Thursday, September 25, 2008

Understanding pain

There is something unimaginable about the pain that another person experiences. It's never easy to witness. My response is to want to do something that will end the pain.

But surely, I am a midwife, I should be used to the intense pain of labour. I tell women to work with their pain; to accept and use it. I know both the mental haze of narcotic drugs, and the total differentness and mental alertness of spontaneous unmedicated birth for myself, and for many of the women I have been with, and the latter is the winner without a doubt. I haven't personally experienced the numbness of regional anaesthesia (such as epidurals and spinals), but I cannot imagine anyone would choose that over the physical achievement and mental exhilaration of normal birth.

Yesterday I was at the home of a mother who was looking forward to the birth of her second child. She was strong and well, and had prepared beautifully, and was now in labour. Her husband gave unconditional personal support, and her sisters and whole family all had their support roles. The bedroom was quiet and almost dark; she spent time on the exercise ball, and resting as the hours lengthened. The birth pool was set up in the bathroom, and soft candle light made the space all the more special as an intimate place to welcome the precious newcomer. Labour had begun in the morning - a lovely clear sunny day in Melbourne. As the afternoon sun set, and the sounds of labour became more regular and stronger, I expected that undefinable change to occur, as a woman surrenders to the enormous power within her body, and her baby is brought forth.

But that didn't happen. The sounds became more distressed. We waited. I withdrew for a while, not wanting the mother to feel pressured. She told me today she wondered if I didn't believe she was really in a lot of pain. I did, and I was concerned about what I was hearing and feeling. I was intuitively sensing what we refer to as 'failure to progress', although intellectually that didn't make sense. It doesn't usually happen with a second labour, when the first baby was born at term, vaginally.

The minutes passed into hours, and the mother became more tired, and vomited. I checked internally for progress. Cervix about 5cm dilated; bulging forewaters; and a very high head that could be easily pushed away. I was careful not to rupture the membranes. The only advice I could give was that we should go to hospital. I hoped we would see progress of this baby, and my intuition would be proved wrong.

It was about six hours later that this family welcomed their new baby, with the help of the midwifery and obstetrics and anaesthetics and paediatric teams at the Women's. The hoped-for progress did not eventuate, and gradually the little one became more distressed. A caesarean birth was the best birth possible, and I was grateful.

I called this post 'Understanding pain'. My understanding of pain in labour includes the belief that there is a pain that is OK, and there is another pain that is intolerable. The distinction between the two is not easy to make, either by the labouring woman or by others. I think a midwife develops an intuition, but I am always ready to question my intuition. The labouring woman is the only person who can say, "this is OK" or "this is not OK". Many women have said, in effect, "this is not OK", in transition, and then gone through the paroxysm of pain, into the wonder of new life and love. But when "this is not OK" continues, without relief, the message is a different one.

By reflecting on an experience such as this one, I am reminded that I must hear what the woman is telling me, whether it fits with my perceived knowledge base or not. I must approach the decision points carefully, with clear thinking and without fear.

Friday, September 19, 2008

Promoting normal birth through BaBs

I have added babs-ies a new blog to my blog list, so I would like to tell my readers a little about babs.
BaBs stands for Birthing and Babies Support.

The Goal of BaBs is to be "a Health Promotion charity, which enables pregnant women and new mothers to increase control over, and to improve, their health in pregnancy and birthing, and in the nurture of their babies."

BaBs was born in 2006, after brainstorming meetings I had with two lovely young mothers, Erika and Deb. A quick stick-figure sketch that I did became the 'babs girls' At the time I was an executive member of Maternity Coalition (MC), and BaBs was set up as an organisation under the umbrella of MC, in a similar way to MIPP. Meetings began at Clota Cottage Neighbourhood House in Box Hill. Since then BaBs groups have been set up in other locations in Victoria and Queensland. BaBs is now incorporated, independent of MC, to enable growth.

The mission of BaBs is to "establish local peer support groups for pregnant and parenting women and their families in their own communities. We work to support women to make informed choices, take action about pregnancy, birth and parenting, to feel empowered and confident in their choices to improve their health, parenting, and life skills."

BaBs groups have been successful in obtaining small grants from local councils to buy books and other material, to print brochures, and to help with the costs of room hire. There is no attendance charge for BaBs groups - a donation is welcome, but not required.

BaBs groups depend on the voluntary support of mothers and midwives who work together to plan and facilitate the program in their own local neighbourhood. I am involved in the Box Hill group, which is close to my home.

I would like to encourage all midwives reading this blog to find a way by which you can make a commitment to mothers in your community - not just the mothers who pay you as their midwife, or the mothers at the hospital where you work. A midwife's duty of care includes to 'promote normal birth' [ICM Definition of a midwife]- and it's a bit late to do that when you arrive for a shift and are told to work with the woman in room 3 who has a Synt drip and an epidural.

I would like to enocourage all mothers who read this blog to find a way to meet with other mothers and midwives with the purpose of promoting health in birthing women and their babies. Normal birth includes a whole raft of 'normal' or physiological activities, including normal attachment and breastfeeding. There is no safer or better way to give birth than the way our bodies were designed, and there is no safer or better way to nurture a child than the physiologically normal way.

Sunday, September 14, 2008

Birth Plan

A birth plan may be set down as Plan A and Plan B.
Plan A: "I am intending to give birth under my own power, and will do all I can to achieve the best outcomes for myself and my baby."
Plan B: "If a medical intervention is recommended in order to achieve the best outcomes for myself and my baby, I need to be given the following information in order to make an informed decision:
  • what do you want to do? (procedure, test, intervention, ...]
  • why do you want to do that?
  • what is likely to happen if I say 'no' - if I don't allow you to do it?"
In this way you will only allow interventions - Plan B - that you believe are best for you and your baby.

See Preparing your birth plan at Maternity Coalition's INFOSHEETS site.

Saturday, September 13, 2008

Understanding fetal monitoring

An article, 'Mother's plea after death of newborn' on p3 of the Saturday Age today has a sad tale, from which I have excerpted a couple of lines:
"[Jane] (the mother) said CTG machines, which monitor an unborn baby's heart rate, were not working properly and her partner had to alert staff when the heart rate dropped well below normal.
"Jane said it seemed obvious that 'our little girl wasn't coping', but she kept being told everything was OK. Shortly after the birth by caesarean, Jane's baby girl died."

I feel great sympathy for these parents. They were isolated in a hospital room, with monitor straps around Jane's belly and the machine that goes 'ping'. The alarm on the monitor would have started sounding when the baby's heart rate dropped - or was it just loss of contact [ie not working properly]? Why was the partner the one who had to alert staff? How did the partner know what was OK or what was not? Jane says it seemed obvious that 'our little girl wasn't coping', so where was the midwife?

The answer seems to be that the midwife was not in the room. It seems that the hospital did not have enough staff to keep a midwife in that room at that time.

Cardio Tocograph (CTG) machines are used consistently and often continuously in hospital births. As with any test, the information provided by the machine needs interpretation - not at some time in the future, but as it happens. That interpretation should not be the job of the partner, or the alarm function on the machine. It should be the work of the midwife who is in the room continuously with the woman.

I would encourage anyone who agrees to electronic fetal monitoring (EFM); having a CTG trace, that you agree ONLY if a person who is able to take responsible action on the results of the trace is present at the time.

Continuous EFM, or any other type of fetal monitoring, including doppler or pinard stethoscope, does not ensure the safety and wellbeing of the baby. It is useful only when appropriate action can be taken on the information that is provided, and the person who receives the information understands its meaning.

Continuous EFM can give a false sense of security, as well as a false sense of doom. The usual response to a non-reassuring CTG trace in today's maternity services is to rush to the operating theatre and have an emergency caesarean birth. In the case highlighted in this story, that did not happen soon enough, with tragic consequences.

The protection of the wellbeing and safety of mother and baby are the guiding principles in all midwifery. A midwife working in a hospital should not leave the room if she considers that a mother requires continuous EFM.

You might say that's unreasonable.
Midwives have to leave the room, to do paperwork, to go to the toilet, to have meal breaks, or whatever.
That's true. So turn off the CTG machine, and take the belts off the woman, before leaving the room. It's unreasonable to expect the mother and her partner to become defacto watchers of the EFM in the absence of a midwife. They are not able to understand what they are hearing and seeing. That's a professional act, and if there is truly a reason to keep the machine running, there must be a person in attendance and an intention to intervene.

Thursday, September 11, 2008

midwifery debate in newspapers

I sent the following letter to The Age in response to a small article 'Doctors Attack Midwives Proposal' (most of this was published in Letters to the Editor 12 Sept)

The statements by the Australian Medical Association, reported in The Age (In Brief p10, 11/12/08) saying the Federal Government’s plans to extend the role of midwives “could threaten the lives of mothers and their babies” and “there was a greater chance of a baby dying during birth if born at home” are not based on any evidence.
Homebirths attended by midwives in Victoria are reported to the government’s Perinatal Data Collection Unit, and reports are published annually. The statistics for women who intended homebirth but transfer before or during labour are also available. Although these reports cannot give specific information on individual cases, the data do not suggest any cause for concern about the midwives’ competence in practising midwifery.
I am an independent midwife, so I obviously have an interest in asking for the right of reply. However, I do not want special treatment – I believe newspapers should look for and report on the truth. In this case the homebirth midwifery profession is small and poorly funded, threatened with extinction, and we are being attacked by a huge, well organised, and well resourced organisation.
Joy Johnston

Friday, September 05, 2008

Reflecting on a difficult birth

After visiting the new parents and their beautiful baby yesterday afternoon, only 12 hours after his birth, I have felt that I need to reflect carefully and write on this birth. Although I enjoy writing, this is not a simple task. The complexities of life, and of each birth, mean that I have to choose a small aspect of the whole experience and write on it. By reflecting on the experience that I had, within a professional partnership as midwife to this woman and her child, I am using the maieutic mode of enquiry. This is the essence of a midwife's work both as a teacher and as a student: enabling learning through reflection on experience.

The dictionaries explain the connection:

Maieutic = act as midwife. Pertaining to the Socratic method of bringing out ideas latent in the mind. [Webster's]

Gr maieutikos maieuomai = act as a midwife. [Concise Oxford]

In summary, the mother, who I will call M, was a primigravida at 41 weeks plus 3 or 4 days' gestation. For the previous week, and particularly for the past few days, M had been experiencing pre-labour contractions, day and night, every 7 to 10 minutes. Each time we spoke, I encouraged M to trust her body's signs, to rest when she could, and to be ready for the establishing of labour. I saw her on Tuesday, and found that her the baby's head was well engaged, and the cervix very thin. Very good! However, M was becoming discouraged. She did not think she could keep going. She had noted a reduction in fetal movements, and we were not sure of the significance of this.

M had chosen to give birth at the Mercy Hospital for Women in Heidelberg, and had an appointment at the hospital the next day. When offered induction of labour, M agreed to having her waters broken, but wanted to see how she could progress without IV oxytocic. Contractions became more frequent, and labour was underway.

Over the next few hours there was little dilatation of her cervix, and the doctor encouraged M to have the oxytocic. Having no alternative plan, this further step in 'Plan B' was agreed to, with an epidural.

It sounds trite to just say 'with an epidural'. Women who have planned for spontaneous unmedicated birthing, and who understand that an epidural comes with at a cost as well as having the apparent benefit of pain obliteration, express grief at this time. But when they see it as the best option, they make the decision. Well, there's no guarantee, and this epidural did not work, and had to be resited. Even when it was correctly placed, there was a persistent painful area in one of M's legs. The anaesthetist was patient and consistent in trouble-shooting, and eventually achieved the desired pain relief. By this time there were 'non-reassuring' fluctuations in the baby's heart trace.

The hospital midwife told M that it would be best to put a scalp clip on the baby's head, in order to monitor more reliably. M asked me what I thought. We agreed to make a decision after we knew what progress the baby had made, with several hours of oxytocin augmentation. Good news - M had dilated to 'fully'. M declined the scalp clip, and found a sitting position which allowed for better external monitoring.

With a deep anaesthesia from the epidural, M's efforts at pushing were insufficient to get this baby born. The heart rate continued to fluctuate. With M pushing, and the doctor pulling, using the Ventouse vacuum cap, the baby was born in good condition. With the baby came thick, heavily meconium stained liquor. He needed to be born, that's for sure.

When attending a complicated birth, with the increasing possibility of harm to the baby (as indicated by the baby's heart rate and rhythm), it is not possible to predict what may happen. In this case, I do not believe the baby would have been in good condition at birth, able to stay in mummy's arms, if the birth had been delayed much longer.

The matter I want to reflect on, and I hope my readers are also able to ponder, is that decision to move from 'Plan A' to 'Plan B' - in this case, accept induction of labour. Here are a few of the points I am conscious of in this decision:

  • the woman is the one who makes the decision
  • I am committed to being 'with woman' in her birthing
  • I want to give the woman information so that she can make decisions that she believes are best for her
  • obstetric and anaesthetic interventions in birth, although they are common, cannot guarantee good outcomes
  • once we have moved to 'Plan B' we can't go back to 'Plan A'.
My question to myself is, was there something else M could have done, rather than accepting induction of labour? How will I advise a mother in a similar situation next time?

With the wisdom of hindsight in this case, I believe M's decision to accept 'Plan B' was the best option she had. Her body had been trying, for the past week, to get started. She was feeling discouraged, and exhausted. Her baby was showing signs of tiring too.

M asked me what I would have done if we had been planning homebirth. I believe my advice on key decisions would have been the same.