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.