Wednesday, April 08, 2009

A fine line: undisturbed, unassisted, and unattended births

Midwives who are experienced in unmedicated spontaneous birth will often take a quiet, unobtrusive role when attending a labouring woman. By the time labour is established, the room is quiet and often lit only by a candle or other soft light source, and no interruptions are allowed. Any voices are hushed, and only when the woman is resting between contractions – not during contractions. If the woman has planned to use water immersion in labour, the tub has been set up and is ready for use. The midwife is constantly observing, expertly using her senses of hearing and sight and intuition (heart). The midwife experiences a parallel journey, as she intuitively harmonises her thoughts and actions with the woman’s. Any observations that require touch, such as listening to the baby’s heart tones, are done in a way to minimise disturbance to the woman. The midwife is not ‘assisting’ the birth; she is in attendance – with woman.

The term ‘undisturbed birth’ has been used by author Sarah Buckley (2005, p110), with reference to her own experience of giving birth to her fourth child, without a midwife in attendance. Other terms used for unattended birth, when it is intentional, are free birth, pure birth, self birth, and unassisted birth.

The fine line that the midwife sometimes walks is being able to be with woman, and yet enabling the woman to proceed without physical or emotional disturbance. Many women would consider that they were able to enter a special ecstatic place in which they remained undisturbed through their birth experience, with a trusted midwife present.

However, if a midwife identifies a complication or condition in the mother or baby, for which she recommends referral to specialist services, the act of disturbance may be in the interests of the wellbeing of her clients, both mother and baby. This is within the professional duty of care, and is the midwife’s skill. The midwife’s guiding principle, that “In normal birth there should be a valid reason to interfere with the natural process” (WHO 1996, p4) informs both the non-interference, and the alternative, in midwifery care.

Dr Buckley argues cogently that the complex natural hormonal mix, and particularly the role of oxytocin, that is the physiological norm in childbirth is also what we experience in loving, passionate sexual intercourse. This connection has previously been clearly described by Michel Odent in many of his writings and lectures. “[oxytocin] is the ‘hormone of love’. Whichever facet of love we consider, oxytocin is involved.” (Odent 2002, p72)

The connection that Dr Buckley makes, in describing and idealising an unattended birth as undisturbed, may encourage other mothers to give birth without professional attention. In Dr Buckley’s case, both she and her husband who was also present, had medical skill and knowledge that could have been used. This is a very different scenario to unattended birth where no person present has a foundational knowledge of progress in labour, normal birth, or normal transition of the newborn from the womb to the outside world.

Dr Buckley observes that “When a midwife’s intuitive skills and ways of knowing are increasingly sacrificed to technology, more and more invasive procedures will be needed to get information that, in other times, her heart and hands would have illuminated.” (p111) The fine line the midwife walks is to use technology appropriately, while valuing and enhancing her skills in promoting normal birth.

The midwife’s goal can and should be ‘undisturbed’ or ‘unassisted’ birth in any situation where there is no valid reason to interfere with the natural process. A midwife cannot ethically support planned ‘unattended’ birth, which is the antithesis of maternity ‘care’, as that situation removes the experienced critical eye and ear and heart of a midwife, and puts the responsibility on the labouring woman, and anyone else who is with her at the time.


Stitch Sista said...

I don't disagree.

Sadly those midwives are not available (or affordable) for all birthing women around Australia.

How blessed are we in Victoria to have the choice of many wonderful practitioners. What is a woman to do however when that is not the case?

Rachael said...

What do you suggest Joy when a woman a term who is having continuity of care with a MIPP who presents with breech etc? A very tricky suitation for both the midwife and the woman, who both value their relationship and neither wish to go to the hospital. Keeping in mind not all midwives have the skill to attend breech births (just an example). And certainly way out of the college guidelines, such is VBAC etc... What a frightening choice for a woman if her midwife with draws her care, the choices are often slim...freebirth or instuitational care..??

Joy Johnston said...

Hi Rachael
As with cephalic presentations, each baby in breech is unique, and the decisions need to be made considering the specific issues of that situation. Please don't imagine that the midwife who is competent in breech birth will be able to somehow guarantee good outcomes for all breech births. Some will definitely need surgery if they are to survive birth.

In my experience with breech presentation at term (not in labour), one line of action is to consider attempting to turn the baby. In Melbourne I know this is available at the Women's and Birralee (Box Hill).

I want to say clearly here that a midwife can have no fear about going to hospital, if the mother agrees that that would be the best place. A midwife working in the community can provide primary care, and the next step, if needed, is specialist services that can only be accessed in hospital. If it's the best place, then that's that.

The only reason we have good outcome statistics for homebirth is that midwives know our own limits and follow simple referral processes. In a (published) review we (MIPP in Victoria) found that about 20% of women planning homebirth transfer to hospital.