Saturday, August 30, 2008

CONTESTED TERRAIN

I don’t want to over-dramatise the issue, but it’s an unavoidable fact: midwives who offer homebirth are in competition with doctors for the work. The contested terrain is the place of birth, and it’s not an equal contest. It’s one of those mad experiences from Alice’s wonderland, when she is either enormous and unable to fit, or so small that she’s likely to be stepped on and squashed.

Homebirth midwives who work independently don’t have ‘much’ to offer – except HOMEBIRTH, that is. And when professionally attended homebirth is not available any other way than through a private agreement between a mother and a midwife, independent homebirth midwives continue to work despite the social and professional restrictions we face each day. If it weren’t for the fact that homebirth makes so much sense to a small number of birthing women that they are prepared to pay for it, we would soon be out of work. We can’t buy insurance; we can’t get visiting access to the same hospitals that are very happy to employ us as ‘their’ midwives; we have to ask women to go to the local GP to request even the most basic blood tests and investigations, and to prescribe oxytocics that are considered essential in preventing or treating post partum haemorrhage.

I am referring only to professionally attended births. There is a steady trend, possibly growing, in which women give birth unattended. Some are surprised by the speed and intensity of their labours, while others consciously delay going to hospital, until the baby is ‘coming: ready or not’. These out of hospital, unattended births have always happened, and will continue. A few Australian women today make a decision to give birth at home without professional attention; possibly with an unregulated lay birth attendant.

Back to my initial statement, that midwives are in competition with doctors for the work of attending birth. There’s a complication that arises in looking at the contested terrain of birth. It’s not only homebirth. We have to include small birth centres and hospitals that are separate from 24-hour anaesthetic or obstetric care. These hospitals and birth centres, like homebirth, can ‘only’ support spontaneous birth. I say ‘only’, and ask, “What’s ‘only’ about that? Is that not enough? It’s huge.” Yet, how available is it? Many rural health services are sending these women to larger regional centres to give birth, because there is no obstetric or anaesthetic cover at a particular time. Do they have midwives? Of course they do. Why can’t those midwives take professional responsibility for the births? Because they never have been expected to work on their own authority, and in many cases they don’t want that responsibility. The hospital system, and those who work in it, expect doctors to be on hand to induce labours, and order narcotics and epidurals. The hospital system, in most cases, has women booked under the name of a doctor. The midwives work shifts, and the mother-to-be is not likely to know or trust the midwife who is working when she comes to the hospital in labour. The midwife is effectively, doctor’s assistant.


You would think that the leaders of a rational, sane society, like ours, committed to providing essential health services for all, would say “Right, there are going to be about 300,000 (and growing) babies born in Australia each year. At least half of these women (actually many more, but I’m not wanting to inflate the calculation) are likely to give birth to healthy babies without any complications. That means a midwife could provide the maternity care, and it means they can give birth wherever they choose.” If those 150,000 women were in the care of a midwife or group of midwives who were competent in attending birth on their own responsibility, which incidentally is what ALL midwives are declared able to do when they graduate, they could all give birth in primary level care, isolated from specialist obstetric or anaesthetic care. That is, almost all could give birth in the small country hospitals, freestanding birth centres, or in their own homes. The few who experience unexpected complication in labour would be transferred to a hospital that provides the service they need, in the same way that women and midwives planning homebirth make informed decisions as labour progresses.

The current annual rate for homebirth is 0.2%, approximately 600. I don’t have the number of babies born in primary maternity units without obstetricians and anaesthetists on call, but it’s also likely to be very small. The hospital based programs that have been offered in recent years have struggled to maintain management support. 600 out of 150,000.

Evidence of the contested terrain of homebirth is clear in the statement against home births by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZOG). The statement “The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) does NOT endorse home birth.” (http://www.ranzcog.edu.au/publications/collegestatements.shtml). This statement has been in effect since 1987, and was most recently updated June 2008. I suspect very few obstetricians have attended or seriously investigated homebirth.

The RANZCOG statement lists a set of recommendations for those women who are planning homebirth, including the statement that “Women choosing home birth should be cared for by both an experienced medical practitioner and a registered midwife, each of whom has agreed to participate”. This paternalistic recommendation is a curious one, as very few medical practitioners in Australia or New Zealand today are attending homebirths. It says: “Don’t do it, but if you do, here’s what you must do!” There does not appear to be any literature quoted in the RANZCOG statement to support this recommendation.

Midwives and obstetricians collaborate in providing expert maternity care for women and their babies. Obstetricians rely on midwives to admit women to hospital maternity units, assess progress, report to, and summon them at certain times. Obstetricians cannot provide maternity care without midwives’ support and collaboration. A RANZCOG statement such as this one imposes a wedge between the midwifery and obstetric professions. Some individual obstetricians support homebirth, having worked in countries where midwifery practice in offering homebirth is accepted and respected.

The midwife is the only professional who offers birthing services without requiring the support of other professional groups, and the only time that sort of birthing service can be offered is when the woman herself does the work. The healthy woman comes into spontaneous labour at term, progresses without artificial stimulation or analgesia, and works with her own body’s power to give birth to her unmedicated, healthy baby. The midwife works in harmony with the woman, and does not interrupt or intervene or disturb the wonderful process of birthing. There is no need in these births for hospital specialties: nursing, anaesthetics, obstetrics, paediatrics, or any other medical specialty. There is also no need for alternative therapies. The woman is not sick; she is giving birth. All she needs is a midwife.

This is the root of the contested terrain of birth.

I think that’s enough for today. Another time I will explore medical dominance of the terrain of birth, and how midwives have apparently accepted a subordinate position.

Wednesday, August 27, 2008

Lessons from homebirth

A midwife who starts attending homebirths with a more experienced independent midwife has an opportunity to learn all sorts of lessons, some predictable, and some unexpected. Yesterday as my colleague Karen was leaving the home, after attending a homebirth as 'second midwife', she commented on the difference between what we had just experienced, and what often happens in hospitals.

As I drove home yesterday afternoon, weary from a 3am call out, but thankful for and energised by the birth of another beautiful child, I was reflecting on the lessons we learn when we begin caseload and homebirth practice. Here are a few. Readers may want too add more in the comments section, or if you want to write a piece to add to this blog, please email it to me.
  • Waiting for the spontaneous onset of labour. Does the midwife's commitment to the natural process mean that we wait passively, or is it an active waiting? How much checking and surveillance of the wellbeing of the baby is appropriate?
  • Midwifery 'interventions' and advice for post Term pregnancies. When is it appropriate to recommend self-induction methods, such as nipple stimulation, or castor oil? Do you recommend acupuncture, or naturopathy, or other alternative medicine options?
  • Technology. I sometimes call a second midwife in the middle of the night, and the phone goes to the message bank. If that happens I then call her on her mobile. I have had the experience of leaving messages on both home phone and mobile, and hoping for the best! Being on call means getting the telephones and other technology to work for you.
  • Petrol. It's good to keep the petrol in the car above a certain point. It's frustrating and can be time consuming to have to put petrol in the tank in the wee hours.
  • Directions. It's no fun getting lost, and trying to read the map in the half-light of a torch or the interior light of a car. In my practice I visit the home at about 36 weeks for the birth talk, or birth preparation meeting. This visit gives me the opportunity to think about the best roads, and check out parking and all those practical matters, when there is no pressure on my mind.
  • Waiting. The father made the comment yesterday "A lot of what you do is waiting". That's right. It's very different waiting in a home than waiting in a hospital. In the hospital birthing suite there is a routine of shifts and rounds and client meals and staff meal breaks and reporting and meetings. In the home it's all about one woman. Many times the midwives move out of the room where the woman is labouring, but they don't move out of her space. Her sounds are the only sounds they hear.
  • Finding the tea bags. This may sound too obvious to mention, but when you open cupboard doors, or rummage through a kitchen draw to find the tea bags, or a mug, or something else, there is an element of that special relationship between a woman and her midwives.
  • Responding to pain. It's never easy to see someone else in pain. We would be heartless if we switched our minds off, and could not feel empathy. Yet the homebirth midwife does not carry pain relieving agents with her, and women who plan homebirth know it. Principles of active birthing, including movement, encouragement, massage, pressure, heat pacs, vocalisation, shower, and water immersion, are useful. Music, candles, a wood fire in the hearth, and aromatherapy may help create a personal intimate space. But it's the woman herself who decides how she can work with her own labour pain. It's the woman herself who decides when and if the pain is excessive or intolerable.
  • When to assess internally for progress. I consider an internal exam an intervention, and there needs to be a valid reason for me to intervene/interrupt/disturb the progress of normal labour in this way. I will ask the woman for her permission to examine vaginally if I need the information that such an examination can provide. For example, a primigravid woman in advanced labour, who has some spontaneous urges to push over a period of a couple of hours, without bringing the baby on view, may have a lip of cervix. The vaginal examination will confirm this, and with permission, I can attempt to reduce the lip and push it back during a contraction. In my examination I feel for the baby's cranial sutures in order to visualise the position of the baby's head. An anterior lip, with the saggital suture off to the side, tells me that the baby's head is tilted, and is asynclitic. My advice to the mother is to walk through contractions, taking exaggerated steps that will move her pelvis, and adjust the fetal head in relation to the pelvis. Up and down stairs a couple of times is very helpful. Then as the baby descends, the mother can try kneeling on one knee, with the other foot on the floor, to tilt her pelvis, then change to kneeling on the other knee. These are fairly simple midwifery interventions, yet the woman's trust in her midwife is challenged, and they will need to work together in order to promote normal birth.
  • Physiological birthing of the placenta. I think I am stating the obvious here, but physiological birthing of the placenta is probably only reasonable when the rest of the labour has also been physiological. Any stimulation or resuscitation of the baby is done with the umbilical cord intact. A midwife who makes a decision to administer an oxytocic to the mother is undertaking a professional intervention, and there is time to obtain the mother's consent for this act.
  • Baby to the breast. It's wonderful to watch a healthy unmedicated newborn baby take the breast. Some do it without a second thought: some need to work hard at it. But they all love it. In homebirth the midwife needs to learn to trust the ability of mother and baby to manage this primal and essential act. Our advice is such that mother is encouraged and enabled to take responsibility, and to be confident in her own mothering.
  • Leaving. A baby has been born; mother and baby are well; the paperwork has been done; and it's time for the midwife to leave - go home - get on with other work, or go to bed. This is another lesson.
  • Completion. The time soon comes when no more postnatal visits are needed. I encourage the mother to call me if she has any questions, or is receiving conflicting advice and wants to know what I think. The invoice is paid, and I enter the information into my Quick Books program, in preparation for the next BAS and Tax statements. I ask the mother to come back for 'show and tell' at six weeks. After that visit I bundle her file into the filing cabinet, sorted alphabetically according to surname. Ready for next baby?

This list is not complete. I need to get dinner ready now, so will hit the publish button. I look forward to messages I may receive. What have you learned from home birthing?
Joy

Saturday, August 23, 2008

Decision Points

Midwifery in Australia today can be one of the most satisfying occupations there is. When a midwife has a ‘caseload’, a group of women to whom she is committed through the pregnancy, birth, and postnatal period, the midwife and each woman are able to learn how to work together before the big event.

Usually the ‘big event’ is labour and birth. Occasionally it comes as a decision point before labour; sometimes there are several ‘big events’ or critical decision points.

Midwifery that is woman centred is neither woman-led nor midwife-led. Neither the woman nor the midwife dictate the terms; both recognise their own, and the other’s unique role and capability in the relationship. It is a dance in which there are separate, but interweaving and sensitive roles. And the dance is not just the woman and the midwife – there is the baby of course, whose presence is profoundly significant, as well as anyone else who the mother-to-be has invited into her presence at the time.

No matter how much research or preparation you, the mother, do, an uncomplicated labour and birth is likely to demand more physical and emotional energy than you thought you had; to take you to a place that you didn’t know existed. The time comes in most labours when you need to surrender any conscious control, and allow your body to do its work. This is the normal way babies are born, and it is usually the safest way for both mother and child. The midwife who is ‘with woman’ is with you in this often challenging and frequently demanding journey, and also has to harmonise with and in a different way surrender to the natural process. I usually come away from a birth emotionally and physically spent.

The trust a midwife has in the woman is that she, the woman, will accept the midwife’s professional partnership. The trust a woman has in her midwife is that she, the midwife, will not disturb or interfere with that deeply demanding process of birthing a child, unless ...

Unless?

Unless a decision point is reached where the mother-to-be is convinced that she is not able or safe to continue in ‘Plan A’ – doing it herself, and accepts an intervention in which she asks another person to take over – ‘Plan B’. It’s that initial decision point of handing over the controls that is the key to interference in normal birth.

This process of making informed decisions is the core of midwifery knowledge and skill. Midwives in all societies can work in harmony with a woman’s natural processes in pregnancy, birth, and nurture of the young – Plan A. Different cultures and different generations have had vastly different options for those who, for whatever reason, move out of Plan A.

The woman is free in our world to ask for, and will often receive, any intervention, including induction, dangerous drugs, regional anaesthesia, or caesarean surgery. In mainstream maternity care there does not seem to be any commitment to working in harmony with the natural process in birth. There does not seem to be any calling to account. Why does Hospital X have such a high rate of caesarean births? What are the midwives doing in Hospital X? Do they not know how to protect and promote normal birth?

A reader might think that the only people committed to working in harmony with the natural process in birth are those on the fringe – independent midwives, and midwives in birth centres or special midwifery caseload programs, who probably account for less than 5% of births. This is not so. By definition, every midwife has a set of requirements, including ‘partnership’ with women, and ‘promotion of normal birth’ (the International Confederation of Midwives’ Definition of the Midwife (2005) is copied below)

Every midwife’s duty of care can be summarised with statements from the Definition.

The midwife:

  • Is a responsible and accountable professional, who
  • works in partnership with women
  • gives the necessary support, care and advice during pregnancy, labour and the postpartum period
  • conducts births on the midwife’s own responsibility
  • provides care for the newborn and the infant
  • (implements) preventative measures
  • promotes normal birth
  • detects complications in mother and child
  • accesses medical care or other appropriate assistance
  • carries out emergency measures
  • engages in health counselling and education

I commenced this piece with the statement “Midwifery in Australia today can be one of the most satisfying occupations there is.” A midwife has a scope of practice and a duty of care that is truly awesome. I hope that some midwives who have read this, and reflect on their own midwifery practice will find ways to make the transition to more woman-centred care in which the midwife and woman work in a partnership based on trust, respect, and reciprocity.

Definition of the Midwife

A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery.

The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.

The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.

A midwife may practise in any setting including the home, community, hospitals, clinics or health units.

Adopted by the International Confederation of Midwives Council meeting, 19th July, 2005, Brisbane, Australia. Supersedes the ICM “Definition of the Midwife” 1972 and its amendments of 1990.

Thursday, August 14, 2008

Tennis on Thursday mornings

Each Thursday morning in school terms, weather permitting, a little group of women get together to play tennis in a back yard in Mont Albert. This group started more than 30 years ago. I have been in the group for about 20 years. The tennis court is situated in a lovely garden, and the owners have generously welcomed our little group.
Readers of this blog will probably wonder what that has to do with midwifery. The answer is nothing. But it has a lot to do with community, and it's one of the parts of my life that I enjoy and value. Being a member of a tennis group means that I have made a commitment to being with that group at a particular time, whenever I can. It's about being responsible to others, to the best of my ability. These women are not particularly interested in my midwifery practice - although they listen when I tell my stories, and they are accepting of my sometimes unpredictable hours. It's good that I can go to the tennis court and leave midwifery at arm's length (as far away as the mobile phone, that is) for a few hours each week.

A midwife with a personal caseload has a problem with commitment to other events - we are, at times, unreliable. We put the mothers and babies first. My children will tell you about their birthdays when I left the family to celebrate, while I headed out to a birth.
Last December, when our daughter Bec was getting married, I did the right thing and arranged for another midwife to cover my practice. On the afternoon before the wedding day I was enjoying the company of my sisters and other relatives who had come to Melbourne. We had 'open house' for tea that night, and I had prepared salads to go with meat done on the bar-b-q. The phone rang, and my client Paula said she thought her labour was getting started.
I phoned my backup midwife, Jan. Jan's reply when she answered the phone was, "You just caught me, I'm on my way to a birth." OK, plan B isn't going to work. There's no plan C, so I had better go back to plan A.
Of course my sisters and their families were able to manage without me, so I said a quick goodbye, and headed out. I had to make my way through peak afternoon traffic, and by the time I got to Paula's home she was holding a very beautiful newborn girl to her breast. The placenta came without difficulty, and I did the paperwork. By the time I got home the family were all enjoying each other's company, and someone had put aside a meal for me.

Readers of this blog probably realise that stories are my way of telling my midwifery knowledge to others. The point I want to make today is that each midwife needs friends and community linkages that are outside her commitment to mothers, babies, and birthing. For me, it's our Church, the tennis group, and of course, our wonderful family. It's not so much that they need me, as I need them.

Saturday, August 09, 2008

What would the village midwife do?

My village is not an ordinary village. It has long busy roads, with lights at intersections and 40K zones outside schools. It has freeways that become very busy and clogged at certain times of the day. There are people and cars and trucks, buses and trains everywhere. It's the 'burbs of Melbourne. (I avoid the city if I can!)
So why do I call it a village?

The title 'village midwife' was given to me years ago when I was employed part time by RMIT University to provide supervision and mentoring for midwifery students at Birralee Maternity Unit (Box Hill Hospital). A hospital midwife discussing care of a woman with one of the students asked,
"What would the village midwife do?"
When the students and I sat down to reflect on the day's work in the afternoon, that question became the focus of our discussion. I was delighted to see the 'village' concept applied to a midwife's decision making. In today's globalised world, with amazing technology and communication, the challenge to give birth in harmony with nature's wonderful processes is the same as it has always been. Just as many of us value food grown in our own gardens, local grocers, schools, or clothes made in our own country, the village concept is readily applied to birth and nurture of our babies. "What would the village midwife do?" becomes a guiding question for me and others who are working to promote normal birth, whether they are out there in the 'village', or working in big modern hospitals.

My village is small, not in physical area, but in the number of mothers I can attend at any one time. This month I have three births booked. Those three women and their families become my neighbours for a brief period, and I join their lives in a special way as the midwife primary carer during their birthing experience.

Yesterday the mother called me in the morning and told me she was having 'niggles'. We spoke again after lunch, and she said nothing much was happening, but she knew her baby was coming. We anticipated the possibility of a rapid birth, as her first baby had been born minutes after I arrive at their home. I assessed the time it would take for me to get from my home to hers, up to 45 minutes, and we agreed that I should go to her home and wait. I put my gear in the car, with a MIDIRS journal to read, some wool and knitting needles, and an apple to eat on the way home (an excellent pick-up for a weary midwife), and headed out.

After a couple of hours the mother decided to have a rest in bed. Whether it was from tiredness or boredom, I don't know. The father went to his computer to check emails, and I nestled into a big red bean bag with the MIDIRS journal. The house was quiet. The bedroom door was ajar.

At about 4.30 the mother got up. Her waters had broken.
After listening to the baby's heart beat I noticed the wet undies on the bathroom floor.
"There's meconium in your baby's amniotic fluid" I said, and explained that this is a reason to consider transfer to hospital for monitoring.
However I was reluctant to cause unnecessary disturbance in this labour, which I expected to be strong and very demanding. It would take us about 30 minutes to get to the hospital, and then another 15 to settle in to a hospital birth room, if there were no delays. I decided to see what happened over the next 15 to 30 minutes - how the baby responded to contractions, and how the labour progressed. If there was fetal distress, or if the labour did not establish quickly, we should go to hospital. I called Katrina to come for the birth, and got my gear ready.

Soon the sounds coming from the bedroom were unmistakably those of strong labour. Contractions became long, with little resting period before the next contraction began. I listened again to the baby, and the heart sounds were strong and reassuring. What would the village midwife do? I was quickly confident that we needed to stay at home - that it would in fact be more harmful to try to move to hospital in this labour. The stress and anxiety of the trip, that would be added to a very demanding time of labour, with the potential for a birth in the car or in the hospital lobby, were more of a threat to this mother and baby than the meconium.

The bedroom was unlit, with a little light coming from the hallway. At about 5.30, only an hour from the time the waters broke, a beautiful baby boy lay on the floor under his mother. I untangled the cord, and wiped the fluids from his face. He was pink, but lay quietly, and I felt his chest - a good heart beat. With a bit more tactile and verbal encouragement he joined us with a lusty cry.

Katrina had just arrived, and heard this from outside the bedroom window. After a few minutes she knocked on the door and I went to bring her in.

As often happens with a very powerful labour, the strong contractions continued, and placenta came soon after. I was once again impressed with the ordinary-ness of an extra-ordinary event, as mother and baby rested in bed, with the proud daddy supporting and watching closely. I got on with the paperwork, and Katrina made a cup of tea and washed some dishes.

The village midwife today has the best of both worlds. When birth is spontaneous and normal, the home is the best place to give birth. When illness or complication is present, the village midwife links in with the team of experts in managing difficult births, and works to get the best possible birth for that individual woman and baby. There are, of course, grey areas. If in this instance I had felt anxious about proceeding with birth at home, because our guidelines say meconium stained liquor is an indication for referral, the birth of this particular baby would not have proceeded in the uncomplicated and undisturbed way that it did at home. This is the duty of care of the midwife - not just the village midwife: every midwife.

Tuesday, August 05, 2008

God bless you

I wrote this brief note a couple of years ago:

It was an hour or so after the birth, as we all relaxed in the quiet peaceful space that settles on a room as a mother rests and her baby takes his fill from her breast. I moved close to her and put my hand on her arm, and whispered, “God bless you, my dear.” I don’t know if she heard my hushed prayer. Then my hand rested on the small head covered with black hair, still glistening with moisture from the birth, and I said “God bless you, little one.”

I know no greater prayer. I have no deeper wish. If God blesses, what more could that one want?

“God bless you, my dear, mother of this child.
You have laboured and you have given birth in pain that went deeper than you could have imagined.
Your dark red lifeblood that sustained this little one
has spilled with the waters and meconium and your bowel’s emptying onto the white sheets.
The fears and pain left you cowering, having nowhere to hide, as the small child prepared to leave your womb.
What did you see as he struggled to take breath and become a separate living soul?
As you rest and begin to recover,
your breasts are now giving, and continuing to give.
Your baby is taking, and growing.”

Joy Johnston 2006

“Take care that you do not despise one of these little ones; for, I tell you, in heaven their angels continually see the face of my Father in heaven.” Matthew 18:10

Monday, August 04, 2008

Nipples that hurt

A mother who welcomes her newborn child to her breast is filled with a surge of love, a surge which is repeated each time they engage in this intimate act. The mother feeds her baby, and the baby feeds from her mother: a dance that takes two people working harmoniously.

Our nipples are beautiful, important, and highly sensitive parts, essential to mother-baby bonding and nurture. And because they are so important, they are also points of vulnerability in the establishment of strong mother-baby attachments. And when nipples become grazed, blistered, and cracked the relationship between that woman and her baby is truly tested. There is no easy option - a newborn baby needs milk from her mother every time she indicates interest or hunger. The act of giving and taking the milk is part of the life struggle that forges a strong bond between them.

Breastfeeding unites mother and baby in a health and wellness cycle. As in birthing, there should always be a 'valid reason to interfere with the natural process', and any interference carries a potential cost. Sometimes there is a valid reason. Bleeding, severe pain, horrible, deep pain. It's the antithesis of that serene Madonna and Child image that has been passed down over many generations.

Breastfeeding experts can list off many reasons why a mother's nipples are hurting. Often the mother gets advice from a variety of caring and concerned people, including family, friends, neighbours, and health professionals.

Damaged nipples usually present in the early postnatal days. There is no single solution to this problem. No matter what caused the initial damage, the process of recovery will require careful and consistent management by the mother, who needs strategies for healing as well as for ensuring that her baby is fed. The mother needs consistent advice from a midwife who she trusts, and who is competent in advising and making interventions that protect nature's goodness in providing the breastmilk for the baby. It's essential to keep the interests of both mother and baby in mind - baby needs frequent feeds that are sufficient to send her off to sleep. Mother needs the milk removed from her breasts, establishing the supply-demand cycle, and protecting the breasts from engorgement.

I have seen many mothers and babies struggle through the early days with painful nipples. My heart goes out to each one - each mother who feels the pain and the distress, and each baby who does all she or he can to get that precious milk from mummy. And I have seen them come through, days or weeks later, proud and confident, with healthy nipples, healthy lactating breasts, and healthy happy babies.

Sunday, August 03, 2008

How many midwives do you need?

I was surprised when Sue, who is planning homebirth, told me that Karen, her midwifery student, was not 'allowed' to be present when she gives birth. Karen has come to several prenatal checks, and is doing the 'Follow Through Journey' with Sue.
"Why?" I asked.
"Karen's mentor from the University told her that she was not allowed to be there because you [referring to me] don't require a second midwife at the birth." was the reply. "She (Karen) said she thought it was a requirement of the Nurses Board, so that students aren't expected to stand in as the secondary midwife."

My surprise turned to annoyance. I felt I needed to defend myself. The logical implication was that I was in some way offering care that was of a lesser standard than those midwives who attend homebirths in pairs. In fact, there is NO requirement of the regulatory board, and there is definitely NO expectation that students will stand in as the 'secondary' midwife, whatever that may mean. I felt annoyed that an assumption had been made about my professional decisions in attending this birth. Anyone who has talked with me about my practice, or looked at the names on the calendar on the wall of my office, would know that whenever possible in homebirth I arrange to have a second midwife as an 'apprentice' - a midwife who is working on making the transition from hospital shiftwork to caseload practice. This is done at no cost to the woman, and is a wonderful opportunity for midwives to extend their knowledge and skill. But it's not done because I need the help, or because the birth becomes in any way safer in having another pair of hands. If I wanted that I would be working in a big hospital with emergency buzzers and operating theatres.

Karen's mentor, appointed by the University, is an independent midwife who does routinely book a second midwife for each planned home birth. That puts her practice and mine in competition for business - women may choose me because the fee they would pay two midwives is considerably greater than the fee I charge. The decision to require two midwives is a risk management strategy, in the same way that some people in Melbourne make a booking with a medical practitioner as well as one or two midwives. That doctor is able to extend the possible interventions that are available: antibiotics or Pethidine can be given, or a Ventouse extraction can be attempted - options that a midwife cannot offer. Women planning homebirth in Melbourne's leafy Eastern suburbs have the choice of a solo midwife, or two midwives, or a midwifery group practice, or a midwife and a doctor.

I want to make it clear that I do not intend to argue that a midwife working 'solo' is better than a midwife working with a partner. I do believe each woman planning homebirth needs to make the decision for herself as to what she needs. If a woman feels she will need a lot of 'support', she will probably not ask me to be her midwife.

One of the main arguments presented as the reason for requiring two midwives is that at the time of birth, both mother and baby may require professional attention. Without going into detail in this brief discussion, I would like to outline some major differences in homebirth as I know it, when compared with standard medical models of maternity care.
  • mother and baby are usually well in the labour - no analgesic medications or stimulants of labour are used in homebirth
  • the baby's umbilical cord is not cut at birth, and usually not cut until after the placenta has been birthed
  • because the baby's umbilical cord has not been cut, any resuscitation of the baby must be done with the assistance of the mother. This would usually be done with the baby lying on a towel on the floor, and the mother kneeling near, and facing the baby. The midwife works to resuscitate the baby in this position
  • if the mother is experiencing excessive blood loss after the birth, an injection of synthetic oxytocic may be used by the midwife in quickly managing the bleeding.
It is not possible to guarantee a particular outcome. However, when working 'solo', a midwife is relying on working with the mother in promoting normal birth, rather than relying on the number or the skills of people in attendance.

If I was setting up a maternity care program with government funding so that all prospective mothers could have access to services that are likely to promote the best health outcomes, that program would include the choice of homebirth. Each woman would be in the care of a midwife who is her primary or first midwife, and a second midwife, who backs up the leading midwife, and assists at the birth. These two midwives provide primary care throughout the pregnancy and birthing journey.

One aspect of working in a little team, with a second midwife, and a midwifery student, that I thoroughly enjoy, is the sharing of knowledge, and the reflecting together on events. Midwives learn from each woman, and from other midwives, each time we enter the intimate birthing space of a woman. Midwives learn to access our own intuitive knowledge, sensing the progress and the struggles that women must engage with as they in turn learn to work in harmony with their bodies.