Birth trauma

Birth Trauma – what does this mean to me?

In Australia, up to one in three women experience a ‘traumatic’ birth, with about 5% of these women developing a post traumatic stress disorder (PTSD).

It's a scary figure when you consider just how often society tells us our pregnancy will leave us ‘glowing’ and how much emphasis is placed on birthing ‘vaginally’, as opposed to birthing 'safely' – which for me as an obstetrician involves both the physical & psychological safety of a mother.

Both my own births were vaginal. My first was fast and furious and done in under four hours. I had a little baby, a tiny tear, and was a great milk bar. I loved both the birth and the postnatal period.

My second birth however was a completely different story, and it left me with both permanent physical damage and birth trauma. If I could have a ‘re-do’ (don't you wish for this at times!) I would have chosen an elective caesarean section.

I love birthing. It’s one of the most intimate and one of the most amazing parts of life. But it is also one of the most terrifying.

So what is birth trauma?

Although most birth trauma is more commonly related to the birth itself, stressful pregnancies complicated by issues such as a short cervix, high-risk twins, placenta praevia, or hyperemesis gravidarium, can all be 'traumatising'.

Birth trauma is most commonly associated with birthing where physical trauma occurs. This may include birthing requiring a forceps delivery, massive bleeding after birthing, nasty vaginal, perineal and rectal tears, unexpected resuscitation for mum or baby, life-saving hysterectomies, or unexpected trips to theatre. In these situations a mother can be left with a number of physical challenges, some short-term, and some for a lifetime.

Even when all goes well physically, the pain and uncertainty of the ‘marathon of birth’, is enough itself to be traumatic for many women. Add in failed hopes, unmet expectations and disappointment, and the risk of birth trauma, both physical and psychological, is ever present.

What should you do if you experience birth trauma?

If you have experienced birth trauma, the most important step to take is to tell someone, whether it be your partner, your midwife or obstetrician, or a close friend.

Ongoing physical trauma or disability is likely correctable, but without acknowledging it your healthcare team cannot give you the best chance of recovery. As healthcare providers we also take responsibility, asking each woman about bowel, bladder, and pelvic floor function and sensation at each postnatal appointment.

Psychological trauma needs acknowledgement and the opportunity for support, both formally and informally. With 1 in 7 mothers and Australia experiencing postnatal depression, and up to 1 in 3 describing a traumatic birth, healthcare providers should be debriefing every woman’s birth, assessing each new mum for depression and birth trauma.

Birthing is one of the most amazing experiences – but for many, also one of the most terrifying life experiences. Your whole world changes in a day.

Thankfully most births are challenging, exhausting, exhilarating and joyous, but not always. As a community we need to better acknowledge birth trauma, and so better support our women and their families when it comes to birthing and parenting.

Resources:

• Birth Trauma Association (UK)

• Perinatal Anxiety & Depression Australia

Diabetes and Pregnancy

Gestational Diabetes. What does this mean for me?

This week is National Diabetes Week in Australia.

Everyone knows someone who has or will have diabetes. In Tasmania there are over 25,000 people who live with diabetes.

Type 1 diabetes mellitus (T1DM) is more common in childhood and early adulthood. Type 1 diabetes can be inherited, but can also arise for the first time with no family history. A healthy lifestyle and diet, insulin injections or insulin pump are the main treatments.

Type 2 diabetes mellitus (T2DM) is more common as we get older. This is now the commonest type of diabetes. Family history (which none of us can escape) and obesity remain the two leading risk factors. A healthy lifestyle and diet, oral tablets and less commonly insulin, are the mainstays of treatment.

Gestational Diabetes Mellitus (GDM) is diabetes of pregnancy. This is usually diagnosed at 24-28 weeks of pregnancy with an oral glucose tolerance test (OGTT), and is seen in 10-15% of pregnancies. Not all women who develop GDM have risk factors (such as obesity, family history, previous GDM or age over 40 years), although these make the condition more likely. Once again, a healthy lifestyle and diet, oral tablets and sometimes insulin, are the main treatments.

Women with diabetes in pregnancy (T1DM, T2DM and GDM) all require a team approach to managing both their diabetes and their pregnancy. The team usually includes the woman and her family supports, her obstetrician, endocrinologist, diabetes educator, dietician and psychologist. Others may be required if the pregnancy or diabetes develops complications.

At TasOGS, as obstetricians who frequently manage women with diabetes in pregnancy we are aware of the different ways in which the different types of diabetes can affect mother, pregnancy and baby.

Extra attention is required to monitor pregnancies involving diabetes as they can have higher rates of complications. These include greater risk of miscarriage, blood pressure problems, risk of both extremely small and extremely large babies, higher rates of early birth, higher caesarean section need, risks of antenatal and postnatal depression, and higher rates of admission of newborn babies to the neonatal nursery.

Pregnancy can also accelerate some of the general complications of diabetes. Knowing this we encourage all women with diabetes to first discuss pregnancy planning with their GP, endocrinologist, or high-risk obstetrician before getting pregnant.

Diabetes is common. In pregnancy diabetes challenges both a women’s physical and psychological wellbeing, as well the wellbeing of her baby and birth experience. Understanding and support is one way to improve this experience for all.

We encourage your support of Diabetes Australia to enable further research in diabetes prevention, treatment and cure.

Models of care in pregnancy

Pregnancy models of care – do they really matter? 

Public or private care? That's the first question most families consider when choosing where to birth their baby.  Soon most realise that the choices are so much wider than even that!

When I was pregnant with my first baby these were the questions I first asked myself when deciding what to choose:

Public or private obstetric care? 

I chose private.

Why? Partly for some assured privacy, as I was working as a training obstetrician at the co-located public women’s hospital.

Though mostly in the knowledge that by choosing a private obstetrician I had a fully qualified specialist, of my choice, available to me 24/7. Continuity of care was also a high priority, allowing me to be cared for by the same obstetrician, her colleagues and midwives throughout my pregnancy.

Unfortunately direct consultant-obstetrician care and continuity of care throughout pregnancy, birth and post-natal time, is only available at very few public hospitals. Choosing a private specialist practice provided this for my baby, family and I.

What if I had birthed at the public hospital? I would have certainly chosen a midwifery team model – again for the importance of continuity of care.

Which maternity hospital? 

The private hospital I choose was co-located on site with the public hospital.

Why was this important?

Because this provided the best of both worlds. As an obstetrician I’ve seen the best and the worst of birth, and I wanted to make sure that both my baby and I could directly access either the neonatal  (NICU) or adult intensive care unit (ICU) in the unlikely event that this was needed. Similarly, having a public hospital on site provided the added backup of 24 hour trainee obstetricians and anaesthetists if there was an emergency and my obstetrician was not yet in the hospital.

I was also keen to avoid any separation from my baby. Because my private hospital was co-located I would not have needed to leave the building to access and visit the NICU.

Male or female obstetrician? 

I think this is a deeply personal choice.

It must first be recognised that interpersonal skills, surgical skills and birthing skills are not gender dependent. My recommendation is to find someone with all three skills, and then choose based upon on their approach to healthcare and birthing.

I chose an all-female group of obstetricians, as these obstetricians best reflected my personal views on birthing and parenting, and were the best fit for me personally.

Individual obstetrician or a group practice of obstetricians?  

I chose a group.

Why? I strongly value transparency. I wanted to know exactly who could or would be at my birth, and by choosing a group I knew this from day one. An obstetric group that only covers within their group ensures you know exactly who could or should be at your birth. I also knew that  because of their rostering I would always be assured of a well-rested obstetrician regardless of the time of day or night.

In the group I choose I met all three other obstetricians during my pregnancy, so not only did they know me, but I knew each of them and we were able to share our expectations for my pregnancy and birth.

All birthing healthcare providers should be driven by safety, patient education and surgical excellence. You should be comfortable expecting this with whatever model you choose.

Be your own advocate or seek out others who can be.  Your birth involves you, your body and your baby.

Your voice should always be heard.

Morning or all-day sickness?

For anyone with nausea and vomiting in pregnancy, you might appropriately assume that the person who coined the term ‘morning sickness’ had never been pregnant! ‘All day, anytime, anywhere sickness’ would have been a better choice of phrase!

My first pregnancy, after a trying time with infertility and reproductive assistance, saw me on regular intravenous fluids from early pregnancy until 16 weeks. I lost four kilograms in the first few weeks, and I can still tell you where every public rubbish bin was located on my drive to and from work. I felt exhausted, frustrated and mostly just miserably sick. Getting out of bed was a struggle and work a challenge.

In my second on-going pregnancy my nausea and vomiting was much less intense but persisted until the moment my daughter was born.

Some degree of nausea, with or without vomiting, is experienced by up to 90 percent of pregnant women. Thankfully for most women this does not continue much beyond 16 weeks and is manageable without admission to hospital.

There are many very safe and appropriate options for managing pregnancy nausea and/or vomiting. These include avoiding trigger foods, changing to smaller and more frequent meals, consuming products containing ginger, ginger extract or vitamin B6 (pyridoxine) supplements, as well as using acupuncture, acupressure or hypnosis.

If these are not successful prescription medication such as metoclopramide (Maxolon), doxylamine (Restavit), promethazine (Phenergan) and ondansetron (Zofran) are commonly used. These later option should be discussed with your doctor before use, but are nonetheless commonly and safely used during pregnancy.

Hyperemesis gravidarum is the medical term for women who experience severe nausea and vomiting. Usually this presents as regular daily vomiting (>3 times/day), weight loss, along with physical and laboratory signs of dehydration.

Hospitalisation is commonly required in order to receive intravenous fluids, and this can sometimes last for an entire pregnancy. Unfortunately there is a high chance of this recurring in later pregnancies – and is sometimes a reason some of us choose to not have more babies!

Whether you have nausea, nausea and vomiting, or hyperemesis itself, thankfully none of these are typically associated with any concerns for the baby.

So why do some get unlucky with nausea and vomiting while others sail through pregnancy?

The short answer is that we don't know. There are many risk factors for nausea and vomiting in pregnancy including twins, female babies, having a mother who had hyperemesis, having underlying gastric reflux, hormonal-related migraines, a history of motion sickness, and having had hyperemesis before.

Unfortunately this still doesn't truly allow us to predict who will experience nausea and vomiting during pregnancy, how bad it will be, or how long it may last.

If you have issues with nausea and vomiting in pregnancy make sure you talk to your obstetrician, GP or midwife. Not all nausea and vomiting needs to be treated, but there can be situations where you may benefit from additional nutritional support, medication, psychological support or hospitalisation.

The Journey of Infertility

If it was not for assisted reproduction treatment (ART) options, such as IVF (In Vitro Fertilisation), I would not have my two amazing daughters. For that I am extremely thankful. IVF is a challenging journey. If I could have chosen another option, I would have. However, like for many women, it was my only option for pregnancy.

During my IVF journey I felt moody, exhausted, disappointed, teary, bloated, nauseated, frustrated, hopeful and overwhelmed – and that could sometimes all be on the same day!

I managed giving myself injections everyday. I endured the multiple vaginal scans by different specialists. I tolerated the egg pick-up process. It was however always the embryo transfer that I found the hardest.....do I remain hopeful or do I maintain a face of resilience, doubt and realistic pessimism...?

Nonetheless, my IVF journey ended with a good result – even if the process was difficult.

Just as with spontaneous pregnancies, sadly not every IVF journey ends the way we hope. Ongoing infertility, pregnancy losses, pregnancy complications and perinatal loss can happen whichever way we conceive.

For some of us, the pregnancy journey is just tough.

Everyone’s journey with fertility is different. IVF is not necessarily better or worse than for those who conceive spontaneously (the old fashion way), but there are some important differences and added challenges.

IVF brings with it significant extra cost; pregnancy rates are not as high; the physical and emotional swings often greater, adding personal and relationship stress; and the pregnancy that follows can be associated with higher risks.

Pregnancies from IVF can have up to a 2-fold greater risk of preterm birth and low birth weight babies. There are associated increased rates of placenta praevia (placenta covering the cervix), placental abruption (the placenta separating too early in a pregnancy), gestational diabetes, pre-eclampsia (blood pressure and protein in a pregnancy after 20 weeks) and higher rates of caesarean section.

For these reasons, we manage your pregnancy closely and carefully, being mindful of these higher risks. Because of this, your pregnancy care with an IVF baby should involve a specialist obstetrician for at least one planning consultation, even if your pregnancy is primarily managed by another healthcare provider.

At TasOGS our obstetricians have significant experience managing high-risk pregnancies, including those from IVF. We are happy to provide single consultations or to care for you and your family throughout your pregnancy journey.

When should you book for pregnancy care?

Congratulations, you’re having a baby! At TasOGS you can choose to book with us as soon as you know that you’re pregnant.

Booking early has the double advantage of ensuring you don’t miss out on the limited spots at TasOGS and allows us to offer you an ultrasound scan as early as 6 weeks.

Early ultrasounds have been shown to improve pregnancy outcomes by improving the accuracy of pregnancy dating. This reduces your risk of a post-dates pregnancy and in turn reduces the risk of stillbirth.

Most importantly, as we found ourselves when pregnant, an early scan allows you and your family to be reassured about the progress of your pregnancy.

Our TasOGS obstetricians Dr Kirsten Connan and Dr Tania Hingston, each care for only 10 new pregnant women and their families every month. Limiting the number of deliveries each month ensures that you will receive the personalised care we aim for at TasOGS and most importantly means you will always be safely supported by a well-rested obstetrician.

Booking early gives you the best chance to secure a spot at TasOGS, depending on your baby’s due date.

If you call and our TasOGS bookings are full for your due month, we will be able to recommend alternative Hobart obstetricians.

Booking early also provides you with an opportunity to consider the many genetic and chromosomal tests  that are now available in pregnancy – often requiring only a simple blood test. Many of these are best performed at 10 weeks gestation or earlier. This maintains your choice about continuing your pregnancy and keeps you well informed about any implications or management options.

When you book with TasOGS you will need to have a referral from your GP or specialist, and we will need to know your baby’s due date, whether calculated by yourself or provided by your GP. It’s an exciting time!

Good luck with the exciting and rewarding parenthood journey ahead!

Guilt and the Caesarean Section

As a mother of two young girls, a wife and a full-time medical specialist, I have tried hard to avoid the trap of ‘guilty parenting’. I am sure many of you know this challenge. There are never enough hours in the day to satisfy all the demands of life and I do not believe there are any true superwomen.

When it comes to parenting, my youngest daughter challenges me most, battling the reality that I am not the stay-at-home mother that she desires.

So what am I left to do?

The answer is simple. When I am working, my priority is the women I am privileged to care for and share with. When I am at home, my priority is my daughters, shared with my husband. Somewhere in the left over hours I find time for the other important parts of life – without all these I could never be the woman, mother, wife or medical specialist I strive to be.

Balancing these many dimensions of life is not easy. Importantly I must be kind to myself and choose to not let guilt be yet another emotion added to the mix.

I sometimes hear my obstetric colleagues talk of the guilt they see some women feeling having needed or chosen a caesarean section as their own birth experience. I find myself saddened that this guilt is a distressing reality for many women. How is it that as women's healthcare providers we have allowed this emotion to persist and perpetuate in our community?

A woman’s birthing journey should primarily be about safety. Safe mother. Safe baby.

The birth itself represents a profound life changing moment in every family’s life. But it is just that, one moment. Don’t get me wrong – I will always remember the first moment I laid eyes on my daughters. Their vaginal births were incredibly special moments in our lives. But being a parent is so much more than the birth moment.

As a parent you make daily decisions that you feel will be best for your family. As a mother or parent to be, it’s no different.

Choosing the way in which your baby is born is a very personal decision.

For most obstetricians and women, a vaginal birth beckons first. But if you need to choose a caesarean section, because it is safest for you physically or psychologically, or because it is the safest way for your baby, then that is the best decision. A decision each woman and her family should feel empowered to make if needed, guided and supported by their obstetrician. Remember: safe mother, safe baby.

With one in three Australian women having a caesarean section today, we can no longer call vaginal birth ‘normal’ – this is language from the past that carries unnecessary judgement.

So I challenge both my colleagues and their women to be kind and not to have any guilt about the way in which they birth. The focus should be on high quality medical care, parental education and support, and safely bringing a new life into the world.

The rest, including the route of exit, is important but still secondary to the experience and safety of each woman, her baby and their needs as unique individuals.

Planning for Pregnancy

Whether you are married, partnered, or single, you have lots to think about when considering getting pregnant and having a baby. For those of us that have needed to walk the IVF path to have our babies, we know all too well the planning (and financial costs) that can go into a pregnancy.

The timing of your pregnancy should always be considered in your decision.

Planning 6 months in advance

If you and your partner are thinking about pregnancy, I recommend you start planning six months in advance.

This gives you time to begin to track your menstrual cycle (period) and learn your body’s signs of ovulation (or lack there-of!). Most women need a cycle between 21 and 35 days to achieve ovulation (the release of an egg). On average you ovulate 14 days before the end of your cycle.

If you are one of the lucky women with a regular cycle length, you will then be able to predict your fertile window. This is usually from 5 days before ovulation to 2 days after.

There are also many handy apps and ovulation kits now available to help you track your cycle and predict this fertile window. If you are still struggling to determine when your fertile window is, or even if ovulation is happening, make sure you have a review with your GP or gynaecologist.

Women commonly ask me how often they need to have sex when they’re planning for a pregnancy.

Obviously you can have sex whenever you like with your partner! But if the goal is fertility, then having sex every second day during your fertile window is enough. Sperm can survive in the vagina for as long as 5 days, though typically last 3 days. An egg released from the ovary needs to be fertilised within 24-48 hours of ovulation to survive. It is these two factors, the longevity of sperm and eggs, that gives us the '5-and-2' fertile window.

Medical conditions

If you have any medication conditions that regularly require you to see a GP or specialist, you should discuss your plans for pregnancy with your doctor.

Although uncommon, there are occasionally medical conditions that place a pregnant woman’s life at risk or increase the risk of pregnancy complications. Knowing this before falling pregnant allows you to make an informed decision about your pregnancy – as well as allowing you and your obstetrician to plan your pregnancy and delivery together as a team.

Pre-pregnancy vitamins

One of the benefits of planning your pregnancy is that it gives you an important opportunity to start taking folate three months before falling pregnant. Folate-supplementation during pregnancy has many health benefits, most importantly it reduces the chance of congenital defects in babies, especially neural tubedefects, such as spina bifida. Most women will need to take 400 mcg of folic acid (folate) per day.

Once you are pregnant you should also take 125 mcg of iodine daily. Iodine deficiency is unfortunately still common in some parts of Australia and has important health consequences for babies.

Women with certain medical conditions may require high dose folic acid (2-5 mg per day). If you have a medical condition, please check with your GP or gynaecologist if you need this high dose folic acid.

You may choose to take your folic acid either as a folate tablet, or as part of a pregnancy multivitamin. Personally I recommend a daily pregnancy multivitamin, such as Elevit™ as these already include iodine, avoiding the need to take anything more than a single tablet.

Other medications in pregnancy

There are some medications that should be avoided in pregnancy, and your GP will be able to advise you on these.

However sometimes the risk to a mother and baby of not taking an important medication is greater than the risk of continuing the medication. For this reason it is important to talk with your GP or obstetrician if you take any regular prescription or over-the-counter medications before becoming pregnant.

The decision to stop, continue or change medications can sometimes be complex, and so is best managed in a personalised and collaborative way between you and your doctors.

Pre-pregnancy vaccinations

I also very strongly recommend that you check your rubella (German measles) and varicella (chicken pox) immunisation status before falling pregnant. This requires only a simple blood test with your GP or obstetrician/gynaecologist.

If you are not immune to one or both of these viruses you should see your GP and get vaccinated as soon as possible. However as these vaccines are not safe to have during pregnancy, you will then need to wait another 3 months before attempting to fall pregnant.

Once pregnant I also strongly recommend that all women receive the annual flu (influenza) vaccine. Pregnant women are unfortunately both at increased risk of catching seasonal flu and also more likely to become seriously unwell if they do contract it.

Pre-pregnancy diet, exercise and stress

Before pregnancy I strongly recommend that you stop smoking, stop drinking alcohol and begin or continue regular exercise. Ideally you should minimise your exposure to stressful environments and sleep deprivation (yes, easier said than done!). Your partner should also do the same.

Sometimes planning your pregnancy and the start or growing of your family can be a great reason further develop a positive and healthy lifestyle. What better way to bring a new life into the world!

So what’s ahead?

Now that you have a plan, great!

Achieving a pregnancy is often fabulous news, but it is also only the first step toward welcoming a healthy baby.

Make sure you see your GP as soon as you are pregnant. You will next need lots of information on preparing and planning for your safe and healthy pregnancy, along with the many rewarding years of parenthood ahead!