Monday, April 19, 2010

when a baby needs to be born

There are many processes that midwives and others in the know about matters maternity are constantly checking. Today my thoughts are directed towards the first-time mother, known as a 'primip' from the Latin words primi (first) and para (birth), as she progresses through her pregnancy to that day when her labour will establish and her baby will be born.

It is normal/ usual for the baby's head to position itself deep in the mother's pelvic cavity from about 36 weeks of the 40 week gestation - weeks before the birth. The mother feels a sense of 'lightening', as there is a fraction more space under her ribs when the baby's head has engaged. When I palpate this engagement I am reassured that all is going to plan. This does not happen by chance. The mother's body is working in the way it was designed - wonderfully. It's as though the baby has discovered the door to this big world, and is waiting for it to open.

So what about the babies who haven't found the passage leading to the door? The baby who thinks she should come feet first, to start out running? The baby whose head stays high and mobile past 38, 39, even 40 weeks? What's the hurry, anyway?

Should the midwife just reassure the mother - we know a baby can be born spontaneously and safely in a breech presentation, and we know that occasionally a head does not engage until strong labour contractions direct it into the pelvic cavity - even in a primip!

Balancing this knowledge is another body of knowledge, which includes the standard of maternity care in the hospitals with which a midwife practising privately needs to collaborate occasionally. I cannot close my mind to the need for a smooth transfer and transition to medically led care from time to time.

I am constantly reflecting on the skills that promote, protect and support physiological processes that lead to spontaneous, safe birthing in the majority of cases.

Three primips in my care come to mind. I will call them A, B, and C. They are aged between 27 and 35, and are strong, healthy women, with caring husbands/partners. They are also normal height and weight - or normal BMI according to statistical charts. In other words, they are beautiful, healthy young women who would be expected to be able to give birth without complication.

A asked me to work with her for birth in a midwife-led Birth Centre attached to a large Melbourne hospital, Mercy Hospital for Women. When I palpated A's baby at about 38 weeks, I found the head engaged, with the fetal back on A's left side.

B asked me to work with her for planned homebirth, and has a booking at the Women's. At 36 weeks her baby was presenting head down, but the head was mobile. At 39 weeks the baby had turned to a breech presentation. I wrote a letter of referral to the hospital, and asked for review and consideration for external cephalic version (ECV). The ultrasonographer showed B that the baby was indeed presenting breech, and reassured her that there was plenty of amniotic fluid, which is considered necessary for ECV. B was told that the hospital preferred to do ECV at 37 weeks; that there was only about 20% chance that it would be successful at almost 40 weeks. B was determined, and she was invited to attend the next day for an ECV. She did not enjoy the sensation of tachycardia (fast pulse) that she experienced when Salbutamol was administered (to relax her uterine muscle). But the turn was successful. I visited her a couple of days later, and confirmed that the little head had stayed where we wanted it to be.

C is also planning homebirth, and her hospital backup is Monash Medical Centre at Clayton. The collaboration agreement with Monash is that the mother is seen in the hospital antenatal clinic at about 36 weeks, and if the midwife detects any issues of potential concern, an obstetrician also reviews the woman's care. As it happened, C's baby's head was high and very mobile. C was not concerned, as her mother had experienced the same situation and gone on to birthing spontaneously, but the doctor expressed his concern.

My midwifery ethos includes the statement "In normal birth there should be a valid reason to interfere with the natural process." (WHO Care in Normal Birth, 1996)

The question is, "Is there a valid reason in any of these cases to interfere with the natural process?"

Is there a valid reason to interfere with A's natural process? I think most midwives would say No, and I agree.

Is there a valid reason to interfere with B's natural process: baby presenting breech? If so, what should the interference be?

Is there a valid reason to interfere with C's natural process: baby's head high and mobile at Term? If so, what should the interference be?

[Any comments are welcome, of course!]

The birthing dance
One midwifery 'intervention' that I am currently asking my clients to consider, that I think may help that wee child find the way to the door in preparation for exiting her or his mother's womb, is a dance that brings on good 'practice' contractions of the womb. From about 37 weeks this dance will include upright movement, while intentionally increasing the release of natural oxytocin through loving body contact, including gentle nipple and clitoral stimulation with the purpose of bringing on a contraction.


Sif said...

I would love to hear other responses to this as my first was still high and very mobile at 42 weeks, at which time I was induced by drip and had him after 8.5 hours of strong labour, including 2.5 hours of pushing, failed ventouse assistance and finally a low forceps assisted birth. The registrar had voiced concerns before inserting the drip as to whether it was wise to induce such a high baby, but proceeded (at what felt like my insistance!). I was happy enough with this birth experience, but wonder if waiting would have led to a natural progression or an emergency c/section? (I guess that question can't be answered!)

Joy Johnston said...

It's a great question Sif. There are so many complex decisions in that brief statement that it's impossible to know what would have happened if ...?
We would be naive to think that doing nothing is always the best option, but once the intervention 'Plan B' (in this case induction of labour) has been commenced, there is no going back to the pre-induction position. The baby must be born.
And btw, well done!

Melissa Maimann said...

"In normal birth there should be a valid reason to interfere with the natural process." - I think the key word is "normal birth" - and how do we define "normal birth"? Breech, high head at term etc - these are natural, but not necessarily normal (in that they don't happen for most women).

But "Is there a valid reason in any of these cases to interfere with the natural process?" depends on the wishes of the woman. Personally, I'd recommend ECV for the woman with the breech baby, but nothing for the woman with the high head. What can be done that would be safer than awaiting labour and seeing if the head comes down? Induction and caesarean carry risks too ... I'd await spontaneous labour.

Joy Johnston said...

Thankyou for this comment, Melissa. I agree that the key is defining 'normal'.
The WHO 1996 Safe Motherhood document 'Care in Normal Birth: a practical guide' from which I quoted "In normal birth there should be a valid reason to interfere with the natural process" defines normal birth as:
"spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth mother and infant are in good condition. However, as the labour and delivery of many high-risk pregnant women have a normal course, a number of the recommendations in this paper also apply to the care of these women." (p4).