Saturday, May 30, 2009

breastfeeding difficulties in the first fortnight

Today I want to reflect on the journeys of two first time mothers and their babies. Although these 'cases' are based on two actual babies and their mothers, the situations are not uncommon, and I hope this account will assist readers in understanding better the complexity and the wonder of the natural processes in nourishing and nurturing newly born babies.

I will call the babies Baby Boy (BB) who weighed about 3.4 kilos, and Baby Girl (BG) who weighed about 4 kilos at birth. Both were born in public hospitals in Melbourne, receiving good midwifery care. Both mothers pushed their babies out under their own steam, so to speak - spontaneous vaginal births. The mother of BG had received an injection of a narcotic a few hours prior to the birth, and the mother of BB received several doses of an oral narcotic after the birth.

Both babies remained skin-to-skin with their mothers for their first hour or so, but neither breast fed in that period. BG's mother was taken to the operating theatre for removal of her placenta, and BB's mother was taken to the operating theatre for repair of a perineal tear. Both babies slept while separated from their mothers.

By 24 hours -
Baby BB had had a couple of brief breast feeds but was still quite sleepy most of the time.
Baby BG had been to the breast several times, without attaching well. She was sucking her lower lip when awake, and seemed content with that.

By 48 hours, second day -
Both mothers and babies had gone home from hospital. Neither of the babies was feeding effectively.

I was in contact with both mothers. I encouraged each to work on learning to express milk by hand, to 'reward' any effort made by her baby with expressed milk, and to give baby as much as she was able to express. This amounted to not much more than a few mililitres. The mother was encouraged to persevere with massaging and expressing her breasts every few hours until her baby's efforts at suckling became strong and effective.

Third day -
Baby BG was checked by hospital midwife. Although she had not yet breastfed effectively, she was receiving about 5 ml of expressed colostrum milk whenever she was awake. Both mother and baby were well. Mother was encouraged to continue, and to give BG access to her breast when ever she was awake.

Baby BB had not woken much, and his mother had kept to the plan of expressing her colostrum every 3-4 hours, and giving him the milk using a syringe or tea spoon. However, that evening the result of BB's serum bilirubin test indicated moderate jaundice, which was at the lower end of the range for which babies of his age are nursed in phototherapy. The hospital nurse called BB's mother, and asked her to bring him to the special care nursery, to be admitted. BB's mother asked if she would be able to stay to continue breastfeeding, and was told 'no'. There was no bed available. The hospital would use any expressed breast milk she provided, as well as artificial formula milk to feed BB while he was in their care.

At the same time, I was visiting BB and his mother. We worked at stimulating little BB, using olive oil to massage him, and co-bathing in the bath tub. We were delighted when he cooperated, and took both breasts better than he had done previously. The mother was not willing to be separated from BB without good reason, and we felt we had turned a corner. With my support the parents made the decision to stay at home, and have BB's jaundice checked again at the hospital the following day.

I had noted that BB was tongue tied, and arranged for the hospital breastfeeding support unit to review that too. BB did a lot of serious breastfeeding overnight, and when his serum bilirubin (jaundice) level was checked the next day he was out of the range requiring admission.

Fourth day -
Baby BG had found the breast, to the delight of her parents. However her mother's nipples were grazed and ridges were forming across the nipple when she nursed. When I visited them I guided mother with a few tips on improving the positioning and attachment - fine tuning the success that they had achieved on their own.

Baby BB also seemed to be progressing well. He and his mother spent the day with the breast feeding support midwife at the hospital. The frenulum (tongue tie) was snipped; the jaundice was settling; the number of wet and pooey nappies increased; and he was settling and sleeping between feeds.

Baby BB's mother was confident to cease expressing milk by about Day 5. However, over the next few days it became clear that his breastfeeding was not as effective as BB needed, as he did not gain any weight from the fourth to the tenth day. He was going to the breast frequently, but often unsettled after feeds. The Maternal and Child health nurse assessed him as dehydrated, considered that the tongue tie was continuing to interfere with BB's sucking, and insisted that he be given baby formula milk supplements. Attempts to express milk by hand and using an electric breast pump resulted in small amounts - about 10 ml.

That evening I visited baby BB and his mother, and once again we devised a plan. This included learning a more effective bi-manual compression of the breast, and regular expressing to stimulate milk production. All expressed milk was given to BB after he had worked at the breast. The record of feeds showed a steady increase in the volume of breastmilk that was given as a supplement to BB.

By about 12 days of age BB's efforts at the breast continue to be supplemented with expressed milk. The tongue tie is to be reviewed by another doctor who is expert in such matters. Mother continues to work consistently on increasing her milk supply. Her beautiful baby boy is responding well: the more milk she gives him, the more he wants.


As I reflect on these real life situations that real mothers and their babies face I am very pleased to record the stories. The issues in getting breastfeeding right are as multi-faceted as any other aspect of life. Each mother-baby pair have their own set of challenges; some expected, and some out of the blue. Each mother-baby pair who manage to overcome their challenges and make the best choices that are available at the time are learning about life and becoming more strongly bonded together. The resulting emotional attachment supports them in dealing with the life challenges that lie ahead.


Wednesday, May 27, 2009

Generation Y birthing


Young and beautiful mummies and daddies, bringing beautiful babies into the world.
Texting their messages in labour, telling a multitude of 'friends' how they feel on facebook, twittering, with baby's website being set up while the labour progresses.

Oh yes, it's not just Gen Y who do it. But, they (Gen Y that is) do it so 'naturally'.

Friday, May 22, 2009

Am I Responsible?

'Am I Responsible?' was the theme of the professional study day presented by the Australian Nursing Federation in Carlton today.

Case studies were presented as examples of the complexities that nurses and midwives face in situations where their professional actions are investigated. Coroner Audrey Jamieson explained the Coroner's role in seeking answers when a death is investigated. Barrister Ron Gipp described legal respresentation given for a nurse who was required to attend the Coroner's Court. Nurses Board CEO, Nigel Fidgeon, presented the Board's role in investigations into professional conduct.

I am interested in these matters, and value the opportunity to consider the issues from the perspective of health care professionals generally. On occasions when I accompany a woman to hospital I am able to observe the practice culture of the unit, as well as the behaviours of individual staff members.

I have recently had reason to be very concerned about what appears to be a culture of carelessness concerning drug administration in a hospital maternity unit. The young midwife had reached the end of her shift and said to the midwife who was replacing her, "I have drawn up the Syntocinon (oxytocic). It's in the fridge (and pointed to the small fridge in the room)." The second midwife seemed happy with that, and did not make any comment.

There was no emergency situation. Baby had been born 30 minutes previously, and mother and baby were well. There was no bleeding. The mother had requested physiological Third Stage.


Hospitals may not have a 'guideline' or 'protocol' on physiological Third Stage. Most hospitals promote active management of the Third Stage. Many midwives in hospitals have had little experience with any part of physiological birth.

I am not criticising the fact that the drug had been drawn up. I am critical of the casual handover from one midwife to the next. There have been far to many cases when the wrong drug has been administered. In birthing suites there have been tragic cases such as mistaken administration of a dose of Syntometrine (Syntocinon and Ergometrine, a common oxytocic mixture used in Third Stage) to a woman in labour, in stead of an analgesic such as Pethidine. The oxytocic had been drawn up 'early' and kept on hand. When Pethidine was also drawn up but the standard checking and adminsitration by two midwives had not been followed, the mistake had taken place.


I had a quiet word with the midwife, and explained my concerns. There was no adverse event at the time, but I hope that by drawing attention to the matter I will be preventing tragic mistakes at some other time. Midwives who administer any medicine or substance to women in our care have a duty of care to take full professional precautions in every instance. Once we step outside 'Plan A' - spontaneous, unmedicated birth - and use drugs and other medical interventions, the risks to both mother and baby are upped. A midwife's competence in management of these medical substances and procedures is, for that woman, just as important as her competence in promoting normal birth.

Tuesday, May 19, 2009

silence

I wonder why virtually noone is making any comment about the midwifery changes announced in last Tuesday's budget - indemnity, Medicare and limited prescribing?

The silence covers the newspapers, TV and radio programs that I have accessed, as well as midwifery and maternity-related email lists. I have been with labouring women in two Melbourne hospitals this week - Mercy and Box Hill - and most of the midwives I have spoken to were not aware that anything has happened. Others seem scared that the reforms will be subjected to excessive gatekeeping, effectively setting hurdles that are too high for ordinary midwives to aspire to, and creating a two-tiered midwifery workforce.

I expected at least a few comments on blogs, but on the whole I'm hearing silence.

Midwife Lisa Barrett has put her opinion on her blog. I have left a comment there, and most of what appears below is copied to this site.

Although I am disappointed and frustrated that homebirth has been sectioned off as a 'no-go' zone, for reasons that can not be taken seriously by anyone who understands evidence, I am really pleased that the government has taken such a big step to dismantle the medical monopoly of maternity care. And in my mind the announcements of reform were more wonderful in the wake of the report of the maternity services review which said a lot of nothing and skirted around the real issues.

The budget press releases from the College of Midwives, as well as from Maternity Coalition and Homebirth Australia were, imho, worded in a politically correct way. I am confident that ACM is the best representative we have for midwives, and I have been assured that the defining of such things as advanced practice and collaboration will be acceptable even to ordinary midwives like me who don't have even a bachelor degree, let alone higher academic quals.

I am also wondering what will be done about homebirth in situations or locations where the publicly funded models are not available. I expect there will be some midwives prepared to go 'underground', while others will seek to comply with the new rules. Noone can force a woman to go to hospital.

I have been actively working for maternity reform since 1993 when I started my private practice. We have a long way to go, but from where I sit the 2009 federal budget is the biggest step forward that I have seen so far in my lifetime. I hope the bill passes in the Senate, and I hope those who represent midwives' and women's interests in bringing in the reforms will be wise and courageous.

I have many questions, and I, like others, will have to exercise patience. That's not easy. I have enjoyed the independence that I have had in midwifery in the past 15 or so years. I accept that there will be changes in how I can practise, if at all, after the middle of next year. I hope that by the end of this year I will still be taking bookings for births beyond 1 July.

Friday, May 15, 2009

BIG reforms for midwifery in Australia

I was on the job, 'with woman', when the announcement was made by the federal Treasurer Wayne Swan in his 2009 Budget speech to Parliament. Please go to the MiPP blog for press releases and more information.

This is a HUGE step forward in reforming maternity care for all women in Australia.

The following statement is from the Department of Health website:

12 May 2009

The 2009-10 Budget includes a $120.5 million package of measures to improve choice and access to maternity services for pregnant women and new mothers in Australia.

As a result of this package, families will have greater choice in the type of care they wish to receive when having a baby. The package also recognises the important role played by qualified midwives in the birthing experience of many Australian women.

Responding to the recently completed national Maternity Services Review, the package includes:

* Medicare Benefits Schedule and Pharmaceutical Benefits Scheme (PBS) benefits for services provided by eligible midwives, to provide greater access to maternity care provided by midwives working in collaboration with doctors – expanding choice for women.
* A Government-supported professional indemnity insurance scheme for eligible midwives.
* More services for rural and remote communities, where the state of maternity services is poor, through an expansion of the successful Medical Specialist Outreach Assistance Program (MSOAP).
* Extra scholarships for GPs and midwives to expand the maternity workforce, particularly in rural and remote Australia.
* A new 24 hour, seven days a week telephone helpline and information service to provide women, their partners and families with greater access to maternity information and support before and after birth.

These arrangements will be subject to agreement with states and territories on a National Maternity Services Plan – who will be asked to make complementary commitments and investments, particularly around the provision of birthing centres and rural maternity units.

The Government’s commitment to a National Maternity Services Plan recognises the importance attached to maternity services by the over 270,000 Australian women who give birth each year, and their families.



At this early stage it is impossible to predict the detail of the new scheme, which is to be introduced from 1 November 2010. (If anyone has questions that you would like discussed, please leave a message in the comments section.) Here are a few points:

* The Australian College of Midwives is 'at the table' with the Health Minister and her department, representing midwives. All midwives would be well advised to get your ongoing professional education systems up to date, using the ACM Mid-PLUS program.

* Maternity Coalition is seeking to represent consumer interests in advocating for women's choice in birthing their babies.

* Homebirth Australia is well positioned to lobby for women's rights to give birth in the setting of their choice, including their own home.

* Local lobby groups such as Homebirth in the Hills, natural parenting groups, and Save Birth Choices have an important role in educating mothers and the general public, and in encouraging activism at a local level.


I know that many blog readers have contacted their local MPs and spoken to them in relation to the Maternity Services Review. Thankyou for your work. I would like to encourage you to keep yourselves well informed, write letters to the editors of newspapers, call radio talk back programs ... keep maternity care as a topic worth thinking about.

Thursday, May 14, 2009

Little one

Tell me what you see, little one,
When the world you know has so suddenly changed.
People coming and going.
And bright lights.
Do you also see tears in my eyes?

Tell me what you hear, little one?
In a world that changes without care of you.
Different people,
Different places.
Do you also hear the voice of love?

Is that your mother's milk on your tongue, little one?
Nurture and warmth.
Blood on your head:
Distance, separation, and fear?
Reality so different from what you instinctively seek.

Loving you so imperfectly,
there are times when the best I have is to cry with you.
Yet in that poor loving you learn living.

May God be with you, to guide and bless you, little one, as you start life's journey.


Joy Johnston, May 2009

Tuesday, May 12, 2009

Being born is important

When you are able to take a moment for reflection, please go to Marina's blog to read this beautiful poem.

Marina is a midwife in Chiapas, Mexico.

The universal nature of deep truth about life, such as the truth so beautifully expressed in this poem, reminds me that we who know birth are the keepers and guardians of a precious treasure.

Sunday, May 10, 2009

Happy Mother's Day

... to all mothers, mothers to be, and any others reading this!


I would like to dedicate this blog to my mother, Ella White, who died 10 May 1985. The picture shows me with three of my (5) sisters: (L-R) Marion Andrews, Jane Ganter, and Annette Enchelmaier.


Today we have enjoyed a traditional family Sunday dinner after church. With a lovely white table cloth, a candle in the middle of the table, using the good crockery and cutlery, the meal was complete with roast chicken and veges, and followed by a lovely dessert, prepared my our daughter Bec.

Having family members around the table is something so basic to a mother that we can easily overlook its importance. Since my four young ones have left the nest, and set up their own homes, I treasure these special meal times. Sometimes we have to extend the table and find extra chairs; in good weather we set up tables al fresco on the deck.


A client phoned thismorning to tell me how disappointed she was; that she had thought her labour was getting underway last night. Contractions were coming regularly every six minutes for a couple of hours. Eventually she went to bed. It had all fizzled. AGAIN!

I reassured her. Her body is preparing for labour; not quite ready yet. I expect we will see this baby soon.

The final days of waiting for labour can be very difficult. It doesn't surprise me that induction of labour is frequently carried out for 'other' than valid reasons. Its not just the mother who can feel disappointed or frustrated in waiting for that indefinable tipping point. The midwife or doctor can find all sorts of reasons why, from a practical, time management point of view, it is reasonable to induce a labour.

However, the finely balanced processes that are orchestrated in normal labour and birth can be terribly disturbed with induction of labour. One intervention leads to another, and quickly the cascade of interventions become the driving force. Once the process has been started there is no going back.

I remember those nights in late pregnancy when I felt secretly hopeful that something was going to happen. I remember the doubts that came up in my mind: will I labour? will I know I am in labour? (silly questions, I know, but that didn't stop them from coming)

I think this mental turmoil is part of our instinctive nesting. We become unsettled, and perhaps difficult to live with. We become self absorbed.
That's good.
The labour will establish, and the child will be born.

Thursday, May 07, 2009

Baby born in a church

'Instant baby delivered in Church'
Here is fascinating footage from youtube, recording the birth of a baby girl in an African church.

The sound and visual quality is poor, but the story is clear. Two young mothers went to the church and were placed in the 'emergency section' to receive special prayer. As the minister prayed for them, one stood up and quickly gave birth to her baby on the concrete floor. She later testifies that she had been told she had a problem with jaundice, and that her baby was obstructed. She felt the baby move into position and she gave birth.

The woman sitting next to her had asked for prayer because her pregnancy was overdue. She testified that, having witnessed the birth in church, she went home and gave birth to a healthy baby boy (whose boy parts were displayed for the record) without any problems.


Most of my readers know of my Christian faith. Although I do not share the charismatic type of religious practice that is obvious in this video clip, I am able with all my heart to praise God for these births to young women in Lagos, Nigeria.

Many midwifery writers and thinkers have drawn attention to the ecstatic, out of body experience that can be part of normal birthing. We have come to understand that in advanced labour a woman's conscious, thinking mind - the neocortex - needs to be quiet, to free her to work with her body's intuitive, instinctive abilities which are based in the deeper part of her brain. In drawing together what I know as a midwife and as a mother who has given birth without medical stimulants or painkillers, with the power I know we have in prayer to the one true God who created us, I am not surprised when I witness this amazing ecstatic birthing.

Tuesday, May 05, 2009

HAPPY INTERNATIONAL MIDWIVES' DAY



[Print: thanks to artist and mother Emma Flaim]


My greetings to all midwives, and to all who value the work of midwives.



International Day of the Midwife – 5 May 2009
The World Needs Midwives Now More Than Ever!