The only hospital-based midwifery practice in Austin, we combine the non-interventionist approach of midwifery with the safety net of western medicine.  Our goal is to allow the onset of natural labor and have patience with labor’s progress given the wide variation in each woman’s labor course.  Our patients meet all six of our providers (Dr. Sebestyen, Dr. Schiemenz, Siobhan Kubesh, CNM, Lisa Carlile CNM, Kathy Harrison-Short CNM, and Liane Miller CNM) as they journey through their prenatal care.  This guarantees that each patient will always know the provider that assists them with their labor as the five of us share labor & delivery call equally with the midwives always backed-up by a physician.  As we all hold the same philosophy about non-interventionist care, our patients have the safety of knowing that the care provided will be consistent and respectful of their birth intentions.

Labor is truly a marathon that requires physical and mental preparation to endure the long journey to an exhilarating birth.  We advocate for women to stay mobile in labor – walking, showering, squatting – to aid in the progress and tolerance of labor.  We use intermittent fetal monitoring (low-risk patients) and heplocks (IV base only) to facilitate this movement.  We encourage comprehensive childbirth education such as the Bradley method, hypnobirthing/babies, and conscious birthing, to ensure a strong preparation.

Although strong advocates for natural birth, we are not the “anti-epidural” practice.  We empower women to make their own choices about pain-relief in labor – understanding both the risks and benefits.  Rather than driving the golf-cart urging the marathon runner to get in, we allow each woman to make that decision for herself whenever she reaches a threshold where she needs help.

We minimize inductions of labor to only true medical indications that threaten maternal/fetal health in order to limit the risks of inductions, particularly cesarean section.  When inductions are necessary, we often employ non-medication methods, such as mechanical balloon cervical dilation and artificial rupture of membranes.  Cervical ripening agents (cervidil) and pitocin have their place, but are used judiciously to closely mimic the natural onset of labor.  Our pitocin protocol is half the strength of the traditional induction protocol – beginning with only 1 milliunit and increasing by 1 milliunit ever 15-30 minutes. 

We encourage VBACs for women with one prior cesarean section, which although not done by many practices in Austin, is clearly sanctioned by the American College of Obstetrics and Gynecology in hospitals with 24-hour anesthesia coverage.  We also allow women to VBAC who have had two prior cesarean sections, but also a previous successful vaginal birth.  VBACs require a special commitment from both patient and provider due to the slight risk for uterine rupture, approximately 1% of which the majority are NOT catastrophic.  Each woman approaching VBAC must change the circumstances from her first birth to increase the likelihood for success, such as allowing spontaneous labor, delaying epidural use, limiting weight gain, and increasing exercise.  Because of the increased risk with VBACs, we do require continuous monitoring which allows for early detection of any fetal compromise.  Thankfully, with the advent of mobile telemonitors, this can be accomplished while still allowing complete mobility.

Our cesarean section rate of 20-25% is well below the Austin hospital average of 40-50%, and is artificially elevated by the large number of women attempting VBACs in our practice.  Because of the number of women that we care for each month, we do about ten cesarean sections per month and are skilled at the surgical art of surgical delivery.  Although a vaginal birth may be preferable, cesarean section is the safety net for the approximately 15% of women that the World Health Organization estimates require surgical birth for the safe passage of the newborn and mother through childbirth.

We care for many sets of twins each month, often in conjunction with a Maternal-Fetal Medicine specialist (David Berry MD and Celeste Sheppard MD).  We advocate for vaginal birth assuming both babies are vertex (head-down), or the first baby is vertex and the second (regardless of position) is the same size of smaller than the first.  Both physicians in our practice are skilled at breech delivery of second-twins which when done appropriately is very safe and sanctioned by the American College of Obstetrics and Gynecology.

Many of our patients are high-risk with a history of high-blood pressure, diabetes, leg/brain clots, aneurysms, recurrent miscarriage, in-vitro fertilization, etc.  These patients receive care from both physicians and midwives in the practice, often in conjunction with a Maternal-Fetal Medicine specialist (David Berry MD and Celeste Sheppard MD).  We are able to fully monitor the progress of the pregnancy and fetal well-being through regular ultrasound and fetal heart rate monitoring to ensure both maternal and fetal safety.  When in labor, these patients often receive team care from both the midwife and physician on call, working together to provide the highest quality of care possible.

Both of our physicians and one midwife are trained in the performance and interpretation of ultrasound.  We have a seasoned licensed sonographer who also performs ultrasounds all day on Wednesdays and Fridays.  We are able to complete all types of obstetrical ultrasound in the office including first-trimester scans for dating, bleeding, pain; second-trimester basic and detailed anatomy surveys; and third-trimester scans for size/date discrepancies, amniotic fluid assessments, and post-dates reassurance.  We also do genetic screenings for patients who desire such testing with both the first-screens (12 week ultrasound and blood draw for Down syndrome and Trisomy 18 risk assessment) and quad-screens (16 week blood draw only for Down syndrome, trisomy 18, and neural tube defects).  Although some offices in town perform ultrasounds at every prenatal visit, we advocate against this for fetal safety, and use ultrasound only when medically indicated.

We are all supportive of a woman’s right to choose not only the nature of her birth experience, but the location as well.  For low-risk patients, home-birth may be an appealing option.  We provide in-office consultation services to the home-birthing midwifery community for pregnancy complications including bleeding, high-blood pressure, and diabetes.  We also offer ultrasound for these women as needed.  Transfers of care are accepted when patients develop high-risk conditions (such as pre-eclampsia, medication-requiring diabetes of pregnancy, etc.) that are outside of the scope of practice for homebirthing midwives.  Thankfully, transports in labor are relatively rare and are accepted on a case-by-case basis when certain criteria for safety are clearly met.  We do NOT accept transport patients that transferred out from our practice to a home-birthing midwife due to the legal implications of dismissal of our practice as the active care provider.  The complete criteria for consultation, transfer, and transport, as well as the self-pay charges for common services, are available HERE (link to information for all home birthing CNMs).

We accept transfer patients who have had previous prenatal care and are less than 35 gestational weeks on a case by case basis. This is to ensure that all transfer patients are able to fully gain the experience of our collaborative model.

We see women of all ages, from teens to their 80s, every day for well-woman exams.  These exams are an essential part of maintaining long-term health and preventing illness before it occurs.  Each visit includes a full medical history, physical exam (general, breast and pelvic), and discussion of health maintenance strategies.  Appropriate mammograms, colonoscopies, and blood work (cholesterol screening) are ordered.  Unfortunately, insurance companies do not allow us to address significant gynecologic problems on the same day as a well-visit, therefore these problem appointments must be scheduled as separate visits.

Abnormal bleeding, whether irregular, heavy, or absent, is a common problem for women.  It can be caused by hormonal problems (low thyroid function, polycystic ovarian syndrome, diabetes), anatomic issues (uterine fibroids, polyps), blood abnormalities (von Willebrands disease), and infection (sexually-transmitted diseases).  It is essential to fully evaluate the source of the problem rather than just masking the symptoms with birth-control pills, as the treatment should be directed at the true cause.  We complete this evaluation in an organized, prompt manner in order to provide understanding to the woman experiencing these symptoms and to provide education to allow her to choose the treatment plan that best fits her lifestyle and beliefs.

Pelvic pain with and between menstrual cycles can impair a woman’s quality of life and ability to work or attend school.  Although endometriosis is one common cause of such symptoms, other causes include fibroids, adhesions, infection, etc.  Such pain is evaluated with pelvic exam, ultrasound, trial of medications, and ultimately explorative surgery. Long-term pain medications are never the ideal solution given issues of addiction and therefore, we always attempt to identify the source of the pain and treat it directly.  If long-term pain medications are required, we work in conjunction with pain management specialists to find the appropriate regimen.  Our ultimate goal is to relieve the pain symptoms and return each woman her quality of life.

Family planning is an essential part of every woman’s life – deciding when to conceive and when to postpone pregnancy.  Pre-pregnancy counseling is especially important for those women with chronic medical problems that might have complications in pregnancy that can be prevented with advanced planning.  Contraceptive options are diverse today, and no longer include just birth-control pills.  Now, traditional birth-control medication (combined estrogen/progesterone) can be administered through a skin patch or vaginal ring.  Progesterone-only birth-control is still available in pill and injection (depo Provera), but now also in a 3-year implantable option (Implanon).  Permanent sterilization through tubal ligation / tying of tubes can be done immediately after childbirth, laparoscopically through telescope into the abdomen, or hysteroscopically through a telescope into the uterus (Essure).  Of course, we always encourage our patients to discuss vasectomy with their partners given that this is the simplest, lowest-risk procedure to achieve permanent sterilization.

Infertility affects up to 15% of the population.  Not all infertility is due to female problems – in fact, 40% has a male source, 40% has a female source, and 20% has no identifiable source.  After 6 – 12 months of trying to conceive without success, we begin the evaluation with blood work, ultrasound, and hysterosalpingogram (HSG) for the female partner and semen analysis for the male partner.  Based on these results, medical (metformin, clomid, etc) and surgical (laparoscopic removal of endometriosis or adhesions) treatments are initiated.  If injectable medications, intrauterine insemination (IUI), or in-vitro fertilization (IVF) are necessary, we refer all patients to the Texas Fertility Group and their fellowship-trained reproductive endocrinology/infertility staff.

Most abnormal pap smears are caused by the human papilloma virus (HPV), which is a virus transmitted through sex.  The Pap smear is a screening test for pre-cancers and cancers of the cervix.  When a Pap smear returns abnormal, the cervix must be examined in detail using a colposcopy (microscope for the cervix) to look for these lesions.  Such lesions are then biopsied to assess whether a true precancer or cancer exists.  Further treatment is then based on these biopsy results – repeat pap smear in 6 months for low-grade lesions, LEEP (loop electrocautery excision procedure) for high-grade lesions, and hysterectomy for cancers.  This can be a very anxiety-provoking experience, particularly given the sexual-transmission of the viral source of this problem.  We schedule these appointments quickly and report results to patients as soon as they are available to reduce this anxiety.

Some women gracefully enter menopause while others find this transition torturous.  For those with significant symptoms, much can be done to reduce these symptoms – both with hormonal, non-hormonal, and herbal treatments.  We explore all of these options with our patients and allow the individual woman to decide which treatment best suits her.  Bioidentical hormones are very popular today and have there place in the treatment of these symptoms.  Bioidentical hormones are available both through compounding and traditional pharmaceutical companies in tablet and cream form.  Most of our patients choose the pharmaceutical options for consistency of content and insurance coverage.  One of our mid-level providers (Kathy Harrison-Short) is currently engaging in continuing education to further her expertise in bioidentical hormones to strengthen this service within our practice. 

In an era of high medical costs, we offer in-office minor surgical procedures one day per month in order to decrease the overall cost to the patient by removing the high surgical center fees.  These procedures are done in conjunction with ENCOMPASS – an in-office mobile surgical unit staffed with excellent surgical nurses and anesthesiologists from Austin Anesthesia Group (the same group that staffs North Austin Medical Center).  General sedation is used to ensure each patient’s comfort.  The procedures that can be done include:  dilatation & curettage (cleaning of inside of uterus), diagnostic hysteroscopy (looking into the uterus with a small telescope), hysteroscopic polypectomy (removing a uterine polyp using the small telescope), Novasure endometrial ablation (burning the uterine lining for heavy bleeding problems), Essure hysteroscopic tubal ligation (closing the fallopian tubes for permanent sterilization), LEEP (removal of precancerous cervical tissue), labial reduction (decreasing the labial size for symptomatic enlarged labia), etc.

Thankfully, many surgeries today can be done in an ambulatory surgical center where the patient is able to return to the comfort of their home on the same day as the procedure.  We use North Austin Surgery Center, which is located on the first floor of our office building (12201 Renfert Way).  All complicated hysteroscopic procedures such as hysteroscopic myomectomies (removing fibroids using the small telescope) and most laparoscopic procedures (looking into the abdomen through the belly button with a small telescope) are done at this location.  This facility offers state-of-the-art surgical equipment coupled with compassionate care.  The procedures that can be done include:  hysteroscopic myomectomies, laparoscopic tubal ligations, laparoscopic removal of ovarian cysts or ovaries, laparoscopic removal of endometriosis, etc.

Unfortunately, sometimes major surgery cannot be avoided, and for these cases, we use North Austin Medical Center, which is located across the street from our office building.  This facility offers the best in surgical technology, including the DaVinci surgical robot, and gynecologic specialty surgical technologists/nurses.  Here, patients are able to stay comfortably overnight after major surgery such as hysterectomy (laparoscopic, vaginal or abdominal approaches), vaginal repairs of bladder or rectal prolapse, urinary incontinence slings, etc.  The length of stay depends on the nature of the surgical procedure and the speed of each patient’s recovery to walking, eating, urinating, and maintaining adequate pain control.