Saturday, May 10, 2008

One of the big issues in having a caseload, and accepting nature's timing in birth unless there is a clear reason to interrupt the natural processes, is that I have no way of knowing when babies will come. The booking dates on my calendar do not tell me when or in what order the mothers and babies who are important to me as my 'caseload' will make their individual claims on my time and skill. I know I will have periods of waiting, as well as times when several babies are needing to be born. This is beyond my control, and my Christian faith allows me to trust not only that my Heavenly Father cares for me and wants to guide me in all the events in my life, but that each new baby is in God's care. There are times when I am tired, and I ask God specifically for strength, wisdom, and understanding as I do my work. In a post-Christian society this concept may be unpalatable to some, but it's very real to me.

This past week I have been busy, with a baby born at home on Tuesday, and twins born in the hospital on Thursday. Today I want to reflect on my emotional journey: waiting for each labour to establish, and being 'with woman' as she labours and births. I will call the mothers, in sequence, A and B - Anna and Beth. Although their due dates were more than a fortnight apart, it became clear that they would both be needing to give birth soon.

Anna's pregnancy had reached 41 weeks when she came into labour with her first child. The waters broke late Monday night, and her labour got started. I had a phone call in the wee hours, and went back to sleep after reassuring Anna, and encouraging her to rest if she could in this early stage of her labour. By the time I saw Anna in the late morning she was labouring well, on all fours, and feeling weary. I didn't want to in any way interrupt what was happening, so I sat in the other room with a cup of tea and my crochet. I encouraged her to be upright, and she progressed quickly. At one point she came into the room where I was, and she saw that I had my crochet, and the gear that I bring to a birth, set out and ready. Anna's baby was born beautifully in the birth pool a couple of hours later.

The principle of undisturbed birth, as I have learnt it from practice, and from readings, was confirmed again. Protecting and promoting normal birth, and working in harmony with the natural processes, requires the mother herself to accept and work in harmony with her labour, as much as it requires the midwife to be quietly protecting the space the mother is in.

Beth's twin pregnancy had progressed well and was now at about 39 weeks. Beth was receiving prenatal care from the Royal Women's Hospital as well as from me, and she had prepared her birth plan carefully and discussed it with the obstetric and midwifery consultants at the hospital. Beth's plan was that she wanted the opportunity to progress naturally and give birth to her babies without interference. This sounds very logical and reasonable, but is very different from the way most twins are born in that or any other hospital today. The decision to go to the hospital for the birth, rather than plan homebirth, was one that Beth had made, after considering the information she was able to gather about twin births. I had been her midwife for her first birth, at her home.

Earlier this week Beth came under increasing pressure from her obstetric carers to have an induction. The ultrasound had suggested that the second twin was smaller than the first, and *might* not be growing well. There is a widely held belief, which I think is a myth, that twin placentas will age more quickly than singleton placentas, and that it's not safe to let twin pregnancies progress to Term. This decision point - to intervene in the interest of one of the babies - became the challenge that Beth, and as her midwife and advisor, I faced. Beth found a recent article in an online journal which seems to challenge the ageing placenta theory. (See
I found this article useful in understanding the big picture, yet I was also wondering if the artificial rupture of the membranes for the first twin was really such a big deal. Beth also seemed to waver in her commitment to trusting and working in harmony with the natural process. We all knew these babies would be born soon. Perhaps we (Beth and I) should be more pragmatic and accept the induction? I assured Beth that the decision was hers, and that I would support her no matter what. I also encouraged her (and encouraged myself) to value spontaneous onset of labour, or at least natural onset of labour.

It can't be called truly spontaneous, as Beth proceeded with the less medical options - acupuncture, nipple stimulation, then a dose of castor oil. On Wednesday afternoon, after the castor oil, she felt regular contractions, but not labour. The booking at the hospital for induction was for Thursday morning. On Wednesday evening Beth called the hospital to say she did not intend to come in for induction, and took more castor oil. Labour became established; we went to the hospital after 6.30am, and the babies were birthed, seven minutes apart, an hour later. It was a 'normal' twin birth - there were none of the complications that we know are possible; no drugs were used; and Beth declined continuous monitoring, and an IV cannula. The second baby was smaller than the first, which is not unusual, but the placentas were healthy - no sign of ageing.

I have mentioned only fragments of the whole story. The record I want to put down today concerns my feelings as I waited for and attended these birthings. It's as though I have a parallel existence to the birthing woman - I need to 'nest' in those final days so that I am prepared for whatever happens, and I face transitions when doubts and fears arise and sometimes swamp me. I can't have a blinkered belief that 'natural is good', because I know that in nature there are many undesirable outcomes. I have to use my knowledge of the human body and birth to protect wellness, as well as to access the best medical services if they are needed. There is no clear 'black and white' in this decision making. The guiding principle is that in birth and nurture of the infant, there is no safer way than to work in harmony with the body's own natural processes, unless there is a clear reason to believe that the natural processes are not likely to lead to the best outcomes.

In both of these birthings, these women could have easily relinquished their authority and rights as the birth 'giver'. Anna's labour could have been induced for convenience, or for 'postmaturity'. Beth's labour could have been induced for this vague idea of 'ageing placenta' or 'non-reassuring ultrasound'. Once the woman submits to the authority of someone else, a doctor or a midwife, who reaches into her vagina to artificially rupture the protective membranes around her baby, it is very difficult for that woman to take back her authority for her own birthing. The hospital's expectations for progress and monitoring become the benchmark for decision making from that moment onward. The pain that the woman feels after induction is interpreted by her as different from what she feels if her body is taking her there naturally.

Again I have been honored to witness the power of women in their birthing. I hope many other midwives are able to work in this ancient and timeless model of care, and protect the authentic role of the midwife, being 'with woman'.


Lisa Barrett said...

Thanks Joy, this is a great post. I often feel the same way and work through feelings prior to births especially when initally they seem to be distances apart and suddenly you realise they are going to be closer together than originally anticipated.

How amazing that we reflect constantly on our own ability to trust birth.

Joy Johnston said...

Hi Lisa. Thanks so much for this comment. There are times when I wonder if my blogging is just self-indulgent navel gazing, but someone says something and I know it's worth doing!
My target audience in the village midwife blog is the group of midwives who are being mentored by me and other midwives into caseload and homebirth practice. I am sure some will recognise your name from ozmidwifery and other lists, and your comment is very helpful.
This twin birth was a little victory for me, in the relationship between independent midwives and the Royal Women's hospital. I noticed today that my name has been recorded as accoucheur for both babies on the hospital birth report. Joy

patsymidwife said...

Joy, Your blog is not for nothing. I stumbled on it and I am sure others will. I have recently written a book, The Blue Cotton Gown: A Midwife's Memoir. It will be out in September on I feel the same way, will anyone ever read this? I admire that you are writing now. I never could when I had kids at home and was delivering babies. I have been a nurse midwife for 30 years at home and in the hospital. My husband, an OB/GYN and I quit after the malpractice insurance got so high in the US. I now do just early office OB and LOTS of Gynecology. Peace be to you all. My midwife heart goes with you. Patsy Harman...Oh, if you want to see more about the book go to If you get two of these comments it is because I couldn't figure out how to get the first to go through. PH