Tuesday, January 08, 2008


Case Summary

A primigravid woman, ‘Tracie’ (not her real name) aged 36 years asked me to be her midwife. At 26 weeks’ gestation I recorded that Tracie wanted to labour at home, and was questioning whether she would go to the local public hospital Birth Centre or stay at home for the birth. Tracie told me she wanted to keep both options open, and she decided to make two bookings – one for birth in hospital, and one for homebirth.

Tracie was working full time, and assured me that her job did not give her any undue stress. She planned to finish work a month before her baby was due. I saw Tracie at 33 weeks, and she was well. I recorded that her fundal height was at about the 32 week level. I palpated the baby, and assessed its size between my hands. Small-ish baby, I thought. There had been no elevated blood pressure or other condition that may compromise fetal growth. The fetal head was presenting nicely, and the back to the left.

I made a booking for a home visit for ‘birth preparation’ at about 36 weeks’ gestation.

Early Sunday morning I was woken by the phone, and was surprised to hear Tracie’s partner say “It looks as though we won’t be having the birth preparation meeting tomorrow”. He went on to tell me that Tracie’s waters had broken at three, and she was now labouring strongly. Only a couple of hours ago, I thought, as I began to discuss the implications of labour before 37 weeks, and the special needs of pre-term babies. Then I heard the sounds of Tracie’s labour in the background.

“Ask Tracie if she wants to go to hospital now, or if she would like me to come to the house,” I said.

“She would like you to come here,” was the reply.

“No worries. I’m on my way.”

It was cold and windy out. It took me about 30 minutes to get there, and I parked my car and went up to the house. As it was my first visit to their home, I was noting things that are usually noted at that preparation visit – the hilly terrain, the steps from the car to the house, and the flight of stairs from the entrance to the upper level where the bedroom was. There were big windows with superb views!

In the bedroom I found Tracie working strongly with each contraction, as the labour surged every couple of minutes. Checking mother and baby – both were fine! Waiting for another contraction to ease, I prepared in my mind to tell Tracie that we would need to go to hospital immediately, so that she could settle in before the baby was born. However, the sounds she made became lower.

“I felt like I needed to push that time,” Tracie said.

After a brief discussion we agreed to continue at home, rather than attempting the steep and exposed journey from the bedroom to the car, and on to the hospital. The birthing progressed beautifully, and soon we had a wee girl in excellent condition, resting on her mother’s abdomen; a proud new mother; and an elated father.

My usual practice at birth is to not intervene unless there is a valid reason. I did not clamp or cut the cord, or do anything to speed up the Third Stage. In the ensuing minutes we quietly watched this baby girl begin to respond in the instinctive way that healthy babies do. She began to lick and salivate, and make rooting movements with her mouth, and strong leg movements that moved her towards the breast [This process is known as the ‘breastcrawl’ – see http://breastcrawl.org ]. That evening I made a note in my journal:

“When baby was near the nipple she flopped her head to the other side. Mother gently put the head back where it was, and baby did the same movement again. After the second time I suggested she might want to be that way, and soon after, she began to take the breast. Strong contractions followed, and the placenta came with minimal blood loss.”

Baby was a couple of hours old when I weighed her, and noted that she was only 2.3 kilos. Despite the small size, her behaviour could not be faulted. She was warm, well fed, and a powerful bond was being forged between her and her mother. When I re-visited the question of transfer to hospital, Tracie reiterated her desire to stay at home, and I agreed.

Since she was a small baby, slightly premature, I set up a care plan of three-hourly feeds, at the breast, or with expressed colostrum if baby didn’t feed well. Each day as I visited I was thankful that Tracie and I were working together. Trust is a two-way process: she had to trust me and I had to trust her. Tracie kept a record of feeds, whether at her breast, or by cup. By 48 hours, baby was needing some expressed colostrum, and Tracie’s nipples were tender. The reality of broken sleep, and constant attention to the needs of a newborn was settling in, as the euphoria of birth subsided. Each day I looked carefully for any reason why this mother and baby should be under the care of a specialist team such as that available at the hospital. Each day Tracie confirmed that she wanted to stay at home in my care, unless I felt that they needed to go to hospital. Each day, as I observed that all was well, my conclusion was that we were acting appropriately.

By the end of that first week I saw a mother who was gaining confidence; her baby waking and feeding vigorously.

I reflected a lot during that first week on the issue of the size of the baby. Had we transferred to the hospital, this baby would have been taken to the Special Care Nursery, separated from the mother, and had her blood sugar levels checked frequently. When the blood sugar level was found to be low, it is most likely that artificial formula would have been given rather than relying solely on breastfeeding. This is a very different scenario than what was experienced by Tracie and her baby in their home, as there was no separation, and small but adequate amounts of colostrum were provided frequently either by baby’s efforts, or with expressed milk.

Despite being smaller than the usual ‘normal’ weight in Australian maternity services, this baby was well within the range of babies for whom weight alone is not an acceptable reason for interfering with the natural process in establishing breastfeeding. The Baby Friendly Hospital Initiative (BFHI) ‘Acceptable medical reasons for supplementation’, lists babies “born preterm, at less than 1500g or 32 weeks gestational age; or infants with severe dysmaturity with potentially severe hypoglycaemia, or who require therapy for hypoglycaemia, and who do not improve through increased breastfeeding or by being given breastmilk.” The guideline states that “For babies who are well enough to be with their mothers on the maternity ward, there are very few indications for supplements.”

[From Booklet 3 of the Global Baby Friendly Hospital Initiative in Australia, ACMI/BFHI, p10.]

The local hospital where Tracie had a booking is an accredited Baby Friendly hospital. Yet on this issue, I felt confident that the BFHI ‘Acceptable medical reasons for supplementation’ would not be followed.

I contacted the Maternal and Child Health (MCH) nurse, and discussed my care plan. When seen by the nurse at eight days of age, baby weighed only 2 kilos. A week later, baby was breastfeeding well with occasional ‘top-ups’ of expressed milk, and she had gained 50 grams, and all clinical signs were positive. Tracie took her baby to the local doctor at about two weeks of age, and he agreed that all was well. By three weeks of age, the baby was clearly thriving.

Reflective comment:

In providing postnatal midwifery care for Tracie and her baby at home I have acted autonomously, outside the National Midwifery Guidelines for Consultation and Referral (‘Guidelines’) (ACM 2004). This was not a pre-meditated decision to act ‘independently’ or to ‘push the boundaries’. It was an action plan that evolved during the first week as each decision point was reached, and as the care was reviewed each day.

The purpose of a systematic set of professional guidelines is to ensure “high quality and safe care” (ACM 2004, p5). However, guidelines should not be treated rigidly; they are guides. The wellness and safety of mother and baby are the primary concern of the midwife, who has the professional expertise to independently assess wellness, and to develop a professional care plan in which she can act confidently. Midwifery at the primary care level is health promotion rather than a treatment of illness or complication.

There are times when I and other independent midwives choose to act outside the Guidelines, such as in providing primary care for women who have had a previous caesarean birth, without consultation and transfer to medical care, and with a plan to give birth at home. When this decision is taken the midwife discusses with the mother the alternatives at that time, and what implications her choices may have as she progresses down the childbearing pathway. Informed decision making is an active process. The woman is encouraged to make her own choices at each decision point, taking into account the complexities of her own life and her knowledge of herself.

There would certainly be times when I would judge a small baby in a similar circumstance to be best cared for within a supportive multi-disciplinary collaborative framework of a maternity hospital. If I was not confident in the mother’s ability to act in the best interests of her vulnerable newborn; or her family support; or her own strength: many possibilities could have led to a different decision on my part.

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