Wednesday, August 27, 2008

Lessons from homebirth

A midwife who starts attending homebirths with a more experienced independent midwife has an opportunity to learn all sorts of lessons, some predictable, and some unexpected. Yesterday as my colleague Karen was leaving the home, after attending a homebirth as 'second midwife', she commented on the difference between what we had just experienced, and what often happens in hospitals.

As I drove home yesterday afternoon, weary from a 3am call out, but thankful for and energised by the birth of another beautiful child, I was reflecting on the lessons we learn when we begin caseload and homebirth practice. Here are a few. Readers may want too add more in the comments section, or if you want to write a piece to add to this blog, please email it to me.
  • Waiting for the spontaneous onset of labour. Does the midwife's commitment to the natural process mean that we wait passively, or is it an active waiting? How much checking and surveillance of the wellbeing of the baby is appropriate?
  • Midwifery 'interventions' and advice for post Term pregnancies. When is it appropriate to recommend self-induction methods, such as nipple stimulation, or castor oil? Do you recommend acupuncture, or naturopathy, or other alternative medicine options?
  • Technology. I sometimes call a second midwife in the middle of the night, and the phone goes to the message bank. If that happens I then call her on her mobile. I have had the experience of leaving messages on both home phone and mobile, and hoping for the best! Being on call means getting the telephones and other technology to work for you.
  • Petrol. It's good to keep the petrol in the car above a certain point. It's frustrating and can be time consuming to have to put petrol in the tank in the wee hours.
  • Directions. It's no fun getting lost, and trying to read the map in the half-light of a torch or the interior light of a car. In my practice I visit the home at about 36 weeks for the birth talk, or birth preparation meeting. This visit gives me the opportunity to think about the best roads, and check out parking and all those practical matters, when there is no pressure on my mind.
  • Waiting. The father made the comment yesterday "A lot of what you do is waiting". That's right. It's very different waiting in a home than waiting in a hospital. In the hospital birthing suite there is a routine of shifts and rounds and client meals and staff meal breaks and reporting and meetings. In the home it's all about one woman. Many times the midwives move out of the room where the woman is labouring, but they don't move out of her space. Her sounds are the only sounds they hear.
  • Finding the tea bags. This may sound too obvious to mention, but when you open cupboard doors, or rummage through a kitchen draw to find the tea bags, or a mug, or something else, there is an element of that special relationship between a woman and her midwives.
  • Responding to pain. It's never easy to see someone else in pain. We would be heartless if we switched our minds off, and could not feel empathy. Yet the homebirth midwife does not carry pain relieving agents with her, and women who plan homebirth know it. Principles of active birthing, including movement, encouragement, massage, pressure, heat pacs, vocalisation, shower, and water immersion, are useful. Music, candles, a wood fire in the hearth, and aromatherapy may help create a personal intimate space. But it's the woman herself who decides how she can work with her own labour pain. It's the woman herself who decides when and if the pain is excessive or intolerable.
  • When to assess internally for progress. I consider an internal exam an intervention, and there needs to be a valid reason for me to intervene/interrupt/disturb the progress of normal labour in this way. I will ask the woman for her permission to examine vaginally if I need the information that such an examination can provide. For example, a primigravid woman in advanced labour, who has some spontaneous urges to push over a period of a couple of hours, without bringing the baby on view, may have a lip of cervix. The vaginal examination will confirm this, and with permission, I can attempt to reduce the lip and push it back during a contraction. In my examination I feel for the baby's cranial sutures in order to visualise the position of the baby's head. An anterior lip, with the saggital suture off to the side, tells me that the baby's head is tilted, and is asynclitic. My advice to the mother is to walk through contractions, taking exaggerated steps that will move her pelvis, and adjust the fetal head in relation to the pelvis. Up and down stairs a couple of times is very helpful. Then as the baby descends, the mother can try kneeling on one knee, with the other foot on the floor, to tilt her pelvis, then change to kneeling on the other knee. These are fairly simple midwifery interventions, yet the woman's trust in her midwife is challenged, and they will need to work together in order to promote normal birth.
  • Physiological birthing of the placenta. I think I am stating the obvious here, but physiological birthing of the placenta is probably only reasonable when the rest of the labour has also been physiological. Any stimulation or resuscitation of the baby is done with the umbilical cord intact. A midwife who makes a decision to administer an oxytocic to the mother is undertaking a professional intervention, and there is time to obtain the mother's consent for this act.
  • Baby to the breast. It's wonderful to watch a healthy unmedicated newborn baby take the breast. Some do it without a second thought: some need to work hard at it. But they all love it. In homebirth the midwife needs to learn to trust the ability of mother and baby to manage this primal and essential act. Our advice is such that mother is encouraged and enabled to take responsibility, and to be confident in her own mothering.
  • Leaving. A baby has been born; mother and baby are well; the paperwork has been done; and it's time for the midwife to leave - go home - get on with other work, or go to bed. This is another lesson.
  • Completion. The time soon comes when no more postnatal visits are needed. I encourage the mother to call me if she has any questions, or is receiving conflicting advice and wants to know what I think. The invoice is paid, and I enter the information into my Quick Books program, in preparation for the next BAS and Tax statements. I ask the mother to come back for 'show and tell' at six weeks. After that visit I bundle her file into the filing cabinet, sorted alphabetically according to surname. Ready for next baby?

This list is not complete. I need to get dinner ready now, so will hit the publish button. I look forward to messages I may receive. What have you learned from home birthing?

1 comment:

Brenda M said...

Had to nod whilst reading this blog Joy !
I can sooooooo relate to some of the points you've mentioned.

# When to wait & when to act.
# Where are the teabags ? (rummaging in a womans pantry is so intimate somehow, it's a very 'personal' thing to do).
# Frustration = Mobiles not on, or flat, or out of range & house phones going to answer phone ! If you are on call you are literally "on call". Please be glued to your mobile or don't volunteer to be my back -up midwife !!
# A Father said to me last week "most of what you do is waiting isn't it " ? I felt a moment of guilt, ought I be more active ?
# How did I even LIVE without Sat Nav ??? Esp at 0300 on wintry nights on the Mornington Peninsula.
# I've never let the fuel tank get below half because I'm paranoid I'd run out of petrol on a call out.
# Love the bright eyed wonder of the undrugged baby & equally how blown away by this the parents are. They can't get over the alertness of the newborn. So sad that they've not seen alot of unmedicated babies so they think this is amazing when it's actually NORMAL !
# Am always amused at how ravenous women are when newly birthed & how specific they are about what they want to eat........NOW !
# Find it extraordinary how tuned into her newborn a mother is without appearing overanxious. It seems to be an unconcious 'watchfulness'. It's less seen in hospital where I guess there is always 'someone more qualified' to do the watching for them.
# I haven't been so conscientous on the show & tell at 6/40. I like this idea but can't seem to co-ordinate it. I think I'll work harder on making it happen.
# I put alot of energy into the last postnatal visit for debrief & closure. The women & all her support team who were present for the birth seem to get alot out of this & I learn heaps (quality control & evaluation)!

Must think more on this, it's a very interesting line of reflection...............