>> STORY BOOK - Natural Birth After Caesarean Section

STORIES

Sharing Stories acknowledges families
who have taken me the midwife on a
myriad of empowering midwifery journeys

The names have been changed at the request of the
family who has given permission for their story and
photographs to be published on the World Wide Web.

Natural Birth After Caesarean Section

Carlie and Kaide are the proud parents of Rose and now Michael who was welcomed into the world by his family at 4:14 am on the 10th January 1999.

Carlie planned to birth at home with her second pregnancy, she needed to heal the lingering remnants of trauma after her planned homebirth with Rose resulted in hospital transfer and a Caesarean Section.

Reflecting and Debriefing

My first meeting with Carlie was soon after the birth of Rose when Carlie came to see me for some help with breastfeeding. Like most women who experience trauma with unexpected intervention/s a good part of the first breastfeeding consultation is about debriefing. Reflecting with an open mind, revisiting the realism and unraveling the hurt empowers a woman to move on with a more positive approach.

Carlie felt “cheated” when her plans went awry, she had achieved 41.2 weeks gestation, laboured well at home until she was transferred into hospital with meconium stained liquor. The cascading intervention and roller coaster ride that followed her admission to hospital terrorised her, she no longer had any control. Others’ had taken away her valuable personal asset – control over herself and her body, replacing her internalisation of the whole experience with fear. Control by fear is commonplace in the hospital - medical system in Australia. The fear of malpractice suits is partially responsible for increases in medical intervention and defensive practice. Her labour was about 6 hours in total and little Rose was born by Caesarean Section on the 3rd February 1995, weighing 2.8 kgms.

Carlie's version:

"I had felt cheated. I felt as though the carpet had been pulled out from under my feet. I felt as though I had been taken advantage of - that perhaps there could have been other choices possible earlier on. I was concerned that the chemicals used to induce me could have had adverse affects on my progress and wellbeing. I felt powerless and helpless and very angry.

After a lot of reflection and debriefing and physical and emotional healing, I came to see my contribution to the whole scenario. I realised that I had prepared for the birth of my first child with the belief that the experts (either midwives or doctors) ultimately knew more about giving birth to a child than I did. I had given my power away before I had started. I had not fully informed myself about what could happen or would happen. I wasn't fully responsible. When I became pregnant again, I decided that I would inform myself about as much as possible and that I would make all the decisions. I decided that I would not be ruled by fear, but make decisions based on a breadth of information. I trusted that I knew what was best for myself and my child."

Debriefing and reflecting on her labour and birth experience with Rose was successful - firstly in terms of her continuing to breastfeed Rose for 18 months and secondly the strength of her convictions to plan a homebirth for her second pregnancy four years later. Aided by her macrobiotic diet, Yoga and Chiropractic care Carlie said she felt “very centered” and much “stronger than she has for years”.

Challenging the Unexpected

Her plans for a Vaginal Birth after Caesarean Section (VBAC) progressed well until 31.4 weeks, estimated gestation. It was a Saturday night when Carlie telephoned me to let me know that she was bleeding (antepartum haemorrhage), we discussed the possible outcomes and the best means to diagnose placenta praevia or isolate the cause of bleeding. We talked about diagnostic ultrasound and the possibility of continued bleeding; my advice was that she should consider placenta praevia as the reason for bleeding until proven otherwise. She agreed to meet me in hospital as soon as possible. As a rule of thumb painless bleeding around 32 weeks gestation is regarded as placenta praevia unless diagnosed otherwise.

I arrived in the hospital labour ward soon after Carlie and Kaide. When I entered the room I was horrified by my first encounter, there was a young male doctor firmly palpating Carlie’s abdomen. There was no time to waste, using a firm voice I quickly introduced myself and in the same breath told this young man that I did not like what he was doing. I asked him to stop immediately, explaining that it is a cardinal sin to palpate any woman who presents with a history of possible intra-uterine bleeding (placental abruption - when there is partial/whole separation of the placenta from the uterine wall). Reiterating that Carlie’s care should be extremely sensitive and the cause of her bleeding must be regarded as placenta praevia until further diagnosis proves otherwise. His reply was that he “wanted to know where the baby was lying”. Politely but firmly I said it is not important where the baby is lying it is more important not to cause any further bleeding by the forces of abdominal palpation. I suggested that he talk to the hospital Obstetric Registrar (senior level doctor with 6 years experience), at which point he left the room somewhat disgruntled by my early and firm advocacy.

At the same time the hospital midwife who was present during my verbal exchange with the resident doctor (first level – junior) approached me to tell me “how rude” I was for interrupting the conversation between the doctor and ‘his patient’. Endemic language is interesting, once you enter the hospital system the emphasis is on ownership, being referred to as a patient removes a person’s rights and disempowers them. Carlie, just like other women in similar circumstances is not a patient she is a woman first and foremost, she does not belong to anyone, she is a strong person in her own right.

My advocacy is expressly strong and especially when challenged in a situation where a woman is at risk or not adequately informed about the consequences of such actions. There was no point wasting any more time on issues that do not relate to the problem at hand. I simply explained to the midwife that Carlie and Kaide had employed me for this very reason, she expected me to protect her from harm, she expected me to keep her adequately informed so that she could make informed decisions based on knowledge that would place her in a position of being in control of any event affecting her or her baby.

I posed this question to my colleague – ‘given the same set of circumstances, what would you do? Would you allow aggressive palpation to continue?’ It must have been difficult for her, she responded with a facial expression of utter annoyance. It was a priority to nip this encounter in the bud, with respect I gave her two options – Firstly she could continue to work together with me because I planned to be around for the duration providing Carlie with continuity of care or - Secondly if she felt it would be to difficult it may be wiser to find another midwife who would work in harmony with me/us. Again there was no response, my colleague just left the room.

A short time later a stern faced, yet quite pleasant, tall dark headed man entered the room and introduced himself as the hospital Obstetric Registrar on duty. He blatantly excluded Carlie's family and me from his introduction and proceeded to talk directly to Carlie. He admitted the Resident was incorrect in his actions. A cold stare was then directed at me, it penetrated my being, so at this point I took the opportunity to introduce myself then continued the verbal exchange by suggesting to him that there was no point being offended by my advocacy and support for Carlie again reiterating that I would be here for the duration, so as colleagues we needed to communicate professionally and effectively. From this point he was very polite, his body language and facial expression relaxed as he went on to tell Carlie that the idea of palpation was not good and added that speculum examination would not be attempted either until placenta praevia was eliminated. He offered to perform an ultrasound with the “Labour Ward Machine” he explained this would be a temporary assessment until the Radiology Department was open in two days. We asked him about his skills for interpreting ultrasound, he acknowledged that he was not the expert, he only did these occasionally, and he was able to give limited information but said he could identify a placenta praevia. Radiology in this major teaching hospital closes down for the weekend so Carlie decided to proceed with this temporary diagnostic approach.

From all of these early events I figured this was a positive outcome, my point had been made and accepted. In the meantime the hospital midwife colleague must have thought about her encounter with me and to her credit she returned to be a part of our team. The environment changed to one of more tolerance, better communication and inclusion of Carlie her family and me in decision-making. After an intravenous drip was inserted as a precaution for any further bleeding, the Registrar returned to do the ultrasound with Carlie’s informed consent. During the ultrasound he explained his findings – he identified the baby’s head, limbs, heart rate and spine. The head was down and there were plenty of pockets of liquor evident. He asked if Carlie wanted to know the sex, “no thank you” she said. He went on to identify the placenta lying low on the posterior uterine wall, preliminary diagnosis was a Grade (1) Placenta Praevia. His findings were confirmed by a repeat ultrasound performed by the hospital ultrasonographer two days later. A grade (1) placenta praevia means that the lower edge of the placenta extends low into the uterus (lower segment), fortunately it does not cover the internal opening of the cervix (Internal cervical os) and is not situated near Carlie’s previous uterine (Caesarean) scar. As the uterus rises with the growing baby a low-lying placenta usually moves/migrates, causing it to detach from the lower segment of the uterine wall resulting in intermittent bleeding. This diagnostic information will help Carlie make future decisions on this unknown journey.

Considering Options

Things that were discussed: concealed-revealed antepartum haemorrhage, the wait and see approach as bleeding sometimes settles and pregnancy continues. Concealed-revealed means that some vaginal bleeding is visible, there maybe further bleeding behind the placenta not visible. If the placenta continues to separate from the uterine wall impaired placental flow to the baby can prevent enough nutrients for further growth and development. Another Caesarean Section and prematurity was possible if the bleeding continued to put Carlie and her baby at further risk. The medical approach of giving Carlie intramuscular cortico-steroids was also discussed. Intramuscular injection of Cortico-steroid for the mother is used in some cases to stimulate production of Surfactant levels to mature the baby’s lungs and help with premature respiratory problems. Surfactant is a naturally occurring substance in the full term baby that assists with expansion of the lungs. Another option to support lung maturation is endotracheal cortico-steroid inhalation spray, used directly on the baby after birth.

At this time Carlie wanted to remain positive and concentrated on keeping her baby in-utero so that increased gestation without major bleeding would give her baby more time to adapt to the blood loss, continue to grow and mature.

Her bleeding gradually stabilised, she was tired and feeling cold, she had not eaten for some time her blood sugars would have been quite low by now. Her observations were normal, blood loss diminishing, her vital signs were normal, not consistent with shock and her baby was active and reactive with a variable baseline heart rate of 146 beats per minute. Some mild irregular contractions were evident. Carlie was fed and warmed, she was soon felt much more rested and relaxed. “Everything is going to be fine, no point panicking” were her spoken words. We talked about homeopathic support to reduce or calm her contractions.

As my thoughts pondered I asked myself what would have been the likely outcome if I hadn’t been there to firstly protect Carlie and secondly, be part of a teaching and learning experience with hospital colleagues, some things I imagine they will probably never forget. The young resident doctor and the hospital employed midwife appeared totally unaware of the importance of his actions; there was a total lack of adequate supervision in their learning capacity within a major teaching hospital.

More Challenges – New Encounters

Carlie remained resting in hospital over the next few days during which time she made extensive enquiries about supportive obstetricians. It was really important to her to find an obstetrician who would value her desire to birth vaginally and most likely within the hospital environment given the current circumstances. I asked a good friend and midwife colleague employed in the Family Birth Centre to visit Carlie to give her ‘inside’ information about various obstetricians who worked within the hospital establishment. Carlie was given a list of names, after more enquiries from various people she now had a short list and asked to talk with the one she thought would be more supportive. She is a very reasonable and levelheaded person who normally asks lot’s of questions and listens intently to the answers. Kaide is strong and direct with his questions. After their first consultation it seemed as though the obstetrician was prepared to see how things would go, without offering her too much in the way of fearful information. Soon after he went on annual leave and left a locum obstetrician to cover. About a week later when the bleeding had settled, she went home to rest.

The locum obstetrician was not so understanding of Carlie’s needs, he was driven by fear and transferred that fear to Carlie, immediately putting her out of sync with him. The aim was just to wait and see and take each hour of each day as it presented. After each encounter with the locum obstetrician Carlie found it necessary to debrief. By using a more logical approach to the impregnated fears and with lot’s of explanation and reassurance each time she was able to return to her confident, innate self.

Over the ensuing five weeks Carlie had intermittent episodes of small fresh to dark blood loss, each time she would telephone me and we would discuss how she felt and her estimated measurement of the loss. Hospitalisation was raised and each time she was able to make an informed judgment and maintain her ‘wait and see’ approach. Episodes of irregular uterine contractions coincided with each small bleed. Each time I visited she was rested, eating well and gaining weight.

Important Considerations

At 35 weeks gestation Carlie’s eyes (conjunctiva-inside the lower lid) and face appeared a little pale, I suggested that she take some Fluradix over the next few weeks to ensure she maintained good iron levels and asked her to consider a repeat full blood examination (FBE). Fluradix is a natural liquid iron supplement, obtained from Health Food Stores.
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We also considered and discussed possible options for her labour and birth given there were no contrary indications with increased bleeding or fetal distress:

Labour at home, birth in hospital below 37 weeks gestation
Labour and birth at home 37 weeks and above
Labour and birth in hospital below 37 weeks or whenever indicated

We talked about inserting an intravenous line when labour established if the decision was to stay at home. Leaving a ‘bung in situ’ (a direct line to a vein) so that access to a vein was available if needed. This not something midwives would do generally, but given the knowledge of previous events it seemed wise to be prepared rather than being faced with last minute decisions. We would not palpate and minimise any unnecessary invasive vaginal examinations. If labour is in hospital minimise any unnecessary interventions such as continuous electronic fetal monitoring (EFM/CTG) and replace with 10 to 15 to 30 minutely hand held Doppler readings so Carlie could continue to have freedom of physical movement and not be ‘restricted or confined’ in any way. Her preference was not to have labour augmented (artificial rupture of membranes in labour – breaking the waters), no opiate drugs such as Pethidine and no Oxytocin Infusion unless necessary. (Oxytocin is a synthetic drug given via intravenous infusion to induce uterine contractions). This is very painful method of induction it confuses the body’s ability to produce natural Oxytocin to establish uterine contractions and accelerates the labour most women will require an epidural when this method of induction is used. We would also check Carlie’s placenta and membranes and arrange to take it home with us. We confirmed that the family had membership with the Victorian Ambulance Service.

Planning Support Systems

Carlie’s fundal height was always small for dates the same with her first pregnency. The current history of placental abruption and her long family history of small baby’s (4 to 6 kgms) were taken into consideration. Pamela (Carlie’s mother) was staying with them and she was able to give an extensive family history. The next five weeks were quite trying for all of us Carlie knew the importance of minimising any further risk of bleeding, she stayed at home, rested most of the time and focused quietly with her innate determination to sustain her pregnancy as long as she could to help her baby grow and reduce the chances of another Caesarean Section. Pamela planned to stay indefinitely which enabled Kaide to continue working. Kaide is a very tall lean person, strong in appearance; he provided her with enormous strength and helped to ensure Rose maintained a normal life style by meeting the active needs of his little girl. These arrangements provided Carlie with continuous family support, no separation from Rose, good nutrition and lots of mothering.

Carlie and I had frequent discussions by telephone, during this ongoing support she continued to share antenatal care between the Obstetrician and myself. Lot’s of information and reassurance was needed to enhance her ability to make decisions especially while she was attending the relieving non-supportive Obstetrician. It was like jumping in a hurdle race, each time she attended this guy she needed to work through the fear barrier to prevent her from falling in a heap. Over the remaining weeks we made clear plans to birth within the hospital system, at no time did Carlie give up hope of birthing her baby at home. When the locum Obstetrician asked her about her plans for homebirth she told him honestly that she would take one day at a time and needed his support to make her decisions on a day-to-day basis. She realised it was highly likely that she may have to have another Caesarean Section, but preferred to focus on a vaginal birth, in hospital (or at home) which ever was appropriate at the time. Needless to say the Obstetrician was not particularly happy about her approach and found it difficult to understand her ability to think this way.

Labour establishes

On the day labour began Carlie had visited my midwife colleague; I had asked Annie to back me up especially if Carlie decided to birth at home. When Carlie rang that night to say she was having some contractions she had reached 36.3 weeks estimated gestation with her fundal height still smaller than dates. I suggested that we should meet in hospital in an attempt to slow the labour. She preferred to stay at home, we arranged for her to call me in half an hour to see if there was any further progress. During our second conversation she was very clearly stating that her baby had to be born ‘sooner than later’, over the telephone it sounded as though it was going to be sooner rather than later. The sounds of a labouring woman are distinct to the midwife, I went straight to her home and arrived at 2.30am, she was in good established labour. Her observations and the fetal heart were all within normal range. There was no further visible bleeding, her vaginal loss was scant and serous (pinkish in colour).

By now she made it clear that she preferred to stay at home, she was guiding me with her innate ability, I trusted she was making the right decision, soon there were early sounds of wanting to push. I didn’t think it would be wise to travel at this late stage and Carlie said she didn’t feel comfortable about traveling, it seemed more risky to birth on the way to hospital than in the safety of her home. I asked Kaide to call Annie and to ask her to “come now”; I needed Annie in the event of any bleeding or resuscitation given Carlie’s history. She arrived at 3.30am and soon after there were several episodes of fetal bradycardia with good recovery, we anticipated some cord compression while Carlie was in a deep squatting position. When we encouraged her to change her position the fetal heart stabilised and recovered to normal. The deep squatting position was causing her baby to react to cranial compression &/or some cord involvement. From here on we encouraged her into various positions combined with more physical movement between each contraction.

Carlie’s Innate Birthing Experience

The fetal heart remained stable and Carlie gently birthed her baby boy at 4.14am in the lounge room of her home with her family around her. An injection of synthetic Oxytocin was ready (for any postpartum bleeding) but not required, her baby’s cord was not clamped nor cut, just simply left to continue flowing with oxygen and nutrients to the baby until she birthed her placenta spontaneously 20 minutes later. We did have suction and oxygen ready, close at hand; this little boy didn’t need any resuscitation, he breathed the air spontaneously as I gently blew around his face while Annie wafted some oxygen over his nose and mouth - mainly for our benefit. He was calm, alert and very aware, he appeared to be saying thank you mummy ‘thank goodness I am here’. His Apgar scores were 8 @1 minute, 9 @ 5 minutes and 10 @ 10 minutes. Annie and I were surface calm, somewhat internally anxious, but very alert watching for any signs of postpartum haemorrhage in light of Carlie’s antepartum bleeding. Antenatal bleeding increases the risk of postpartum haemorrhage. We derived our strength from believing in Carlie’s innate ability to know that she would do what was best for her and her baby. His initial assessment showed he was quite mature, probably 36 to 37 weeks gestation but small for gestational age, which we had anticipated. The medical term is Small For Dates or Inter Uterine Growth Retardation (IUGR) – quite negative language. He weighed in at 1.88 kgms. A combination of family history of small babies and intrauterine bleeding made for a very small but healthy baby boy. Let’s concentrate on feeding and calorie intake now.

Breastfeeding

Carlie is an experienced breastfeeder thanks to Rose. This little boy breastfed beautifully within 20 minutes of birth, he milked colostrom from the breast with vigor and efficiency. His alignment, attachment, sucking rhythm and colour was excellent and he continued to feed for 3 hours before he went off to sleep cuddled up with Carlie. Baby Michael was ready for his birth there was very little liquor evident, his cord was thin and his placenta was small and thinish with some small surface infarctions. Together we looked at the placenta and could determine the low-lying area by the shape, there was thinning of an extended area where the bleeding had originated. The cord had a vallamentous insertion of the vessels a short distance from the fetal placental surface. According to Derek Llewellyn-Jones in about 1% of cases a vallamentous insertion occurs where the cord originates in the membranes some distance from the placenta, the vessels (2 arteries and a Vein) run in the membranes to reach the placental surface. (Fundamentals of Obstetrics & Gynaecology).

Right from the outset Michael was very capable of determining his nutritional needs and continued to exclusively breastfeed 2 to 3 hourly, both breasts per feed from the time he was born. His weight gain was consistently excellent at an average of 2.88 grams per day.

On a couple of occasions Carlie who is very fine in physical structure felt “very, very tired”, sleep deprived to the maximum. This is common in the early weeks for most women and can be a precursor to postnatal depression. The mammoth task of constant mothering together with the excitement of her achievement caught up with her, she was so tired Michael’s feeds had spaced to 4 hourly plus Melbourne’s weather was extremely hot at the time. The environmental temperature together with spaced feeds and Carlie’s heavily laden breasts caused an elevation in basal body temperature around the third day for both of them. Michael had also developed a sticky eye, he was looking plethoric (red skin) on exertion, had poor skin turgor of his upper arms and thighs. He looked dehydrated but was quite active and not lethargic, he needed no encouragement he was interested in feeding. I was concerned and talked about medical assessment and/or hospital admission if his appearance didn’t improve.

We started with a plan of close observation, frequent feeding and continued recording of his progress and observations. This would eliminate infection if his temperature settled with more milk volume reducing the risk of any further dehydration. By setting her clock Carlie was able to feed him 2 hourly again. It is not my normal practice to encourage the use of a clock but it was easier and less stressful for Carlie to be sure she offered him breast milk every 2 hours. Within 24 hours there was amazing improvement, temperature returned to normal plethora stabilised and his skin turgor improved. He maintained a stable core temperature as before and passed lots of yellow to mustard, curd stools and had a huge increase in urinary output. His jaundice fluctuated but didn’t reach a point where we felt compelled to order Serum Billirubin Levels (SBR).

After several days of discussion we decided to give Michael some oral Vitamin K1, this was driven mainly by fear rather than intuition and common sense. It is my observation that Vitamin K or any drugs taken by the mother in pregnancy and given to the newborn or the mother in labour or after birth increases jaundice of the newborn. The half-life of any medication circulating the baby’s systems takes much longer to break down and excrete. We were concerned that his jaundice may increase but decided to give it in a smaller dose. Because of his size we mixed 75% of an ampoule of Vitamin K1 with breast milk and gave it to him by mouth using a periodontal syringe, which has a long tapered tip. With this syringe the vitamin K and breast milk mixture was given while he was sucking at the breast during an active suck-swallow cycle. Vitamin K1 from the ampoule has a very bitter taste, mixing it with breast milk makes it a little more palatable for the baby.

Kangaroo Time

Pamela, Kaide and Rose made sure that Carlie was nutritionally sound with good food and frequent nourishing fluids to maintain her blood sugar levels and energy to breastfeed. Baby Michael had unlimited access to the breast and was Kangaroo carried most of the time by Pamela, Kaide or Carlie. Even little Rose would lie with him on her chest or with his body close beside her. Each time Carlie needed to get some uninterrupted, well-deserved sleep, Kaide would finger feed Michael some expressed breast milk with a periodontal syringe for one feed in 24 hours. Carlie would return from her sleep “feeling like a bird and flying again, feeling on top of the world to carry on”. Michael continues his amazing progress 38 weeks adjusted gestational age now.

My visits are less and less; there is no reason to believe that Carlie will continue to do well with all her helpers close at hand, she has close contact with me by phone whenever she needs it. Michael’s parents, his sister and grandmother are very vigilant; offering lots of encouragement to each other to do whatever is needed to maintain each other’s strength and wellbeing. Rose has a very important ‘big sister role’ in between her growing needs to be with her friends having 4 year old fun. My last postnatal visit was mainly social, not much for me to do now, so I took Carlie, Kaide and Rose out for a couple of hours, we found a nice eating place and reminisced the previous weeks while Pamela (Nanna) continued to Kangaroo her little grandson at home.

I say special thanks to Carlie and Kaide for providing me with the strength and trust to continue to do what I do best, being a Midwife. I thank them also for confirming my knowledge about innateness what they know best, being the parents responsible for the care of themselves and their children and how a baby will thrive and recover when not separated from his/her mother.

I thank them for fulfilling my professional desire to help, by making decisions with them when confronted with the unknown, which for me is compounded by the constant nagging of a learned medical model, where I was conditioned by fear, the ‘what if’ syndrome. Wondering how ‘they’ my professional colleagues will they treat me; how badly will I be labeled if things don’t go according to the powerful medical model, hospital practice and policy expectation. I thank them for empowering the midwife within. A really special thanks to my midwife colleague Annie who is always willing to be there with her warmth, strength, cheery encouragement, professional and personal support.

The healing process for Carlie is incredible as we move through unplanned debriefing, reflecting on the events each time I see them. Carlie tells me that she finds it easier to accept the way things went for Rose’s birth now she has had this experience.

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20th June 1999 – A letter from Carlie
Dear Robyn
How are you? I am enclosing the photo taken when we last met. You look gorgeous! Michael continues to be doing well. He is getting chubbier each day and brightens our lives with his frequent smiles and laughing. Mum is still here. She will be going to Tassie (Tasmania) at the end of winter to do some renovations to my parent’s house and then probably join my father and sister in Coffs Harbour. Genevieve my youngest sister is here on holidays for four weeks. We all love her company. I am experiencing a moment of peace and quiet at the moment as mum is looking after Michael and Genevieve is entertaining Rose – doing some painting with her. It’s great to be by myself for a little while! Life is good.
I hope that things have panned out well for you. How’s your book writing going? Have you finally decided to ease off with the birthing for a while? I am glad that I was able to have you for my midwife. “Incredibly thankful” would probably be a better way of putting it. Your guidance and support took me through life-changing experiences. You were like a messenger from heaven.
Thank you.
From all of us, much love and best wishes to you.
Until next time, lots of love from Carlie

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29th April, 2002 - Carlie’s Reflections:
Michael is now over three years old and Rose is seven. I feel very happy and fulfilled with my birth experiences. Rose's birth was the catalyst for a lot of extremely valuable thinking, healing and growing in my life and Michael's birth was the opportunity to experience a dream coming true, in the face of all apparent obstacles. I am incredibly grateful to Robyn for enriching our lives, for validating our strengths and for assisting us to experience this part of our lives so joyfully and powerfully.

Copyright
Robyn Thompson
Melbourne Midwifery Specialist Services Pty Ltd

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