Wednesday, July 30, 2008

NOT QUITE 24/7

On Sunday I was feeling quite unwell, and thought I was coming down with a cold, so I asked Karen if she could do a postnatal home visit for me. It was good to stay in my nightie and spend a quiet day, rugged up by the fire.

I had agreed to cover for Andrea on Sunday night and Monday, as she was taking the Lactation Consultant (IBCLC) exam. On Monday morning I woke up feeling stronger and was thankful that I had not been called out that night. Shortly thereafter the phone rang, and it was the husband of Andrea's client, who I will call Jen. Jen was having some contractions; her waters had not broken, and she had not noticed a show. She didn't want me to come yet - just wanted to know that I was available for her.
It was not long before Jen's husband rang again and asked me to come. I headed down the new East Link toll road, and found the house without difficulty.
This was Jen's second baby, and she progressed quickly and beautifully. After getting into the bath she asked me if I thought she had long to go. "Not long now" I said. "Are you just saying that?" she asked, with a look of surprise. The next contraction was strong and she felt the unmistakable bulge. I called her husband, and she gave birth in the bath tub to a healthy baby boy. The baby's bag of waters had not broken until after his body had birthed, so I lifted back the membrane as we welcomed the little one.

As I drove home I reflected on midwives covering for each other. We do our very best to be there 24/7, but there are times when we need to be somewhere else. I had conflicting emotions. I felt delighted to be asked to be able to stand in for Andrea, and I was also very happy to be able to ask Karen to cover for me the previous day; yet it was difficult for me to come to that point of acknowledging that I needed to ask for help.

I have chosen to be a solo practitioner, 'independent' within what I consider reasonable limits. It is uncommon for me not to 'be there' for women who book with me. I don't have any dependent children, and have sustained a caseload of 3 or 4 births a month, providing the continuity of care for each woman. The other fairly obvious fact in independent midwifery practice is that we are paid only for what we do. A midwife who misses a birth forgoes the fee that she would have charged. If we take a day 'off' work, we do so without pay.

Some midwives form group practices and agree to cover for each other at certain times, such as one weekend in three. There are obvious benefits, but disadvantages as well. I am happy to discuss this further if anyone wants to engage in discussion.

Wednesday, July 23, 2008

Circles of support for mothers

"Support a mother to provide a golden start for her child! With breastfeeding everyone wins!" These statements are themes that are being promoted by WABA for the World Breastfeeding Week 1-7 August [http://www.worldbreastfeedingweek.org/].

Thisafternoon I sat with a circle of women and their children at the Box Hill Birthing and Babies Support (BaBS) group http://birthingandbabies.info/
BaBS groups are sometimes chaotic, with toddlers and little children, babies, and mothers all being who they are.
Today we supported each other in being mothers, and members of families and communities, the way women have since time began. We listened to mothers speaking of their lives, and we grieved with those who spoke of emotional pain and frustration, and the one who shed tears. We talked about maintaining our emotional reserves so that we can cope with the often unpredictable ups and downs in ordinary life. We used butcher paper and drew pictures that recorded our feelings, and some of the children added their squiggles and lines and blotches to complete the picture. We acknowledged that a mother's life is never separate from her children - her life and theirs' are constantly interconnected.

The WABA World Breastfeeding Week program this year is promoting the Global Initiative for Mother Support, and is using the Olympic Games circles to remind us of the need for 'circles of support'. WABA states that:
MOTHERS DESERVE AND NEED
  • empathetic listening
  • basic, accurate and timely information
  • skilled and practical help
  • encouragement
These four points are the 'circles of support'.

Mothers don't just need circles of support for breastfeeding - they need it for all aspects of normal birthing and nurture. Breastfeeding is an absolutely important aspect of what I would call 'normal' parenting. Not necessarily 'usual' or 'most common' parenting - normal in that this is the physiologically normal, and the most basic way of enabling health and nourishing and nurturing the infant and young child.

The four WABA 'circles of support' apply equally to the promotion and support of normal birthing as they do to breastfeeding. In promoting normal birth, we are establishing the best set of circumstances for the initiation and establishment of a strong breastfeeding bond between mother and baby, and consequently strong emotional bonding. This is true even when the mother experiences complications or illness in her pregnancy or birthing or breastfeeding: the promotion of normal birth within a partnership between a woman and her midwife enables good decision-making, and protects the mother's sense of personal autonomy in her care.

Next month we will hear a lot about the world's best sporting performances. Let's also remember to: "Support a mother to provide a golden start for her child!"

Wednesday, July 16, 2008

When birthing becomes abnormal

I want to tell you, my readers, about Julie's birthing of her first baby. Julie asked me to be her midwife, and I worked with her obstetrician and the midwives at a Melbourne private hospital. We did not achieve normal birth, but I believe it was a very good birth.

I have heard some independent midwives saying that they don't accept bookings for private hospital births; that women who go down that track aren't trusting their bodies; that they, the midwives, feel unable to truly exercise their skill when they go into hospitals. I do not agree. All I ask is that a woman who engages me as her midwife is planning to do all she can to give birth, and will not interrupt or interfere with her natural processes without a good reason. I am not committed to either home or hospital - I believe the woman should be free to decide the right place for birthing when she is in labour. Sometimes women planning homebirth go to hospital, and sometimes women planning hospital birth make the intentional decision in labour to give birth at home.

Julie is a beautiful woman: healthy, fit, and in her late 20s. As we approached the due date her baby's head had not engaged, and we chatted about what that might mean. My usual advice is to remain active, but not to try to bring on labour until after 41 weeks. I planned to talk to Julie about a couple of 'self-induction' options such as a does of castor oil, and/or a program of nipple stimulation and pelvic movement. Julie's doctor talked about induction of labour at 10 days after the due date. However Julie's labour started spontaneously at 41 weeks. She was awakened with early contractions one night, and they continued irregularly through the next day.

Labour established that night, and Julie asked me to be with her. The sheer physical demand of a couple of sleepless nights was telling on her and her husband. I sent him off to bed, and Julie's mother and I kept her company. When I palpated I noticed that the baby's head was in a good position, well flexed, engaged, but high. An internal examination confirmed this assessment. There was a lot of work ahead - this baby was not going to slip out easily.

Labour progressed and we went to hospital. As often happens, contractions that had been close and strong became irregular and infrequent. It was frustrating as the hours rolled on, and the 'team' became more weary. By late morning Julie was nearly fully dilated, and the baby's head had progressed - a very encouraging sign. Someone (not I!) suggested a lunchtime birth. (in your dreams, I thought) Soon Julie was pushing, and got her baby deep into her pelvis. In the next couple of hours we tried different positions and all we could do to move that little one a bit further, without effect.

Some readers may think that Julie would have been able to do more if she wasn't in hospital, or if she was in a tub of water. I don't think so. This baby's head was such a tight fit and Julie was doing all she could, which was not enough.

The doctor was prepared to attempt an assisted birth, but warned that he may still need to do a Caesarean birth. This is a professional decision point that obstetricians face from time to time, and in today's private maternity system the die is often cast in favour of the surgery.

Julie pushed, and her doctor pulled, and after three good pulls the very elongated, molded head was birthed. Julie took her little boy to her breast as I and another midwife dried him, and after a couple of minutes he cried lustily - a wonderful sound.


Recently I have been reminded of the work of Dr Catherine Hamlyn, repairing obstetric fistulae in Ethiopia. The women with fistulae have had complicated births, and face dreadful incontinence and social exclusion. These women may have laboured for days in agony before their babies died, and were eventually stillborn. The link to the ABC TV interview is:

http://mpegmedia.abc.net.au/tv/talkingheads/vodcast/talkingheads_2008_catherine_hamlin.wmv

Catherine noted in the interview that they are now educating midwives to go into the communities and attend the women in birth.

Midwives are required, by definition, to promote normal birth. This duty of care must be understood alongside our knowledge of abnormal birthing, and our other duty to access appropriate care when complications occur. Always the wellbeing of the mother and child are foremost in our minds.

We live in a privileged society. Even if Julie had been planning homebirth I believe, with the benefit of hindsight, that we would have needed to go to hospital and ask for obstetric assistance with the birth. I also believe that we could have expected the clear decision making process and personal respect that Julie received, in a public maternity hospital. Good maternity care should not be linked to wealth or insurance status.

Sunday, July 13, 2008

Safe motherhood in a safe country

I am sure I am not alone when I admit to being overwhelmed when I hear of the lack of safety for mothers and their little children in many of the poorest communities in this world. The tragedy of loss of the life of a baby is heartbreaking, while the loss of a mother cannot be comprehended.

Here I am, a midwife in Melbourne, Australia. Any time I am concerned about a woman in my care I can make a telephone call to a large, well equipped maternity hospital, and refer the woman for complex investigations, or for skilled management of whatever the problem is. Women can travel by car or, if needed, by ambulance, at any time of the day or night. Although there are no guarantees in this or any other life event I have no reason to fear. I can certainly find fault with the mainstream public hospital system, and I believe it could be improved particularly in providing services for well women, but it is pretty good when women or babies are ill, or develop complications.
Most of the women in my care give birth to healthy babies at home, without drugs to stimulate labour or to relieve pain, and with very little or no help from me.

A story in the World section of today's newspaper describes a woman in Peru, pregnant with her seventh child, who hiked for hours through the Andes mountains to a health clinic where she gave birth. The clinic's notable difference from hospital maternity care is that women are encouraged to give birth standing up. (Sunday Age, July 13 2008, p11) The program described in this article encourages mothers who had previously given birth at home to go to the health clinics in an effort to reduce Peru's awful maternal death rate of185 per 100,000 births. This compares with around 10 women per 100,000 births in Australia (http://www.aihw.gov.au/publications).

A call has recently gone out from World Health Organisation and other leading organisations to the G8 leaders to address maternal and child health. "We don't need a new cure to save the lives of 6 million women and children. What we need is political leadership and investment. The Partnership has issued a Global Call asking G8 Leaders to fund basic health services for women, newborns and children." http://www.who.int/pmnch/en/ This call is in concert with the UN Millennium Development Goals, particularly #4 and #5 http://www.un.org/millenniumgoals/
The Countdown to 2015 http://www.countdown2015mnch.org/ has been set up "to track progress made towards the achievement of the United Nations Millennium Development Goals 1, 4 and 5 and promote evidence-based information for better health investments and decisions by policy-makers regarding health needs at the country level."

The message I have heard, and that I want to send out to any readers of this blog is that "we don't need a new cure to save the lives of 6 million women and children." We need midwives who work at the primary care or basic level in all communities. For the majority of women we need to protect normal birth. That may be, as in Peru, saying it's OK to stand up to give birth. But you can't stand up to give birth if you are loaded with narcotics or if you are numbed by epidural. You can only stand up and give birth actively, or kneel, or choose to lie down, if your mind and body are strong and working in harmony with your God-given birthing power.
For the minority of women and babies who experience complications or illness we need health clinics and referral hospitals that are accessible when they are needed.



Friday, July 11, 2008

Alice’s adventures giving birth

Alice looks radiant as she soaks in the golden beams of afternoon light. Not long ago she was that little girl in a Wonderland inhabited by the strangest of creatures and a Queen and things great and small. I can now see Alice in the after-time, herself a grown woman, as she awaits the birth of her first baby. She finds herself in another Wonderland, also inhabited by strange creatures and people with incredible powers that can make her feel great or very small, and she follows the White Rabbit into the hole in another mystery journey.

There are three strong voices competing for Alice’s attention as she approaches her special time. Voices 1, 2 and 3: Prima, Secunda, and Tertia (in Latin, making them seem so much more important than they really are.)

“Imperious Prima flashes forth

Her edict “to begin it”;

In gentler tones Secunda hopes

“There will be nonsense in it!”

While Tertia interrupts the tale

Not more than once a minute.”

Prima, the first, is direct and clear – there is one way, the right way, the normal way. Like the Queen of Hearts she gives her pronouncement. But is ‘normal’ what is normally done, or is it something else? Having never been there before Alice wonders how she will know the right way when she sees it.

The second voice Secunda is less sure, and more pragmatic, expecting she will somehow find a way through the underground maze. With a label that says ‘Drink me’, she offers all the choices as if they were of equal worth. Alice wonders if it is safe. “the wise little Alice was not going to do that in a hurry. “No, I’ll look first,” she said, “and see whether it’s marked ‘poison’ or not”; for she had read several nice little stories …”

“Would you like something to help with the pain?” Secunda inquires, and Alice says “Yes, please”. “This bottle was not marked “poison” so Alice ventured to taste it….” She did not see the locked cupboard where it was stored, with “Dangerous Drugs” on the front.

Tertia, meanwhile, has the oversight of all things obstetric, and considers herself in charge. With stop watch in hand, and pointing to (Capital E) Evidence, she demands that the times and calculations be correct. Alice becomes quickly confused with Tertia’s arguments:

“If you knew Time as well as I do,” said the Hatter, “you wouldn’t talk about wasting it. It’s him.”

I don’t know what you mean,” said Alice.

“Of course you don’t!” the Hatter said, tossing his head contemptuously.

Being very keen to please, Alice listens to all the voices. !,2 and 3; 3, 2 and 1; 2,1 and 3 and in whatever order they speak.

Alice found her way out of Tertia the Mad Hatter’s Tea Party; escaped Secunda’s potions and cakes that made her alternately very large and very small; and stood up to Prima, the Queen.

“Stuff and nonsense!” said Alice loudly. “The idea of having the sentence first!”

“Hold your tongue!” said the Queen, turning purple.

“I wo’n’t!” said Alice.

“Off with her head!” the Queen shouted at the top of her voice. Nobody moved.

“Who cares for you?” said Alice (she had grown to her full size by this time). “You’re nothing but a pack of cards!”

Alice returned to the grassy bank in the golden afternoon light and decided not to go down that rabbit hole again. She stayed above ground and with her sister accompanying her, they took the path that was ahead of her. The path became steeper in places, and at times there were forks in the road that appeared to offer an easier way. Accepting her sister’s wisdom they stayed on the main path. They could see the goal, and knew that they must persevere. Alice’s mind and body became strong: she accepted the demands of each climb. Alice’s sister stayed with her, and encouraged her to keep the goal in sight. Then, as Alice began to doubt and cried out for help, her child was born. Alice rested a moment as the little one gave its first cry, then triumphantly and with her heart almost bursting with joy, took her child to her breast.

Joy Johnston, 11 July 2008.

[Note: Quotations are taken from Alice’s Adventures in Wonderland, by Lewis Carroll. First Published 1865 by Macmillan & Co Ltd.]

Tuesday, July 08, 2008

"Thanks, Noel!"

When lactating breasts become blocked in the early weeks and months after birth the mother feels very unwell, very quickly. A fever, severe flu-like aches and pains, a red painful quadrant of the breast, a very sore nipple - and often at a very inconvenient time.
This happened to 'Annie', whose baby is six weeks old, and she phoned on Sunday evening when I was out and another birth was imminent. Noel, my husband and No1 helper/supporter, took the call and said he would contact me. "'Annie' has a temperature of 39.5 and wants to know what to do."
I didn't have time to ask questions about other symptoms, and assumed that it might be mastitis.
Noel gave my instructions - "keep on feeding baby, massage the blocked part of your breast, take 2 Panadol, and a big drink, and have a bath. Then go to bed."

The next day I received an email from Annie:
"Thank you and Noel for bringing me to health again. Just talking to Noel decreased my temperature one degree! and then it started slowly getting back to normal. I feel better today, the temperature is normal, the breast hurts less. I'm little bit weak after a high temperature, but still can do all my usual things. I am happy to continue breastfeeding S... - she needs it very much. Thank you for your advice very much."

Breasts are one main point of vulnerability in an otherwise healthy woman postnatally. A blockage can occur very quickly. If the blockage is relieved quickly there is no need to treat with antibiotics, and the mother is able to recover naturally.

Monday, July 07, 2008

Expecting better days

Tonight I am feeling weary from a night out for a birth last night, but very hopeful that there is a trend towards better days for homebirth mothers and their families.

A couple of weeks ago a young woman and her man came to see me, and asked me to accept a booking for homebirth, and the baby was due any day. This woman had not had any prenatal care, and did not know her blood group, or any of the other basic screening results that are usually done. There was no local GP who she could ask to do this work, and expect anything other than rejection.

I spoke to the clinical midwife specialist at the local hospital, Sunshine. The midwife was happy to support this woman, and guided her through making a booking at the hospital. The blood tests were done without any fuss. The blood group was Rh Negative, so the midwife prepared request slips and tubes. The baby was born beautifully, at home, last night. An hour after the birth I collected blood from the large venous sinuses on the fetal side of the placenta - the homebirth 'alternative' to cutting the cord immediately after birth to collect cord blood. [I must remember to write a blog on the undisturbed third stage of labour.] The hospital pathology department processed the blood samples, and the midwife organised the Anti-d immunoglobulin and paperwork for me to collect.

Any midwife reading this may wonder what's so special about all that? That's what is supposed to happen.

What we have experienced in this case is a seamless interface between independent midwifery practice and a public hospital. I am blogging because I am so pleased that it has happened this way.

We talk about 'woman centred' care; we talk about 'collaboration'; we talk about 'partnership' between the woman and the midwife. This care was 'woman centred' in that each time a decision point was reached and a need was identified it was simply and efficiently met. The care was collaborative - the hospital midwife and I collaborated in accessing a service that was appropriate, and that neither of us could provide independently. The care respected the partnership between my client and me, which was a new and fragile relationship, not the usual trust that is established during months of traveling together through the unpredictable terrain of pregnancy.

I have no idea if anyone who knows about Sunshine hospital will read this blog. It's a sprawling public hospital situated to the West of Melbourne, and it's not the maternity fashion centre. Yet Sunshine is a leader in offering midwives a new respect for our skill, and moving ahead with caseload midwifery practice. It's not a big step for the hospital to move a little further and offer homebirth.

In May I wrote a blog 'Waiting patiently', about a twin birth at the Royal Women's Hospital. This was another instance of cooperation and collaboration that I have experienced with a senior midwife employed by a large public hospital. I don't think I am wearing rose-tinted glasses. I think there is evidence of change, and I am expecting better days.

Wednesday, July 02, 2008

THE D I Y MIDWIFE

I had heard recently that some expectant mums were buying gadgets so that they could listen to their unborn babies whenever they felt like it. That didn't bother me - I assumed they went to one of the online supplies stores, and bought a Doppler device similar to the one I use. They're quite expensive. I suppose if you could buy an ultrasound machine some people would want one of them too. Along with all the other gadgets and monitoring devices that money can buy.

I have seen new mothers with their digital scales set up proudly in the colour and theme coordinated nursery, so that they can weigh their babies whenever they want to. Much more high-tech than the simple spring scales with the cloth 'what the stork brought' holder that I use.

The other day I was in a new client's house and saw a plastic pod with straps and a earpiece. The woman told me she bought it at [big store - unnamed]. The pod sits over the front of your belly and the straps go around your back, and you put the earpiece in your ear and listen to your baby. Not much different from the continuous electronic fetal monitoring that goes on in hospital, except a fraction of the price! So now you can have continuous electronic fetal monitoring whenever you like.

Listening to your own baby is not new. Anyone who has been pregnant and knows how to use a stethoscope has probaby listened. They are likely to get pretty bored listening to a heart beat. Whether the availability of this gadget is going to help or harm the birthing process is another question.

Some mothers-in-waiting like to check what's going on by feeling inside their bodies. One client told me she would get her man to examine her in labour to work out how far dilated her cervix was, so that she could decide when to call me. OK, I said. It's not rocket science. Anyone can give permission to another adult to digitally or otherwise penetrate or feel any part of their body.

Some people are into DIY, Do It Yourself, everything. Perhaps they are breaking some unspoken taboos by stepping inside what had previously been the territory of a professional group - in this case midwives.

Midwives often question how useful it is for us to listen to the baby's heart beat, how frequently. There is no evidence that any particular schedule of listening improves outcomes for the baby, but we do it anyhow. There have been times in my midwifery experience when I have detected a baby who was distressed, and the heart beat pattern was the tell tale sign. I have seen mothers tragically lose their babies in this situation, when the action taken was too little, too late. Everyone who has worked in acute maternity care has seen that, and would do anything they could to prevent it happening again. If they could.

If I thought that listening to an unborn baby continuously was going to help that mother give birth spontaneously, I would go out and buy one of these little gadgets. But I don't - I think it would be more likely to interfere with the mother's ability to work harmoniously with her body as labour progresses, which would increase her perception of pain, and slow the progress. Babies may in fact be harmed by the interference and subsequent interventions.

I don't want to write more detail in this blog - the topic is huge. I have just touched the surface.

To anyone who is going down the DIY pathway, I would encourage you to speak to a midwife. In order to monitor your own progress, especially in labour, you would need to maintain an active calculating-thinking brain, your neocortex. This brain activity will inhibit the deeper, more instinctive brain, that is needed as you release your mind so that your body can engage in the wonderful process of birthing your baby.

Your midwife does not - can not - do it for you, but goes with you.