Saturday, December 29, 2007
I talk a lot about normal birth, and I aim to protect and support the natural process whenever possible. However, the other side to the 'normal' birth coin is the 'abnormal'. The midwife's job is not only to work with the natural process, but to identify any complications and to take appropriate action to protect wellness in mother and baby.
There is a young man who works at the local grocery store, who has Erb's palsy - the paralysis of the brachial nerve. He has limited function in his Right arm and hand, which are small and distorted compared with the other. He gathers the shopping trolleys and arranges them in the front of the store - a job he has been doing since he was a teenager. He always seems cheerful and energetic.
This was probably a birth injury. Those moments between the birth of the baby's head, and the rotation of the whole body to free the leading shoulder, can be critical. The midwife or doctor attending the birth can either facilitate a normal birth which protects health and wellness, or potentially allow damage to the baby in a way that will never heal.
My thoughts on birth trauma have been stimulated this past week since Marie (not her real name) gave birth to her baby boy at home. This baby weighed over four kilos, and Marie had to work with all her might to give birth to him. I assisted her birth the baby's shoulders, gently supporting the baby 's head after it had restituted from occiput anterior to the transverse plane. The shoulder was not obstructed - my intervention was more from a concern that the baby needed to be born, to fill his lungs with air. I didn't want any unnecessary moments' delay in the birth process.
Baby was floppy and pale initially, but the cord pulsated strongly. I was confident that he would resuscitate spontaneously. Marie was kneeling and he was on the mattress under her, as I used nappies to dry him and stimulate him. Soon a raspy cry came from him, followed quickly by improvement in his colour. I knew that all was well. As Marie reached for him and took him into her arms I had a moment of deep thankfulness to God for this blessing.
Marie was quite exhausted, and became chilled. Although the weather was mild, her room was cool, and there had not been any room heater set up. I worked on getting her more stable as she held her baby to her breast. She was trembling and weak. I wanted to see the placenta out, and be sure that she was not going into shock from blood loss. Marie agreed to an injection of the synthetic oxytocic Syntocinon, and soon the placenta was birthed as I exerted some traction on the cord. Marie felt huge relief, and rested quietly.
Over the next hour or so the baby found the breast and began suckling strongly, while the mother's strength returned. I felt confident once more that any potential crisis had been averted. Later that evening when I left them, the parents were proud and happy, and ready to introduce their other little son to his new baby brother.
A baby's transition from the womb to the outside world has many points at which damage or trauma can occur. These include physical - the passage through the birth canal; and physiological - the opening of the lungs to take in air for the very first time; and the closing down of the placental circulation, leaving the baby reliant on his own body's systems for circulation, excretion, and nourishment. This transition takes place in a very brief space of time, and although the transition is usually without incident, it is of profound importance to the baby.
When I visited Marie the next morning I found her well, and her partner busily attending to the household. The new baby was sleeping quietly. Marie had noticed that his skin was yellow, and had placed him next to the window to expose him to light.
Jaundice in a healthy Term baby is usually manageable at home, but this was obviously more serious than physiological jaundice. I quickly explained that we needed to take baby to hospital, so that he could receive appropriate care. A baby who develops obvious jaundice in the first 24 hours of life needs medical management without delay. I made a call to the local hospital, so that they would expect this baby in the emergency department.
A blood test confirmed that the level of jaundice was high, and the baby was admitted and put under phototherapy lights in the Special Care Nursery. Marie stayed as a 'boarder', and continued breastfeeding every three hours. Baby fed vigorously. The next day the serum bilirubin levels had increased, as expected. After 48 hours the level was falling, and they went home after three days in hospital.
Marie asked me what was the risk if we had not gone to hospital. A serious complication that occurs when severe jaundice in not treated appropriately is brain damage and deafness. In Marie's case there was no indicator prior to the birth that the baby was likely to become jaundiced. The subsequent care that the baby needed was the same whether he had been born in a birth centre, hospital, or home.
Friday, November 30, 2007
I was not idealistic about my own ability to engage in labour, and to give birth to my children.
There was an unspoken rule that medical and surgical interventions were only used when necessary, and everyone understood that the doctor would act in a way that protected the interests of the mother and her baby. I never considered that there was any choice other than to expect my body to do the work of childbirth. There was no notion of consumer choice, or discussion about decision making. The doctor/nurse/person in authority - knew best.
I don't want to imply by this that maternity care was particularly good when I studied midwifery, and became a mother myself, in the 70s. In fact it's difficult to find a time, or culture, where people have understood the power and rightness of normal birth. Perhaps if we look way back to the Biblical time described in Exodus 1, we find an example of civil disobedience that suggests both the midwives and mothers held birth as something that not even the king could interfere with.
"The king of Egypt said to the Hebrew midwives, one of whom was named Shiphrah and the other Puah, 'When you act as midwives to the Hebrew women, and see them on the birthstool, if it is a boy, kill him; but if it is a girl, she shall live.' But the midwives feared God; they did not do as the king of Egypt commanded them, but they let the boys live. So the king of Egypt summoned the midwives and said to them, 'Why have you done this, and allowed the boys to live?' The midwives said to Pharoah, 'Because the Hebrew women are not like the Egyptian women; for they are vigorous and give birth before the midwife comes to them.' So God dealt well with the midwives; and the people multiplied and became very strong. And because the midwives feared God, he gave them families." (Exodus 1:15-21)
The threat today to normal birth is quite different, but it calls for a similar degree of bravery on the part of those who are guardians of the natural processes.
Sunday, November 25, 2007
Thismorning I witnessed the birth of a healthy baby girl. A few hours later I returned home, leaving mother and baby resting quietly in bed. Baby had suckled strongly, and was now asleep. Mother had not slept much last night, and was happy to enjoy the sweetness of her new baby daughter. I will visit them tomorrow, and a few more times in the coming week, and check that all's well.
A couple of weeks ago this mother, who I will refer to as Lisa (not her real name) was facing the difficult choice of either elective caesarean, or vaginal breech birth against medical advice. Lisa had told me she thought her baby was presenting breech, and after palpating her belly I agreed. After visiting the hospital the presentation was confirmed, and Lisa was told that she would no longer be eligible for the Birth Centre, and would be scheduled for caesarean birth.
Lisa immediately visited her traditional Chinese medicine practitioner, who used acupuncture and moxibustion, to no avail. This process was repeated as the days passed.
I spoke to an obstetrician who is expert in external cephalic version. I outlined the situation that Lisa is a mother who has previously given birth, and is now at Term; she and her baby are healthy; the breech is mobile above the pelvic inlet, and there is plenty of amniotic fluid. The obstetrician confirmed my assessment, that external cephalic version should be attempted, and was likely to succeed. He gave me the name of the doctor who he knew would be able to turn the baby at the hospital where Lisa was booked. He knows that I am a homebirth midwife, and I commented that Lisa would consider breech vaginal birth at home, and his response was quick "so that's all the more reason why this baby should be turned!" I agreed.
Lisa went to the hospital and the midwife spoke on the phone to the doctor about arranging external cephalic version (ECV). The doctor said it was too late in the pregnancy. She usually does ECVs on Tuesdays, and next Tuesday she would not be at the hospital. I encouraged Lisa to persevere - I felt that the doctor needed to palpate Lisa's abdomen, and feel how ready this baby was to be turned.
After several visits to the hospital for monitoring, and a considerable degree of persistence, Lisa was seen in person by the doctor. The doctor agreed that a turn should be attempted, and told Lisa she could do it that day. The version took only moments, and was successful.
Attempting ECV for a breech at or near Term is a reasonable option in protecting normal birth.
Monday, June 25, 2007
The homeborn newborn: how do mothers manage breastfeeding when there's noone to show them what to do?
Based on a presentation given to midwifery staff at Royal Women's Hospital, Carlton in June 2006.
Today I have been asked to talk about why babies born at home generally do better with breastfeeding than hospital born babies and how midwives in birth suites can better support their clients.
The first point I would like to make is the safety of homebirth. We all know that babies and mothers are best able to get breastfeeding started if they are both well, and without dangerous drugs influencing their behaviours.
“The safety of planned homebirth has been well established. Mothers who give birth at home have less interventions and babies born at home consistently have less distress, respiratory problems and birth trauma.
“With homebirth there is less disruption for the entire family and more control over the birth environment. Mothers and fathers report birth at home to be more enjoyable, satisfying, intimate and beautiful.” (Maternity Coalition 2006)
We can add to that statement that babies born at home are unlikely to be separated from their mothers for any reason. Babies born at home are unlikely to be fed foods other than mother’s milk. Babies born at home are unlikely to have narcotics in their systems, dangerous drugs which inhibit basic neuro responsive activities which are important in the initiation of breastfeeding.
In addressing this broad topic I want to make two claims about mothers who give birth at home:
- They are ordinary mothers – no more or less ‘ideal’ for natural birth or breastfeeding than the general population.
- Breastfeeding is the norm
I would also like to make a parallel claim about the midwives attending homebirth – we are ordinary midwives; our qualification and education is the same as that of hospital midwives. Some but not many have qualified as lactation consultants or bring other skills. Many are mothers who have learnt from experience rather than from text books how to breastfeed their own babies. Midwives who attend homebirth have chosen to work within the boundaries of the natural birthing process, within a one-to-one relationship with each woman, and over time there is a strong trusting partnership that develops between the woman and her known midwife.
Breastfeeding is like birth – it’s part of the natural birthing continuum. For many women, there is no need for expert skill – it just works. But as with birth there are some, a minority, for whom there are difficulties, and there are sometimes difficult decisions that need to be made. At any decision point the midwife’s skill as well as the woman’s trust in her midwife or other professional advisor are challenged. These decision points come at home as well as in the hospital, and they come at all hours of the day and night. As with birth there are many interferences that can in themselves lead to a downward spiral in which the woman quickly loses confidence in her own ability to achieve this basic life challenge, interferences with the breastfeeding process can lead to a loss of confidence.
Breastfeeding is like birth – it’s not something that can be taught in a lecture situation, or bought off the counter. There are no gadgets that make breastfeeding (or birth) work. It is a process that is learnt by each mother, with her own baby, and their own unique situations. The best teacher is intuition – a deep knowledge that’s already within each mother. The midwife supports this natural learning process and enables the mother to take responsibility for her own wellbeing. At the end of the day the mother is often amazed and proud and can rightly say “I did it myself.”
- Health Promotion – enabling
“Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being.” (from
When applied to the birthing event and establishing breastfeeding, the midwife stands out as the leading health professional who is positioned to enable each woman to increase control over her health and the health of her family.
- Baby-friendly is mother-friendly
The protection, promotion and support of breastfeeding is, first of all, the responsibility of the midwife. This is the case whether the mother gives birth or received postnatal care in the home or the hospital.
More reading: Baby Friendly Mother Friendly Ed Susan F Murray 1996.
When assessing hospitals for the Baby Friendly Hospital Initiative I have been surprised at the number of breastfed babies who receive formula supplements, even in hospitals that have passed the BFHI accreditation several times. It seems that there is a culture of reliance on artificial supplements. When I look at the situations in which these babies are supplemented, there are often alternatives, such as teaching the mother to express colostrum, that have not been done. I encourage hospitals to look critically at every situation in which babies are given artificial supplements.
- Impact of hospital practices on breastfeeding
More reading: Impact of Birthing Practices on Breastfeeding: Protecting the mother and baby Continuum. Mary Kroeger with Linda J Smith. 2004Conclusion
It would be easy for me to paint a picture of good/bad, black/white – but that would be a false portrayal of the world in which we live.
The reality is that the Australian government’s funding for maternity services does not support a woman-centred philosophy of care, or women who choose homebirth, or midwives who practise in the home. Hospital birth is the norm, and is likely to stay that way for the foreseeable future.
The reality is that Australian breastfeeding rates are as good as or better than many other similar countries around the world. The
The reality is that commercial pressures will continue to undermine a mother’s reliance on her own milk as the unique and ideal food for her child.
The reality is that the fathers, grandmothers and other family members will continue to have a significant impact on a mother’s confidence to work through any challenges that arise.
The place of birth, though significant in many ways, is not the key issue. I believe that the midwife as the primary carer, working in a partnership with individual women, and collaborating with other care providers when specialist skills are needed, whether it’s for a complicated birth or a sick baby or a difficult breastfeeding breastfeeding situation, will begin to turn the tide towards health promotion through enabling women in their birthing, nurture, and nourishing of their newborn children.
Saturday, June 23, 2007
You are free, my dove
I want to hold you, my child.
These are not apron strings, they are strong cords of the heart.
When you go away, you do not miss me. You take me with you.
I am there, in every movement, every cell.
But you have gone from me.
I hold but the memory.
What is this dread, this fear?
What could I do if I were at your side?
Could I counsel you, and would you hear it?
Would I ever presume to try?
Does my grief shock you?
I am usually calm and direct, objective and deliberate.
I know you must leave.
What is it that opens the flood gates?
Must this birth mean total separation?
Can we not linger as you take your first breaths?
Must the cord be severed thoughtlessly?
Can you not remain on my bosom, in my arms,
As I take in your sweetness.
In holding you, I prepare to let you go.
You are free, my dove.
Fly over the earth. Seek a place of your own.
Return with that twig. Return and go again.
Midwife for Christ’s birth
Christmas is a special time from a midwife’s viewpoint, celebrating birth at its purest and best. We sing ‘Born in the night, Mary’s child’, and I identified with that – was out through the night for a baby this past week. We sing “Enough for Him, whom cherubim worship night and day. A breast full of milk, and a manger full of hay.” I like that! The needs of the newborn are pretty simple – a breast full of milk, and warmth and love. But there’s nothing simple about any of that! It’s a blessing, and one of life’s great but ordinary miracles.
I’m looking at Luke’s Gospel. If he was a physician, two thousand years ago, he probably understood some of the same truths that I understand. Midwives then probably understood much more than I do about the amazing and profound natural processes of birth and nurture of the young.
Jesus’ birth is described in the context of a family. His mother, father, aunt, uncle and cousin are named and events of their lives recorded. It’s in the context of local political realities: everyone had to submit to Caesar Augustus’ census. It took place in real time, in a real place, and with real people. The shepherds in the fields and the wise elders in the temple, and probably many more ordinary people from that place and time witnessed the ordinary sequence of events that accompanied the birth of that extraordinary child, Jesus.
I sometimes ponder the details that are not recorded by Luke or the other Gospel writers. A little group of women in Bethlehem, who were probably also of the house and lineage of King David, and who were used to the work of childbirth, would have come to the stable prepared in their minds for the difficulties as well as the joys of childbirth. As they remembered the arrival of their children and grandchildren, and the ones that had not survived the transition of water and blood to the outer world, did they sense something special in this woman?
The midwife, the woman who was called to be with Mary through her time as she brought forth her child, what did she see? A young woman whose body and spirit was strong and who embraced the work as she surrendered her own will to divine purpose, even as she had replied to the angel Gabriel, “Behold, I am the handmaiden (doula) of the Lord. Let it be to me according to your word.” As each powerful uterine contraction took hold, and her belly hardened, she who had “found favour with God” yielded and accepted, and felt the power of the Almighty working in her body.
I think if I were that midwife, preparing my own mind for the work of bringing forth, I would have guarded myself from thinking about the unwelcome possibilities. I don’t know what that midwife would have faced in the event of obstruction, severe pain, and loss. I live in a world that knows little of such matters.
I know that our bodies have been created wonderfully and beautifully. I know that the child within works with the mother, and together they achieve the profound mystery of birth. This is the ordinary situation in birth. I know that my emotions will follow a similar course to the mother’s, as my intuitive senses tune themselves to the senses of the labouring woman. I will shut out all that would distract me, and will stay close to the woman. I will feel, with her, the need to be quiet and the need to be ready. I know that there will be times when fear can rise up. Yet I know that that very experience of fear can prepare both child and mother, so that they are alert and ready to do all that they will be called upon to do.
If I were that midwife, listening to the deep birthing sounds as the climax approached, I would be joyfully praising God in my heart for the good progress. My heart would be swollen with thankfulness, as her belly is swollen with child. The energy of the mother, the movements of the child, and the synchronised urges that result in beautiful coordinated motion are telling me that all is well. My sounds are simple and deep words of trust and encouragement.
I am that midwife. As the baby’s head begins to open the outer curtain of the secret place I guide the mother to bring her child across that strong barrier. She finds a body posture that is best for her in that moment, and accesses a new inner power that she has not previously known. Strongly, with an exultant cry, she brings forth her child.
The child in my hands is glistening with the birthing fluids. I watch as his little arms move away from his chest, drawing air into his lungs and he utters his first sounds. His body tone is strong, and his colour is right. The mother reaches out and eagerly takes him to her breast, and I place a warm wrap over both of them. In the soft light she looks at him and speaks words that are deeper than memory can hold. His little eyes are wide open, his pupils dilated. Together they begin to discover the wonders of a mother’s milk, with warmth and energy flowing both ways.
I am that midwife, and I am oblivious to all, except the miracle that is unfolding in my presence. I hold the quietness of the space around the mother. It does not matter that it’s a stable. The sounds of life from the child blend with the sounds of the other occupants of that simple dwelling place.
I am that midwife as the mother brings out the afterbirth. The work is done, and she rests back, contented.
In the quietness and ordinariness of that night, is it any wonder that heaven’s hosts sang out: “Glory to God in the highest, and on earth peace, good will toward men.”?
Tuesday, June 19, 2007
COMMENTING ON SOME OF LIFE’S BIG MOMENTS
As I observe new mothers and their babies, new dads, and new families, I see wonderful patterns in the natural order of life. Being a midwife allows me a special closeness, and I witness life’s miracles every day. My job is to protect and support that woman’s and her baby’s own natural abilities. I remind myself, and anyone who’s listening, of the profound reality that birth is not an illness. I encourage the mother and father to learn how to optimise their family’s health and wellness within any limitations that their own situation presents.
There are two principles that are foundational to all of life:
Principle 1 The natural process is good. God the Creator looked on the whole creation, including man and woman who were made in God’s image, and God saw that it was good (Genesis 1). Our bodies and minds, their functions and abilities, are beautifully and wonderfully made.
Principle 2 The natural process is limited, and imperfect. Disease, decay, corruption and death are, since the fall when sin entered God’s creation, as much part of the natural process as are all the beautiful and wondrous moments of life.
Applying these principles to some of life’s big questions, I offer my comments with the prayer that some insights will be useful to those who are seeking, in dependence on God’s loving guidance, to make good decisions. I write about childbearing with the authority of my qualifications and lifelong learning in midwifery, which require me to be answerable and accountable in all professional activities. I write on matters of Christian faith with confidence of an elder in the faith, and one who has experienced and observed the sufficiency of the God of the Scriptures of the Old and New Testaments, and His Son, our Lord Jesus. I write about matters of love and family life from my own experience with one life partner, and my observations of others.
As there is no part of the natural process that is perfect, there can be no guarantees about any natural process. Advances in knowledge of health care, medicines, and technology have protected and extended the lives of many people who would, in a world without these capacities, have died or been severely disabled. Although I accept the fallen nature of all creation, I reject any notion or teaching of total depravity. I hold to the basic Christian teaching that although all human nature has been corrupted by sin “there remain tokens of [all people’s] greatness as created in the image of God, that [s/he] posses a knowledge of God and of duty – that … [s/he] is yet capable of affections and actions which of themselves are virtuous and praiseworthy.”Although I have focused on the natural process, that’s not all we have to work with. There are times when our instinct is to look after ourselves, and ignore the needs of another. As responsible adults we must weigh up our instinctive or natural directions against our knowledge of our relationship to another person, whether that’s a professional or ethical duty, or family duty to care for our children. In providing for our children we can enjoy all the intuitive provisions, but we are also responsible to protect and provide for our children, whether that comes ‘naturally’ or not.
 Presbyterian Church of
The life of the unborn child in the womb, and imprinting at birth
An unborn child in the mother’s womb experiences life within that water filled capsule in the same way that the mother goes through her day. The noises of the mother’s world are the noises the baby hears, along with the sounds of the mother’s heart and digestive workings. The food that the mother eats is passed to the baby. When the mother laughs, the baby feels and hears laughter, both physically and physiologically, in the change of hormones and other substances in the mother’s blood. In the same way anxiety and fear are transmitted to the baby. The mother’s body produces antibodies to any potential germs in her world, and the baby has this immunity and protection already in place at birth.
An unborn baby knows only the mother who carried her (or him). The baby of a gentle timid woman is used to the gentle, quiet movements of that mother, just as the baby of a strong, deliberate woman with a loud voice knows her mother. The home terrain of the baby is her own mother – not someone else’s. The baby is used to receiving the foods that her mother ate during the pregnancy. The baby ‘knows’ the environment of the family into which she is born.
The baby who is born into her mother’s arms, and is able to adapt to life outside the womb in the way her body was designed, the natural process, experiences smells, sights, sounds, and feeling that are all consistent with the life inside the womb. The first voice is that of her mother, and her father’s voice is also known. The strong sense of smell and other wonderful instincts lead the baby to seek the breast, and its life-giving milk. Skin-to-skin contact with the mother enables quick transfer of the normal bacteria that live on the mother’s skin to populate the skin and digestive system of the baby, and provides some protection against disease-causing germs.
A mother who goes through severe physical or emotional stress during her pregnancy cannot keep the unborn baby free of that stress. The mother who smokes passes harmful substances to her child. The mother who eats too much sugar can harm her unborn child by that high level of sugar. Mothers in socially unsupported situations are more likely to have premature labours than mothers who are well supported. This is all ‘natural’.
Mothers who are addicted to narcotics give birth to babies who are also addicted, and who go into withdrawal as soon as the supply, via the umbilical cord, is cut. Mothers who receive narcotic drugs for pain relief in labour, through injection into their muscle or via epidural, also pass those drugs to their babies. The babies may take days to come out of the drug induced haze that impairs their neurological responses. The imprinting of the new world outside the womb on a baby born with a heavy dose of narcotics is a hazy and dysfunctional world. These ‘dangerous drugs’ can only be obtained on medical prescription because they are dangerous!
New parents will often go to great lengths and expense to make life just right for their new baby. Natural instinctive knowledge guides a new mother to be attentive to her new baby, to protect her from all potentially harmful forces, and to feed her well. Yet many mothers soon reach their limits of endurance; they feel exhausted within days of the birth, and are dealing with pain and discomfort after giving birth. It’s a terrible reality to find that this beautiful child has needs that the mother is unable to meet. Both are in tears. The ideal of a perfect world has been shattered, when even the person who loves the little one most is unable to achieve the standard she would like.
This reality is a lesson that mothers, babies, and other family members need to accept. In doing our best for our babies we are not always able to understand or meet all their needs; and even if we could, the baby would grow up in an unreal world. We are never going to be perfect, but we know we can give a baby a good, happy home, and teach that little one the way to live in an imperfect world.
There is no safer or better way for a baby to develop than in the womb of a mother who cares about her own health, who is in a socially supportive environment, and who has no unreasonable stress or anxiety. There is no better way for a baby to be born than within the natural process, without medication, and into the arms of her own mother. The natural process is usually the safest way for a baby.In some individual situations the natural process is known not to be safe, and the potential disadvantage of medication or surgery may outweigh a known risk. The mother needs to make the best decision that she can in her particular situation, taking expert advice from her professional carers at the time.
Within the natural process a mother and baby must work together to open the womb and bring about the series of miracles that we call birth. The phrase “giving birth” indicates action, as does the word “labour”. Many mothers today will use words such as “my doctor delivered my baby”, or “the hospital midwife delivered him (or her)”. This is a sad reflection of our community’s attitude towards birth, as though pregnancy is a medical condition, and babies need to be extracted like a bad tooth.
I will state the obvious. Birth is not an illness. Birth has never been safer than it is today, yet many people are terribly fearful. Despite all the advances in technology and drugs and sanitation over the past hundred years or so, there is still no safer way to give birth than for a woman to come into spontaneous labour at Term (37-42 weeks of pregnancy), and to progress and give birth under her own amazing power, without any drugs or substances to make the labour stronger, or to ease the pain of labour. A woman who is labouring, and is attended by a midwife who she trusts, is able to engage with and accept the powerful and often demanding work of birthing.
A healthy woman in labour is like an athlete who is giving all she has to complete the course; who pays no attention to anything else, and presses on towards the finish line. The natural process is good, as natural, pain-relieving substances, endorphins, are made within her body in response to the work she is doing. The labour requires her to shut down her usual thinking capacity; to surrender her ideas and plans and allow her body to do its work.
Yet the natural process can be interrupted, and interfered with, leading to distress in the mother and the baby.
At any time in the pregnancy-birthing journey a mother or baby can experience problems that may even threaten life. Although birth is not an illness, there are many illnesses that can affect the mother or her baby. Some of these conditions can be treated, and the mother and baby monitored over a period of time, leading to good birthing outcomes – healthy mothers and babies. A mother with insulin dependent diabetes that would be life threatening if not treated, can carry her babies safely to Term, and give birth spontaneously. Diabetes is an illness – birth is not.
Some conditions can occur without any warning, and occasionally babies’ and mothers’ lives are in grave danger. The midwife or doctor who takes professional responsibility for a woman in pregnancy is often able to intervene appropriately if there are signs of complications.
Pain in childbearing is a point of debate. It is well accepted among Christians that our mother Eve received punishment for her actions when God said “I will greatly increase your pangs in childbearing; in pain you shall bring forth children …”. (Genesis 3: 16 NRSV). Another translation of Genesis 3:16, from the Geneva Bible of 1560, reads: “Unto the woman He said, I will greatly increase thy sorrows, and thy conceptions. In sorrow shalt thou bring forth children and thy desire shall be subject to thine husband, and he shall rule over thee.” This was the translation of William Tyndale, and the comparison between it and the more modern translations which use the word ‘pain’ rather than ‘sorrow’, gives an alternative understanding of the text.
The woman was not cursed. The serpent was cursed (3:14) and the ground was cursed (3:17), while Eve and her husband Adam suffered severe consequences for their disobedience. Although through the redeeming work of our Lord Jesus, the offspring of the woman (3:15) on the Cross we have been freed from the power of sin, we continue to bring forth our children with sorrows that are reminders of our dependence on our creator God.
Pain in labour is useful. A labouring woman who can accept the pain she is feeling, and engage actively in bringing her child to birth is labouring well and should not be disturbed. A midwife distinguishes between tolerable, productive pain, and intolerable pain. It’s only in the latter case that interventions are needed to attempt to relieve the pain.
God’s provision in the natural process of birth is good. This discussion does not attempt to give clinical information about decision making, but as a midwife the question in my mind when any assessment is being made is “Is the mother well; is the baby well.” It’s a double question, and as long as the answer is “yes-yes”, I know that we can continue working with the natural process. I am able to wait patiently without interrupting, as the labour and birth proceed.
Having established the fact that the created natural process is good, according to God the creator in Genesis 1, the present reality for us is that sin has marred it.
When I am practising midwifery, being with woman through her childbearing, I have a professional responsibility to observe for any sign of complications, and to obtain medical attention if that need arises. Complications can arise at any time, in any woman or baby. No mother can assume that she is exempt from possible complications. Yet, in supporting and protecting the natural process in childbearing, the midwife is able to minimise complications that would happen as a result of interferences and interventions into the natural process. The guideline that has been promoted globally by World Health Organisation is that “In normal birth there should be a valid reason to interfere with the natural process.”
 “Whether readers like the attitudes of the Jewish patriarchs or not, the word pain does not appear in this verse and indeed, the Hebrew word ‘etzev’, which so many translators since 1560 have felt impelled to translate to mean physical ‘pain’, is correctly translated here as “sorrow.” [From an unpublished paper ‘Pain in Childbirth’, written by L Dick-Read (personal communication, 2007).]
Mother-infant bonding, and maternal instincts
God has made the mother wonderfully able, not just to give all that’s needed for a new baby, but to want to give. God has made babies able to recognise and want their own mothers. In a day when women aspire to work in many occupations alongside men as equals, this is one occupation in which gender does matter. Giving birth, breastfeeding, and nurturing very young infants are quintessentially and exclusively women’s work. When a couple come to me and say “We want a natural birth”, or “We are planning to breastfeed”, I seek an opportunity to remind them, gently of course, that only the woman can give birth; only the woman can breastfeed. Only a mother has maternal instinct to guide her response to her own baby.
I think my father understood this fact. Many times I heard him advise fathers, and he would always say “The best thing you can do for your little children is to love their mother.”
The establishment of strong attachment or bond between a mother and her newborn is one of the miracles that happens after birth, and is enhanced by close contact. Bonding is supported by all the mother’s senses, and we know that oxytocin, the love hormone, surges in the mother’s blood as she feels, smells, hears, and sees her new baby and experiences the baby seeking her breast. Mothers who have given birth spontaneously, without drugs, experience a natural surge of oxytocin within minutes of the baby being born, often as the baby seeks the breast. This is a potentially significant moment in establishing a strong mother-baby attachment. This hormonal surge also has an important role in separating the placenta from the wall of the uterus, and minimising blood loss.
A natural or physiological Third Stage (birthing of the placenta or ‘after-birth’) is the usual practice of midwives attending birth at home, and in some birth centres, even though we have the synthetic oxytocics, and will use them if needed. Hospital maternity services usually have a protocol for medically managed Third Stage, in which a synthetic form of oxytocin is injected into the mother’s blood or muscle, resulting in strong contraction of the uterus. The synthetic hormone overrides the mother’s body’s natural processes, and although the synthetic oxytocin acts on her uterus, it does not cross the blood-brain barrier in the way that her naturally produced hormone does. This is an important area of physiology in which midwives and doctors who attend birth need to constantly update our knowledge with the findings of research.
I wonder if a woman who has not experienced spontaneous, unmedicated birth, is likely to wonder, if what I have written is true, she may have harmed her relationship with her child. Are mothers and babies able to bond well when the natural processes in birth are interfered with?
If we consider for a moment the release by the mother’s pituitary gland of natural oxytocin, the love hormone, and its impact on mother-baby bonding, the importance of early skin to skin contact and initiation of breastfeeding, regardless of the mother’s experiences in birth, cannot be overstated. Oxytocin is released into the mother’s blood stream when her baby seeks the breast, and suckles. Breastfeeding is not a technologically driven event – it involves the senses of touch, sight, taste, smell and hearing of both mother and baby. The surge of oxytocin in the mother causes contraction of muscles around the milk producing cells in the breast, leading to ejection or squirting of milk. Once the milk supply is established, the baby needs to work strongly to coordinate sucking and swallowing at this time, and if he releases the breast, the milk may squirt strongly for a few moments and spray anything nearby.
At the same time, as a result of the oxytocin surge, the mother’s uterine muscles also contract, and these contractions are often painful immediately after birth. This phenomenon, known as ‘after pains’ is stronger in mothers who have had several babies than it is after the first baby.
It is clear from everyday human experience that oxytocin has an important role in the lives of mothers and their new babies. This observation has been backed up by scientific studies on behavioural patterns in animals when their oxytocin and other normal hormonal patterns are manipulated and interfered with. A logical question is, how much oxytocin-based activity is essential for mother-baby bonding, or, putting the question in another way, how much interference is too much? I cannot answer this question, but I do strongly suspect that there is a point in the early postnatal period at which the individual mother-baby bonding can be seriously compromised. The basic philosophy of non-interference in the birthing continuum, without a good reason, protects mothers, babies, and society in ways that we do not fully understand.
Instinct is an internally driven provision that God has made for the protection and preservation of life and wellness.
Biological scientists and anthropologists seek to understand and describe mothering behaviours. Laboratory animals have been manipulated and experimented with in an effort to understand intricate relationships between environment, genetics, hormones, and other factors. Experiments in the 1960s which have outraged many people and fueled the animal rights movement had baby monkeys removed from their mothers, and deprived all natural contact. Yet many young human babies today are left alone to cry, and some exhibit detachment behaviours, showing that they have given up trying to call for their mother’s attention.
We live in a society in which approximately 30% of babies in
Many wedding services have a statement such as “marriage was instituted for the forming of a family, so that children may be raised in a loving environment. … for mutual companionship, help and comfort, in good times and bad.” The way a mother and father work together in providing for children has huge significance for all concerned.
Just as mothers have specific design that supports and protects their ability to give birth and care for their infants, the father’s role is also supported by intuitive forces. The man’s role as provider and protector is especially important during the childbearing years. Dad’s advice, “The best thing you can do for your little children is to love their mother” is a simple statement of this reality.
If we try to understand what the baby experiences in relating to his daddy and his mummy, we can begin to understand one of the great mysteries of a baby’s life. As already described, baby knows his mother well from a long time before birth: he recognises her movements, her voice, her touch, her responses. He also knows his father who is companion, friend, and lover of his mother, to whom she responds in a positive, loving way. The father’s voice and activities are part of the world that is home base to the baby. After birth, baby learns very quickly that his mother’s breast is a place of comfort, warmth, and satisfying almost every need. Quickly he also learns that daddy is the interesting, exciting person who is frequently in close contact. Daddy’s strength, energy, and individual behaviours, whether in singing with a big, deep voice, or gently embracing mummy, are also familiar terrain for the very young baby. Daddy and mummy are very different people in baby’s mind.
The father and mother complement each other in providing all the basic needs of a newborn baby, and of young children as they grow. The father’s strength, and freedom from the restrictions that come with childbearing and nurture, provide support and safety for the more vulnerable mother and children. The father’s difference from the mother gives the new baby a model of the big world out there; an understanding that different people relate to you in different ways. It seems to me that the baby sees daddy as the exciting one, who opens up new possibilities, while mummy is the more plain person who is always there when you need food or comfort or warmth.
Even amongst those parents who set out with the very best of intentions to love their children, and set precepts for healthy and God honouring lives, we soon find evidence of our imperfections. This is often evident within days of the birth, as the father faces exhaustion of sleep deprivation. This realisation of our failure to meet even our own expectations in parenting comes as a hard lesson that new parents need to confront.
Nurture and nourishment of the newborn baby
A baby who enters the world without complication or medication, and who is held skin to skin by her mother immediately after birth will seek the mother’s breast in a way that is truly instinctive. We know that newborn mammals also do this – kittens with closed eyes; lambs on wobbly legs; and even tiny kangaroo babies climbing from the mother’s vaginal opening to the relatively distant pouch.
Babies who are born after surgery or strong medication may be delayed, but will, if given the opportunity and good support, act in the same instinctive way when they are able.
The Western ‘traditions’ of baby care that have prevailed during our lifetime include wrapping of the baby, separation of mother and baby, washing away birth fluids, and imposed routines in feeding, whether at the breast or artificially. As recently as the1990s researchers were able to publish papers and demonstrate to the professional community that the behaviours of a normal, unmedicated infant at birth are very similar to that of other mammals. Newborn babies who are skin to skin with the mother immediately after birth will open their eyes, lick and salivate, put a fist to their mouth and make rooting movements, then move in a deliberate way towards the breast, and work until they have achieved a strong attachment over the nipple and surrounding breast tissue (areola). They then begin a period of suckling, drawing strongly on the mother’s wonderful colostrum, and will, after a couple of hours of breastfeeding, usually fall into a restful sleep.
The healthy newborn baby quickly learns that her mother is the source of nourishment and nurture. If there has been separation at birth, such as in situations where mother or baby need special medical care, the instinctive (non-learned) patterns of behaviour can be re-triggered when mother and baby are well and able to be together. The early instinctive behaviours can be seen in a quiet, unhurried, softly lit environment, where the naked baby and mother come together. This strategy is often used by midwives and lactation consultants when a baby is having difficulty achieving effective breast feeding – a situation that is often the consequence of separation or drugs used in labour. The mother may rest quietly in a deep warm bath, with her baby on her chest. The baby will rest initially, then follow the distinct pattern of breast-seeking behaviours described above.
The message that ‘breast is best’ is well accepted, in theory at least, by expectant parents today. Very few will make a choice to against breastfeeding prior to the birth of their babies. Despite the knowledge that a mother’s own milk is unique and important for the human infant, many will have resorted to using some artificial feeds by the end of the first week, and weaned their babies in the early months. Breastfeeding is learnt by both mother and baby in the early weeks. When they receive appropriate support and expert advice, whatever early difficulties that are experienced can be overcome.
Breastfeeding, although natural, is not simple. There are many subtle physical and psychological factors in both mother and baby that can influence success. Once confidence in breastfeeding has been compromised in either mother or baby it can be quickly lost.
Who let the dads in?
This article is from The Age, 30 April 2006 http://www.theage.com.au/news/books/who-let-the-dads-in/2006/04/29/1146198391686.html Here’s the opening section: Who let the dads in? By Danielle Teutsch
April 30, 2006
Page 1 of 3 | Thirty years ago, men were barred from the birthing suite. Now their presence is almost compulsory. A book of men's birth stories questions whether that's always a good thing. By Danielle Teutsch. WHEN Joy Johnston was a midwifery student in 1973, she told her supervisor she was planning to have her husband at the birth of her child. Johnston still recalls the icy response. "She looked over her spectacles at me and said, 'You mark my words. Men are going to cause trouble in the labour ward'," Johnston says. In those days, the idea of men attending births was radical, shocking, even "dirty". Husbands who did manage to slip in to the delivery room were given a seat and told to stay there in case they fainted. In little more than 30 years, a revolution has taken place in maternity hospitals. Men, once left to bite their nails and smoke cigarettes as they paced the corridor nervously, are now encouraged to coach their partner through labour, catch the baby as it arrives, and cut the cord. Their presence is not only welcomed, it has become obligatory. Brave would be the bloke who backed out on the big day. "It's not a choice these days," says Johnston, an independent midwife. "It's a command." The question is, are all men thrilled to have front-row tickets at this event? Or would some secretly prefer to be in the pub until bub was washed and wrapped?
Vaginal breech birth
Women who are planning homebirth often ask me if I would be happy to attend a breech birth at home. There’s no easy answer. I have had very little experience in breech birth, and breech is clearly outside the boundaries of ‘normal’ birth, even though it is natural. The very real situation that presents itself today is the deskilling of midwives, and of obstetricians, in breech birth. A baby may be harmed or die simply because the midwife or doctor did not know what a more skilled person could have done to achieve the best outcomes.
A large multi-centre research trial, the ‘Term Breech Trial’ by Hannah and others (2000) has led to the conclusion that: “Planned caesarean section compared with planned vaginal birth reduced perinatal or neonatal death or serious neonatal morbidity, …” There has been a lot of discussion in professional circles as to why this conclusion was reached, not the least being that the people (professionals and women) who agreed to participate in the research were more likely to be those who did not value vaginal breech birth. The women who wanted to give birth naturally, and the practitioners who were skilled at facilitating breech birth, could not agree to randomisation into either elective caesarean or a ‘trial of labour’.
The Term Breech Trial, and the general trends to manage birth medically, have led to the current situation that most babies presenting in breech are now delivered by elective caesarean surgery. Breech presentation occurs in 2-4% of all births. The rate of vaginal breech birth in
One exception is the situation of advanced labour with undiagnosed breech presentation, when the midwife or anyone else in attendance can act to either support and protect the birthing process, or interfere in a way that may harm the baby.
Management of a breech birth by midwives working with the natural process is to keep the mother upright to aid the descent of the baby just prior to the birth of the baby’s head. Phrases like “hands off the breech” and “let the breech hang” have been retained by generations of midwives skilled in breech birth. Obstetric management, on the other hand, would usually be to have the mother in lithotomy position (lying on her back, legs in stirrups), and the obstetrician would control the birth, and sometimes put forceps on the head.
This brief discussion would be incomplete without mention of external cephalic version (ECV), when the fetal head is moved gently by the hand of the operator, in a forward roll motion, in an attempt to bring it to the mother’s pelvic inlet. ECV is being attempted from about 35 weeks by some obstetricians and midwives in an effort to avoid caesarean births. The procedure is carried out in hospital, with technological and medical support to monitor the baby.
Monday, June 18, 2007
The culture of birthing
I am asking for a total change in the culture of birthing, changing the focus of all the care from the provider to the woman. We seek a new culture that recognises the natural order in pregnancy, birth and nurture of the baby as superior to any artificially contrived system.
Remember ‘if it’s not broken, don’t fix it’. I was delighted to hear that Chinese traditional wisdom has the same concept in ‘wu wei’ - the following excerpt from Wikipedia was given to me by a friend "One way of thinking of wu wei is through Zhuangzi's writing about how a prince should govern his kingdom. The advice that was given is that it is similar to frying a small fish (too much poking and the meal is ruined).”
The culture of birth will change only when women reclaim their authority for their own bodies; only when the message that ‘birth is not an illness’ is heard. The role of maternity professionals will then change from being predominantly carers of sick people to agents of health promotion, working together to enable women to improve their health through pregnancy and birth, and to have strong, healthy and resilient families.
Natural birthing in Australia today
The protection and promotion of natural birth within our maternity services, the protection of women’s rights to plan spontaneous natural childbirth, and the protection of the midwife’s right to practise midwifery are essential in a world that has increasingly looked to technology as the answer to everything.
In a society that has approximately 30% of births being managed surgically by caesarean, and a large proportion of the remainder being managed with potentially dangerous drugs to stimulate labour and override natural responses, there is an increasing need for support for women who choose to work with natural processes. As caesarean rates increase there is an increasing need for expert maternity services that are skilled in vaginal births after caesarean (VBAC). As rates of medically managed births increase, maternity care providers will become progressively more de-skilled in working with the natural processes in the birthing continuum.