Sunday, March 30, 2008

What kind of support do new mothers need?
This question has been thought about by people through time.
When my mother was having her babies through the 1950s mothers were kept in hospital for two weeks, and sometimes nursed in bed for much of that time. Sponge baths and bed pans were the norm. Life was regimented in Brisbane during the post-war baby boom, and mothers and babies were expected to perform on time in all activities including eating and sleeping. Visiting by husbands was strictly controlled, and older children did not visit mother or baby in hospital. Mothers returned home to the realities of their own lives - washing, cooking, cleaning, chooks, children, and whatever else. They apparently knew that their time in hospital was important for their recovery.

When my grandmother had her children in 1910 through the 1920s she initially went to a 'nursing home' or lying in hospital which was owned and operated by a midwife. That's where her first child, Halley, and the twins Frances and Frank, were born. Subsequent births were at the farm in Redland Bay. My father told me how he and his siblings were sent to their grandparents' home, and the midwife, Mrs Heinemann, stayed at least a week with 'Mother'.

When I studied midwifery in Melbourne in 1972, prior to the birth of my first child, mothers usually stayed in hospital about one week, with 10-day stays being not uncommon. The first few days were for resting and recovery, and many of the women spent a pleasant time, enjoying the food that appeared at meal time, the clean sheets, and the company. Babies were cared for in the nursery, and mothers who were breastfeeding were encouraged to take a sleeping tablet. Breast engorgement was very common. Breastfeeding rates were at an all time low then, and midwives made up jugs of a mixture of sweetened condensed milk and water (strengths 1 in 8 or 1 in 6 1/2) and gave it to the babies. Visiting hours were fairly strictly controlled, and babies were looked at through the glass window of the nursery.

When I gave birth to my first child, Miriam, in Michigan USA in 1973, I was keen to do it my way. I went home on the third day. That would have raised eyebrows back home, but the cost of hospital care in the US had hit hard, and short stays were common there. I did not observe any rules as to how long you should stay at home and be looked after. My babies were very portable from day 1: they breast fed and slept without regard to where they were. Noel did what he could to look after me for a few days, but I was much better at cooking and home management, so it wasn't long before I took over and he was happy.

When our second baby, Rebecca, was due, my mother came to stay with us in Michigan for six weeks. I still remember how wonderful her cooking was. Shepherds pie and mashed pumpkin had never tasted so good! I learnt a lesson then about mothers.

We managed without my mother for the births of the two boys, Paul and Josh, but I always remembered how good mum's presence was in those early days after Bec's birth.

This past year or so I have been in the Box Hill BaBS (Birthing and Babies Support) group, meeting each week during the school term for peer support of mothers in pregnancy and with their new babies. Many of these young mothers are isolated from their families, and a new phenomenon that they experience today is that many of their friendships are via the internet. They chat together in chat rooms and email groups, but rarely see each other. The beauty of a BaBS group is that it is face to face; it is a community.

One of the wonderful things that has happened with the BaBS group is mothers caring for one another. The women have organised themselves to support the new mothers in the group. They have prepared food, or just gone to visit that person and see if any practical help is needed. The significant act is that they are with that new mother, in person. They become her sisters, her friends, and that's what she needs.

What kind of support do new mothers need today? There's no one answer. What they need is a caring community that is responsive to them as individuals. This can't be done by email. It takes effort and time, and face to face communication.

Sunday, March 23, 2008

PAID MATERNITY LEAVE
Today's newspaper brought an article renewing calls to the Australian government to introduce paid maternity leave. I haven't been following it closely, but I understand that the matter has been referred to the Productivity Commission, which will delay action for another year.

It happens that today is Easter Sunday, probably the most distinctive and precious day in the Christian calendar, when we celebrate the bodily resurrection of our Lord Jesus. I was sitting next to Noel in our usual place in the Presbyterian Church in Surrey Hills when my phone vibrated, and I went out to answer it. A reporter from Channel 7 news asked me if I would be happy to talk about paid maternity leave. I explained that I would be available to talk in about an hour, and the reporter said she would arrange a cameraman to come to the Church at that time.

I don't have answers to the questions about paid maternity leave. How many weeks, or months? Full pay or 80%? For all workers or just those with permanent positions? What about low-paid casual workers? What about struggling small businesses? Would they simply avoid employing any woman who looked as though she might be likely to want to have a family? What about mothers who are already at home with a couple of littlies, who with their husbands have made the choice to live on one income while they have dependent children?

I can only give my answer from the midwife's perspective, in promoting health for mothers and babies.

I am deeply saddened that our society does not value the work of mothering. I am sorry that many new mothers feel that they must return to work and forego their place as mother to their young children. In making the decision to return to work, leaving a young baby in the care of someone else, a mother has, to a greater or lesser degree, to deny her natural maternal instinct and bonding with her child. She has to interfere with the natural processes in nurture and breastfeeding, while her sister who is able to learn mothering becomes intimately involved in all aspects of her child's life, and enjoys the unique attachment between herself and her child.

We like to quantify things, so for the purpose of this discussion I am going to limit my comments to the mother-baby relationship in the first year of the baby's life. I say without a doubt that any society that cares about its future must support all mothers to stay with their babies throughout the first six months, as a basic essential. I would add that ideally mothers should be able to delay any return to regular work that requires separation until the baby has past her or his first birthday.

There's no milk like mum's milk. Of course there are breast pumps that can be used in the office, and mother-friendly workplaces provide suitable spaces for mothers to express milk and refrigerate it. But breastfeeding is not just x milliliters of a white liquid - it comes with warmth, and the smell and feel of a mother's body. It comes with the voice that the little one has known since her hearing began in the womb. It comes with the unique familiar environment that is home terrain for that child.

What I am saying is that breastfeeding is a relationship - not simply an act of transferring fluid and food from a mother's breast to her child's stomach. Exclusive breastfeeding, recommended for at least the first six months of life, cannot be accomplished without the mother and baby working together. There is no substitute food so uniquely suitable for babies as their own mother's milk. Breastfeeding is not an end in itself, but it is a key that opens the door to strong mother-baby attachments and focused parenting. The health promotion, both in terms of disease prevention, and protection of normal relationships, that comes when a mother is supported in developing mothering skills and attitudes, cannot be measured in economic and productivity terms.

There is no 'one size fits all' solution to the paid maternity leave question. I would like to see all mothers supported in their early parenting, not just those who have good jobs. Programs that identify socially vulnerable women, and provide trusted peer support as well as professional carers will enable many of those women to take action to improve their own health and the health of their families. I would like to see a government working from the principle of protecting and promoting and supporting mothers and babies in achieving optimal breastfeeding as an indicator of healthy communities.

This statement may have alienated or angered some readers. You may argue that some mothers can't breastfeed. That's true, for a few, and there are alternatives available. Some couples can't conceive a child the natural way, and there are alternatives which they may try, but noone would argue that the alternatives are equally as satisfying or fulfilling to the relationship as the natural. I hope you will continue exploring this issue, and thinking carefully and critically about the importance of physiological mothering. If you do not want to leave a comment on this blog you can email me joy@aitex.com.au .

Sunday, March 16, 2008

THE ‘B’ WORD

Breech. A woman today whose baby is discovered to be presenting bottom or feet first (breech) will often be given no other option than elective caesarean.

The evidence that is used in directing mothers with breech babies at Term into the operating theatres was produced in a big multi-centre randomised controlled trial. It’s the most reliable type of quantitative evidence that is available. The research concluded that it’s safer for the baby to be surgically delivered than to be born vaginally.

There are several compelling reasons why I and some other midwives and medical practitioners are reluctant to submit to the breech-caesarean rule. We know that many babies in the past were born safely feet-first, and we know that many women have a strong preference for natural, non-surgical birthing options. We know that some breech presentations in advanced spontaneous labour will be undiagnosed, and that the skill of the midwife in attendance could be a deciding factor in the safety of that baby. The unintended and unfortunate reality of a professional terrain in which vaginal breech births are rarely seen is the de-skilling of the professions.

Another consideration that I will try to briefly outline here is the fact that a randomised controlled trial cannot truly reflect likely outcomes for women who want to work, undisturbed and unmedicated, with the power of their own bodies. So, even though I cannot challenge the results of the Term Breech Trial for the people who were involved, I consider that the very fact that pregnant participants agreed to be randomised into either the ‘labour’ or the ‘elective caesarean’ groups prevented them from engaging with their own natural resources needed for giving birth themselves.

The women enlisted in a randomised controlled trial are treated as though they have a medical condition, and the trial looks at different options for treatment. The hospitals and the maternity professionals who participated in the research could not have been committed to protecting and promoting wellness in childbirth, and many may have lacked the skills of midwifery in protecting natural birthing, particularly in breech vaginal birth. The results cannot apply to women who want to work with the wonderfully powerful natural processes in birthing their babies, as these women would have refused to be enlisted in the research.

Perhaps writing for my blog gives me an unrealistic sense of my own authority. This medium allows me to declare my opinion for the world to hear.

I have two birth stories to illustrate my current practice in relation to breech births.

‘Megan’ was about 39 weeks, carrying her second baby, when she became aware of a hard round lump under her rib cage. She found herself rubbing it from time to time, and thought it might be her baby’s head. She went to the Birth Centre for a checkup, and asked the midwife if she thought the baby might be presenting as breech. The midwife wasn’t sure, and called a more experienced midwife, who palpated and told Megan she was pretty sure the head was down. Megan phoned me a few days later to get my opinion. I visited her, and agreed with her - breech. The presenting part was not engaged, and moved easily. I encouraged Megan to seek ways of turning her baby, and to ask the hospital to attempt external cephalic version. She had an acupuncturist who she trusted, and suggested that she would ask for some acupuncture and moxibustion.

Megan went back to the Birth Centre, and this time the breech presentation was confirmed. She was told that she would no longer be able to keep her booking at the Birth Centre, as she would be booked for elective caesarean. She was already close to her due date, so an appointment was made with an obstetrician.

Megan asked if the baby could be turned. The midwife phoned a doctor at the hospital, who is involved in a trial of external cephalic version (ECV). The doctor said it was too late – the pregnancy was too advanced for her to try.

Megan was disappointed, and told me that she would rather plan a vaginal breech birth at home than have an elective caesarean. I agreed that that was a reasonable backup plan. Having palpated Megan’s abdomen, and felt how readily the baby’s bottom moved, I encouraged her to persevere with the quest for ECV. She made an appointment with the doctor who does ECVs. Megan is quite small and timid, but I admired her strength in this whole process. I encouraged her to go to the hospital with her partner, and ask the doctor to put her hands on her belly and feel her baby. If the doctor then said she could not attempt an ECV, then she would have to accept it and move on.

The doctor did agree to the ECV; the baby turned easily, and after monitoring Megan and her partner went home. Megan gave birth spontaneously to a healthy baby girl who came out head first, a couple of days later.

The lesson I learnt was to persevere. The hospital maternity care system may not automatically provide the options that the woman wants, particularly when those options are in supporting and protecting normal birth. But a woman is quite within her rights to request the sort of help that Megan received, even if that help is not readily available.

The second breech birth story does not have a happy ending. I learnt about this birth when I was asked to review the case on behalf of a law firm in Melbourne, and provide a report on the role of the midwives who provide care.

The mother arrived at a private hospital in strong labour with her second child, and was admitted by a midwife. The mother did not know her baby’s presentation was breech, as her doctor had checked her a couple of days ago and told her the head was presenting. Shortly after arrival the mother felt an urge to push, and the midwife arranged for the doctor to be called to attend for the birth. Before the doctor arrived the waters broke and baby’s legs and bottom were born. The baby’s body was initially pink, but after a few minutes the cord pulsation ceased and the baby became white. The midwives did what they could for the mother, but they did not have the skill or confidence to attempt to deliver the baby’s head. The doctor arrived and the baby’s head was born with assistance, followed immediately by the placenta which had probably separated at the time when cord pulsation ceased. The baby was resuscitated, and transferred to a neonatal intensive care unit. The baby’s brain had been damaged, and the lawyers were now acting on behalf of the child in suing the hospital and the doctor.

The question that was put to me was, should a midwife have been able to assist the birth of this baby?

This tragedy happened as a result of de-skilling of midwives. Today’s new midwives and obstetricians will possibly have had little or no experience in breech vaginal births, and this scenario is likely to be repeated from time to time.

When a baby's presentation is breech, the partnership between the mother and her midwife is put to the test. Various decision points are reached, and sometimes as in Megan's case, the baby can be turned and proceed to a normal cephalic birth. Such choices were not available for the second mother, because the breech presentation was not known until the birth was underway. Any midwife reading this story will do well to review the principles of an assisted birth of the after-coming head; a manoeuver that could have prevented the hypoxic brain damage to this baby.

Friday, March 07, 2008

Decision Points

The other evening a healthy baby boy was born vba2c to Julie (not her real name). For those who don't understand the abbreviation, that's vaginal birth after two caesareans. Words can't express the elation that we all felt as Julie held her new baby in her arms.

This birth took place in a private hospital, and I worked with an obstetrician and several shifts of hospital midwives in the labour. It was not a highly medicalised birth - Julie had stipulated in her birth plan that she did not want anyone to offer pain killing drugs, and at no time did she seem to be looking for medical pain relief. Electronic fetal monitoring (EFM) was used - the hospital's new telemetry monitor was put into use, enabling Julie to move freely, and spend all the time she wanted to in the bath. Julie's doctor had agreed to her plans with the understanding that if she did not progress in labour there would be no artificial stimulation of contractions. Julie was not asked to have an IV cannula in her vein.

Many of my stories are about women who give birth without any complications, in as close as we can to an 'undisturbed' state. The use of EFM is a disturbance, no matter how up to date and wonderful the gadgets are. But Julie had agreed to that disturbance, and was able to labour without letting it bother her. Julie's previous births had both been by emergency caesarean, early in the labours, when both babies had showed clear signs of distress.

Julie and I agreed to approach this birth with the intention of 'normal until proved otherwise'. I explained decision points - any time when a decision could be made. The 'default' decision was that Julie was giving birth. Plan A. At any time an alternative plan may be considered, if a valid reason for interference had arisen. This is the same basic plan that I encourage every woman to adopt.

It was not a simple journey from the first signs of labour to the birth, two days later. We reached several unexpected decision points, and each time, after careful consideration, agreed that Plan A was good. There was the high and very mobile head which did not engage until the second day. There was the vaginal loss, clear at first, then apparently meconium stained. There were subsequent concerns about infection and fetal distress. I called the loss a hindwater leak - the obstetrician disagreed. He did agree that the forewaters were intact, so as long as Julie's temperature remained normal, no treatment was required. At the end of the first day Julie was having contractions but not dilated, and the baby's head was still high. We assessed that she was not in labour; Julie agreed to stay in the hospital; the monitor was removed, and I went home to bed.

Julie's husband called me back to the hospital the next morning, as her contractions were becoming stronger. On palpation I was pleased to discover that the baby's head was engaged. Julie had not slept much, and was now putting all her focus into working with the labour. A dilute mixture of juice and water kept her well hydrated, with a little ready energy. By midday we were all delighted that Julie had progressed to 5-6cm dilatation, more advanced than she had been in either of her previous labours. Another decision point was reached in the afternoon, when the waters were broken artificially. The baby's head was still quite high. I was still concerned enough about that baby's high head that I wondered if we would have a caesarean at that late stage.

However, shortly after, Julie began pushing. Each step had been taken, and we all sensed the birth was near.

The baby's heart rate became very slow in second stage, and the doctor was consulted. Julie's baby's birth was assisted with the Ventouse cap - she pushed and the doctor pulled, for just one contraction. He went straight to Julie's abdomen, and I dried his body as he started to take some breaths then give out a strong cry.

I won't attempt to tell the story from Julie's perspective, or from her partner's. The midwifery lesson from this birth is that patience and consistent decision making enabled the mother to come into spontaneous labour, and to work through her own birthing journey. She can rightly say "We did it ourselves".



Sunday, March 02, 2008

Knowing

Denise [not her real name] is a practical, down to earth young woman who lives with her two happy little boys and their father. When she booked me for homebirth she was sure that her baby would be born without too much bother, consistent with her previous birthing experiences. Denise asked me to visit her at home for a couple of prenatal checks - she doesn't own a car, and public transport between her place and mine is not easy. She had made a 'shared care' booking at the Women's, which means that most of her prenatal checkups were with the local doctor. I felt confident in Denise's knowledge of herself, her baby, and her trust in her own body, and I was happy to take her booking.

A couple of days before the due date Denise phoned me around midnight to tell me her waters had broken, but she was not in labour. She wanted to know if that was alright - it had not happened that way previously. In a brief conversation I reviewed a few important points - a small amount of clear liquor, and baby is kicking. The head had been presenting well last time I palpated her, so I reassured her and encouraged her to get some sleep before labour became strong.

The next phone call was after four in the morning, and Denise's husband asked me to come. I put on some easy clothes, brushed my teeth, and got my gear into the car without delay. It took 40 minutes or so as I drove towards the city, and across the flat docklands. I was conscious of the early light of dawn, and the movements of a city that is waking up, and I committed my work, and this family to God. I always ask for strength and wisdom as I go to a labouring woman.

The husband greeted me at the door, and told me she was still in bed - hadn't wanted to get up, in case the baby slipped out. I greeted Denise, who looked relaxed and well, and settled in. There was no rush, but I set up the basic equipment as is my routine.

I don't want to record here a blow-by-blow description of progress in labour. Denise was surprised that her contractions were irregular in their strength, and frequency. Her expectation of quick progress was not met. Yet she was well, and her baby was well, so I had no reason for concern. At one time she asked me if it was taking too long. No, I replied. Each baby has to find its own way through the birth canal.

Over the next few hours the labour became more powerful, and Denise moved into the isolation of her bedroom. Her cries indicated the intensity of the pain she was experiencing, yet her quiet confidence between contractions reassured us that she was well. She worried about her boys, who were watching a DVD - a rare treat for them. The younger one, who is about four, came to the door and checked his mother as her vocalisations became stronger. Each time she reassured him, and he seemed quite satisfied.

A change came eventually, and at the peak of a strong contraction there was a pop, as the bag of forewaters broke. The next contraction brought a strong urge to push. Denise was working intensely with her body as she progressed the baby through her birth canal, and into view. The brother checked once again from the doorway, saw the baby's head crowning, and went back to the television. It was just before 11 am when a beautiful, healthy baby girl was taken into her mother's arms. The two little boys came in, met their new sister, and left in a very matter of fact way. Their mother had had a baby. That's what mothers do!

Many times in the past I have experienced the 'knowing' that women have about their own birthing processes. I hear the woman's expectation through a critical ear, as I know that there are times when knowing is not what we think. Although Denise's knowing, or belief, that this baby was likely to be born very quickly, did not eventuate, that doesn't matter. Time takes on a different quality in uncomplicated, undisturbed birth, than in the world of measurements and calculations. As the labouring mother's mind progresses from neocortical activity to intuitive, hormone-mediated activity, the midwife protects the space around the woman so that she and her baby are free to take the journey. This is one of the secrets of midwifery.
First child

Lovely young woman,
your body firm and fresh.
Perfect.
A precious curtain was torn in two
from top to bottom,
making a way from the sacred place
into this broken existence.

Archetype of the primipara,
feel that deep pain;
mingle unshed tears with the wonder of life that has awoken.

The wound heals over.
The suckling child urges you on,
despite daily reminders.
In giving birth, you have given strength -
wholeness.
A scar remains.
A reminder of the open gape.

When another curtain was torn in two from top to bottom
the way was made into the holy place.
Ponder these things.
Treasure them in your heart.

Joy Johnston [I wrote this poem in my diary 30/6/2001]