Wednesday, July 16, 2008

When birthing becomes abnormal

I want to tell you, my readers, about Julie's birthing of her first baby. Julie asked me to be her midwife, and I worked with her obstetrician and the midwives at a Melbourne private hospital. We did not achieve normal birth, but I believe it was a very good birth.

I have heard some independent midwives saying that they don't accept bookings for private hospital births; that women who go down that track aren't trusting their bodies; that they, the midwives, feel unable to truly exercise their skill when they go into hospitals. I do not agree. All I ask is that a woman who engages me as her midwife is planning to do all she can to give birth, and will not interrupt or interfere with her natural processes without a good reason. I am not committed to either home or hospital - I believe the woman should be free to decide the right place for birthing when she is in labour. Sometimes women planning homebirth go to hospital, and sometimes women planning hospital birth make the intentional decision in labour to give birth at home.

Julie is a beautiful woman: healthy, fit, and in her late 20s. As we approached the due date her baby's head had not engaged, and we chatted about what that might mean. My usual advice is to remain active, but not to try to bring on labour until after 41 weeks. I planned to talk to Julie about a couple of 'self-induction' options such as a does of castor oil, and/or a program of nipple stimulation and pelvic movement. Julie's doctor talked about induction of labour at 10 days after the due date. However Julie's labour started spontaneously at 41 weeks. She was awakened with early contractions one night, and they continued irregularly through the next day.

Labour established that night, and Julie asked me to be with her. The sheer physical demand of a couple of sleepless nights was telling on her and her husband. I sent him off to bed, and Julie's mother and I kept her company. When I palpated I noticed that the baby's head was in a good position, well flexed, engaged, but high. An internal examination confirmed this assessment. There was a lot of work ahead - this baby was not going to slip out easily.

Labour progressed and we went to hospital. As often happens, contractions that had been close and strong became irregular and infrequent. It was frustrating as the hours rolled on, and the 'team' became more weary. By late morning Julie was nearly fully dilated, and the baby's head had progressed - a very encouraging sign. Someone (not I!) suggested a lunchtime birth. (in your dreams, I thought) Soon Julie was pushing, and got her baby deep into her pelvis. In the next couple of hours we tried different positions and all we could do to move that little one a bit further, without effect.

Some readers may think that Julie would have been able to do more if she wasn't in hospital, or if she was in a tub of water. I don't think so. This baby's head was such a tight fit and Julie was doing all she could, which was not enough.

The doctor was prepared to attempt an assisted birth, but warned that he may still need to do a Caesarean birth. This is a professional decision point that obstetricians face from time to time, and in today's private maternity system the die is often cast in favour of the surgery.

Julie pushed, and her doctor pulled, and after three good pulls the very elongated, molded head was birthed. Julie took her little boy to her breast as I and another midwife dried him, and after a couple of minutes he cried lustily - a wonderful sound.

Recently I have been reminded of the work of Dr Catherine Hamlyn, repairing obstetric fistulae in Ethiopia. The women with fistulae have had complicated births, and face dreadful incontinence and social exclusion. These women may have laboured for days in agony before their babies died, and were eventually stillborn. The link to the ABC TV interview is:

Catherine noted in the interview that they are now educating midwives to go into the communities and attend the women in birth.

Midwives are required, by definition, to promote normal birth. This duty of care must be understood alongside our knowledge of abnormal birthing, and our other duty to access appropriate care when complications occur. Always the wellbeing of the mother and child are foremost in our minds.

We live in a privileged society. Even if Julie had been planning homebirth I believe, with the benefit of hindsight, that we would have needed to go to hospital and ask for obstetric assistance with the birth. I also believe that we could have expected the clear decision making process and personal respect that Julie received, in a public maternity hospital. Good maternity care should not be linked to wealth or insurance status.


Julie said...

Thanks for sharing this story Joy -it was so lovely to read that even in the context of a neccesary medical intervention this new mum was able to bring her baby straight to her breast :)

Joy Johnston said...

That's right Julie. A few years ago we would have expected a paediatrician to take the baby, who had passed meconium, and 'resuscitate' him before mum got much more than a peep at him. I am an assessor for the Baby Friendly Health Initiative, and am very pleased to see hospitals make changes protecting bonding and breastfeeding immediately after birth.