Planning for birth

I have updated my little booklet, Planning for birth, which I have used for many years as a handout for women who visit me, making inquiries about having a baby, and for midwives and students of midwifery.

This booklet is self-published, and copies are printed as required. Readers who would like like a .pdf copy, please request by email joy@aitex.com.au [I have not hyperlinked this email address, as that may invite spam] I am happy to share my work. If you want to use copyrighted items such as the poem 'waiting' on page 8, please give reference.

waiting

You are waiting to give birth.

Your pregnancy is a statement of your wellness, life and strength.  New life is swelling your womb. 
 

You and your mate accept the gift of life with eager anticipation.

Your body tells you that change and growth are following nature’s course.   The cessation of your menstrual flow, the desire for good food and rest, the enlargement of your breasts - all external - accompany the private dreaming.

As your midwife I am committed to supporting you and your family through this wonderfully basic life event - the birth of your baby - your personal, intimate celebration of life and health.

 ©Joy Johnston

The pages of the booklet are also scanned here - 4 sheets with 2 pages per side. 

Finding a mentor - being a mentor

A mentoring agreement between two midwives can enrich and support both the mentor, and the one who is being mentored.
I have experienced this special relationship in the past two years, with a colleague who asked me to mentor her as she explored and experienced private midwifery practice as a career option for herself. During face to face meetings, phone calls, and email messages we discussed and questioned and reflected upon our shared and separate experiences as midwife, as woman, wife, mother, sister, and many other roles.

We each learnt to trust the other, and avoid defensiveness, when a question, such as "Why did you do that?", or, "... not do X" arose. Trust enables truthfulness, which leads to accountability and critical thinking, which can lead to changes in the way we behave in a given situation: the lifelong learning pattern that a midwife will always value.

I have titled this post 'finding a mentor, and being a mentor', as the midwife who is being mentored will quickly realise that she is able in turn to mentor others. The role of ‘mentor’ as it is commonly used in midwifery literature and discussion, is

mentor: a trusted friend, counselor or teacher, usually a more experienced person. ... Today mentors provide their expertise to less experienced individuals in order to help them advance their careers, enhance their education, and build their networks. [Wikipedia] 

Although there are no set ‘rules’, the following simple points may guide you in choosing a potential mentor:

• • The mentor should be a midwife who is practising or has recently practised in the scope of midwifery that you are entering; eg having a caseload 
• • In asking another midwife to be your mentor, you need to find ways in which you are able to work together, so that you are able to learn from your mentor, and she/he can observe your professional activity. This can be within a midwifery group practice, or as self employed midwives, or as volunteer members of a group, such as the local committee for the College of Midwives, or Maternity Coalition. 
• • The midwife who agrees to a mentoring agreement may ask you to do something as your side of the arrangement. She may ask you to be accountable to her, in giving regular updates on your learning goals, using the ACM MidPLUS professional development recording system. 
• • Review your situation from time to time, and be ready to become mentor.

$? What fee does a mentor charge? 

Of course there is no simple answer to that question.  A great deal of informal mentoring happens, without any fee and without being given any title, as midwives support one another within their communities. 

Sharing of skill and knowledge is a logical and accepted principle in health professional ethics.  Putting it another way, if there is insufficient sharing and passing on, that skill and knowledge will quickly be lost.

However, being a mentor requires commitment of time and interest. I have found that midwives who ask me to mentor them are happy to come to an agreement in which there is an exchange of money, and an expectation of commitment over a period of time. 


Here are a couple of examples of mentoring arrangements between midwives:

• Midwife A is an experienced independent midwife, who has established a midwifery business (or group practice) which enables other midwives to practise privately under the name of the business.  Midwife B asks A to mentor her, and comes into A's business as a partner.  The agreement between B and A's business is that B will pay an agreed percentage (eg 20%) of her earnings to A's business.  In return, B and A meet together for professional discussion each month; B is able to telephone A for direct support and advice at any time; and the advertising, book keeping, superannuation, and tax requirements of B's income are managed within A's business.  
• Midwife C is working part-time in a hospital, as she establishes her own midwifery practice.  C asks Midwife A to mentor her, but she does not want to become a partner in A's business/practice.  A and C come to an agreement that C will pay an amount for professional mentoring, and A will provide C with a receipt for that payment.  The support agreement between A and C is otherwise the same as between A and B.

Millennium Development Goals: How are we progressing with the maternity goals?

Millennium Declaration

In 2000, 189 nations made a promise to free people from extreme poverty and multiple deprivations. This pledge became the eight Millennium Development Goals to be achieved by 2015. In September 2010, the world recommitted itself to accelerate progress towards these goals.

The 8 Millennium Development Goals are:

1 Eradicate extreme poverty and hunger
2 Achieve universal primary education
3 Promote gender equality and empower women

4 Reduce child mortality

5 Improve maternal health

6 Combat HIV/AIDS, malaria and other diseases
7 Ensure environmental sustainability
8 Develop a global partnership for development

Each of these goals has a potential to improve maternity outcomes in the world's poorest countries.  Goals 4 and 5 give direct measures of maternity care.
If you would like to see the UN 2011 table summarising progress, click here.


Readers may wonder what significance the MDGs have in the context in which I practise midwifery.  Private midwifery in and around Melbourne is, surely, for a privileged minority, who are usually healthy, well educated women, and able to pay for the maternity care they choose.

This is true.

Women who plan homebirth in my practice understand that my role includes arranging transfer to hospital if complications are detected.  Well staffed and equipped maternity hospitals are within easy reach by car or ambulance, in most instances.  Availability of appropriate referral services is a key to safe and optimal outcomes, whether the referral is from planned homebirth, or from small primary maternity care units in rural towns.

Women in places where maternal mortality is high may not be within reasonable reach of emergency obstetric services; may face prohibitive costs if they do go to hospital; and often delay in seeking medical intervention.  Their bodies are often weakened by anaemia, malaria, HIV/AIDS, intestinal parasites, and other preventable conditions.  Mothers and babies die from Tetanus, because the mothers have never been vaccinated against Tetanus.   Women do not have access to acceptable family planning measures; child-brides are pregnant before their bodies are fully developed; too many women develop obstetric fistula; and the list goes on.

The challenge that I see in comparing maternity care here in Melbourne, with maternity care in some of the world's most disadvantaged settings, such as Sub-Saharan Africa, or the highlands of Papua New Guinea, is the continuing and increasing reliance on medical and surgical management of birth in the West.  This logically equates to a loss of knowledge, a loss of expertise, in working with natural processes in the childbearing continuum.  The excessive and unnecessary medicalisation of birth and everything related to maternity care, as is seen in mainstream maternity care in Melbourne, will not improve maternal or infant health in less developed countries. Melbourne hospitals are teaching doctors and midwives who will pass contemporary practices on to their students in all parts of the globe.  Melbourne, which has world-best facilities for those who need them, must set an example of best practice in protecting each woman's ability to give birth under her own amazing power - 'Plan A', unless there is a valid reason for 'Plan B'.

For decades we have seen the global impact on the lives of babies of the loss of collective confidence in breastfeeding.  Efforts to protect, promote, and support breastfeeding are required in the rich world if we want to have any impact in poorer countries.  The Baby Friendly Hospital Initiative (BFHI), which in Australia is known as the Baby Friendly Health Initiative, has the expectation of the same high standards in each of the '10 Steps to successful breastfeeding', whether the hospital provides care for those who pay big money, or those who are in low socio-economic settings.

Childbirth is not very different from breastfeeding.  The loss of confidence in natural physiological processes in childbirth, including the spontaneous onset of labour, progress in labour, giving birth without medical pain relief or physical assistance, expelling the placenta, and establishing breastfeeding, to name a few key points, needs to be recognised and rectified in Australian mainstream maternity care.  There is no safer or more reasonable way to proceed with childbirth, for most women, than to do so under the natural, hormonally-driven processes within each woman's body.  Only those for whom a valid reason to interrupt the natural processes will be better off with such intervention.

I expect any readers are likely to be already convinced of these facts, so I won't press on.   

Midwives, we carry the knowledge of normal birth!  We must value that knowledge, and hold on to the skills of working in harmony with women's natural physiological processes, whether in early labour, breastfeeding, birth, or the third stage. 

The 1996 'Care in normal birth' instruction from World Health Organisation, that
"In normal birth there should be a valid reason to interfere with the natural process" is as relevant when applied to the Millennium Development Goals, as it is in a Birth Centre in the rich world.

more thoughts on the birthing space

I have appreciated the recent thought-provoking discussion in connection with the previous post in this blog, which is also linked to Carolyn Hastie's thinkbirth blog.

In the past couple of weeks I have attended three births; two at home and one in hospital. These three mothers were 'first timers'; primipara; a special category worthy of consideration in any maternity setting.

Picture this scene:

A woman is labouring strongly and consistently in an inflated birthing pool, set up in her home.  It's 2 or 3 in the morning, the 'wee hours', when everyone is overcome by weariness.  Her man, whose sleep was interrupted by early labour the previous night, is asleep on a couch.  The midwife is nearby - within reach but dropping off to sleep between contractions, occasionally mumbling words of encouragement.  The student midwife is stretched out on another couch. There is a little light from a lamp or candle; the birthing space is quiet except for the sounds of the labour.  

After some time, the woman's sounds become deeper.  Her midwife encourages her "let your baby come down deep in your body; feel the fullness; you're doing well", and listens to the fetal heart after a contraction.  The woman does not notice that the 'period pain' she had been experiencing has gone.  In fact she has stopped thinking about her labour and has surrendered to the work that her body is doing.

By the time the early signs of daylight are peeping through the cracks in the blinds, the urge to push has become strong.  Daddy-to-be and student midwife are awake; midwife is awake and ready; and mother gives birth, through the water, to her first child.  Mother and child complete the mysterious dance of birth, as baby searches for the breast, and the placenta is expelled.

Today I would like to reflect on recent primipara births, and (without identifying individual women) discuss how the birthing space has supported these births. In the past 18 months, approximately, I have attended 10 women giving birth for the first time. 

Before looking at the birthing spaces, here is an overview of these births.  Of the 10 women:

• 10 came into spontaneous labour; which became strong as the night progressed (there's something special about night and birth!)
• 5 gave birth in water: 4 at home; 1 at hospital
• 2 planned hospital birth; both gave birth spontaneously to healthy babies
• 8 planned home birth
• 5 gave birth at home to healthy babies, without complication
• 3 who planned home birth transferred from home to hospital in labour
• 2 proceeded to spontaneous unmedicated births of healthy babies
• 1 was delivered of a healthy baby by emergency Caesarean surgery

The ages of these women ranged from 24 to 37.
The length of gestation ranged from 36 to less than 42 weeks.
The weights of these babies ranged from 2670g to 4250g.
All babies breastfed from birth.
The estimated blood loss for the 9 women who gave birth spontaneously ranged from 100 to 600ml.


I want to make a point here, which may be obvious to some, yet others may find it a challenging statement in the maternity environment in Australia.
Place of birth - home or hospital - is not a measure of good midwifery care.
Yet the decision to plan homebirth is a huge statement of intent, by the woman, that her plan is for spontaneous, unassisted, unmedicated birth.  Those who plan homebirth with an experienced midwife are able, I believe, to proceed down the path of physiological birth if that is feasible, with a high degree of safety.  Those who plan homebirth, then make an informed decision to transfer their care to hospital because there is an indication - a valid reason - are also able to protect their ability to give birth in harmony with the natural, hormonal, physiological processes that direct labour, birth, and the baby's transition from the womb to the outside world. 

In my previous discussion on birthing spaces I wrote about the physiological phenomenon of *Nesting*.  Understanding normal birth in terms of nesting, as the woman progresses under the influence of an amazing cocktail of hormones, provides a key to the mysteries of birthing.  Nesting supported each of these 10 women, as they came into spontaneous labour.  Nesting supported the three who made a decision in labour to move from home to hospital, and obtain special medical intervention that had become necessary for them.  Nesting supported the choice of position for birth, whether kneeling beside the bed, or squatting in the birth pool, or lying on the bed.

Cessation of nesting happens, I think, when the woman is able to surrender to the huge expulsive urges within her body.  Baby is "coming, ready or not".  Night time and weariness enables this transition to occur without question.  The woman, and her personal support team, have given up trying to understand what's going on; to do it the way they were taught in class.  The midwife is skilled at keeping watch, guiding when needed, without taking control from the woman.

The essential elements of the space for optimal birthing are few.  As long as the woman is able to proceed without interruption; as long as the woman is able to trust her midwife; as long as the woman and her support team are able to hold confidence in the process of birthing ...

... a baby is born.

It just happens.



Your comments are, of course, welcome.

optimal space for birthing?

There is a special interest branch within midwifery and maternity care that overlaps with design and architecture disciplines, exploring the creation of optimal spaces for birthing. I have been reminded of this field of interest, when reading a recent post by my colleague and friend Carolyn Hastie, who writes the thinkbirth blog. Carolyn refers to, and provides a link to a presentation on optimal birth spaces by Maralyn Foureur, Professor of Midwifery at the University of Technology of Sydney (UTS). I wrote in the comments to thinkbirth:

I have seen some wonderfully designed spaces in which women can give birth. I have also seen women give birth beautifully (and, I would say, optimally) in settings that would seem to contravene every goal of the optimal birthing space ideology.

The woman's own nesting, which I believe is hormonally driven more than the result of intelligent planning and preparation, seems to be the key. Nesting can include the choice of setting, as well as the choice of people who make up that woman's birthing team. Nesting also enables the woman to change her plan if her situation requires it, without losing the ability to proceed normally.

I don't want to be critical of the optimal birth space ideology.

HOWEVER ...

The reality in my world is that each birth space is often very different from what the woman had planned or wanted, yet women are able to give birth in that wonderfully spontaneous way, without any regrets.

It would be naive to imagine that a woman's home is automatically the optimal birthing space for her.

I need to do a postnatal visit now, but hope to get back to this post later, and write some more.

[Melbourne readers may know that a private hospital in Hawthorn had recently set up a beautifully designed birthing facility, which has closed its doors after just a few months' operation, because the plan was not working, and there were too few women making bookings.]


NESTING and optimal birthing conditions
Nesting is one of those normal physiological functions that everyone knows about, but rarely pays much attention to.   While researchers have for a couple of decades looked seriously at the impact of the love hormone oxytocin, and the 'fight-or-flight' adrenal hormones, on the birth and mothering behaviours of laboratory animals, nesting doesn't seem to raise research interest or dollars.

A woman anticipating the birth of her child will usually have a 'to do' list, including stocking and preparation of food and other consumables, washing and setting out baby clothes, and packing a bag for herself and her baby in preparation for a stay in hospital, or 'birth kit' items in readiness for giving birth at home.  This process of getting ready would be recognised broadly as 'nesting'.  I have known some who feel the need to clean windows, and sweep, vacuum, and dust almost obsessively in the days leading up to the labour.  This is all intentional nesting, driven mainly by the woman's intellectual grasp of the enormity of the job that lies ahead.

With the establishment of spontaneous labour, physiological nesting becomes more pronounced.  Women who thought they would like to have the other children present for the birth of their sibling will often withdraw into a secluded space.  Women who have a plan to call a trusted midwife will often call her, just to check that she is able to come when called.  Nesting can continue until the peak of first stage, often called 'transition', when the woman must give up conscious control and surrender to the work of bringing her child out of her body. 

Women who plan to go to hospital to give birth face a nesting conflict.  It goes something like this:
"If I go to hospital too early my labour might fizzle.  If I stay at home I won't want to move when the labour becomes strong."  It's their natural nesting drive that makes them want to find the place where they will give birth - not the street address, but the actual room, with its contents, and the actual people with whom she will need to communicate.

Women who are booked at a modern hospital Birth Centre, where there are well-designed birthing rooms, often experience a conflict about the availability of a room.  They know that if the rooms are all in use when they arrive, they will be admitted to a standard hospital suite.  They have heard stories about how often this might happen.  Other matters of 'nesting' concern might focus on the times of shift changes in the hospital. 

I have, on occasion, been called to a 'planned' home birth, only to find that the woman and her home show no sign of nesting.  This dysfunctional nesting is, I think, a sign that the woman's sensitivity to natural instinctive urges has been in some way shut down.  The woman's labour can continue without nesting, and the baby can be born, "ready or not!"

Returning to the initial question of this blog: is there, and what is, an optimal space for birthing?
I would refine the question further, and add the word 'physiological' - the space for medically managed care in labour and childbirth must be very different from the space that enables and supports and protects physiological processes.  Here are a few ideals for that space:

• a place that the woman has chosen to be in
• a place that the woman is happy to continue in, as labour progresses
• a place where the woman can receive care, support, and guidance from a trusted midwife, and other chosen people
• a place where the woman is able to cover windows, dim lights, and make other physical adjustments when she wishes
• a place that allows the woman to feel private and unobserved
• a place where the midwife, as the responsible professional at the time, is confident that the wellbeing of mother and baby are being protected.

As with all other basic life events, "the best laid plans of mice and men ..."  There can be no guarantees.  The only people who we can be sure will be at a birth are the mother and her baby. 

The optimal space for physiological birthing in suburban Melbourne should not be very different from the optimal space for physiological birthing for Inuit women in Nunavik in the Arctic Circle.  The type of bed or birthing pool; the colour of the walls or the pattern of the furnishings - these things can be nice, but are of little significance to the woman giving birth.  The woman's feeling of unintruded privacy, as she reaches the point of surrender, knowing that her midwife is *with* her, is the essence of optimality. 


Your comments are very welcome.

spontaneous birthing

There was no acceptable alternative; no short-cut or easy way.  The labour had established.
The young mother struggled with every surge of uterine activity.  "I can't do it!  I am too tired!", she cried in English, then lots more in another language.
If one of us had been able to step in as proxy; to labour and give birth, or even to do some of the work, and lessen her load, we would have.  Surely it's unfair that the woman has to do it all?

Each time I witness the massive effort that culminates in the unmedicated, unassisted birth of a baby - and particularly a first baby - I am in awe.   The journey that can have many unpredictable and unexpected turns in the path; many forks in the road.  At each decision point, only one way can be taken.  Is this the best way?

As midwife, I hear many voices.  The mother's body, the baby's body, my own mind, the voice of professional and scientific knowledge, and the words of others participating in the birthing journey.

When the mother's mind says "I can't do it! I'm too tired!" I can't just block my ears.

I ask, what does her body tell me?

There is power in these contractions, and I have seen progress over time.
There is strength in this young body.  Her pulse rate is steady and strong.
There is quietness in the moments of resting between contractions.
Is mother well?  At present, yes.

I know we can continue.

I ask, what does her baby's body tell me?

The baby's heart rate is strong and steady.
The contractions, although strong, do not bring any sign of distress in the baby.
The baby's station is progressing with time.
Is baby well?  At present, yes.

I know we can continue.

I ask, what does my own mind tell me?

It's the middle of the night, and my mind is also weary.
I hear the cries.  I know that she is sleep-deprived.
I seek to guide this girl who is being transformed into a mother through this rough terrain.

I will not interrupt or interfere with the amazing metamorphosis; the life-giving struggle that we are witnessing.

I ask, what does professional and scientific knowledge tell me?

Simply this: that there is no safer or more appropriate way for this baby to be brought into the world, than for the midwife to work in harmony with natural physiological processes in labour and birth.
That this woman's body is wonderfully made, that this baby's body is uniquely suited to this mother, and that the process of birth is so much more than delivery of a child from the womb to the outside world.
That the transitions which must take place shortly are best supported in strong, unmedicated birthing.

I know we can continue.

I ask, what do the others - the husband, the friend, the student - tell me?

We are working together, and I am responsible for so much.  These members of the team are looking to me for encouragement and strength.  They do not have the years of life experience that I have, and they are quietly learning to harmonise their actions with those of the labouring woman.

I know we can continue.



We moved to the birthing pool.  The pushing had been ineffective, and the voice "I can't do it, I'm too tired!" was becoming more persistent.

Then, as an expulsive urge was about to go, I saw some fine, thick black hair peep out between the labia, then disappear again.

"I can tell you what colour your baby's hair is" I said.  "Black."

We all laughed.  Babies from their people group all have black hair.


I don't know when the young mother realised that she actually could give birth, that she was giving birth.  But I know and hold onto the look of utter amazement and satisfaction as she took her child into her arms.

Thanksgiving

Me with my girls

From time to time as that special day passed I rubbed my belly, enjoying the sensation of tightening as the fundus became firm. I was as confident and ready as a 23-year-old entering motherhood for the first time could be.

For most of the week prior to this day we had gone for walks in the evening, and the tightenings had come for a while, then stopped. Each night as we went to bed I wondered, "Is this the night?" Each morning I awoke, rubbed the bump that protruded under my diaphragm, looked in the mirror at the enormity of my previously flat abdomen, and continued in waiting mode.

The special day was Thanksgiving Day in the USA. We had settled in to our home in Michigan; Noel had commenced his graduate studies in the Dairy Science department at Michigan State University; and we had been invited to join the Professor, Wayne Oxender DVM, and his partner, for our first American Thanksgiving meal.

Our hosts had prepared special food that had significance to the celebration of thanksgiving to God for preserving the lives of the Pilgrim fathers through the previous year, with food stored for the coming winter.

Decorations had been carefully made using corn husks and natural fibers. The turkey had been stuffed and was basted carefully as it roasted to perfection for many hours. I had never seen a turkey like that one. There was abundant sweet corn, sweet potatoes, and corn bread. Probably a dish of spinnach. I don't remember the details. A large bowl was set up with hot apple cider that had sticks of cinnamon floating in it. We dipped into it many times. It was sooo good!

This was a totally new culinary experience for a girl from sunny Queensland. Then pumpkin pie - who ever would have thought of using pumpkin, the staple vegetable, as a dessert? On top of the servings of pumpkin pie someone squirted fake cream out of a pressurised can - the fashion at that time. Who ever would have thought of putting cream into a pressure pac? The irony of using fake cream on this most basic of 'back to the simple life' feasts stuck in my mind, but I was too polite, too blown away, to say anything.

As I said at the start of this post, I was experiencing some tightenings which were preparatory for my labour with my first child, Miriam. That evening the labour became established, and I gave birth the following day.

The good company, good food, and totally new world that we experienced in late November 1973 prepared me for motherhood. Being surrounded by members of the veterinary profession, with their special interest in reproduction and raising of calves, was good for me. I have often reflected on that period in my life, and it has in many ways supported my efforts to work in harmony with natural physiological processes in the birth and nurture of babies in my care.