of these studiesin the next few pages.Will the results of these studies apply to me?The studies we’ve included are studies of different women, somewho were described as low risk (no complications) and some whowere described as high risk. However, every woman’s pregnancy isdifferent, so the possible outcomes of each option might be differentfor you. You might like to talk to your care provider who can give youextra information that is suited to your unique pregnancy.Photo courtesy of Little Posers Photography130

What are the differences between not havingan epidural and having an epidural?Studies have found thereis a difference betweennot having an epidural andhaving an epidural in:Women who did nothave an epidural...Women who hadan epidural...The chance of having anaugmentation (where a drug is givento you to speed up your labour) [18,19]38 out of every 100 womenhad an augmentation45 out of every 100women had an augmentationWomen who hadan augmentationWomen who did nothave an augmentationThe chance of having lowblood pressure during firstand second stage labour[18]1 out of every 1000 womenhad low blood pressure170 out of every 1000 womenhad low blood pressureThe chance of secondstage labour lasting morethan two hours [19]3 out of every 100 secondstage labour last more thantwo hours7 out of every 100 secondstage labour last more thantwo hoursWomen whose second stage labourlasted more than two hoursWomen whose second stage labourdidn’t last more than two hours131

What are the differences between havingan epidural and not having an epidural? Continued...Studies have found thereis a difference betweennot having an epidural andhaving an epidural in:Women who did nothave an epidural...Women who hadan epidural...The length of second stagelabour [18,21]On average, women’slabour lasted 47 minutesOn average, women’s labourlasted 1 hour and 4 minutesThe chance of losing thefeeling of needing to passurine during labour [18]6 out of every 1000 womenlost the feeling of needing topass urine210 out of every 1000 womenlost the feeling of needing topass urineThe chance of having aninstrumental birth (where forceps(tongs) and/or a vacuum (suction) capis used to help pull the baby out of thevagina) [18,19]Women who had aninstrumental birthWomen who did not havean instrumental birth9 out of every 100 womenhad an instrumental birth15 out of every 100 womenhad an instrumental birth132

What are the differences between havingan epidural and not having an epidural? ContinuedStudies have found thereis a difference betweennot having an epidural andhaving an epidural in:Women who did nothave an epidural...Women who hadan epidural...Continued...The chance of a womanhaving a fever (a temperaturegreater than 38 degrees) [18–19]6 out of every 100women had a fever21 out of every 100women had a feverWomen whohad a feverWomen who didnot have a feverWomen’s rating of pain[18]Women rated their amountof pain as 6.8 out of 10Women rated their amountof pain as 4.2 out of 10Studies have found thereis no difference betweennot having an epidural andhaving an epidural in:Women’s satisfaction with pain management [18]Women’s satisfaction with their birth experience [18]The chance of women having nausea and vomiting [18]The chance of women feeling drowsy [18]133

What are the differences between nothaving an epidural and having an epidural? Continued...Studies have found thereis no difference betweennot having an epidural andhaving an epidural in:Continued...The length of first stage labour [18]The length of the active phase of first stage labour [20]The chance of feeling in control during first and second stage labour [24]The chance of the baby being in a position other than head first [18]The chance of having a headache during labour, birth and shortly after birth [18]The chance of having a caesarean section [18,21]The chance of having long-term (after birth) backache [18]The chance of having depression [18]The chance of the baby going into the Neonatal Intensive Care Unit (a unit in the hospital forbabies who need a high level of special medical care) [18]The chance of the baby having a low APGAR score (a score to assess a baby’s well-being afterbirth, a score lower than 7 means that a baby might need help breathing) five minutes after birth [18–21]Studies are not clearabout whether there isany difference betweennot having an epiduraland having an epiduralin:The chance of breastfeeding [22,23]134

How can I makethe decision that’sbest for me?Reasons I might notwant to have an epidural...Reasons I might wantto have an epidural...At the moment, I am leaning towards…Not havingan epiduralI’munsureHaving anepidural135

How can I askquestions to getmore information?Asking your care provider questions can help you get the information you want and need. Below are some questions you might want to askyour care provider to get more information during your pregnancy:Are there guidelines at my planned place of birth about having an epidural?How would you feel if I refused to have an epidural if it was offered to me?How would you feel if I asked for an epidural?Would you give me an epidural if I asked you to?What are the possible outcomes in my unique pregnancy of not having an epidural?What are the possible outcomes in my unique pregnancy of having an epidural?What are the side effects of having an epidural?Is there a time limit for when I can have an epidural in labour?Are epidurals available at all times at my planned birth place?Will I be able to have a shower or bath if I have an epidural?How will having an epidural affect my ability to move around in labour?How long do I have to think about choosing whether or not to have an epidural?136

Myquestionsand notes137

Where hasthis informationcome from?The information in this decision aid has come from the best scientific studies available to us. A list of these studies is included below:[18] Anim-Somuah, M., R.M.D. Smyth, and C.J. Howell, Epidural versus non-epidural or no analgesia in labour. Cochrane Database of SystematicReviews, 2005. 4: p. 42.[19] Ramin, S.M., et al., Randomized trial of epidural versus intravenous analgesia during labor. Obstretrics and Gynecology, 1995. 86(5): p. 783-789.[20] Nafisi, S., Effects of epidural lidocaine analgesia on labor and delivery: A randomized, prospective, controlled trial. BMC Anesthesiology, 2006. 6(15): p. 1-6.{21] Halpern, S., et al., A multicenter randomized controlled trial comparing patient-controlled epidural with intravenous analgesia for pain relief in labour.Anesthesia and Analgesia, 2004. 99: p. 1532-8.[22] Chang, Z.M. and M.I. Heaman, Epidural analgesia during labour and delivery: Effects on the initiation and continuation of effective breastfeeding. Journal of HumanLactation, 2005. 21: p. 305-314.[23] Lieberman, E. and C. O’Donoghue, Unintended effects of epidural analgesia during labour: A systematice review. American Journal of Obstetrics and Gynecology,2002. 186: p. S31-68.[24] Howell, C.J., et al., A randomised control trial of epidural compared with non-epidural analgesia in labour. BJOG: an international journal of Obstetrics andGynaecology, 2001. 108(1): p. 27-33.138

Yourperineumduring birthChoices about episiotomy:A decision aid for womenhaving a vaginal birth139

The research and development of this decision aid was conducted by Rachel Thompson,a health psychology researcher at the Queensland Centre for Mothers & Babies.What is this decision aid about?This decision aid has been written to support women who areplanning a vaginal birth to know what to expect and to have a sayin making decisions about episiotomy (when a care provider usesscissors to make a cut to increase the size of the opening of thevagina).This decision aid provides information about two options:1. Choose not to have an episiotomy2. Choose to have an episiotomyThis decision aid will answer the following questions:» What happens during vaginal birth?» What can affect my chance of having a tear during vaginal birth?» What is an episiotomy?» What are my options?» Will I always be able to choose?» How might I choose between not having and havingan episiotomy?» What are the differences between selective use of episiotomyand routine use of episiotomy?» How can I make the decision that is best for me?» How can I ask questions to get more information?This decision aid is not meant to give you medical advice or recommend a course oftreatment and you should not rely on it to provide you with a recommended course oftreatment. It is not intended and should not be used to replace the advice or care providedby your midwife, your doctor and/or your obstetrician. You should consult and discussyour treatment options with your midwife, your doctor and/or your obstetrician beforemaking any treatment decisions.140

What happensduring avaginal birth?During a vaginal birth, the baby usually moves head first down fromthe uterus (womb), through the cervix (the opening between theuterus and vagina) and out of the vagina. Before coming out of thevagina, the baby’s head pushes on the woman’s perineum, whichmakes the perineum bulge and stretch. The perineum is the areabetween the vagina and the anus (the opening to the back passage).Sometimes during a vaginal birth, the pressure of the baby’s headcan cause a woman to have a tear in the skin or muscles aroundher vagina, in her labia (the flaps of skin around her vagina), or in herperineum. If a tear happens, it usually happens around the time thatthe baby’s head passes through the opening to the vagina.There are different types of tears, with some tears more serious thanothers. More serious tears are usually stitched up after birth. Lessserious tears often heal by themselves without stitches. The mostcommon types of tears are described below.ClitorisUrethraLabiaVaginaPerineumAnus»»Graze — A graze is a scratch to the surface level of the skin.Very few women who have a graze have stitches to repair thegraze [1].»»1 st degree tear — A 1 st degree tear is a tear involving skin only.About half the women who have a 1 st degree tear have stitchesto repair the tear [1].»»2 nd degree tear — A 2 nd degree tear is a tear involving both skinand muscles, but not involving the anus. Most women who havea 2 nd degree tear have stitches to repair the tear [1].»»3 rd or 4 th degree tear — A 3 rd or 4 th degree tear is a tear thatinvolves the skin, muscles and anus. All women who have a 3 rdor 4 th degree tear have stitches to repair the tear [1]. A 3 rd or 4 thdegree tear is also called a severe tear.Different care providers have different opinions about when it isuseful to stitch up a tear and when a tear is better left to heal byitself. You might like to ask your care provider about when he orshe usually offers to do stitches after a perineal tear and why.141

What can affect mychance of having a tearduring vaginal birth?Some things can increase your chance of having a tear. Forexample, a tear can be more likely if your baby’s head is in anunusual position, such as an occipito-posterior position (or OPposition) during birth [2]. An occipito-posterior position is whenthe baby is in a head down position, but is facing the front of thewoman, rather than facing the back. The chance of tearing canalso be higher for women having their first birth than for womenwho have had a baby before [3].There are also some things that can reduce a woman’s chance ofhaving a tear. For example, doing perineal massage in pregnancycan reduce the chance of having stitches in the vagina or perineumafter birth for women having their first vaginal birth [3]. Perinealmassage is when you use your fingers or thumbs, inserted intoyour vagina, to massage and stretch your perineum. Perinealmassage can also reduce the chance of having an episiotomy forwomen having their first vaginal birth [3]. More information aboutepisiotomy is provided below.You might like to ask your care provider more about perinealmassage (eg how and when to do it) and other things that canreduce or increase your chance of having a tear during vaginalbirth.Photo courtesy of Rachel FordPhoto courtesy of Rachel Ford142

Whatis anepisiotomy?Sometimes during a vaginal birth, a care provider might offer to doan episiotomy. An episiotomy is when a care provider uses scissorsto make a cut in the woman’s perineum to increase the size of theopening of the vagina. The cut is usually between 2cm and 4cmlong [4]. An episiotomy is about the same in size as having a 2 nddegree tear.There are different reasons that a care provider might offer to do anepisiotomy. Some common reasons for offering to do an episiotomyare explained below.To try to prevent a severe tearYour care provider might offer to do an episiotomy if he or she thinksyou might have a severe tear (a 3 rd or 4 th degree tear). It used to bethought that episiotomies prevented severe tears. Studies now showthat severe tears are more common when episiotomies are routinely(all the time) given than when episiotomies are done selectively (onlyin certain circumstances) [5]. More information about this is providedon pages 148–150.Because you have had a severe tear in a previous birthYour care provider might offer to do an episiotomy if you have had asevere tear in a previous birth. Women who have had a severe tearin a previous birth have the same chance of having a severe tear aswomen having their first baby [6].To help the baby to be born quicklyTo allow forceps or a vacuum cap to be usedYour care provider might offer to do an episiotomy if forceps (metaltongs) or a vacuum cap (suction cap) are going to be used tohelp pull your baby out. Increasing the size of the opening of yourvagina means there is more room to insert the forceps or vacuumcap. Increasing the size of the opening of your vagina means thereis also more room to birth the baby’s head with the forceps orvacuum cap around it. Without an episiotomy, care providers maynot be able to use the forceps or vacuum cap effectively to helppull the baby out.To make more room to rotate or move the baby during birthYour care provider might offer to do an episiotomy if your baby isgoing to be moved or rotated manually (when your care provideruses his or her hands) during birth. Reasons for wanting to moveor rotate your baby might include your baby having shoulderdystocia (when the baby’s shoulder gets stuck while travellingdown through the vagina). Increasing the size of the opening ofthe vagina means there is more room for the care provider tomove or rotate the baby.Some care providers do an episiotomy more often than other careproviders. Some care providers also do an episiotomy for differentreasons than other care providers. You might like to ask your careprovider when he or she would usually offer to do an episiotomyand why.Your care provider might offer to do an episiotomy if your baby’shead is on your perineum and your care provider thinks he or she isbecoming distressed and needs to be born quickly. Increasing thesize of the opening of the vagina means there is more room for thebaby’s head and that the baby can be born more quickly.143

Whatare myoptions?If you are having a vaginal birth, there are two options:Option 1Choose not to havean episiotomyOption 2Choose to havean episiotomyPhoto courtesy of Matthew Seaman144

Option 1What happens if I choosenot to have an episiotomy?If you choose not to have an episiotomy, you will birth your babywithout having a cut to enlarge your vagina. If you choose not tohave an episiotomy, you may have a tear during your birth.For every 100 women in Queensland who did not have anepisiotomy [1]:No tear (39)Graze or 1 st degree tear (33)2 nd degree tear (26)3 rd or 4 th degree tear (2)After birth, your care provider will usually do an examination ofyour vagina, labia and surrounding areas to see whether you hada tear during birth. Before the examination, your care providershould explain what he or she plans to do and why, and ask yourpermission. You may also be offered gas and air (drugs you breathethrough a mask or mouthpiece) to manage pain or discomfort duringthe examination.that makes a specific part of the body numb. If you have had amore serious tear, you may be asked to be taken to theatre (theoperating room), where repairs might be done after giving you alocal anaesthetic or a general anaesthetic (when you are put tosleep).If you have a tear, you might have soreness or pain around yourvagina and perineum after birth. You might like to ask your careprovider about your options for pain relief after birth. Your careprovider will also give you information about things like eating anddrinking, going to the toilet, hygiene and pelvic floor exercises(exercises you can do to strengthen the muscles in and aroundyour vagina).What if I don’t have a tear?If you don’t have a tear, no stitches will need to be done after birth.However, you may still have some soreness or pain around yourvagina and perineum after birth.What if I have a tear?If you have a tear, a more detailed examination may be done. Thismay include a rectal examination. A rectal examination is when acare provider does an internal examination of your back passagewith his or her finger. Again, before the detailed examination, yourcare provider should explain what he or she plans to do and whyand ask your permission.Your care provider will sometimes offer to do stitches to repair thetear. If you like, you can use a mirror to look at the tear yourselfbefore you choose whether to have stitches or not. Usually, stitchescan be done straight away or later (eg after you have had some timewith your baby). You might like to ask your care provider when he orshe usually does stitches to repair a tear.If you choose to have stitches, the stitches usually dissolve bythemselves within about 6 weeks and do not need to be removed.Your care provider will usually give you local anaesthetic beforedoing the stitches. A local anaesthetic is a drug given in a needle145

Option 2What happens if I chooseto have an episiotomy?If you choose to have an episiotomy, the episiotomy can be doneby either a midwife or a doctor in the room where you are birthingyour baby. Your care provider will usually give you a local anaestheticbefore doing the episiotomy. The episiotomy is usually done duringthe last part of the second stage of labour. The last part of thesecond stage of labour is when you push your baby down and outthrough your vagina.There are two main ways an episiotomy can be done. The first wayis called a midline episiotomy. A midline episiotomy is when theepisiotomy is cut in a straight line from the vagina towards the anus.The second way is called a mediolateral episiotomy. A mediolateralepisiotomy is when the episiotomy is cut on an angle away fromthe anus, towards the left or right hand side. Studies are not clearabout whether there is any difference between midline episiotomyand mediolateral episiotomy in terms of the outcomes for women orfor babies [5]. You might like to ask your care provider whether he orshe usually does a midline episiotomy or a mediolateral episiotomy.Some women who have an episiotomy also have a tear. This tearcan happen before the episiotomy is done. The tear can alsohappen after the episiotomy is done, when the cut that has beenmade tears further.After an examination, your care provider will usually offer to dostitches to repair the episiotomy and any additional tearing. If youlike, you can use a mirror to look at the episiotomy yourself beforeyou choose whether or not to have stitches. Usually, stitches canbe done straight away or later (eg after you have had some timewith your baby). You might like to ask your care provider when he orshe usually does stitches to repair an episiotomy and any additionaltearing.If you choose to have stitches, the stitches usually dissolve bythemselves within about 6 weeks and do not need to be removed.Your care provider will usually give you some more local anaestheticbefore doing the stitches. If you have had a serious tear as wellas an episiotomy, you may be asked to be taken to theatre whererepairs might be done after giving you a local anaesthetic or ageneral anaesthetic.If you have an episiotomy, you might have soreness or pain aroundyour vagina and perineum after birth. You might like to ask your careprovider about your options for pain relief after birth. Your careprovider will also give you information about things like eating anddrinking, going to the toilet, hygiene and pelvic floor exercises.For every 100 women in Queensland who have an episiotomy [1]:Do not have a tear (86)Have a tear as well (14)Your care provider will usually do a detailed examination of yourvagina, labia and surrounding areas after your birth to check on yourepisiotomy and to see whether you also had a tear during birth. Thismay also include a rectal examination. Before the examination, yourcare provider should explain what he or she plans to do and why, andask your permission. You may also be offered gas and air to managepain or discomfort during the examination.Photo courtesy of Herston Multimedia Unit146

Will I alwaysbe ableto choose?How might I choosebetween not having andhaving an episiotomy?In some situations, your care provider might suggest that you havean episiotomy. If this happens, you can ask your care provider aboutthe reasons for their suggestion and make decisions as a team. Youcan choose to follow their suggestion or you can choose to say no.You may not always be able to choose to have an episiotomy.Usually episiotomy is only offered to a woman in labour when it isbelieved that not having an episiotomy might cause problems for awoman and/or her baby. You might like to ask your care provider formore information about when an episiotomy might be offered.Some care providers choose not to offer, or are not comfortableoffering, all options to women. If you are not able to be offered alloptions, or the option you prefer, you can ask to have another careprovider.A number of studies have looked at what happens whenepisiotomies are done selectively (only in certain circumstances)compared to when episiotomies are done routinely (all the time).We have included some of the results of these studies in the nextfew pages. Only high quality studies have been included in thisdecision aid.Will the results of these studies apply to me?The studies we’ve included are mostly studies of women whowere described as low risk (women who were not thought to haveany complications with their pregnancy or labour). However, everywoman’s pregnancy is different, so the possible consequences ofeach option might be different for you. Your care provider can giveyou extra information that is suited to your unique pregnancy.Photo courtesy of Little Posers Photography147

What are the differences between selective useof episiotomy and routine use of episiotomy?Studies have found thereis a difference betweenselective use ofepisiotomy and routineuse of episiotomy in:The chance of having posteriorperineal trauma (damage from atear or cut to the back of the vagina, theperineum or the anus) [5]Selective use of episiotomy(only in certain circumstances)72 out of every 100 womenhad posterior perineal traumaRoutine use of episiotomy(all of the time)82 out of every 100 womenhad posterior perineal traumaWomen who hadposterior perineal traumaWomen who did not haveposterior perineal traumaThe chance of having anteriortrauma (damage from a tear or cut tothe labia, the front of the vagina, the urethraor the clitoris) [5]21 out of every 100 womenhad anterior trauma11 out of every 100 womenhad anterior traumaWomen who hadanterior traumaWomen who did nothave anterior traumaThe chance of havingsevere perineal trauma(a 3 rd and/or 4 th degree tear) [5]3 out of every 100 womenhad severe perineal trauma4 out of every 100 womenhad severe perineal traumaWomen who hadsevere perineal traumaWomen who did not havesevere perineal trauma148

Selective use of episiotomy(only in certain circumstances)Routine use of episiotomy(all of the time)The chance of having healingcomplications (when a tear or cutdoes not heal as well as expected 7 daysafter birth) [5]21 out of every 100 womenhad healing complications30 out of every 100 womenhad healing complicationsWomen who hadhealing complicationsWomen who did not havehealing complicationsThe chance of having perinealwound dehiscence (when a tear orcut has opened back-up 7 days after birth)[5]Women who hadwound dehiscenceWomen who did nothave wound dehiscence4 out of every 100 womenhad wound dehiscence9 out of every 100 womenhad wound dehiscenceThe chance of havingperineal pain at discharge(when leaving one’s place of birth)[5]Women who had perinealpain at dischargeWomen who did not haveperineal pain at discharge31 out of every 100 womenhad perineal pain at discharge42 out of every 100 womenhad perineal pain at discharge149

What are the differences between selective useepisiotomy and routine use of episiotomy? Continued...Studies have foundthere is a differencebetween selectiveuse of episiotomyand routine use ofepisiotomy in:The chance of havingstitches after birth [5]Selective use of episiotomy(only in certain circumstances)64 out of every 100women had stitchesRoutine use of episiotomy(all of the time)86 out of every 100women had stitchesWomen who hadWomenhealing complicationswhohad stitchesWomen who did not haveWomen healing complicationswho didnot have stitchesThe amount of blood a womanloses during birth [5]On average, women lost214ml of blood during birthOn average, women lost272ml of blood during birthStudies have found nodifference betweenselective use ofepisiotomy and routineuse of episiotomy in:The chance of having a perineal infection [5]The chance of having a perineal haematoma (a collection of blood, like a bruise, in the area between the vagina and the anus)at discharge [5]The chance of having moderate or severe perineal pain up to 3 months after birth [5]The chance of having sex, or trying to, during the first three months after birth [5]The chance of having dyspareunia (pain during sex) during the first three months after birth [5]The chance of having urinary incontinence (losing control of your bladder) within 3 to 7 months [5]The chance of the baby having a low APGAR score (being slow to breathe and respond) one minute after birth [5]The chance of the baby going into the special care baby unit (unit in the hospital for babies who need special medical care) [5]150

How can I makethe decision that’sbest for me?Reasons I might choose tonot have an episiotomy...Reasons I might choose to havean episiotomy...At the moment, I am leaning towards…Not having anepisiotomyI’munsureHaving anepisiotomy151

How can I askquestions to getmore information?Asking your care provider questions can help you get the information you want and need. Below are some questionsyou might want to ask your care provider to get more information during your pregnancy.When would you normally offer a woman an episiotomy?How often do you do an episiotomy?Are there guidelines at my planned place of birth about episiotomy?Would you do an episiotomy if I asked for one?How would you feel if I refused an episiotomy if it was offered it to me?Are there things I can do during my pregnancy to reduce my chance of having a perineal tear?Are there things I can do during my pregnancy to reduce my chance of having an episiotomy?Are there things I can do during my labour to reduce my chance of having a perineal tear?Are there things I can do during my labour to reduce my chance of having an episiotomy?Under what circumstances do you usually offer a woman stitches to repair an episiotomy or tear?How long after birth do you usually do stitches to repair an episiotomy or tear?Below are some questions you might ask your care provider to get more information if you are offered an episiotomy.How long do I have to think about this decision?What are the possible outcomes in my unique pregnancy if I do not have an episiotomy?What are the possible outcomes in my unique pregnancy if I have an episiotomy?Are there any alternatives?152

Myquestionsand notes153

Where hasthis informationcome from?The information in this decision aid has come from the best scientific studies available to us. A list of these studies is included below:[1] Queensland Health, Perinatal Statistics Queensland 2007. 2009, Health Statistics Centre: Brisbane.[2] Hornemann, A., et al., Advanced age is a risk factor for higher grade perineal lacerations during delivery in nulliparous women. Arch GynecolObstet, 2010. 281: p. 59-64.[3] Beckmann, M.M. and A.J. Garrett, Antenatal perineal massage for reducing perineal trauma [Review]. Cochrane Database of Systematic Reviews,2006.[4] Rizk, D.E.E., et al., Determinants of the lenght of episiotomy or spontaneous posterior perineal lacerations during vaginal birth. Int Urogynecol J,2005. 16: p. 395-400.[5] Carroli, G. and L. Mignini, Episiotomy for vaginal birth. [Review]. Cochrane Database of Systematic Reviews, 2009: p. Issue 1. Art. No.: CD000081.DOI: 10.1002/14651858.CD000081.pub2.[6] National Collaborating Centre for Women's and Children's Health, Intrapartum care: Care of healthy women and their babies during childbirth. 2007,Author: London.154

BirthingyourplacentaChoosing how tobirth your placenta:A decision aid for womenhaving a vaginal birth155

The research and development of this decision aid was conducted by Aimée Dane, ahealth psychology researcher at the Queensland Centre for Mothers & Babies.What is this decision aid about?This decision aid has been written to support women who have avaginal birth to know what to expect and to have a say in makingdecisions about the third stage of labour. The third stage of labour(or just the third stage) is the time from when a woman births herbaby to when she births her placenta (or the afterbirth).This decision aid provides information about two options:1. Choose to have a physiological third stage of labour2. Choose to have an actively managed third stage of labourThis decision aid will answer the following questions:» What is the placenta and what is third stage of labour?» How can I be cared for during the third stage?» How might cord clamping and cutting affect my baby?» What happens if my placenta doesn’t birth?» Will I always be able to choose?» How might I choose between physiological third stage andactively managed third stage?» What are the differences between having a physiological thirdstage and having an actively managed third stage?» How can I make the decision that’s best for me?» How can I ask questions to get more information?This decision aid is not meant to give you medical advice or recommend a course oftreatment and you should not rely on it to provide you with a recommended course oftreatment. It is not intended and should not be used to replace the advice or care providedby your midwife, your doctor and/or your obstetrician. You should consult and discussyour treatment options with your midwife, your doctor and/or your obstetrician beforemaking any treatment decisions.156

What is the placentaand what is the thirdstage of labour?The third stage of labour (or just the third stage) is the time fromwhen a woman births her baby to when she births her placenta. Theplacenta is an organ that connects to the wall of a pregnant woman’suterus (womb). The baby is connected to the placenta by the umbilicalcord. The umbilical cord allows nutrients (eg vitamins and minerals)and oxygen from the woman to travel to her baby.After a woman births her baby, she also births her placenta. Thecontractions (tightening of the uterus) a woman has during herlabour and birth continue after her baby is born and help her birththe placenta. These contractions also help to stop any bleeding fromthe uterus that a woman may have. The length of the third stage isdifferent for every woman. For some this stage can last for less than30 minutes, for others it can last over an hour [2].When your baby is born, he or she will still be attached to the placentaby the umbilical cord. For some women, their baby’s umbilical cordwill be clamped and cut. The umbilical cord is clamped and cut toseparate the baby from the placenta. Some women choose not toclamp or cut the umbilical cord and wait for the cord and placentato detach a few days after the birth. This is called a lotus birth.It is normal for a woman to have bleeding from her uterus during thethird stage. Sometimes, a woman has a postpartum haemorrhage(or PPH). A postpartum haemorrhage is when a woman has morebleeding than usual. A postpartum haemorrhage usually happens ifa woman’s uterus doesn’t contract enough during the third stage.Usually, a postpartum haemorrhage is defined as losing more than500ml of blood [2]. To give you an idea of how much this is, whenyou donate blood around 600ml to 750ml is usually taken [3]. Whena woman has a postpartum haemorrhage, her care provider willusually offer her drugs to help stop the bleeding.Some things may make a woman more likely to have a postpartumhaemorrhage, such as being pregnant with more than one baby. Youmight like to ask your care provider about the things that increase awoman’s chance of having a postpartum haemorrhage.PlacentaUterusAmniotic SacCervixBladderVaginaLabiaUmbilical CordAnusPerineumAmnioticFluid157

How can I becared for duringthe third stage?There are two options for how you can be cared for during the thirdstage:Option 1Choose a physiologicalthird stageOption 2Choose an activelymanaged third stagePhoto courtesy of Deirdrie Cullen158

Option 1What happens if I choosea physiological third stage?A physiological third stage is when a woman relies on her ownproduction of oxytocin (a natural hormone produced during labourand birth) to birth her placenta. Oxytocin makes a woman’s uteruscontinue contracting after her baby is born and helps her placentaseparate from her uterus. Oxytocin also helps to stop any bleedingfrom a woman’s uterus and can prevent a postpartum haemorrhage.In a physiological third stage, the woman is not given Syntocinon ® (adrug that has been made to copy oxytocin as closely as possible).In a physiological third stage, you and your care provider wait for theplacenta to detach from the inside wall of the uterus and move downthe birth canal (the passage from the uterus that leads down throughthe vagina). While you wait, you might be kneeling or standing, oryou might sit on a special stool called a birth stool. Most womenhold their baby and/or have skin-to-skin contact (having your babyagainst your chest, without any clothing in between) and/or put theirbaby to their breast during the third stage. Studies have shown thatskin-to-skin contact and breastfeeding increase the production ofoxytocin in a woman’s body [4-6]. The production of oxytocin helpsthe placenta to birth by causing the uterus to contract. If youwould like skin-to-skin contact with your baby, you might like to askyour care provider that this happens immediately after birth.What are the best conditions for a physiological third stage?A study has shown that the chance of having a postpartumhaemorrhage during a physiological third stage is lower when [1]:»»a woman feels she is in a safe, calm and supportiveenvironment, and»»a woman’s care provider is experienced and skilled at aphysiological third stage, and»»a woman’s labour and birth proceed without drugs, and»»a woman and her baby are healthy after the second stage oflabour (the birth of the baby), and»»a woman has immediate and continued skin-to-skin contactafter birth, and»»a woman and her baby are kept warm, and»»a woman’s baby starts breastfeeding, and»»a woman is in an upright position during the birth of herplacenta, eg kneeling, standing or sitting on a birth stool, and»»a woman’s placenta is birthed with gravity and pushing only, and»»a woman’s uterus is not massaged (this is done by massagingthe abdomen), and controlled cord traction is not used (gentlypulling down on the umbilical cord to help birth the placenta).Once the placenta has detached from the uterus and is movingdown the birth canal, your care provider might suggest that you tryto push the placenta out. After the placenta has been birthed, yourcare provider will usually check your uterus to see that there are noplacental membranes (parts of the placenta) still in your uterus, andthat you are not bleeding more than expected.Some cultures have different ways of birthing the placenta. Youmight like to talk to your care provider about what options there arefor women with special cultural needs.Sometimes, unexpectedly, you or your baby may need extra medicalcare just as the third stage is about to start. For example, a womanmay have excessive bleeding or her baby may not be breathing afterbirth. If you have chosen to have a physiological third stage, and anunexpected emergency occurs, your care provider may suggest thatyou have an actively managed third stage instead by giving you thedrug Syntocinon ® . You might like to discuss with your care providerwhat might happen if an unexpected emergency occurs during thethird stage and what your options are if this happens.159

Option 2What happens if I choose an activelymanaged third stage?An actively managed third stage is when a woman is givenSyntocinon ® to help her birth the placenta. Syntocinon ® makes theuterus continue contracting after the baby is born. Syntocinon ® alsohelps to stop any bleeding from a woman’s uterus and helps preventa postpartum haemorrhage. Syntometrine ® is another drug that isan artificial form of oxytocin. Syntometrine ® is slightly different toSyntocinon ® and is usually used only if a woman is thought to havea higher chance of a postpartum haemorrhage or if Syntocinon ® hasnot worked.If you choose an actively managed third stage, your care providerwill give you Syntocinon ® soon after the birth of your baby.Syntocinon ® will usually be given through an intravenous (IV) drip(which is a bag of liquid that enters your body through a needlein your hand or arm) or as an injection into your leg. Syntocinon ®usually causes a contraction of the uterus within a few minutes.Some women hold their baby and/or have skin-to-skin contact and/or put their baby to the breast during the third stage. If you wouldlike skin-to-skin contact with your baby, you might like to ask yourcare provider that this happens immediately after birth.After your baby’s umbilical cord has been clamped and cut, yourcare provider will do controlled cord traction. Controlled cord tractionis when your care provider holds the umbilical cord and gently pullsdown on it, while pushing on the uterus with their hand (outside yourbody). A small amount of bleeding from a woman’s uterus at thistime is common.Finally, your care provider will usually help ease the placenta out ofyour vagina. After this, your care provider will usually massage youruterus by massaging your abdomen, to make sure it has contractedwell. Your care provider will usually also check your uterus to seethat there are no placental membranes still in your uterus and thatyou are not bleeding more than expected.Sometimes, unexpectedly, you or your baby may need extra medicalcare just as the third stage is about to start. You might like todiscuss with your care provider what might happen if an unexpectedemergency occurs during the third stage and what your options areif this happens.Some things, like receiving drugs to start off labour or tomanage labour pain, as well as the occurrence of unexpectedemergencies, are thought to reduce how much oxytocin awoman naturally produces during and after birth. You might like toask your care provider about the things that can affect how muchnatural oxytocin you produce.160

How might cordclamping and cuttingaffect my baby?What happensif my placentadoesn’t birth?A woman can choose to do early cord clamping or late cordclamping regardless of the kind of third stage she chooses. Earlycord clamping is when a clamp is put on the baby’s umbilical cord,which is still attached to the baby and to the placenta, as soon ashe or she is born. After clamping, the umbilical cord is usually cut toseparate the baby from the placenta. Late cord clamping is whenthe baby’s umbilical cord is left attached to the placenta and notclamped or cut for several minutes. When you wait longer to clampand cut the umbilical cord, blood can continue travelling from theplacenta to your baby’s body. You might notice the umbilical cordpulsating (beating like a heart beat) as blood travels to your baby.Usually, if you choose a physiological third stage, your care providermay do late cord clamping. Sometimes in a physiological third stage,the umbilical cord is not clamped or cut until after a woman birthsthe placenta. Some women choose not to clamp or cut the umbilicalcord at all and wait for cord and placenta to detach from the baby afew days after the birth.Sometimes a woman takes longer than usual to birth herplacenta. If you haven’t birthed your placenta within a certainamount of time, your care provider may offer you Syntocinon ® ,if you have not already been given it. The amount of timebefore you are offered Syntocinon ® is different for different careproviders, so you might like to ask your care provider what theyusually do. If your placenta is still not birthed after some time,your care provider may offer to remove your placenta manually.Removing the placenta manually is when your care provider useshis or her hand to gently scrape away the placenta from theuterus, through your vagina. Sometimes there are times when theplacenta is removed through an incision (cut) in your abdomen.You might like to ask your care provider about why manualremoval may be used.If you choose an actively managed third stage your care provider willusually do early cord clamping.There are differences in health and other outcomes for babies havingearly cord clamping compared to late cord clamping. You might liketo ask your care provider about these differences.Photo courtesy of Little Posers Photography161

Will I alwaysbe ableto choose?How might I choosebetween a physiologicaland actively managedthird stage?Most hospitals in Queensland will do an actively managed thirdstage unless a physiological third stage is requested. If you planto have your baby in a hospital, you might like to discuss yourpreferences for the third stage with your care provider duringpregnancy.Most births at home or in a birth centre will do a physiological thirdstage unless an actively managed third stage is requested. If youplan to have your baby at home or in a birth centre, you mightlike to discuss your preferences for the third stage with your careprovider.Different care providers care for women having a physiological oractively managed third stage in different ways. There might alsobe guidelines at your planned place of birth for how women arecared for if they choose a physiological or actively managed thirdstage. You might like to ask your care provider about how he orshe usually cares for a woman having a physiological or activelymanaged third stage and if there are guidelines at your plannedplace of birth.A number of studies have looked at what happens when womenhave a physiological compared to when women have an activelymanaged third stage. We have included some of the results ofthese studies in the next few pages.Will the results of these studies apply to me?The studies we’ve included are studies of women who weredescribed as low risk (eg women who were thought to have a lowchance of a postpartum haemorrhage). However, every woman’spregnancy is different, so the possible outcomes of each optionmight be different for you. You might like to talk to your careprovider who can give you extra information that is suited to yourunique pregnancy.In some situations, your care provider might suggest oneoption instead of the other. If this happens, you can ask yourcare provider about the reasons for their suggestion and makedecisions as a team. If one option is suggested by your careprovider instead of another, you can choose to follow theirsuggestion or choose to say no. Some care providers choose notto offer, or are not comfortable offering, all options to women. Ifyou are not able to be offered all options, or the option you prefer,you can ask to have another care provider.162

What are the differences between havinga physiological third stage and havingan actively managed third stage?Studies have found thereis a difference betweenhaving a physiologicaland having an activelymanaged third stageof labour in:The average amountof blood lost [3]Women who had aphysiological third stage…Women lost on average286ml of bloodWomen who had an activelymanaged third stage…Women lost on average209ml of bloodThe chance of having highblood pressure in thehours after birth [3]4 out of every 1000 womenhad high blood pressure inthe hours after birth28 out of every 1000 womenhad high blood pressure inthe hours after birthThe chance of havingafterpains (pains from theuterus contracting after birth) [3]2 out of every 100women had afterpains5 out of every 100women had afterpainsWomen who had afterpainsWomen who did not have afterpainsThe chance of havinga blood transfusion(being given blood) [3]15 out of every 1000 womenhad a blood transfusion4 out of every 1000 womenhad a blood transfusion163

What are the differences between havinga physiological third stage and havingan actively managed third stage? Continued...Studies have found thereis a difference betweenhaving a physiologicaland having an activelymanaged third stageof labour in:The chance of using painmanagement for sorenessafter birth [3]Women who had aphysiological third stage…1 out of every 100 womenused pain management forsoreness after birthWomen who had an activelymanaged third stage…2 out of every 100 womenused pain management forsoreness after birthWomen who used pain managementfor soreness after birthWomen who did not use painmanagement for soreness after birthThe chance of returningto the hospital due tobleeding after goinghome [3]1 out of every 100 womenreturned to the hospital dueto bleeding3 out of every 100 womenreturned to the hospital dueto bleedingWomen who returned to thehospital due to bleedingWomen who did not return tothe hospital due to bleedingNote: This is only if the best conditionsfor a physiological third stage are met(see page 159)The chance of having apostpartum haemorrhage(losing more than 500ml of blood) [1]3 out of every 100 womenhad a postpartum haemorrhage11 out of every 100 womenhad a postpartum haemorrhageWomen who had a postpartumhaemorrhageWomen who did not havea postpartum haemorrhage164

Studies have found nodifference between havinga physiological and havingan actively managed thirdstage in:The length of the third stage of labour [3]The chance of having manual removal of the placenta or when the placenta isremoved from an incision in your abdomen [3]The chance of having headaches, nausea or vomiting after birth [3]The chance of the baby having jaundice (yellowing of the skin and eyes) that is treated [8]The chance of the baby going into the Neonatal Intensive Care Unit‘NICU’ (a unit in the hospital for babies who need a high level of special medical care) [8]The chance of breastfeeding the baby until at least 6 weeks [3]The chance of having low iron levels immediately after birth [3]The chance of having low iron levels at two days of birth [9]The chance of having antibiotics for vaginal bleeding [3]Studies are not clearabout whether there is anydifference between havinga physiological and havingan actively managed thirdstage in:The chance of having a more serious postpartum haemorrhage (losing more than 1000ml of blood) [3, 8]165

How can I makethe decision that’sbest for me?Reasons I might choose to have a physiologicalthird stage...Reasons I might choose to have an activelymanaged third stage…At the moment, I am leaning towards…A physiologicalthird stageI’munsureAn actively managedthird stage166

How can I askquestions to getmore information?Asking your care provider questions can help you get the information you want and need. Below are somequestions you might want to ask your care provider to get more information during your pregnancy:How often do you care for a woman having a physiological third stage?How do you care for a woman having a physiological third stage?How often do you care for a woman having an actively managed third stage?How do you care for a woman having an actively managed third stage?What are my options if I would like a care provider who is experienced and skilled at caring for awoman having a physiological third stage?Are there guidelines at my planned place of birth about how women having a physiological thirdstage are cared for?Are there guidelines at my planned place of birth about how women having an actively managedthird stage are cared for?How would you feel if I refused a physiological third stage if it was offered to me?How would you feel if I refused an actively managed third stage if it was offered to me?Do I have a higher chance of having a postpartum haemorrhage? Why or why not?What are the possible outcomes in my unique pregnancy of having a physiological third stage?What are the possible outcomes in my unique pregnancy of having an actively managed third stage?How might my chance of having a postpartum haemorrhage change during my pregnancy andlabour?Are there things I can do during my pregnancy to decrease my chance of having a postpartumhaemorrhage?167

Where hasthis informationcome from?The information in this decision aid has come from the best scientific studies available to us. A list of these studies is included below:[1] Fahy, K.M., et al., Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartumhaemorrhage: A cohort study. Women and Birth, in press.[2] National Collaborating Centre for Women's and Children's Health, Intrapartum care: Care of healthy women and their babies during childbirth.September 2007.[3] Begley, C.M., et al., Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews2010(7).[4] Matthiesen, A., et al., Postpartum maternal oxytocin release by newborns: Effects of infant hand massage and sucking. Birth, 2001. 28(1): p.13-19.[5] Nissen, E., et al., Elevation of oxytocin levels early post partum in women. Acta Obstetricia et Gynecologica Scandinavica, 1995. 74(7):p. 530-533.[6] McNeilly, A.S., et al., Release of oxytocin and prolactin in response to suckling. British Medical Journal, 1983. 286(6361): p. 257-259.[8] Rogers, J., et al., Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial. The Lancet,1998. 351(9104): p. 693-699.[9] Thilaganathan, B., et al., Management of the 3rd stage of labor in women at low-risk of postpartum hemorrhage. European Journal of ObstetricsGynecology and Reproductive Biology, 1993. 48(1): p. 19-22.167

Myquestionsand notes168