Anyone who knows me well will know that I am a huge advocate for respectful, evidence based, consensual medical care. You would also know that I am hugely against inadequate medical care when medical care is absolutely necessary and INSANELY AGAINST biased and coercive based medical care.

If you didn’t know any of that, then congratulations! Now you know and I won’t have to say it all again later on.
Before I really get started on what this blog post is about though I’d like you all to picture something in your minds for me:

• A man goes to the emergency department of his local hospital at night for excruciating lower abdominal pain, non-stomach-bug-related vomiting and inability to walk without aid.
  The pain doesn't respond to any of the standard pain relief medication normally given when people present with severe (currently) unexplained pain – paracetamol and ibuprofen doesn’t work, the maximum doses of endone or buprenorphine doesn’t work. Usually when that happens the nurses consult with the on call registrar and stronger pain medications are ordered (morphine, fentanyl etc).
  The man gets to stay in the hospital for a couple of days or so days with regular morphine and/or fentanyl and/or every other strong pain relief available to try and get the pain under control while having in depth investigations to find out exactly what is causing the pain (by in depth I don’t just mean the standard urine and blood tests and maybe an ultrasound – I mean the full kit & caboodle testing to rule out everything from appendicitis to cancer to an obstructed bowel). The man walks out of the hospital with his pain under control and either a diagnosis or a referral to a specialist who can diagnose him.
  
  

Now I ask you to picture this:

• A woman with a pre-existing incurable and generally painful disease goes to the emergency department of her local hospital at night for excruciating lower abdominal pain, non-stomach-bug-related vomiting and inability to walk without aid.
  She is only given one endone every 4 hours and two paracetamol every 6 hours. When she tells the nurse that neither of those pain medications is helping at all she is given a heat pack and told “that will help” (what the nurse hasn’t been told is that the patient spent the previous 6 hours before rocking up at the hospital at home taking the buprenorphine she normally takes for severe pain related to her pre-existing disease with a heat pack so hot that it is burning the skin on her lower abdomen). Only the basic tests (urine, bloods and an ultrasound – a basic one that cannot pick up the disease that she has and has been proven in the past to not show serious things that were happening within her body) – are done and she’s left to suffer and cry alone in her bed on the ward while still in excruciating pain. After about 12-18 hours, and maybe in a rare case after a second overnight stay, she is sent home and told to “wait it out” as it is assumed to just be a 100 times nastier than normal flare up of her incurable condition – no in depth testing has been done, the pain is still not under control and the woman in question can barely walk let alone speak up for herself as she’s pushed out the automatic doors with no real help and told to see her GP in the morning, all so the hospital can make room for someone “who really needs the bed”.
  
  

After visualising both of those scenarios can you see the difference between the two? The differences between the tests that were done and the treatments that were given? In how both patients are cared for and the results that both received? In when and how they went home?

The man received better treatment, his pain with an unknown cause was taken much more seriously and given top priority to find out what was wrong, and he was given adequate pain relief and left the hospital with the pain in control and a plan in place.

The woman wasn’t given adequate treatment, was given inadequate pain relief, was brushed off and mostly ignored, and, potentially even more dangerously, her pain was solely attributed to a pre-existing condition with only minimal investigation done - what if it had been her appendix getting ready to burst? Or what if part of her bowel that wasn’t visible on ultrasound had ruptured? Or what if her fallopian tube and ovary had twisted right behind her uterus where it can’t be seen clearly and had gone into torsion which can result in the loss of an ovary if it isn’t picked up in less than 6 hours of onset and can be deadly if it is left untreated? All of these are valid concerns but sadly a lot of them are brushed off and ignored if there isn’t anything visible on an ultrasound or if the symptoms don’t exactly match what most doctors have been trained to recognise.

If you can’t tell already I’ll explain this now – there is HUGE inequality between how men and women (and this is not even going into how those who don’t associate as either are often treated!) are treated when it comes to the quality of the medical care given to them.

In some ways - and some places - we are still very much in the dark ages with how women experiencing reproductive, lower abdominal and pelvic issues are treated in hospital settings. This is not to say that there aren’t some wonderful care providers out there because there are, I’ve personally met some of them, but they are few and far in between and the chances of one of them being on duty when you end up in hospital are really slim.
You may think that these are just random scenarios created in the fertile darkness of my crazy mind but I must sadly inform you right now that this isn’t the case.

These scenarios are both based on very true stories – the inspiration for the man’s scenario came from a combination of my own husband’s experience and the experiences of random men who have shared their stories online, the woman’s scenario actually happened only this past week, and the woman’s scenario is also, I am very sad to report, the real life outcome that happens to hundreds of women every single day all around Australia.

When I randomly questioned a group of women (some who have children and some who don’t have children, some with a painful health condition and some without any known conditions at all) about the two scenarios above the answers were empathetic towards the woman’s scenario and many shared their own experiences.

• W- “It is like you have written the experiences of myself and my husband”
  
  
• Another, Anonymous, responded with – “The world is sexist as if a man says he is in pain he is surrounded by help but a woman has pain she is told to deal with it.”
  
  
• P says – “It's BECAUSE pain associated with women's reproductive organs is accepted as "normal".
  
  
• From B – “I'm a part of a huge Perth group and I honestly just saw a story like this on there, but it was a mental health thing. They kept the person in overnight but then said they assessed her and she wasn't deemed worthy of a bed and was discharged even though she went in with suicidal tenancies - yet someone else (male) posted their experiences with the same hospital in the same mental health unit and couldn't stop praising the hospital saying how great they were for him and how they must have been leaving something out for them to have kicked her out. Yet, when copious amounts of other women came along and said they experienced the same thing, said male 'joked' that men have it harder anyways which is why they're better looked after.
  I know it's not the same thing but in some aspects is because it shows that there are some discrepancies in care.
  I have seen this before myself and been a part of it. A few years ago, I presented to the ED with chest pains and numbness down my arm. I got taken in 2 hours later, put on an ECG machine and monitored for an hour maybe 2 before told I could go home. Given pills for the pain and dizziness I was feeling at the time too. Nothing worked and I felt so horrible and tired that while on the ECG machine, I fell asleep. Next morning, woke up and felt horrible and the pain wasn't gone but dulled down.
  A couple years later, XH goes to hospital with exactly the same as what I was feeling and ended up staying overnight and having all tests run on him under the sun (Luckily they did cause they found gall stones but still) and I remember just saying to him that he was get preferential treatment cause he was a male - little did I know how true it actually felt.”
  
  

Every single day in Australia women are treated as second class patients compared to their male counterparts and have their pain ignored, they are told to “suck it up”, that pain is “normal” (pain is not “normal”, even the scientific literature agrees that pain isn’t “normal” and is a symptom of an underlying issue that needs to be treated) and that we just need to live with it, to go and see a psychologist or therapist because it’s “all in our heads” and if we “fix our heads” the pain will “go away” (it won’t, physical pain can’t just be stopped by a psychologist or therapy, it needs adequate physical medical treatment and pain relief as well and even then it may not be “fixed”).
What can you do to change this? There are several things and I’ll outline them below.

• Contact your local members for parliament. By sending your local members for parliament letters outlining your anger at how women are treated in the healthcare system you can help to promote more awareness by making them aware. Not all of them will respond or take it seriously, but some will take action on it.
  
  
• If you or someone you know has been on the receiving end of this sort of treatment lodge a complaint with your local hospital. While most of the time you’ll only get a generic apology letter it is known that the more times that complaints are made, and the more people who kick up a huge stink about how they have been treated, the more that problems are taken seriously and the better the treatment will be for similar scenarios in the future.
  
  
• If you or someone you know are currently being treated inadequately in a hospital setting and located in QLD you can call 13HEALTH and quote “Ryan’s Rule” (you can find the details of Ryan’s Rule here - https://www.health.qld.gov.au/cairns_hinterland/html/ryan-home)
  
  
• If a specific doctor has treated you or someone you know like this you can lodge a complaint with the Medical Board (http://www.medicalboard.gov.au/~/link.aspx?_id=60F806737FE14B28AF314FB306B4BFBE&_z=z) and also with the Australian Medical Association (https://ama.com.au/tas/health-complaints)
  
  
• Share awareness amongst your friends, family and anyone else who will listen. Many won’t be interested and some may even ridicule you but there will be people who are receptive to what you have to say and will listen and take action themselves.
  
  
• Continue to advocate for yourself and those who rely on you for their care. If you don’t advocate for yourself you can’t change how you are treated. As part of advocating for yourself you can ban any practitioner from treating you or being in charge of your care and can request another practitioner if needed. You have the right to receive the best healthcare and treatment possible (and also to refuse any healthcare that you don’t want to have). The more people who advocate for better healthcare for themselves and others the more that Australia’s care providers will see how much people aren’t willing to put up with substandard treatment.
  
  

Lastly I want to say this – in order for the treatment of women in the healthcare system to be improved those who are in charge of our care need to be taught that we women are equal to and just as deserving of high quality medical treatment as our male counterparts who are also patients. They need to learn that our pain is real, that it exists physically and that a lack of adequate treatment is not only detrimental to our health and well-being (as women) but also to that of our families and friends too. Care providers need to take our pain seriously and provide adequate pain relief (not just minimal pain relief) and need to be educated on the various diseases and conditions that can cause it – not just the basic information from one paragraph in a medical text book but actual first hand information provided by a specialist in that particular field. They also need to respect us not only as fellow human beings but also as people who are intelligent, educated, able to recognise when something is wrong with our own bodies (it is our body after all and no one knows it better than ourselves) and able to make informed, intelligent and needed decisions for ourselves without being coerced, manipulated, forced or scared through fear mongering into making a decision that we otherwise wouldn’t make.

Recently I saw a question on a pregnancy and parenting page asking about being induced at 37 weeks for a “Big Baby” (estimated to be around 9ish pounds/4-4.5kg by 40 weeks). This particular mum-to-be didn’t feel comfortable with being induced then, and did say that, but was seeking advice and support that it was the right thing to do.
I did what I usually do, I advised of the risks, the benefits, that the estimated weight was not “Big” at all and many women birth babies even bigger than that vaginally and after spontaneous labour with no issues at all, and reassured the mum-to-be to follow her heart – in that if it didn’t feel right then tell her doctor that she didn’t want to be induced and would wait until baby decided to arrive on his/her own.

This kind of question is becoming more and more common these days, women being told they are having “Big Babies” estimated to be between 9 and 10pd (which isn’t “big” as such, it is just another variation of normal size) and will be induced between 37 and 38 weeks gestation because of that. These women are apparently not being given any choice in the matter, they are being told it WILL happen, that they NEED to be induced as if they don’t their baby will get stuck (shoulder dystocia) and die because it is too big to be born vaginally.

For the record, this is not evidence based medical practice, this is fear mongering and scare tactics and outright lying by medical professionals in order to get an expectant mother to do what THEY want her to do. A 9-10pd baby is not big, 11+ pounds is “big”. 9-13pd babies are born all around the world all the time without any issues when the mother is able to move around in whatever way she finds comfortable and as a result assist the baby in manoeuvring through the birth canal. In these cases there is no respect for a mother’s decision making, no allowing the woman’s body to do what it was made to do, preventing the natural physiological process of birth from occurring when the time is truly right and making women around the world afraid of a natural body process. To add to this a small baby is just as likely to get stuck as a larger baby if baby’s position and mothers position while birthing are not ideal. There are ways to prevent it and to reduce the chances of it happening, and early induction is not one of them and has a higher chance of shoulder dystocia by preventing the mother from adopting natural birthing positions due to the CTG monitoring and in many cases an epidural as well when the induced contractions become too much for the mother to bare and increasing the chances of baby being malpositioned when artificial rupture of the membranes (amniotic sac) is done as part of the standard practice of induction, traumatic physical and emotional intervention with the use of ventouse (vacuum), episiotomy, forceps and physical pressure on the mothers abdomen, and fetal distress from the induction itself resulting in either the above mentioned interventions or an emergency cesarean occurring.

But what I've mentioned just above is not what prompted this blog post. What prompted this is the lack of up to date knowledge in obstetricians and other mothers who were “fans” of this particular page and answered this particular question.
These “fans” were promoting induction at 37 weeks with no major risk factors or true need, stating that it was “term” and “baby would be fine”. This information is incorrect, not only have the WHO and ACoG, within the last 12 months, updated their guidelines of when “term”, “full term” and “post dates” are, but an induction at 37 weeks for no reason other than an ultrasound weight estimate (proven to be inaccurate in the majority of cases) shows that baby is measuring larger than average. The new guidelines state that “term” is now from 39 weeks to 39+6 weeks after recent research showing that a lot of important brain development occurs in-utero between 37 and 39 weeks and babies who stay in longer have less physical issues than babies born before 39 weeks gestations (eg feeding issues, regulating of body temperature issues etc), “full term” is now from 40 weeks to 42 weeks gestation, and “post dates” is now from 42+1 weeks onwards.

What does this mean for pregnancy and birth and going past 41 weeks gestation? Well frankly it means that every woman should now have a much higher chance of being able to go into labour naturally when their baby and body are really ready without the need to be induced, whether it is at 37 weeks that their baby decides that he or she is ready, or at 43 weeks, AS LONG AS all obstetricians and doctors follow the ACoG and WHO guidelines, which unfortunately for all of us women is not the case. Sadly most obstetricians and doctors do not follow these guidelines, they follow their own guidelines and the hospitals outdated policies on “management” of pregnancy and labour. And “management” it is, they are “managing” us like animals, inducing when they want, cutting us open when they want, giving us medication when they want, telling us what we can and can’t do, scaring us and putting the fear of death into us, only telling us what they want us to know and not what we need to know, essentially taking away our basic human rights and preventing us from making our own truly informed choices and decisions by not providing all of the information and only telling us what they want us to hear.
There are of course exceptions to this, there are some wonderful and truly amazing obstetricians and doctors out there who treat women with respect and dignity that they deserve and do everything that they can to inform women of ALL of the risks and benefits, accept a woman’s choices without trying to change her mind, support her unconditionally in those choices and go out of their way to try and give the woman the birth that she desires. They are few and far between, a dozen or so in every state, a few hundred or so in every country out of a hundred thousand or more obstetricians and doctors around the world that are trained in high risk pregnancy and birth.

“So what?” You might say, “They are trained in pregnancy and birth, they know what they are doing.” Yes, they are trained, in “HIGH RISK” pregnancy and birth, the types of pregnancies that might be dangerous for mum and/or baby. They are NOT trained in natural physiological childbirth, they are not trained in the kind of birth that does not need drugs to make it start, that does not need intervention or constant monitoring, that does not result in a mother on her back in a bed unable or "not allowed" to get up and move around and physically help her baby to get into a better position for birth, they are not trained in allowing a woman’s body to do what it was made to do and treat every woman the same as if they have the same risks as every other woman. Every woman, every body and every baby are different with different risks and different needs, we do not all fit into same mold (eg not everyone has a 12 hour or less labour just as not every woman has a very long 55+ hour labour), but obstetricians and doctors are trained to fit everyone into the same mold with the same risks regardless our own individual risk factors, body shapes, histories, abilities and needs.

How can we change this? How can we make pregnancy and birth an individual thing again? How can we make obstetricians treat us with the respect and dignity that we deserve? How can we make them respect our decisions and choices without trying to scare us or bully us into what they want us to do? The answer is that every woman and every man must make the decision to stand up for themselves and their partner, to say NO, to make obstetricians and doctors understand that it is NOT a medical professionals or hospitals decision to make on when a baby comes into the world, to make obstetricians and doctors stop scaring women with generalised risks and outright lies, to make the maternity system in whatever country you live in stop and listen and change its policies for the benefit of ALL women, to make pregnancy and birth about the woman once again and not about the medical side of things. Women everywhere need to take their bodies back, to make sure that everyone knows that SHE makes the decisions regarding HER body and HER baby, and that hospitals, obstetricians and doctors are NOT the ones to make the decisions. Even in a life or death situation the mother has the right to decide what is to be done and should be given the chance to do so, even if there is only a minute available for her to make that decision that will affect her and her family for the rest of their lives, she should be the one to decide, not someone else who doesn’t have to live with the consequences.

So there you have it. We live in a medicalised world that is slowly trying to remove all natural bodily autonomy from women, that is trying to stop women from being able to choose if she has an induction or cesarean or waits until her baby and body decide that it is the right time, a world where women are being scared and bullied into inductions and cesareans instead of being given the right information and support to make a truly informed decision over their bodies and method of birth, a world where women are ridiculed for their decisions, denied good care, denied the right support that they need and are traumatised on a regular basis when they are in the most vulnerable state and position.

Can you imagine a world where women are supported personally in a way that fits their individual needs and wants and are empowered in the process? Can you see a world where a woman is able to choose whenever she wants if she has a home birth, an unassisted birth, a hospital birth, an induction or a cesarean without being judged, ridiculed or traumatised in the process? Where she is truly informed about the risks and benefits of every procedure instead of only informed that  the medical professional feels is all she needs to know? Where she can birth however she wants without being lied to or scared by medical professionals? Where she can trust those who are caring for her and supporting her to give her the power to make her own decisions regardless of where she lives, her body shape, her previous history, or what she looks like? I can, I can see that world, our world can become that world. If we all worked together to make changes, if we all supported one another in our individual decisions regardless of what they are, we can create that world and make it ours.

Jenna Edgley
Student Birth Doula
Placenta Encapsulator
FOOTPRINTS & RAINBOWS

Here are 10 frequently asked questions (including one interesting question that came up a few months ago) about Meconium and their answers for you all. I have tried to keep them simple and to the point with easy to understand language.



Q1) What is meconium?

 A) Meconium is our first poo. It starts being produced inside the intestines while we are still within the womb and remains there until the bowel becomes mature enough for the baby to do its first poo. It is made up of amniotic fluid, intestinal epithelial cells, lanugo, mucus and bile.


Q2) Why do some doctors think that meconium as a bad thing?

A) Some doctors consider the present of meconium in the amniotic fluid to be a bad thing as it produces the risk of meconium aspiration. More details on meconium aspiration can be found in the answer to Question 4.


Q3) What does meconium look like?

A) Meconium usually looks green-black or olive green in colour and has a tar-like consistency, meaning that it is very sticky. It is mostly odourless. When meconium has been passed in utero it can make the amniotic fluid appear to be any of various shades of green, brown or yellow.


Q4) What is meconium aspiration, how common is it and what can be done to prevent it?

A) Meconium aspiration is the one real risk of there being meconium present in the amniotic fluid. It occurs when the baby inhales meconium during pregnancy, labour or birth and results in the meconium being lodged in the lungs. While meconium is present in the amniotic fluid of 5-20% of all births only approximately 5% of those babies will aspirate meconium, making it not very common compared to other risks of childbirth, and yet it is still more common than uterine rupture or hemorraghe, however the rates of infant death as a result of meconium aspiration is higher than the rate of infant deaths where no meconium is present.
Currently there is nothing “official” that can be done to prevent meconium aspiration; however some birth professionals have suggested that induction of labour, speeding up labour with drugs, hyper stimulation of the uterus and baby before it is born (or before the head is out in the case of breech babies) and severe dehydration in the mother can contribute to it happening. Other causes like a brief cord accident and placental abruption cannot currently be prevented. Suction of the baby directly after a vaginal birth may help with removing the meconium within the amniotic fluid in the mouth and throat that has been pushed out from the lungs however as meconium aspiration from the meconium that remains in the lungs still occurs even with this technique and its success is limited. A caesarean delivery where meconium is present may also produce higher rates of meconium aspiration as the baby’s body has not been squeezed through the birth canal and the fluid can remain in the lungs even after suction is done.
Meconium aspiration can cause respiratory distress which can then turn into pneumonia in babies and can be fatal although I do not currently have the Australian statistics for fetal mortality from meconium aspiration.


Q5) What should I do if meconium is present in the amniotic fluid?

A) First of all, don’t panic. While 5-20% of all births have meconium in the amniotic fluid only 5% of those will result in meconium aspiration, which makes it a rather small number of approximately 0.25% or less of all deliveries which is really quite low.
Secondly, relax. As long as baby is happy and is not in actual distress (a scalp clip monitor or ultrasound are currently the best ways to assess how baby is coping and if distress is present) then you have nothing to worry about.
Lastly, the risk of meconium aspiration is very low, and well trained care providers can pick it up very fast and treat it quickly.


Q6) My doctor told me that meconium was present in the amniotic fluid on the ultrasound and said that I needed to have a caesarean section, is this really my only option?

A) For all of you pregnancy/birth-savvy readers who know as much as I do or more than I do about meconium, yes this is a real question that was asked a few months ago in a pregnancy support group (I have however changed the wording of the question). For those who don’t understand what I mean and are wanting to learn more – meconium cannot currently be identified via ultrasound. It is currently impossible to be able to see meconium on an ultrasound, even on those fancy 4D ones.
So to answer this question – No, caesarean is not your only option! You can birth however you want, whichever way you want. At this point I would be doubting the capability of any doctor who mentioned that to me, and anyone who is told this should question their care provider fully on how they came to this conclusion.


Q7) What causes meconium to be produced?

A) Meconium presence can be caused by hypoxia (lack of oxygen to the brain) which can cause the bowels to contract and release meconium, fetal distress is along the same lines as hypoxia in how it produces meconium but is usually not quite as bad and can eventually result in hypoxia as well if it is not picked up quickly, and it can also be a cause of baby being post estimated due dates. Meconium can also be produced during labour when the baby’s head is compressed while moving down the birth canal combined with the lack of oxygen during a contraction when the blood is squeezed out of the uterus by the contraction of the uterine muscles (a very normal thing and this can be reduced by breathing normally throughout contractions and while pushing instead of holding your breath). This can stress the baby out a bit – being squeezed and having your oxygen supply limited could stress anyone out really – which results in the involuntary contraction and release of the bowel and passing of meconium, this is not the same as true fetal distress however.


Q8) Is there anything that I can do to prevent meconium from being produced?

A) No not really. It is usually out of our control, however some birth professionals have suggested that avoiding an unnecessary induction (just being post dates, baby estimated as being “big”/“large” or having controlled gestational diabetes does not automatically mean that you need to be induced if baby is still happy in there), and avoiding augmentation (speeding up) of labour can reduce the occurrence of some of the things (fetal distress and unexpected cord compression) that can cause meconium to be passed early. For the most part in a normal pregnancy meconium is only produced once the babies bowels are mature, so if you go into spontaneous labour and baby is otherwise happy and there are no signs of fetal distress and there is meconium present then you can be assured that your baby is ready to be born and his/her bowels are mature.


Q9) Why must I be constantly monitored if meconium is present in the amniotic fluid?

A) The idea behind constant monitoring is to pick up fetal distress early enough for emergency life saving measures to be implemented. As the presence of meconium can sometimes indicate that the baby is in distress hospital policies, and many obstetricians themselves, prefer to err on the side of caution and monitor the baby continuously so that the distress can be picked up quickly if it occurs and the monitoring is usually done using a CTG machine.  However recent research on constant monitoring has found that constant fetal monitoring does not improve outcomes by very much and the CTG machines can show false readings if baby moves too much or if the mother moves. The monitoring also limits movement of the mother which can result in other issues as well. Intermittent monitoring using a hand-held Doppler, constant monitoring using a scalp clip or regular monitoring by ultrasound can give better results and prove without a doubt whether the baby is in distress or not.


Q10) So I really shouldn’t stress about meconium then?

A) This depends on the reason for the presence of the meconium. If it is because baby is already in distress then it is time to worry, and you will be meeting your baby very soon either via caesarean or if you are already pushing then usually via assisted delivery using either forceps or ventouse (vacuum) extraction. If it’s there just because you are post estimated due date and baby is otherwise happy then you don’t have to worry. Meconium can also be present but be “old” meconium from a few weeks to a month or more earlier which can be caused by severe dehydration in the mother, baby pinching his/her cord, medication that the mother was given or another reason entirely. However it is always best to try not to stress at all and even if baby is in distress try to remember that your care provider will do everything in his/her power to make sure that baby arrives safely and is healthy and happy.


To conclude this blog post, as a general rule Meconium is nothing to be really worried about with no other issues present. It can be a sign of fetal distress which can be accurately ruled out via ultrasound, Doppler and fetal scalp monitor. Meconium aspiration as a result of meconium being present while it is a bad thing it is not very common at all and should not be a concern if there are no other risk factors and baby does not get over stimulated enough to take a breath before the mucous has been cleared from his/her lungs. Meconium can be produced by hypoxia or fetal distress (which as stated can be confirmed or ruled out quite easily), and can also be a very normal part of development for a baby in utero.

As always, feel free to share!

Jenna Edgley
Student Birth Doula
FOOTPRINTS & RAINBOWS

Image courtesy of and Copyright FOOTPRINTS & RAINBOWS 2014

It doesn’t matter if it was an emergency caesarean or an elective caesarean, it was still a caesarean and a major abdominal surgery and it is essential that you look after yourself properly in the first 6 weeks after a caesarean, and that you look after yourself in general for the first 6 months after your caesarean.

When you’ve had a caesarean it can be hard to remember to take it easy and look after yourself properly – especially if you have older children that you need to look after.

When you had your caesarean the surgeon not only cut through the skin on your lower belly/bikini line horizontally (or possibly he did a vertical incision running up/down your belly instead of horizontally), but he or she also cut through the nerves located in the skin of your belly, either divided your lower abdominal muscles or cut through them (depending on if they were able to be stretched apart enough for the uterus to be pulled through or not), cut through the outer, middle and inner layers (including the muscle layers) of your uterus, cut through numerous blood vessels and nerve pathways, may have cut through some fluid drainage systems, cut through the tissue barriers that separate the various parts of the body (the fascia, and the peritoneum which is cut through twice during the procedure) and then stitched it all back together to make you as close to whole as possible again. The surgeon may have cut your uterus horizontally (transverse incision), or he/she may have cut it vertically (classical incision) or in a “J” or “inverted T” incision if a horizontal incision wasn’t an option at the time.

Major abdominal surgery like a caesarean takes 6 months to become 100% fully healed, and although the incisions themselves will be healed by 6 weeks post partum there is a lot of microscopic repairs that need the rest of those 6 months to be completed. If you had complications with your surgery or developed an infection in the incisions or in your uterus afterwards it can take longer than 6 months – sometimes in rare cases up to 2 years – for it to be completely healed.

During those 6 months there are many ways that you can take care of yourself. Not driving for those first 6 weeks is usually one of the first things that you are told – driving uses the abdominal and core muscles and can put strain on your incisions, you are also not covered by insurance during those first 6 weeks after a caesarean, and if you have an accident while driving during that time your incisions can reopen which can cause some serious complications.

One of the other things you are first told is that you cannot lift anything heavier than your new baby. If you have older children, for example toddlers, who like to be lifted up and held this can be difficult to do, and it is essential that you don’t lift them up in those first 6 weeks as in doing so you run the risk of your incisions reopening or causing further damage.

You need to rest as much as possible and get a good amount of quality sleep. The majority of healing a repair work within the body is done while you are sleeping, and you need quality sleep with at least 2 REM cycles (around 7-8 hours of sleep) every night in order for it to work efficiently. This can be difficult with a new baby who may wake up several times a night for a nappy change and/or a feed, so sleep whenever you can, sleep when baby is sleeping, and don’t stress about the housework, right now you need to focus on you and on healing your body, the housework can wait until later on when your partner (if you have one) is home or until the weekend. If you have older children at home it can be even more difficult to get enough sleep and sleeping when your new baby is asleep can be close to impossible. If you are in that predicament then it is time to ask for help – from family and friends that you trust who can help look after your children for an hour or two each day while you take a much needed nap - or time to send the older kids to day care one or two days a week to give you a break and time to catch up on sleep (and housework if you need to catch up on it as well).

You need to eat a healthy and well balanced diet. Your body stores many of the vitamins and minerals that it needs within it until they are needed. During pregnancy your baby takes nutrients from your body, even when you haven’t had enough of them during your daily food intake (in which case the baby takes them from your internal stores), and by the time your baby has arrived you may be running low on some essential vitamins and minerals like Vitamin D and Iron. If you choose to breastfeed these vitamins and minerals will be going into your breast milk for your baby as well, so it is essential to make sure that you are getting enough from your food (and in the case of Vitamin D, from sunlight. You produce the highest amount from exposure of the areas of skin between your lower ribs and the base of your neck, so wearing a shirt in the sun all the time while it is good for helping to prevent skin cancer it can greatly reduce the amount of Vitamin D that your body produces). Eat healthy foods with lots of carbohydrates, a reasonable amount of natural fat (you need this to help with energy) and protein. During the 6 months that it takes for abdominal surgery to fully heal ensure that you eat an increased amount of protein in your diet. Your uterus is made up of 3 layers of muscles, and the incision from the surgery did cut through part of your uterus. Muscles need protein to grow and to heal, so for those first 6 months after your caesarean make sure you eat more protein than normal to help your uterus heal well and to help reduce your risk of uterine rupture and other complications in any future pregnancies (while the risk of uterine rupture during labour is actually less than 0.5% after 1 caesarean and less than 1% after 3 cesareans it doesn’t only happen during labour, it can happen during pregnancy too, so if you strengthen your uterine muscles now, and continue a high protein diet during your next pregnancy your muscles will be stronger and your risk of rupture will be reduced).

Take care of your emotional health. This side of things can often be forgotten, and good emotional health is just as important as good physical health. If you aren’t emotionally healthy then that will affect the rest of your life and will also affect your baby and any other children you might have. If you experienced a traumatic delivery there are many people and groups who deal with that and can help you, for example in Victoria, Australia, there is now a Maternal Mental Health Service that has a section dealing specifically with Birth Trauma. There may be similar services in other states within Australia, and in other countries around the world.
If you are feeling down or just don’t feel right go and see your family doctor. If they brush off your concerns see someone else, because you may have a mild case of post partum depression (or something else might be going on) and you will need support. If you are having visuals of your child/ren or yourself being hurt (by you or someone else), combined with these feelings and are having dreams that are similar to the visuals as well go and seek help now.

Make time for you! I have mentioned this in several other blog posts, because it is very important and follows on from the above section on your emotional health.
You need to have something special that you do for yourself, without children, and without your partner, that makes you feel good and happy. Whether it’s going out to see a movie or meeting up with your friends, getting your hair done, taking up a hobby, going back to work (if that’s what makes you happy), whatever makes you happy go out and do it.
And don’t feel guilty about doing something for yourself, it makes for a happier mum, and by proxy it makes for happier kids and a happier home. Therefore by doing things for yourself as well you are making your home a much better place to live in.

Lastly, and most importantly, keep an eye on your physical health post caesarean, in particular the scar area for separation of the incision or signs of infection (more redness than is normal, puss, a foul odour, seepage that doesn’t look right etc) and your legs for signs of a blood clot (a bruise that cannot be explained that spreads quickly over a 12 hour period, and/or redness and/or pain and/or a localised area of swelling spreading in a meandering line across and/or up/down your leg). If you notice any of these things go and see your GP right away, if you notice all the symptoms of a blood clot go straight to your local Hospitals Emergency Department to get checked out.

Also keep an eye on your general physical health, if you develop a fever in the first 2 weeks post partum go and see your GP, especially if it is within 5 days of coming home from hospital. If your post partum bleeding suddenly increases and you are going through a maternity pad in an hour or less go straight to the emergency room to get checked out as it could be a sign of a post partum haemorrhage (contrary to most common knowledge in the mummy world haemorrhages can occur right up until your post partum bleeding ends anywhere between 2-10 weeks post partum). If you are having clots larger than the size of a 50 cent piece (or larger than the size of a golf ball) go and get checked out. If your post partum bleeding continues for longer than 10 weeks go and get checked out as well. If you are feeling run down then you may be overdoing things and it is time to slow down and take care of yourself for a while, because you are important and need to be healthy and in good health just as much as your baby is.

As always, feel free to share.

Jenna Edgley
Student Birth Doula
FOOTPRINTS & RAINBOWS

By Jenna Edgley, Student Doula, FOOTPRINTS & RAINBOWS

A big thank you to Janelle Durham for compiling the results of so many studies in one place.

How many of you know all about epidurals? Do you know all of the possible side effects? Do you know what good things that they can do? Do you know what can happen when things do go bad? And do you know the medical interventions that they can cause? Do you know when they are truly needed or when they aren’t actually needed and can be detrimental to your labour?

In this blog post I will be addressing all of these questions and more and supplying the most current (at the time of writing this) risk percentages in easy to understand explanations without all of the medical jargon (apart from the actual name of things like artificial rupture of membranes, where I also supply an explanation in layman’s terms).

What is an epidural and what does it do?

Epidural anaesthesia is a form of anaesthesia that blocks pain in a particular region of the body. The goal of an epidural is to provide pain relief rather than anaesthesia which leads to total lack of feeling, however many epidurals end up being quite strong and take all feeling away. Epidurals block the nerve impulses from the lower spinal segments which results in a decreased or completely numbed sensation in the lower half of the body. Epidural medications fall into a class of drugs called local anaesthetics. They are often delivered in combination with opioids or narcotics in order to decrease the required dose of local anaesthetic. This produces pain relief with minimal effects. These medications may be used in combination with other drugs to prolong the epidural’s effect or to stabilize the mother’s blood pressure. There are two types of epidural – the “numbing” epidural that numbs the lower half of your body, and the “walking” epidural, where after the initial dose only 1 of the drugs used in an epidural is administered, which reduces the amount of sensation to the lower half of the body while still allowing movement and the ability to feel contractions (in effect it takes the edge off the pain so that you can manage it successfully).

Will an epidural affect my baby?

Yes it will. The drugs used in an epidural travel through the blood stream, go through the placenta and go into your baby’s blood stream. In some cases the drugs used in the epidural can make the baby very sleepy after birth which can impact latching and sucking (if you are breastfeeding) and affect how much of the bottle the baby drinks and how well it sucks (if you are formula feeding). Sometimes the epidural drugs can make your babies heart rate go up really high (180 beats per minute or higher) or really low (under 90 beats per minute), this is classed as distress and in the majority of cases a cesarean is needed quite quickly to get the baby out safely.

What are the side effects of having an epidural and how common are they?

An epidural can lower your blood pressure which in turn can reduce your baby’s heart rate and reduce the amount of oxygen that baby gets. You are approximately 74.2 times more likely to have this happen than someone who does not have an epidural (depending on which study you read you have up to a 50% risk of this happening with an epidural).

An epidural can cause you to develop a fever (raised temperature above 38 degrees Celsius). You are 5.6 times more likely to develop a fever than someone who doesn’t have an epidural (depending on which study you read you have a 4%-24% risk of this happening with an epidural, some studies showed that 95% of those with epidurals developed a fever).

An epidural may cause uncontrollable itching, especially when an opioid (a drug made from opiates and their derivatives for example anything with morphine or codeine in it) was included in the medication. An average of 62% of women with an epidural with opioid medication included experienced itching of various intensities. Without the opioid only up to 4% of women experienced itching with most cases appearing to be mild and very few mums requesting treatment for the itching.

An epidural can cause sedation or drowsiness. The Mayberry study showed that an average of 21% of women with an epidural experienced this.

You may need augmentation with pitocin or similar induction drugs if you have an epidural. The Mayberry study showed that women with an epidural were 2.8 times more likely to need augmentation of their labours if they had an epidural.

If you have an epidural you will be more likely to need an assisted delivery (ventouse/vacuum or forceps delivery). In the Lieberman compilation of 16 individual studies it showed that an average of over 50% of women with an epidural were unable to push their babies out without the assistance of the ventouse (vacuum extraction) or forceps.

According to Thorp’s study of 93 women (only 1 woman in the non-epidural control group opted for an epidural) you are 11 times more likely to end up with a caesarean section with an epidural than a woman without an epidural. Lieberman et al (1996), found that there was a 17% risk of caesarean from an epidural.

An epidural may increase your risk of having a post partum haemorrhage, the Lieberman study showed that women who had an epidural where twice as likely to have a post partum haemorrhage than women who didn’t have an epidural (10% with epidural compared to only 5% without an epidural).

You may experience a severe headache after birth. These can last for as little as 8 weeks, or as long as 8 years after birth. This is caused by a small leak of spinal fluid into your blood (also called a dural puncture) and can be fixed with a blood patch where a small amount of your own blood is injected into the epidural space and can relieve the headache.

You may develop a back ache on the first day after your epidural is removed. The few studies on this have shown no noticeable percentages in further abnormal headaches at 1 week and 7 weeks post partum, but there could always be exceptions.

What is good about having an epidural?

An epidural can block or reduce the pain from contractions.

An epidural can help you to rest and recover your energy during a long labour or a very painful labour (an induced labour involving pitocin or similar inducing drugs can be more painful than a “natural” labour so an epidural can be helpful in inductions).

It can lower your blood pressure (this doesn’t happen to everyone and is extended upon in another answer below).

It can help you to relax if you are “tensed up”.

Some women have a more positive birth experience with an epidural.

If I have an epidural what are the most common interventions that can occur as a result?

The most common interventions are:

1 – Artificial rupture of membranes (if they haven’t already broken) where the Midwife/Nurse/ObGyn breaks the amniotic sac.

2 – Pitocin/Syntocinon, an artificial oxytocin drug that is used to induce or augment labour and is used by many obstetricians to make labours go faster than they would normally may be started if the epidural causes your labour to slow down or stop. Pitocin/Syntocinon has its own risks that could be detrimental to labour and babies health as well.

3 – A caesarean section (c-sec) where the baby is cut out of your uterus. This is major abdominal surgery and in the average woman who has no complications as a result of the surgery is not fully healed until around 6 months after it occurs.

4 – Consistent Electro- Foetal Monitoring (CFM), where special pads are placed against the mothers skin to pick up the babies heart rate and another pad that picks up the contractions, these are often held in place by stretchy straps (that appear similar to seat belts), or in some hospitals this is done with the use of sticky pads similar to what is used to monitor your heart in an echocardiogram or a it can be done with a clip that is placed on the baby’s skull. This can be very uncomfortable for many mums and usually means that the mum has to remain on her back on the bed as movement can make the baby move away from the pad picking up the baby’s heart beat.

5 – A urinary catheter. Basically when you have a run of the mill (or full) epidural, and even quite often with a walking epidural, you can no longer feel when you need to do a wee. A urinary catheter is placed, with a small medical balloon attached to the end of it which is inside your bladder which is inflated to hold the catheter in place, and has a collection bag attached to it to collect the urine so that the urine doesn’t build up in the bladder. The side effects of this are discomfort for a few weeks afterwards, urinary tract infections (these don’t always happen but have been reported as a common occurrence by many mums) and the possibility of receiving a diagnosis of “obstructed labour” if the urine starts to get a rose coloured tint to it (this can sometimes be caused by baby’s head pressing on the bladder as he/she descends into the birth canal and the balloon from the catheter can cause baby to get stuck and not descend any further – in this instance deflating the balloon and repositioning it further into the bladder can help a lot – rather than being a genuinely obstructed – read stuck – baby), and incontinence. A not very common complication of having a urinary catheter is scarring and bladder damage.

When is an epidural really needed?

There are several things that could suggest that you may need an epidural.

The most common of these is exhaustion, when you are extremely tired and have been labouring for over 24 hours without sleep an epidural can be placed to allow you to “have a break” from the contractions and enable you to get some decent sleep before the big show starts.

Another time an epidural may be needed is if your blood pressure is steadily rising during labour and is getting close to dangerously high levels. One of the side effects of an epidural is lowered blood pressure, and in this instance an epidural can be very helpful. This doesn’t always work for everyone however, and in some cases it can do the opposite and make a woman’s blood pressure go even higher. No one can predict who this will work for, and sometimes it can work for one labour and not for the next labour and vice versa, so it really is a “see as you go” scenario.

Epidurals can also be easily turned into spinal blocks, so if you are attempting to have a “Natural Caesarean with trial of labour beforehand” then an epidural can work really well in helping you to avoid the pain caused by contractions to begin and making it easier for you to get a spinal block when you do go to theatre. The down side of this is that labour can stop shortly after an epidural is placed which may mean that your body doesn’t get the full effects of natural oxytocins, or it can drop your blood pressure so low that you don’t get to experience your “Natural Caesarean” in the way that you wanted to.

If you are “tensed up” from the pain then that can slow your labour down and make it last longer than it normally would. In this instance there is around a 50/50 chance that having an epidural placed can allow you to relax enough to dilate quicker than you previously were and enable your baby to be born sooner.

When isn’t an epidural needed?
1 - An epidural isn’t needed as soon as you arrive at the hospital if you and baby are happy and you are not exhausted.
2 - An epidural isn’t needed before you reach 4cm dilated.
3 - An epidural shouldn’t be placed after you reach 8-9cm dilated.
4 - An epidural should not be placed if your blood pressure is already lower than normal. It may make it drop even lower which will not be good for you and can negatively affect your baby.
5 - If you are in transition and start demanding an epidural (which happens more often than you would think even in mums who are labouring drug and intervention free by their own choice) an epidural should not be given. Not only will it most likely not start to work on time, but if there is enough time for it to work it can make pushing very hard and even make your pushing not be effective enough to get the baby out.
6 - If you use blood thinners then you should not have an epidural.
7 - If your platelet counts are low then you should not have an epidural.
8 - If you are hemoraghing or in shock you should not have an epidural.
9 - If you have an infection in your back then you should not have an epidural.
10 - If you have a blood infection then you shouldn’t have an epidural.
11 - An epidural should not be done if the epidural space cannot be located by the anaesthetist.
12 - If labour is progressing too fast and there is not enough time to administer the drug (mentioned in #'s 3 and 5 of this section).

Why do some doctors insist on epidurals as soon as a woman gets to hospital while in labour?

Training, hospital policy and personal beliefs. Many older doctors were trained when epidurals were considered to be “the next best thing to chloroform” (chloroform, amongst other drugs that are now not used, was used extensively in the 50’s and 60’s to effectively “knock women out” so that they wouldn’t have to be in pain or make a sound during labour and birth) and they see it as an “aid for labouring women” in a misguided belief that no woman should go through that kind of “pain”. Many also feel that women should not make a sound during labour or pushing and a full epidural is the best way to achieve that in lieu of performing a caesarean section. Newer doctors are trained differently but their personal beliefs and desire to prevent what they see as “unnecessary pain” can make them think that epidurals should be given to everyone.

I must point out that not all doctors are like this, there are many who prefer to avoid the use of an epidural if they can, and many who prefer for the woman to decide if she has one or not rather than forcing it on her.

Some hospitals have a policy of making every woman who arrives in labour between 4cm and 8cm have an epidural placed. This is not evidence based and can be detrimental to a woman’s labour and birthing experience. Hospital policy is not law however, and you always have the right to refuse if you wish to. If anyone tells you otherwise then they are not supportive of you and you can request someone else to look after you.

What can I do to reduce my risks of further intervention or any damage to my spine if I choose to get an epidural?

Have a very experienced anaesthetist administer your epidural, and ensure that the cords are placed somewhere where they won’t be underfoot. Also if you already have spine issues (bulging/compressed disks and spine damage) then it might be best to avoid an epidural altogether.

To avoid further intervention get a “walking” epidural, which only has one of the 2 epidural drugs administered to you. This way you can stay active and “feel” the contractions without feeling all of the “pain” as well. This kind of epidural is beneficial for pushing as you can still feel the surges and the pressure and can push more effectively.



Study Sources:
Lieberman E, O’Donoghue C. Unintended effects of epidural anaesthesia during labor: A systematic review. Am J Obstet Gynecol 2002; 186:S31-68. A total of 1900 articles were examined, and evaluated for inclusion in the review based on the authors’ criteria. They limited their review to original reports in English, in peer review journals since 1980; they included both randomized trials and observational studies; they excluded studies with no control group, studies that evaluate specific drug regimens, studies that examine epidurals for anaesthesia during cesareans, studies conducted exclusively on high-risk populations, studies where population selection renders results uninformative, studies with analytic choices that make results impossible to interpret, and studies that examine outcomes only for the overall population of delivering women.

Mayberry LJ, Clemmens D, De A. Epidural analgesia side effects, co-interventions, and care of women during childbirth: A systematic review. Am J Obstet Gynecol 2002; 186:S81-93. More than 700 publications were identified; they narrowed that down to 150 studies that addressed one or more of the common side effects and co-interventions, plus 75 articles addressing relevant clinical or nursing care information related to unintended effects of epidurals. They only included prospective, randomized, controlled trials published between 1990 and 2000. These studies were then further limited by pre-established criteria: evidence of little or no crossover effect, minimal loss of subjects after random allocation to comparison groups, and satisfactory description of the randomization procedures. In the final review, they included 19 studies, with a total sample size of 2708 women.

Thorp JA, Hu DH, Albin RM, McNitt J, Meyer BA, Cohen GR, et al. The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. Am J Obstet Gynecol 1993; 851-8.

Other Sources
http://americanpregnancy.org/labornbirth/ (under the section on Epidurals)