Thursday, October 30, 2008

NORMAL BIRTH: The bare necessities

Understanding that physiologically normal birth is a quintessential female act
• only women can give birth
• other people can greatly influence a woman’s ability to work in harmony with her natural processes.
Each woman chooses her professional care provider(s), as well as her own trusted team, which may include
• Partner
• Family members
• Friends
• Other supporters such as lay birth helper (doula)

Recognising the importance in physiologically normal birth that a mother is able to
• feel safe, personally respected, in a personal, intimate space
• be flexible – the mother can change what she wants/ doesn’t want
• move out of her thinking mind, and work in harmony with her intuitive brain
A mother who is able to take control of her environment, the space in which she labours, or the amount of light in the room, or personal touches such as her own music, or essential oils, can minimise feelings of alienation in labour, and enable her body to work effectively.

Minimising sensory stimulation in labour protects normal birth. Interference from anxiety, fear, higher brain activity, such as thinking about
• time between contractions,
• amount of dilatation, and other calculations that are in fact indicators of progress, which may inhibit normal birth
A woman may also be inhibited by the feeling of being observed, through photography, or strangers entering her labouring/birthing space. Any sensory stimulation may be unwelcome, and many mothers ask midwives to please refrain from using perfumes when attending births.

Being well. Healthy women usually give birth to healthy babies. Healthy diet, exercise, no exposure to smoking or other harmful substances in the environment, good social/emotional support in pregnancy and after the birth, access to professional care (eg dentist, physiotherapist, GP) as needed support wellness in pregnancy and birthing.

Knowing and trusting the midwife who can act with authority and take professional responsibility for primary maternity care. Being attended by a known midwife helps a woman to
• understand choices and make informed decisions
• have confidence in the knowledge base of her care provider
• be realistic about expectations

If a decision is made to accept medical intervention, the change of plan is made from the physiologically normal birth, to the best birth that can be achieved with the collaborative efforts of the maternity care providers in that situation.

Copyright: Joy Johnston 2008
[If you would like a .pdf of this document, to use as a handout without charge, please contact me

Sunday, October 26, 2008


This word cloud was made by posting the url to this blog at the Wordle site.

Wordle - Beautiful Word Clouds

Wordle - Beautiful Word Clouds

Friday, October 24, 2008

normal breastfeeding

Recently I received an email message from someone named Nimal, who I do not know, in Sri Lanka, saying

"I was quite impressed by your website in which you talk to many mothers and mothers-to-be with your in depth experience. I feel a website like this helps many mothers who are looking forward to be mothers and those who are already mothers. I found there are so many useful articles in your website.
I feel you could add another valuable article to your website, thats about the crucial importance of breast feeding, the length of it etc etc."

Thankyou, Nimal, for this invitation to write more about breastfeeding.

Briefly, one cannot promote physiologically normal birth without also promoting physiologically normal nourishment and nurture of the newborn child. Breastfeeding is part of that natural continuum. In fact, if the woman is privileged to experience minimal disturbance in the crucial moments around the time of birth, it is unlikely that the midwife in attendance will need to do anything about breastfeeding. The mother and baby proceed on the intuitive journey, in skin to skin contact, making eye contact, and soon the baby searches for the breast.

Once the baby knows that food is found at the breast, and the mother has mastered a few basic skills such as holding the baby in a relaxed way, lovingly molding baby's body to her own, with baby's chest agaist her chest, baby's chin against her breast, baby's head slightly tilted back ... breastfeeding happens whenever baby is hungry or just needs mummy's special comfort*.

How long should this continue before weaning begins? That's easy. As long as it takes.

By this I mean, until baby starts putting pieces of suitable food into his or her own mouth, and tells mummy it's time to give me more than the breast milk. This is usually around 6 months of age. There should be no dairy or soy artificial alternatives to mother's own milk, except in situations so dire that an inferior substitute is truly all that's available.

This discussion leads me to an obvious line of comment: what about the mother and baby who do not experience physiologically normal birth and initiation of breastfeeding?

I have often used the principles of the breastcrawl for babies who have spent time away from their mothers, or whose experiences at learning to breastfeed have been less than satisfactory. Babies have an amazing capacity to learn, and it seems that the triggering of that instinctive ability to seek the breast and obtain mummy's milk is not well understood.

* The asterisk is on comfort. Breastfeeding is the essence of comfort, for both the mother and baby. Too often, in Melbourne the city where I live, where babies can be seen as accessories for the woman who has everything, the phrase 'comfort sucking' is used, usually in a negative way. What a shame!

Friday, October 17, 2008

Preventing and treating post partum haemorrhage

Since attending a study day last week, I have been reflecting on the way midwives and obstetricians 'manage' the third stage of labour, and the effect this has on the amount of blood loss a woman experiences.

Karen Moffatt, a senior midwife at the Women's, illustrated the unreliable nature of the estimates of blood loss recorded after birth. The test is to ask midwives, doctors, and students, to record their estimates after looking at fake blood that is poured and spread over sheets and pads, in a way that is meant to approximate what we see as we clean up after a birth. The results of these tests are usually that we are more correct on smaller amounts, such as 100-300 ml, and seriously less correct on the larger amounts, such as 1000ml. My guesses were, too. I underestimated the larger amount.

Blood loss in excess of 500 ml is recorded as a post partum haemorrhage. But if we are mis-recording the amounts, it's difficult to make any conclusions from what we record.

I would like to ask any blog readers who are interested in this topic to tell me what you think of it.

At the study day the presenters were unequivocal - they require midwives in the hospital to practise active management of third stage because it's supported by the evidence. The International Confederation of Midwives and FIGO, the international peak body for obstetricians, have written a joint statement, requiring all skilled birth attendants to carry out active management of third stage of labour.

Independent midwives attending homebirth in Australia carry the oxytocic drugs (Trade names Syntocinon and Syntometrine), and would usually use them as treatment rather than prophyllaxis. This means taking a 'wait and see' attitude, or as Michel Odent says, "don't manage the third stage".

I do not want to argue against the evidence, which applies to most women in hospital settings. But I do want to argue that women who are giving birth to the baby safely under optimal physiological conditions are more likely to ALSO safely complete the process by expelling their placentas without excessive blood loss and potential morbidity.

What are the optimal physiological conditions I speak of? This will be slightly different for each woman, because it will be her own space. The same undisturbed space in which she entered the deepest and most demanding stage of her labour. The personal, quiet space. There can be many 'non-medical' disturbances and disruptions, some of which are inadvertently brought on by the mother herself or her midwife. Photography, family congratulations, phones, showing the baby to the children - these are often enough to take the mother out of her birthing space, and interrupt the intense hormonal and physical process of receiving and bonding with a newborn baby.

Since establishing my private practice about 15 years ago, I have needed to learn from women how to work in harmony with the wonderful natural processes in birth. I did not know about physiologically normal third stage. I knew how to administer oxytocic, how to apply controlled cord traction, and how to record blood loss.

In my early years as a homebirth midwife I experienced one serious post partum haemorrhage, and transferred that mother to hospital for a manual removal of the placenta. It was a horrible experience for the mother, the father, the second midwife, and for me.

The promotion of normal birth includes protecting women from excessive blood loss. That's obvious. I am concerned, and have therefore written this blog, because the way to achieve the protection from excessive blood loss for well women seems to be so very different from the way it's done in mainstream maternity services. I look forward to hearing from anyone who has wisdom on this matter.


Sunday, October 12, 2008

A new law

This past week has seen the passage of a new law through the Victorian parliament - the Abortion Law Reform Bill 2008. In responding to this new law, I hope to present a brief summary of how I believe the decision to terminate the life of an unborn child impacts of our lives, and on our society. I do believe there is another higher law, that of God the creator and sustainer of life, to which we are all answerable. This principle is often referred to as the sanctity of human life.

Abortion has been available through medical referral in Victoria for the past 40 years or so. The 'new' law takes abortion out of the criminal code.

Most terminations of pregnancy are carried out prior to 22 weeks' gestation, and are performed on the grounds that the mother's physical or mental health would be compromised by continuing the pregnancy.

A case that received a great deal of publicity in 2000 and subsequently, when a group of doctors at a Melbourne public hospital performed a termination of pregnancy at 31 weeks for a baby with dwarfism has been, I believe, a driver for the new legislation. This case is discussed in a 2004 MJA article, Abortion: time to clarify Australia's confusing laws.

My purpose in writing this blog is to state that I am shocked and disturbed by our society's huge reliance on abortion. The rate quoted in the abovementioned article is "more than one for every three livebirths. Less than 2% of these abortions are for fetal abnormality." Most of the terminations of pregnancy are for social reasons.

In the 40-year period since abortion became not only legal but more commonplace, there has been a parallel loss of ability with normal birth. Women choose regional anaesthesia, taking away their ability to feel the passage of the baby through their highly sensitive birth canals. Women are ending up on the operating table for caesarean surgery at an alarming rate. The highest rates of interventions in birth occur not among the unhealthy, low socio-economic groups, but among healthy, well educated women with private health insurance, booked at private maternity hospitals.

Why is this so?

In recent generations women have been told we have an absolute right of control over our bodies, and the baby we carry. Modern technology has 'forced' us to make decisions about prenatal screening, and sometimes to consider terminating the pregnancy. We move quickly along the production line, with an early pregnancy blood test and ultrasound, giving risk ratios that predict the likelihood of Down Syndrome. If the risk is considered too high, we have to decide whether or not to have an amniocentesis. Then at 18 weeks or so we have the 'anomaly' ultrasound scan, checking all the organs and measuring the parts. Another decision point has been reached. Some women are shocked at this time to be told of 'ecogenic foci' or 'soft markers' for Down Syndrome. Words that they have never before encountered suddenly become a cruel refrain that plays over and over in their minds. "Is my baby alright?" Yet this deeply distressing decision process accounts for only a tiny minority of abortions. Most abortions are for babies who are conceived at a time that is inconvenient in the mother's life.

Our bodies are wonderfully made. The ability to conceive and give birth to our children is among the most life-affirming, intimate acts that we will experience. But something so precious is also very easily damaged.

One of the reasons some women are unable to tolerate the pain of even normal birth is the memory of previous sexual or reproductive experiences. This memory is deeply stored, and may even be hidden for many years. When labour is progressing the memory surfaces, and may overwhelm the mother, adding to her pain and distress.

I believe the progressive increase in surgical births - an indicator of women's inability to give birth safely under natural processes - is strongly linked to our society's teaching that women can terminate pregnancies that they don't want.

Although I believe there is a greater principle of sanctity of human life, I do believe the laws of the land need to be carefully written to provide for legal abortion. Even with the new law, abortion carries definite physical risks to the mother; infection and haemorrhage being the main ones. The alternative of backyard, septic abortions, is too terrible to allow.

When I have the opportunity to counsel a woman about prenatal screening, or about the possible detection of abnormalities in their babies, I try to encourage them to face the situation carefully and honestly. We cannot guarantee a 'normal' or 'healthy' child - whatever those words may mean. Life is not about perfection. A child is not a commodity - an accessory for the girl who has everything. Some of the most tragic disabilities that parents face as their children grow are conditions that cannot be detected prenatally.

Friday, October 10, 2008

When the penny drops

It was good to spend two days with other midwives this week, in a conference on 'emerging issues in pregnancy, birth and postnatal care' at the new Women's hospital There were many interesting presentations by midwives who are involved in research on topics including estimating the volume of blood loss at a particular time; urinary incontinence experienced by women who are pregnant with their first child; an audit of treatment of newborn babies with antibiotics; expressing breast milk; and 'New look' postnatal care in Barwon Health, where well women with healthy babies are 'cared for' in a way that is radically different from standard medically based postnatal care.

An outstanding presentation, in my opinion, was given by several midwives who are providing one-to-one primary care through the Cosmos Trial. These midwives told about the changes they have experienced since managing their own caseloads. They expressed pride, and satisfaction, and told of the positive responses of women who are enlisted in the trial, and who have been allocated to receive the 'intervention' - a known midwife.

It is interesting to note that a new Cochrane Review of Midwife-led versus other models of care for childbearing women has been released. This review recommends that "all women should be offered midwife-led models of care" - that is, primary maternity care by a known midwife who is committed to attending that woman as the responsible professional in pregnancy, labour and birth, and through the postnatal care. This is what the caseload midwives at the Women's, and at Sunshine, Geelong, and other places are offering. It's also what independent midwives do.

It is quite thrilling to me to see this 'evidence based' model of midwifery care being implemented and researched in the major, mainstream maternity services. The midwives who have stepped out of their previous shift work, hospital nurse mode, and embraced the full midwife identity are excited about what they are doing. That's what I mean by 'when the penny drops'. Midwifery becomes so much more meaningful. We ARE 'with woman'. It's real.

Some readers of this blog may remember how, several years ago, there was strong consumer outcry objecting to the closure of the Family Birth Centre at the Women's. Many women have used Birth Centres over the past 30 years. My fourth child, Josh, was born at the Women's Birth Centre.

The hospital is seeking now to enable normal birthing for any woman in its care; that the focus be on the woman rather than the facility. Having heard the presentations by the caseload midwives, I believe this is now beginning to happen.

Saturday, October 04, 2008

Thinking about choice

The maternity reform movement has for many years now used 'choice' as a key demand. Women want choice. My body, my baby, my choice!

Today, I encourage women to avoid what I call the supermarket attitude to choice in maternity care: "I want that, and I don't want that, and I'll have a pink one of that, and two of that ..." Choice is still a key demand, but it's a limited choice.

There is really only one choice at any time in maternity care: either you do it yourself, or you ask someone else to do it for you. While you can proceed under natural, intuitive processes, you are free to decline all other offers of help if you so choose. However, once you choose an unnatural pathway, whether it's speeding up the labour, or taking away the pain, or surgical birth, you relinquish your right to choice. How strange it would be if you were asked would you prefer a 14 or 16 gauge cannula in your vein! Or into which intervertebral space would you like the epidural anaesthetic to be administered?

The midwife's commitment is to work in a way the promotes normal birth. The partnership between a woman and her midwife supports the woman who chooses to work in harmony with her natural processes.

About seven years ago I worked with a group of committed consumers and midwives in Maternity to produce and publish the National Materntiy Action Plan (2002) which included the key demand that women have the right to choose a midwife as their leading or primary materntiy carer.

"The National Maternity Action Plan is a blueprint for reform of Australia's maternity services.
It has been put together by pregnant women and mothers who are committed to seeing women have the choice of a known midwife to care for them throughout pregnancy, birth and the first few weeks after the birth.
The right to choose a midwife as her lead carer is available to women in many other OECD countries, but not to women in Australia. It is based on scientific evidence that shows women and babies have very good outcomes from midwife-led care. The National Maternity Action Plan explains why reform of our maternity services is needed and how women and babies will benefit.
It calls on governments to respond as a matter of priority."

It is encouraging to note that the current national Review of Maternity Services quotes the National Maternity Action Plan in the call for "urgent reform to promote access to community midwives, including funding, legislation, standards of care, and indemnity arrangements." (from the Introduction)

I am thinking about choice, as it applies to maternity care today.

In the early 1970s I was amongst the outspoken young women who demanded that our husbands be allowed into the birth room. As a recently graduated midwife, and obviously pregnant, I proudly and somewhat naiively told the hospital matron about my choice. She looked icily at me as she said "Mark my words, Sister, there can only be trouble from that. Men don't belong in the delivery room." I quickly dismissed her warning - how could she understand my choice?

In the '80s the wonder of ultrasound became available, and I and many others presented in early pregnancy, holding on to a full bladder, and took home the grey polaroid image of a fetus. My choice, no questions asked.

In the early 90s there was a government report in the UK which identified 'choice, continuity and control' as what women want. At that time I was beginning to identify strongly with the birth reform movement, and I embraced those demands. Anything about midwifery in the UK, where midwives could be real midwives, had to be so much better than what we have. I bowed uncritically to a higher authority, and went about integrating the notion of 'choice' for women into my midwifery identity.

By the early years of this century, with the State and National caesarean birth rates rising by about 2% each year, word got out that women were increasingly choosing caesarean. These were said to be sensible, organised women, who wanted to be able to schedule the birth of a child into the other important matters of their lives, like work and maternity leave. These included women who were averse to the unpredictable nature of natural childbirth; who wanted to keep their "honeymoon vagina" and were "too posh to push". Their choice. And they found doctors who would respect their choice without question.

I do not want to suggest that choice should not continue to be a key demand of the birth reform movement. Yet when the 'choice' for costly and possibly harmful interventions into birthing is made for no reason other than preference, I object. I do not think it is reasonable for hospitals, doctors, and all the other staff to be distracted from their ongoing professionally valid work in order to provide a consumer items and interventions at public expense, unless those interventions are likely to improve the outcomes for the mother or her child. The items to which I refer come from a long list, including induction of labour, continuous electronic fetal monitoring, narcotic pain killers and epidural anaesthesia, and caesarean surgery.

A mother who was particularly anxious about her healthy newborn baby is not able to 'choose' to place the child in a high dependency special care nursery. That would be ridiculous. The mother does need help to develop skills and confidence in caring for the newborn, and that support can be provided by a midwife or sister or friend. Yet the 'choice' of epidural or caesarean on demand is not dissimilar. With good support that mother can learn how to work with her labour, and make truly informed decisions as the labour progresses. Having an epidural or a caesarean is not a failure, or in any way wrong in itself, when the decision is made carefully. But a system that allows women to choose such major and potentially harmful options, without first exploring less harmful alternatives, is failing in its duty of care to the woman and her child.

Someone might say that they are choosing carefully, and they choose an elective caesarean. At present that's not difficult to do, particularly in the private maternity system. The same public funding is applied through hospital funding arrangements, and Medicare, and the Medicare Safety Net, and the Private Health Insurance tax incentives, as would apply for caesarean surgery on medical grounds. That is, in my opinion, an abuse of public funding.

Midwives have choice too. We can choose to get alongside women, establish partnerships based on trust, and organise ourselves so that our services are available and we minimise the risk of burnout. Or we can choose to be obstetric technicians, managing the monitoring and surveillance of women in birth, and making sure that the paperwork is up to date.

I don't think many midwives can, in the present maternity terrain, choose to be self employed. The stresses of irregular bookings, and unreliable income, and unpredictable work hours are too much for many to take on. But changes are occurring throughout the public hospital materntiy system, particularly in places like Sunshine, Geelong, Casey, and the COSMOS trial at the Women's. I am watching these places, and others, with keen interest.