Monday, January 28, 2008

ANGRY MOTHERS

A friend recently sent me a rant from an email list, in which someone told the story of a recent birth in country Victoria. In almost every paragraph, as the story unfolded interspersed with the cyber-chat language of that generation, there was anger expressed toward the obstetrician, the other doctors, the hospital system, and the caesarean surgery. The comment by the writer was “Wasn't sure where to put this, but need somewhere to get angry! LOL.”

The story was that M (the mother-to-be) went to hospital when her waters broke one morning: she was at 40 weeks and 5 days’ gestation. Labour was beginning, but after a couple of hours the decision was made to augment labour with a drip (Intravenous Syntocinon).

After “travelling really well”, labouring without drugs, a “student obstetrician” (possibly a junior doctor, the hospital resident) told her she was fully dilated and could start pushing. M tried to comply, without success. The consultant obstetrician then examined her, and told her she was only 5cm dilated – had a long way to go.

At this point M “loses hope and asks for an epidural”. But the epidural does not work properly – one side of her body is numb, and the other side is in pain. At 2am the “Ob decides it is time to C-Sec because he needs to get home to bed. M is beyond it by this stage and kinda agrees. So they spend half an hour taking off her freaking toe nail polish and to allow the epi to wear off so they can do a spinal. Which also doesn't work so they give her a G.A.”

M woke up when her baby was two hours old, and was told that the baby was born with a low apgar score – 2 at one minute, and 5 at five minutes. “M is kinda happy she didn't see all the slapping around that has traumatised her DH.”

“… She feels like a failure. Was told by the Ob that on top of that she will HAVE to have C-secs with all subsequent births because her pelvis is too small (oh gagf!) and besides her uterus will definitely rupture if she even tries for a vaginal birth.”

What can I say? Unfortunately this story is all too common.

The obvious question is, could things have been done differently? Could this mother and her baby have somehow progressed safely to a normal vaginal birth?

In labour and birth there is a sequence of decisions that need to be made, but can only be made in relation to what is happening at that time. There is no turning back. Decision points in labour are times when the decision is made to either continue with the natural process, or to intervene. Once an intervention has taken place, such as induction or augmentation of labour, it is no longer ‘natural’ labour, and subsequent care may become more and more medical. This is often referred to as the ‘cascade of interventions.’

In this case some of the key decisions that were made were to go to hospital, to augment labour, to assess progress, to have epidural anaesthesia, to perform caesarean surgery under general anaesthesia. I will go through these decisions in reverse order, and comment where I consider it useful in understanding how a sequence of events like this one is likely to unfold.

Decision point 5: Caesarean surgery under general anaesthetic

By the time the baby was taken from the mother, the baby’s condition was poor – she needed to be born and start breathing on her own, and she was given expert resuscitation immediately. It appears from the account that the baby recovered well.

Attempts had been made to give firstly epidural then spinal anaesthesia, without success, so the only alternative at that point in time was a general anaesthetic. During the interval when the anaesthetist was attempting to achieve anaesthesia (numbness) there would have been observations made of the baby’s heart sounds, and it is likely, in view of the baby’s poor condition at birth, that the baby was becoming distressed. It can be assumed from the account that the caesarean surgery was life-saving for this baby.

The obvious question is, therefore, could this baby have been safely born vaginally? The previous decision points may throw some light on the matter.

Decision point 4: to use epidural anaesthesia

As this case exemplifies, epidural anaesthesia is not necessarily a passport to pain-free birth. The treatment in itself may bring problems – in this case the torture of being numb and unable to move down one side of the body, and the pain of labour down the other side. In addition, the natural pain-relieving substances, endorphins, that build up in a woman’s body during unmedicated labour, are quickly rendered ineffective when medical management of pain is commenced. I do not have a physiological explanation for this – production of hormones and action on pain receptor cells is beyond my personal knowledge base - but I know it happens.

If the epidural had been successful, and the labour could have continued for several hours, a different conclusion could have been reached. The epidural in established labour will not, of itself, reduce the chance of vaginal birth.

We may wonder why some epidurals are ineffective. The skill of the anaesthetist is an obvious question. Also there may be some women whose inter-vertebral spaces make it easier for epidural to be administered than others.

There are serious risks to the epidural such as paralysis and infection. These, thankfully, are rare. However there is also the ‘minor’ morbidity which is probably under-estimated, and under-reported. Physiotherapists often see women with chronic lower back pain as a symptom after epidural in childbirth.

I cannot argue against the use of regional (epidural or spinal) anaesthetic in labour, because I know there will be some women who are not able to tolerate the pain for reasons such as obstructed labour. The only alternative management of severe pain is repeated doses of opiates, which also have unwanted consequences. Without regional anaesthesia the only surgical alternative is the general anaesthetic, which has potentially serious consequences for mother and baby.

It appears that in this case the decision to use epidural was made by the mother in response to her disappointment over being ‘only 5’ centimetres dilated, after having been told she was fully dilated. It is truly discouraging when a mistake like this is made. Yet the decision to ask for epidural was probably the point in this labour at which the cascade of interventions became overwhelming to the mother.

The lesson to women contemplating birth, and to midwives providing care for these women, is surely to value unmedicated birth, and to do all we can to protect and support the natural processes in birth.

Decision Point 3: to assess progress

The decision to assess progress is a standard protocol in maternity services. The people providing the care are responsible to assess and record the condition of the mother and baby, and this includes progress in labour. Yet the woman is the person who gives permission for the observation or assessment to be made. I can’t even take your pulse without permission, let alone put my fingers in your vagina and reach up to make contact with your baby’s head, and cervix.

We must not overlook any assessment or recording of observations as a point at which decisions need to be made.

The skill of the person who makes an internal assessment of dilatation is crucial. It seems that in this case there was an error made by the junior doctor: not an unexpected event in teaching hospitals.

My comment to midwives is to challenge any assessment that seems unbelievable. The midwife who was at that hospital must surely have doubted the doctor’s assessment.

My comment to mothers is also to challenge – to remain sceptical. If you don’t feel like pushing and someone tells you to push, ask them to convince you as to why that’s the best thing to do.

Decision Point 2: to augment labour

Augmentation is a decision that is often used in medically managed maternity care, with the rationale being the need to progress before the labouring woman and her baby become exhausted. This is particularly the case with primiparous (first baby) women. When the membranes have ruptured, as in this case, there is the additional consideration of increasing risk of infection being passed from the mother’s vagina to her baby. M was in early labour, with her first baby, with ruptured membranes.

Decision Point 1: to go to hospital

It is usual for women to go to hospital, or to be seen by their midwife, when their membranes rupture. Had M been able to stay at home, unobserved and active, it is likely that her labour would have progressed well. It is clear from the story that the baby was well until the later stages of labour. M would have been aware of her baby’s movements and the tone of her baby’s body, and this would have given her confidence to go on.


Where’s the midwife?

I can’t argue that women ought to know this; and somehow be a DIY midwife. The woman’s midwife is the person who is missing from the story. The midwife could have spoken to M on the phone; could have ascertained that all was well with the labour; could have visited her at home, and encouraged her without taking over or interrupting in any way. The midwife would have assessed progress at an appropriate time for M, rather than the junior doctor learning from his/her mistakes. The midwife who acts to protect and support the healthy natural processes in birthing has skills that obstetricians and other doctors do not have.

The midwife also recognises complications, and refers the woman to an appropriate care provides when complications arise. M may have needed medical support in birthing her baby: we don’t know. But without the partnership of a trusted and competent midwife, M did not have much chance at all to attempt normal birth.

Saturday, January 26, 2008

HER DEATH WAS PREVENTABLE

Today’s newspaper carries a report on the coroner’s findings after investigating the death of a young mother, six hours after the birth of her first child. The coroner found that the cause of death was “post partum haemorrhage complicating amniotic fluid embolism”, and considered that there was a good chance that the death could have been prevented with better medical and nursing management.

Having read the coroner’s report, which is a public document, available at http://www.theage.com.au/ed_docs/coroner.pdf , I want to make a few comments. Several people have told me that they read this blog in order to obtain a better understanding of maternity issues, and I know that we all have big questions in our minds when we hear of a tragic death such as this one. I hope you find my comments useful. You may contact me joy@aitex.com.au or in the comments section of this page.

The only information I have on this case is the coroner’s report. However every midwife and doctor who attends births must be prepared to deal with post partum haemorrhage, and to that extent the coroner’s report is useful in focusing our thoughts on the topic.

Amniotic fluid embolism

Some readers may wonder about the significance of amniotic fluid embolism in this sequence of events. Expert opinion provided in the coroner’s report is worth reading. There is no doubt that amniotic fluid escaped from the baby’s sac to the mother’s blood stream. It is known that this event, though very rare, is likely to cause catastrophic consequences in the mother’s body.

How did the amniotic fluid embolism occur? The report states that there was “probably” a lower uterine segment rupture. This could have allowed amniotic fluid to pass into the mother’s blood stream.

Uterine rupture

How did a uterine rupture occur? This question is not addressed, and I don’t have enough information to form an opinion in this particular case. We are not told any details of the actual birth, whether it was spontaneous or assisted. The assumption is that it was a vaginal birth. We know that the labour was induced at 41 weeks’ gestation. Induction of labour is usually achieved by artificially rupturing the membranes, and administering an artificial oxytocic, Syntocinon® intravenously, gradually increasing the dose over time.

The women today who are most likely to be confronted with concerns about uterine rupture are those with previous uterine surgery – usually a caesarean birth. The scar itself can dehis or ‘buttonhole’, something that may even happen prior to the onset of labour. This is a serious complication, but may not lead to catastrophic haemorrhage. The rupture of the upper uterine segment in obstructed labour or following prior classical caesarean surgery is the most life-threatening complication in this group, as the muscle of the upper segment is thick and has a large blood supply. Tearing of the lower segment may occur in an assisted birth in which a tear in the cervix which was not fully dilated and taken up extends to the lower segment.

Post partum haemorrhage

The severity of the haemorrhage described in this account is far greater than most midwives will ever experience. In the six hours after the birth, from the description of events in the report, there would have been no time when this new mother would have felt well. Her blood pressure was low, her pulse weak, and when conscious she would have been aware that her life’s blood was flowing from her. Whether she experienced the joy of holding her baby or not, we will never know.

Large doses of oxytocics were administered to keep the uterus contracted, without success. It appears that there was no thought of possible uterine rupture in all the decision making and treatment that ensued. Even when the mother’s uterus was examined under anaesthetic, the doctor was looking for retained placenta as the possible cause of haemorrhage.

Coagulopathy

As the haemorrhaging continued over the hours after the birth, the mother’s ability to form clots became progressively worse. This is to be expected in serious haemorrhage of any kind, and requires expert medical management.

Model of care

The model of care in which this mother gave birth, with a specialist obstetrician being the primary carer in a private maternity unit for a healthy thirty-three year old primipara, received no comment from the coroner. It’s so *usual* that noone thinks critically of it in this country. The woman chose to have her baby in Melbourne, probably as ‘safe’ as any other place in the world from a maternity outcome point of view, and she chose the doctor. What more could one want?

In no other life event is there an expectation that well women will be given basic care by a specialist doctor. Yet this is the case in Australian maternity care, due in a large part to the government’s tax incentives to encourage private health insurance, and financial incentives through Medicare and the Medicare safety net.

An informed observer would ask “where was the woman’s midwife?” In this particular model of care the midwife who was present during labour would have been a stranger to the woman, and would not have acted autonomously in providing intrapartum care. Midwives working in private maternity hospitals in Australia usually work as assistants to the obstetrician, informing him or her of progress, administering treatments ordered by the doctor, and maintaining the record of observations. The baby girl was born at about eight in the morning, so a new midwife, rostered to work the day shift, would have taken over the care at about that time.

Perhaps the doctor had been called out to the hospital during the night, and was tired by the time the baby was born? We don't know - that's only conjecture. But had this woman's care been in the hands of a midwife, and everything else been the same, it's to be expected that a specialist obstetrician would have been called to manage the care as soon as the haemorrhage had been seen. Or, if the woman was in a primary care unit such as a birth centre without surgical facilities, or at home, a transfer would have been organised to a suitable backup hospital as soon as the haemorrhage had been seen. (note that a birth centre or midwife at home would not have provided induction of labour on maternal request, and that's a major difference in risk management.)

The point I am making is that when primary care is in the hands of the specialist, there is no further specialist to refer to when complications arise. The model of care put this woman at greater risk than another model, in which a specialist would have looked with fresh eyes at a woman who had experienced a severe post partum haemorrhage, and who was still in shock, and would have instituted aggressive measures to support the woman's circulation, and to stop further haemorrhage.

When a midwife attends a birth as primary carer, and the woman experiences excessive blood loss, the midwife acts quickly to prevent further loss. The uterine fundus is rubbed up and any blood expelled - an empty uterus does not bleed. The midwife administers oxytocics - my usual dose would be Syntocinon 10units intramuscularly, followed by Syntometrine 1ml intramuscularly if the first dose is inadequate. A woman who is still bleeding, with signs of low volume shock, would be transported to hospital by ambulance as soon as possible. An IV infusion would be started, and transfer of care to a backup medical team would occur without delay. This action would usually take place within an hour or so of the birth.

It's easy to be wise in hindsight. Errors of judgment clearly happened in this case, and the coroner described the decision making process as a "study in chaos". Whether the doctors concerned will be judged by their peers as having been professionally negligent or incompetent is up to the statutory body to decide. We expect the ‘eye for an eye’ – someone has to be punished. The lawyers will no doubt organise to sue for compensation, and the insurer will no doubt pay out. Yet nothing has been done to address the underlying cause, which had more to do with the model of care than the actual people involved. A precious life was lost; a baby began her life without her mother; and a new father lost the woman he loved, and who gave birth to their child. It's so sad.

Wednesday, January 16, 2008


A PLACE OF QUIETNESS
We have sought a place of quietness
resting mind, body, and spirit.
Relative solitude.
Separation from business and busyness.

Quietness opens a door for other sounds -
I hear the hum that rises and settles as the wind works its music in the multiple reeds and strings made up of leaves and branches and wires around me.
I hear the sound before feeling the breeze.
Bird sounds come and go: some bright and clear, and others soft and almost incidental.
A buzzing insect, a mosquito's whine, the croaking of frogs, and even the harsh flapping of a piece of corrugated iron that has come loose on the roof of the old shed - these are players in the orchestra of quietude.
These are the sounds I am hearing.

J Johnston. 5 January 2007
[This little piece was written a year ago, when we were having a holiday in Roma, Queensland.]

Saturday, January 12, 2008

Today I am bringing two poems from my stored files to this blog. Two mothers; two families; two births. Two babies, but only one living. I hope the thoughts expressed here are helpful to others in coming to terms with the big questions of life and death. Joy Johnston

Tears

Salty tears fall from swollen eyes
as the woman mourns for her child.

In the day and in the night
surges of pain and sorrow
are reminders of her loss.


White milky tears flow from firm tender breasts
that never will feel those rosebud lips.

Deep pain of heart and breast and womb
is soothed a little by the warm and generous torrent from the shower above.

Tears, milk, and dark drops of blood
mingle at her feet
and are washed away.

J Johnston, January 2003


Uneventful

I called it an uneventful birth.

There was no time of fear or doubt,
no place for concern.

Progress was swift as you opened and gave up your treasure into my hands.

Uneventful?

How could I call it that?

When heaven opened a little
and a sunbeam in the night showed an angel the way to your home.

When your beautiful pink babe was ushered into your arms.

When heaven’s host watched on in awe,
and a little cherub said “ah - ah - ah!”

When your heart swelled to pour out its love.

As mother and father, and the whole circle of family and dear ones greeted and welcomed the newest member.
As you and your loved ones watched
an unfolding miracle.

Uneventful?

The rush of waters.

The surges of power from within, urging the little one forward.

The need to be ready, as fullness and heaviness preceded her arrival.

The moment between times – still within, and yet without,
and a small cry before the release.

Warm, wet, and glistening in my hands
held over the welcoming mat.

Could this be called uneventful?

Arms stretched wide, and air filled the little lungs for the very first time.

The baby heart undergoes the miracle of changing from the placental circulation
to its own supply.

The baby skin feels warm at mother’s breast
and the baby lips search for sweet warm milk.

The mother’s arms encircle her soft baby child.

Senses are fully alert, as sight, touch, smell and sound
imprint on the mother memory.

Others are reverently quiet, unwilling to interrupt this falling in love.

And her womb gives up the afterbirth.

What great mysteries we have witnessed!

A child has been born.

Events too momentous for description.

The early light of dawn can be seen above the hills to the East
as a family settles down to rest
before the new day begins.

Uneventful – yet extraordinary!

“Praise God, from whom all blessings flow.

Praise Him all creatures here below.

Praise Him above ye heavenly host.”

J Johnston

January 2003

Tuesday, January 08, 2008



MIDWIFE AUTONOMY

Case Summary

A primigravid woman, ‘Tracie’ (not her real name) aged 36 years asked me to be her midwife. At 26 weeks’ gestation I recorded that Tracie wanted to labour at home, and was questioning whether she would go to the local public hospital Birth Centre or stay at home for the birth. Tracie told me she wanted to keep both options open, and she decided to make two bookings – one for birth in hospital, and one for homebirth.

Tracie was working full time, and assured me that her job did not give her any undue stress. She planned to finish work a month before her baby was due. I saw Tracie at 33 weeks, and she was well. I recorded that her fundal height was at about the 32 week level. I palpated the baby, and assessed its size between my hands. Small-ish baby, I thought. There had been no elevated blood pressure or other condition that may compromise fetal growth. The fetal head was presenting nicely, and the back to the left.

I made a booking for a home visit for ‘birth preparation’ at about 36 weeks’ gestation.

Early Sunday morning I was woken by the phone, and was surprised to hear Tracie’s partner say “It looks as though we won’t be having the birth preparation meeting tomorrow”. He went on to tell me that Tracie’s waters had broken at three, and she was now labouring strongly. Only a couple of hours ago, I thought, as I began to discuss the implications of labour before 37 weeks, and the special needs of pre-term babies. Then I heard the sounds of Tracie’s labour in the background.

“Ask Tracie if she wants to go to hospital now, or if she would like me to come to the house,” I said.

“She would like you to come here,” was the reply.

“No worries. I’m on my way.”

It was cold and windy out. It took me about 30 minutes to get there, and I parked my car and went up to the house. As it was my first visit to their home, I was noting things that are usually noted at that preparation visit – the hilly terrain, the steps from the car to the house, and the flight of stairs from the entrance to the upper level where the bedroom was. There were big windows with superb views!

In the bedroom I found Tracie working strongly with each contraction, as the labour surged every couple of minutes. Checking mother and baby – both were fine! Waiting for another contraction to ease, I prepared in my mind to tell Tracie that we would need to go to hospital immediately, so that she could settle in before the baby was born. However, the sounds she made became lower.

“I felt like I needed to push that time,” Tracie said.

After a brief discussion we agreed to continue at home, rather than attempting the steep and exposed journey from the bedroom to the car, and on to the hospital. The birthing progressed beautifully, and soon we had a wee girl in excellent condition, resting on her mother’s abdomen; a proud new mother; and an elated father.

My usual practice at birth is to not intervene unless there is a valid reason. I did not clamp or cut the cord, or do anything to speed up the Third Stage. In the ensuing minutes we quietly watched this baby girl begin to respond in the instinctive way that healthy babies do. She began to lick and salivate, and make rooting movements with her mouth, and strong leg movements that moved her towards the breast [This process is known as the ‘breastcrawl’ – see http://breastcrawl.org ]. That evening I made a note in my journal:

“When baby was near the nipple she flopped her head to the other side. Mother gently put the head back where it was, and baby did the same movement again. After the second time I suggested she might want to be that way, and soon after, she began to take the breast. Strong contractions followed, and the placenta came with minimal blood loss.”

Baby was a couple of hours old when I weighed her, and noted that she was only 2.3 kilos. Despite the small size, her behaviour could not be faulted. She was warm, well fed, and a powerful bond was being forged between her and her mother. When I re-visited the question of transfer to hospital, Tracie reiterated her desire to stay at home, and I agreed.

Since she was a small baby, slightly premature, I set up a care plan of three-hourly feeds, at the breast, or with expressed colostrum if baby didn’t feed well. Each day as I visited I was thankful that Tracie and I were working together. Trust is a two-way process: she had to trust me and I had to trust her. Tracie kept a record of feeds, whether at her breast, or by cup. By 48 hours, baby was needing some expressed colostrum, and Tracie’s nipples were tender. The reality of broken sleep, and constant attention to the needs of a newborn was settling in, as the euphoria of birth subsided. Each day I looked carefully for any reason why this mother and baby should be under the care of a specialist team such as that available at the hospital. Each day Tracie confirmed that she wanted to stay at home in my care, unless I felt that they needed to go to hospital. Each day, as I observed that all was well, my conclusion was that we were acting appropriately.

By the end of that first week I saw a mother who was gaining confidence; her baby waking and feeding vigorously.

I reflected a lot during that first week on the issue of the size of the baby. Had we transferred to the hospital, this baby would have been taken to the Special Care Nursery, separated from the mother, and had her blood sugar levels checked frequently. When the blood sugar level was found to be low, it is most likely that artificial formula would have been given rather than relying solely on breastfeeding. This is a very different scenario than what was experienced by Tracie and her baby in their home, as there was no separation, and small but adequate amounts of colostrum were provided frequently either by baby’s efforts, or with expressed milk.

Despite being smaller than the usual ‘normal’ weight in Australian maternity services, this baby was well within the range of babies for whom weight alone is not an acceptable reason for interfering with the natural process in establishing breastfeeding. The Baby Friendly Hospital Initiative (BFHI) ‘Acceptable medical reasons for supplementation’, lists babies “born preterm, at less than 1500g or 32 weeks gestational age; or infants with severe dysmaturity with potentially severe hypoglycaemia, or who require therapy for hypoglycaemia, and who do not improve through increased breastfeeding or by being given breastmilk.” The guideline states that “For babies who are well enough to be with their mothers on the maternity ward, there are very few indications for supplements.”

[From Booklet 3 of the Global Baby Friendly Hospital Initiative in Australia, ACMI/BFHI, p10.]

The local hospital where Tracie had a booking is an accredited Baby Friendly hospital. Yet on this issue, I felt confident that the BFHI ‘Acceptable medical reasons for supplementation’ would not be followed.

I contacted the Maternal and Child Health (MCH) nurse, and discussed my care plan. When seen by the nurse at eight days of age, baby weighed only 2 kilos. A week later, baby was breastfeeding well with occasional ‘top-ups’ of expressed milk, and she had gained 50 grams, and all clinical signs were positive. Tracie took her baby to the local doctor at about two weeks of age, and he agreed that all was well. By three weeks of age, the baby was clearly thriving.


Reflective comment:

In providing postnatal midwifery care for Tracie and her baby at home I have acted autonomously, outside the National Midwifery Guidelines for Consultation and Referral (‘Guidelines’) (ACM 2004). This was not a pre-meditated decision to act ‘independently’ or to ‘push the boundaries’. It was an action plan that evolved during the first week as each decision point was reached, and as the care was reviewed each day.

The purpose of a systematic set of professional guidelines is to ensure “high quality and safe care” (ACM 2004, p5). However, guidelines should not be treated rigidly; they are guides. The wellness and safety of mother and baby are the primary concern of the midwife, who has the professional expertise to independently assess wellness, and to develop a professional care plan in which she can act confidently. Midwifery at the primary care level is health promotion rather than a treatment of illness or complication.

There are times when I and other independent midwives choose to act outside the Guidelines, such as in providing primary care for women who have had a previous caesarean birth, without consultation and transfer to medical care, and with a plan to give birth at home. When this decision is taken the midwife discusses with the mother the alternatives at that time, and what implications her choices may have as she progresses down the childbearing pathway. Informed decision making is an active process. The woman is encouraged to make her own choices at each decision point, taking into account the complexities of her own life and her knowledge of herself.

There would certainly be times when I would judge a small baby in a similar circumstance to be best cared for within a supportive multi-disciplinary collaborative framework of a maternity hospital. If I was not confident in the mother’s ability to act in the best interests of her vulnerable newborn; or her family support; or her own strength: many possibilities could have led to a different decision on my part.