Monday, March 05, 2018

MY body ...

Thoughts on choice, effective communication, and decision making in childbirth

Dear reader,
Now that I am retired from midwifery practice I don't have the same access to real life events that used to prompt me to write in the past.   I am 'restricted', so to speak, to my circle of friends, acquaintances, family, and what comes my way via the already-filtered social media the 'news'.  

Today I want to reflect on a very real, every day situation in the world of the midwife; a situation that I have recently been reminded of in real life.

A woman, aged 30 years, at Term, comes into labour with her first child.  She has been well through the pregnancy.  Her BMI is in the 'high' range, and she has followed dietary advice, maintaining minimal weight gain, and keeping blood sugars within the normal range.  Throughout the pregnancy she has stated clearly that she is planning a birth without interventions.

My body ...

Labour progressed well.  The pain became intolerable, and they went to the hospital where she had booked.  The hospital midwife focused on the baby's heart rate being too slow at times.  The labouring mumma just wanted a break!   Someone offered an epidural, and the mother accepted it. 
Everyone can relax now.  Baby's heart rate is fine - it must have been a problem with the pickup of heart sounds by the monitor.


My body, except that I can't feel anything below my waist. 

My baby ... 

Some time later the monitor declared that baby's heart rate was slowing down.  Doctors who mother hadn't previously met entered the room.  They had been watching the monitor trace at the ward desk computers.  
Brief introductions, 
legs go up in stirrups that appeared out of nowhere ... 
and a procedure to determine baby's blood gas levels. 

Consent form is signed

Rush to the operating theatre
Casearean surgery
Baby is fine!

... forward 5 days

Mother is overwhelmed.  The preceding days are just a haze in her mind, having received generous doses of opiate drugs to numb her pain.  She cries and sobs "Everything that I planned has gone wrong". 

The mother sits with a breast pump in the beautiful room that she had prepared so lovingly.  Somebody else gives the baby a bottle of expressed breast milk, and a 'top up' of artificial milk from a formula can.  Attempts at breast feeding have been less than satisfactory.  Baby just goes to sleep - out like a light.  Doesn't know what to do.  A couple of times baby did seem to be sucking at the breast, but left ridges and blisters on the nipples that quickly progressed to bleeding.  Now someone else changes baby's nappy, and cuddles her after the feed.  


I am reflecting on this birth, focusing on choice, communication, and decision making in childbirth

  • Choice:  From early pregnancy this mother had made what she considered to be an informed choice.  She wanted what was best for her baby, herself, her family.  She researched childbirth advice, went to classes, and spoke with friends.  It was a no-brainer.  She wanted to give birth without [that ugly thing, whatever it was] intervention.  Drugs are bad for mother and baby.  Drugs are dangerous.  No drugs.  Birth is natural.  Natural is best.

  • Communication: The words clearly communicated by the mother; "no intervention", became less meaningful as labour became established.  This is not news to a midwife or a doctor working in maternity.  Even as the night progresses and weariness sets in, some women become more and more distressed with the pain of labour.  The midwife can't ignore a woman's pain.   It can be a sign that everything is going well, and the mother is resisting the need to surrender neo-cortical control.  Or sometimes it may mean that the labour is obstructing.  This is one point at which a known and trusted midwife who is primary carer is able to either reassure the woman or prepare her for ongoing decision making in labour.  There was no such midwife for this mother. 

  • Decision making:  In all the prenatal preparation that this mother had done she had not grasped decision making as an ongoing, active process in pregnancy, birth, and all that childbearing entails.  She liked 'choice', and 'control'.  'Choice' gives the mirage of control.  Yet noone has absolute control of their own body's function, let alone control of the actions of other people such as the staff of a hospital.  This mother did not understand that each decision she made influenced the next option she would have.   

For some years now there has been a push by some midwives and birth activists to assert birth rights within a global human rights agenda.  A march planned in Melbourne is headed 'Birth Rights are Women's Rights'.  The promotional material for this march states:
"... Getting it right in the birth context could provide a strong platform from which to assert how vital it is that all women are treated as humans at all times, with the rights this should afford them.
By contrast, childbirth also provides the perfect opportunity to undermine those rights. Looking across the developed and developing world it is clear that the broad spectrum of women's freedoms is undermined daily in birth. If we don't value their experiences in an act that is particular to them, we make it an easy access point for those who seek to disrupt feminist process." - Rebecca Schiller Why Human Rights in Childbirth Matter

I don't think there was any intention in the case I am reflecting on, or the many others that take place daily in our maternity hospitals, to ignore or undermine the woman's rights or freedom.  When the mother declared that she wanted to give birth without intervention it wasn't a wish list.  She considered it her right to choose.  That's where she was misguided.  In choosing to give birth without intervention she needed to know how to give birth under physiological conditions.   She was a victim of her own ignorance, rather than a system designed to undermine her freedom and disrupt the female process. 

I believe there is a lot of mis-information doing the rounds of childbirth education classes - both those given by hospitals and those provided privately.  I have seen claims that the choice of place of birth, and choice of who provides midwifery care, are human rights.  No!  They are (in this part of the world at least) usually linked to a person's ability to pay, and occasionally linked to the person's access to a funded program.  It has nothing to do with being "treated as humans at all times" (Schiller, R. quoted above).  

In an ideal world, every pregnant woman would have access to, if they wished, a known and skilled midwife who facilitates effective maternity care for women planning homebirth, and hospital care for those for whom it is appropriate.   There is plenty of literature supporting this model as safe.  But it's not easy.

Dear reader, I am writing this because I am very sorry for the young mother and father and baby in the case I have described.  I am sorry that she feels so very disappointed.  

Yet, I am optimistic that there is hope for this mother to recover, and to become strong again.  As she and her baby learn breastfeeding and the hormones of love surge in their bodies, there will be healing for both of them.  Even in sub-optimal situations there are many blessings.  Young women become strong and resilient as they learn to deal with real life situations.  Children thrive in the care of strong, loving families.

Friday, December 22, 2017

Thinking about Christmas cards and greetings

Some of what I post here has been comments I made on my Facebook account, so if you are a 'friend' of mine (as defined by FB) you may have seen some of this.  I am aware that some who receive notification of my writings at this villagemidwife site may have no other links with me.  So rather than speaking just to 'friends' - and only those whose FB accounts are set to receive my posts - I have moved my deliberations to this site. 

Has anyone else pondered how very complex our sending and receiving of Christmas greetings has become? There was a day when everyone bought their standard Christmas cards by early December, put an address on an envelope, wrote a few words, affixed a special stamp that was less expensive than ordinary stamps, and posted them. Done and dusted! In those days the verb to 'post' referred to use of the post office. 

Then we had the option of a personalised card, with a picture that meant something special about the person sending the card. This card below, with our little family: Noel, beautiful little Miriam, and I, was our 1974 greeting. Over the years I have looked out for a good family pic to include in our annual letter. That hasn't always been easy. Sometimes one or more of the children may be less than cooperative ... (you know what happens then!) And then, as the family grows up, I have sometimes wondered if it's OTT (over the top) to (over-)share on the lives of our offspring. Those questions come and go without any resolution. We have generous, loving offspring who accept their parents without too much critical comment.

In the past 20 or so years we, and most of our peers, have embraced everything digital. Some haven't. Which brings me to my initial comment on the complex nature of sending and receiving Christmas greetings. So now we send a message via fb, as I did yesterday, as well as some by email, and paper copies via Australia Post to a few special people for whom the other systems are not acceptable. And my 'system' includes 'posting' our annual greeting on a blog which gives me, and anyone else who finds their way to the site, me a readily available summary of our lives.
Are paper copies of a greeting more meaningful than digital?
That's a question that I will not try to answer.

We live in a day when there are so many ways of connecting with people we know that we could easily become overwhelmed. The Christmas card in the post 30 years ago was probably a lot more meaningful than it is today, when the pretty cards can also be sent by email, fb, messenger, blogs and other forms of social media. Are friendships enhanced by one method of communication or another?

I have found the old style of communication - face to face, with a loving hug or smile, or a phone call from someone who I won't be able to see - these are the ways that I feel loved and cared about. And of course we are limited to just a few people with those old forms of communication, compared with the massive reach of digital magic. So can I encourage anyone who reads this to give your loving greetings in person, or a phone call, to someone who may not have much personal contact with others.

Tuesday, October 10, 2017

Replacing the midwife?

The woman found it difficult to trust anyone.  Very difficult.  Her anxieties about bad people and bad things were overwhelming.  'They' were likely to force her to take medicines that were bad.  The bacteria and viruses in public spaces were bad.  The 'system' would force her to have surgery that she didn't want.

The woman became pregnant.  She had been pregnant a couple of times previously, but had terminated those pregnancies early.  She wasn't ready then.  For some reason this baby stayed in place and before long she was experiencing new feelings - movements.  Her need to control must have been weakened as the maternal and placental hormone levels surged.

She was strong and healthy, and avoided anything that sounded like professional maternity care.  But she was curious, and a bit of a geek, well versed in all things digital, so a couple of ultrasound scans were arranged through a local medical practice.  Fascinated by the imaging, she asked lots of questions of the technician.

The woman found a new world opening up in cyber space.  Groups and forums, with varying levels of security, brought a host of information and options, as well as a sense of belonging.  It wasn't long before she found herself linked to a network of like-minded women, or at least she thought they were.  One was close to giving birth, and described her plans to bring together a supportive group of women, all with positive energy, so that she could give birth in a state of ecstasy.

The woman found a fetal monitoring device on e-bay.   She bought it, strapped it on, and listened to the rapid wop-wop-wop, with occasional kicks or hicoughs to break the monotony.  Over time the woman was becoming more excited about the thought of 'free' birth.  It ticked all her boxes.  And a couple of friends from the online community had told her they would help her.  These women were experienced, from their own births especially.


This story is based on real people; real events.  I do not want to describe it further.  The reader can envisage the possibilities.

There have always been people with anxiety neuroses and other aspects of mental health impairment.  The distrust and fear of everything bad, as this woman experienced, is not new.   A midwife who earns the respect and trust of a woman whose mental state is fragile may be able to support and empower her in a restorative way, as she prepares to bring a baby into her life.

The element that has recently been added, in some cases triggering the perfect storm, is the information overload that has been unleashed via the internet and social media.

In this story there has been no midwife, no systematic maternity care or surveillance.  Babies will eventually be born, even if there is noone providing care or checking health and development.  In this world of distrust the midwife is seen as a medical person, and anything medical is to be avoided and not trusted.  But, you will say, surely the ultrasound scans are medical?  Surely the strapped on monitoring device is medical?  Of course.  This world is not always logical.  The fragments of professional knowledge that can be shared digitally from person to person via social media can give a sense of great knowledge, especially to the novice who is just beginning to navigate the terrain.

In my experience this woman did seek out midwifery care, quite late in her pregnancy.  That's how I come to know about her.  There was no development of a mutually trusting relationship or partnership.  Distrust was worse than the germ-phobia.  My professional guidance was received at arms length, and it was being checked against the mirage of wisdom of the team of guides.  On the positive side of the ledger was a healthy baby and a physically healthy mother, and a process that does not submit to intellectual control, but is driven by wonderfully powerful physical and physiological-hormonal forces.


Now imagine ....
  • that a digital device was developed to replace the personal midwife
  • that this device could be strapped on or implanted or otherwise attached to the woman 
  • that this device monitored and recorded all the physical observations recommended in maternity care
  • that this device provided the woman with a real time decision making guide
  • that the information recorded by this device could be accessed remotely, by whom-ever the woman chose to share it with
  •  ... and so on   

It sounds so realistic, so do-able, that now I'm getting anxious.

Already many women in labour are connected to continuous electronic fetal monitoring devices that record the baby's heart rate and the time/duration of maternal contractions, maternal pulse and blood pressure.  Already those machines are linked to a monitor that is usually stationed at the 'desk' of the birth suite, and can be looked at by whoever is at the desk: a midwife, obstetrician, or someone else.  Already digital cameras exist that could be placed in the woman's vagina to record the dilatation of the cervix and the progress of the presenting part.

Our society has embraced technological interventions in pregnancy and birth to such a degree that these points I have imagined are not really fanciful.  We have the technology.  Someone just needs to put it together.  And just as our world is preparing for driver-less cars, the medico-legal world is ready to embrace technology that would give a new level of assurance, accountability, and what would be seen as less chance of human error.  Although research has failed to support improved outcomes from routine continuous electronic fetal monitoring, few women avoid it in maternity care.

The next step with the introduction of this unnamed device is that a woman who cannot trust the 'system' could see this as useful for her DIY 'free' birth.  Just as she strapped on the monitor at 26 weeks' gestation and listened to the rapid thudding of that tiny heart, she would likely see this device as something that would give her confidence, without the threat of 'bad' things happening at the hands of an un-trusted other person or system.

Yes, the system is full of flaws.  Yes, there are people with the title 'midwife' or 'doctor' who do not understand the woman's fears  and anxieties.  I hope maternity services will be reformed around care that centres on the needs of the individual woman, and enables her to trust the care she receives, and understand the imperfections as they arise.

I would like to think that a device will not replace the midwife.

Thursday, December 08, 2016

Coroner's reports and expert witness

'Midwives and the medicolegal system'

·       [These are the notes I prepared for a talk given at MAMA Caulfield today.]

My interest – 
§  a midwife in private practice 1992-2015.  Included many births that would be called ‘high risk’ today – grand multipara, births after caesareans, previous history of haemorrhage, undiagnosed twins and breech births.
§  Activism around the laws and regulations relevant to midwifery, particularly in the 1990s and 2000s.
§  Appointed to the (then) Nurses Board of Victoria. 
§  Ongoing, as a member of this society, a mother, grandmother &c, and a lifelong learner.  Reflecting on cases, and learning what happened, why, what could have been done differently, what would I do differently next time this happens

EXERCISE: Write down any phrases or sayings you can think of relevant to birth & midwifery (you don’t have to agree with them)
·       “Birth is not an illness”

·       “In normal birth there should be a valid reason to interfere with the natural process.”

·       “A midwife sits on her hands”

·       “Hands off the breech”

·       “My body, my baby, my birth”

·       “with woman”

·       “wise woman, sage femme”

·       Every woman needs a midwife

·       Choice, control, continuity of carer

A few links:
Planned homebirths in NSW*

*Note the finding that "Characterising these homebirths as a patient’s choice misrepresents the patient’s knowledge base in making that (uninformed, or not sufficiently informed) decision, and misunderstands the role of the professional in explaining risk and recommending safe practice"
Facebook site ‘Childbirth and the Law – Australia’ – “...This group is for discussing developments in the law about pregnancy and childbirth in Australia. It is not a forum for soliciting or giving legal advice or legal information.”

Examples of cases for which I have provided expert witness review on behalf of the legal team for one of the parties to litigation.

Baby developed cerebral palsy, and was suing the hospital.  Baby was born in hospital, vaginal birth after induction of labour at 38 weeks.  At about 3 hours after birth the mother discovered that her baby had become floppy and was not breathing.  Immediate resuscitation attempts and transfer to SCN, and appeared to recover well.

“Following your consideration of the material,:
(1) Please provide your opinion as to whether the midwives at [Hospital], in their treatment and management of the plaintiff , acted in a manner that was widely accepted in Australia by a significant number of respected midwives, as competent professional practice in the circumstances.
(2) If you are of the opinion that the midwives at [H] acted in a manner that was widely accepted in Australia as competent professional practice, please outline the basis of your opinion the practice was ‘widely accepted’.  Please note that as a matter of law, peer professional opinion does not have to be universally accepted to be considered widely accepted.
(3) Please provide your opinion on each of the allegations of negligence made against [H] in paragraph (xx) of the Statement of Claims.

Baby developed cerebral palsy after VBAC complicated by shoulder dystocia. Parents had begun proceedings against private midwife who was primary carer for planned homebirth, transferred in second stage to hospital. 

Based on the facts outlined in this case, I was asked whether I consider that:
(a)        M’s [Midwife’s] management of W’s [Woman’s] pregnancy and labour was in accordance with what would be widely accepted by peer opinion as competent professional practice.
(b)        it was appropriate for M to agree to manage the labour as a home birth.
(c)        M should have transferred W to hospital earlier.  If so, when and on the basis of what signs of symptoms?
(d)        there were any indications prior to x:xx pm (the time of birth) of possible shoulder dystocia or an increased risk of shoulder dystocia.

Medical negligence claim in which the doctor [D] disputes key aspects of the records made by the hospital midwives [M] at the time of birth of baby [B] who was delivered by Ventouse extraction, had Apgar scores of 1 at 1min and 3 at 5min, and developed cerebral palsy.  B has commenced a claim against Doctor D and the hospital.

My report addressed the following questions:
1.     In relation to the actions of the hospital staff, we ask you to examine the partogram and the other records made by the nursing staff and comment on their adequacy,
2.     We note the plaintiff pleads in paragraph [x] of the Statement of Claim that between 03:00 and 06:00 hours there was a reduction in the variability of the foetal heart rate.  In your opinion, should the midwives have contacted Dr [D] prior to his attendance at 06:30 hours?
3.     We note the hospital staff recorded “B.S.” (we assume this means blood-stained liquor) at 03:00 hours and “mec” (we assume this means meconium) at 03:30 hours, and “B.S.” and “mec” at 04:30 /05:00 hours.  Should the midwives have contacted Dr [D] and informed him of these developments?
4.     Any other comments you wish to make on the midwives’ management.
5.     We would be grateful if you could please confine your comments to the midwives’ management.  An obstetric expert will provide a view on Dr [D]’s management.


  • 1.     Mother’s rights vs baby’s (fetal) rights “my body, my baby, my birth”. Decision-making (not ‘choice’) Informed refusal, uninformed, or not sufficiently informed decision.
  • 2.     Communication and social media – huge change in past decade.  What’s in store?
  • 3.     True believer – ‘choice’, ‘control’, informed consent, non-intervention, natural, even ‘breast is best’
  • 4.     What it means to the midwife to plan for homebirth.
  • 5.     Lack of respect for the amazing processes of pregnancy, birth and nurture of the baby

Although birth is not an illness, the process carries potential for damage and death.  In birth there is a finite point after which the baby (or mother) will not do well, but it's impossible to predict where that point is.  Midwives accept and embrace this uncertainty, as we work in harmony with natural physiological processes which usually lead to spontaneous birth, or alternately as we intervene and interrupt that natural process. 

Monday, November 21, 2016


This time of the year is a time of thanksgiving in our home.  I thank God for another year in the life of the man I love, and another year since I first became a mother.

In 1973 we experienced our first Thanksgiving feast in the USA.  It must have been November 22 that year, and we were invited to spend the day with Noel's major professor and his wife.  The food that I remember was roast turkey with all the trimmings including cranberry sauce; warm apple juice that had been pressed from the fruit locally, with sticks of cinnamon floating in the pot; sweet potatoes with a whole lot of brown sugar added to make them even sweeter, corn on the cob, apple pie topped off with some sort of cream that came out of a pressure pack - we were taken on a culinary voyage of discovery.  The food - most of which we had never experienced before - was wonderful!

 Another memory from that day was that I was coming into labour.  The tightenings of my womb were becoming stronger and more regular, and I was excited.  But not too excited to enjoy the feast, which I think primed me for the work ahead.  Our first child, who we named Miriam, was born in the evening of the next day.

The Thanksgiving tradition in North America recalls the pilgrim immigrants who had established a home for themselves in the new world, where they hoped to be free to live their lives and follow their faith.  They thanked their God for preserving their lives, often through grave difficulties, and for giving them hope for the future.

Yesterday we had our own family 'Thanksgiving' afternoon tea.  We celebrate the two birthdays, which come each year at this time.   We have much to celebrate and be thankful for.

My mother used to often remind me to "count your blessings".  As I progress through the years of my life, the magnitude and number of blessings has often become more clear to me.

The photo of the seven beautiful 'blessings', lined up on the old pew near our front door, will hold me in that state of thankfulness. 

Wednesday, November 16, 2016

Spring in Kyneton

Nothing deep and meaningful today.  It's springtime, and I need a place to post some of the pictures I took today in the garden.
Bonsai Japanese Maples

various Bonsai pots

Japanese Maple

Bonsai pines


... and a nice new sand pit in the shade of the birch trees.

Friday, October 21, 2016

Idealism and midwifery - continued

In the previous posting on this topic, I attempted to introduce the notion that idealism around the birth of a baby impacts on what we do and how we do it in both negative and positive ways.


I have recently noticed a degree of idealism around the circumstances of a birth that has left me troubled.  That has led me back to writing to you, dear blog reader, as has been my custom for many years.

To set the scene, there is a social media group that focuses on childbirth and the law.  The usual contributors to the discussions in this group are midwives, a few lawyers, and childbirth educators, lay birth attendants, and women who from time to time take an activist position, particularly in relation to natural birth.

From time to time I or someone else will post a link to a Coroners report of interest to the group, such as the death of a baby soon after birth.  Recently a report was released by the Victorian coroner, on the death of baby Martha from complications in a spontaneous breech birth.  A few weeks ago the New South Wales Coroner reported on the death of baby NA, also from complications in a spontaneous breech birth.

Readers who follow the links provided will see that these two cases have little in common, except the tragic loss of a baby's life.

The matter that disturbed me in reviewing both cases, and that I call idealistic, naive, and uninformed, is the notion expressed strongly in the group that a mother might have avoided the birthing complications had she been left undisturbed, "truly unhindered".

The sort of midwifery I have practised for many years, with a high degree of safety, includes respect for the woman's need to feel unwatched.  Ina May (Gaskin)'s rule, that sphincters work best at home and when unobserved is a truism that midwives love to quote.  Michel Odent has spent his life after obstetrics teaching us that the human woman is a mammal, and has similar needs to other mammals.  World Health Organisation published an excellent handbook on normal birth in the 1990s, stating that "In normal birth there should be a valid reason to interfere with the natural process."

Somehow the pendulum has swung, in the natural birth community at least, to promote non-interference in an extreme way.  There seems to be a growing group of mothers who believe they themselves and their babies are better off if there is no professional (midwife or doctor) who will intervene in the progress of their labours and births.

When a baby is presenting feet or bottom first (breech) it's not a normal birth - even though it may be spontaneous and natural, and even though there may be no adverse outcomes.  Under the WHO normal birth rule quoted above, there may be (in spontaneous breech birth) a valid reason for interfering with the natural process.  The skilled midwife recognises points at which an intervention (interference) with the natural process is optimal and may be life saving.  There is no time then to call for assistance.  A baby being born breech whose head has become entrapped needs to be released immediately. This urgency, which does not happen in the same way when a baby comes out head first, is what has driven the medical world to preference of caesarean birth for breech babies.

The person who thinks that a woman who is totally unhindered and relaxed can birth a baby smoother and faster than the alternative situation does not understand that death and life are in the balance at the time of birth.  

Nature is under no obligation to be kind, or to give us the outcomes we want.