Wednesday, June 30, 2010

Preterm labour

This document, Neuro-endocrinology Briefing 35: Preterm labour is available online at the British Society for Neuroendocrinology.

The briefing was sent to me by my friend and mentor, Wolfgang Jochle, who lives in New Jersey, USA. Wolfgang's life work has focused on understanding the physiology of animal reproduction. A conversation with Wolfgang always extends my thinking, even though my education in the biological sciences is very limited.

My interest in the topic of preterm labour was heightened just this morning, as a colleague and I discussed a recent experience of working with a woman in spontaneous labour at 35 weeks' gestation. The timely arrival (by air-snail-mail) of this document in today's mail was just one of life's interesting coincidences.

Here's a brief excerpt ...
"But why is birth difficult to delay long enough to reach term? The answer may lie in the recruitment of the oxytocin neurones which, once primed by the initial signals, then respond to any small trigger (including uterine factors/contraction and or psychological situations such as stress that activate parallel brain pathways). This results in an ever-increasing positive feedback that promotes oxytocin secretion in larger pulses which inevitably precipitate further uterine contraction and birth. So, far from uterine mechanisms sustaining labour, brain activity is crucial, and drugs targeting oxytocin neurone priming mechanisms may be an appropriate way forward for therapeutic intervention in preterm labour." (Author: Dr Alison J Douglas, Edinburgh, UK)

A midwife working with healthy, socially well supported, well nourished women planning homebirth does not see much preterm labour. In fact we worry more about pregnancies that extend beyond 42 weeks. (I wonder if the science of neuroendocrinology has a physiological explanation for prolonged pregnancy?)

The time, and nature, of the onset of labour hold many mysteries. The image of "ever-increasing positive feedback that promotes oxytocin secretion in larger pulses" fits well with my understanding of the vastly varied experiences women have as they approach that tipping point, which means their baby will soon be born.

A midwife is conscious of this intricate balance of physical and psychological factors in birthing.

Sunday, June 27, 2010

A year in review

A year ago I wrote in this blog: "We (the community of independent midwives and homebirth parents) are all wondering what will happen to homebirth after July next year."

I encouraged my small group of readers to write submissions to inquiries, to attend rallies, to contact the radio stations .... 

I argued that the legislation which mandated something that was not possible to access (professional indemnity insurance) in order for a midwife to practise "denies a woman’s natural law right to give birth under natural physiological conditions, in the place of her choosing."

Now, with only a few days remaining before the new legislation comes into force, I am content that the time-honoured profession of the midwife attending a woman in her own home will continue. 

I am not suggesting that the government has managed maternity reform well.  They have not.  Concessions have been made in response to the unprecedented outcry by the small but resillient group of homebirth parents and the midwives who attend them, as well as other fair-minded supporters. Midwives attending homebirth have been given a temporary (2-year) exemption from the insurance requirement. This awkward exemption may in fact protect lives, by averting the alternative, of driving homebirth underground or into the hands of unregulated birth attendants.

I am not suggesting that the government will manage maternity reform better, now that Australia has our first female PM.  Julia Gillard was Opposition Health spokesperson a few years ago, and made all sorts of positive gestures to birth activists and midwives in the lead up to the election.  Julia Gillard appeared to be listening to reason; appeared to be impressed by evidence supporting the safety and importance of enabling women to make their own decisions about childbirth, in a partnership with a known and trusted midwife who provides primary care throughout the pregnancy-birth-newborn care periods.  Once Ms Gillard became deputy to the PM, the spirit of working together with women for better birthing was quickly forgotten.

Many midwives are not satisfied with the way things are. The cost of indemnity insurance that will meet the requirements of the national registration law is between about $2000 and $7,500. (see the MiPP blog for detail) A midwife whose private practice brings in less than $10,000 annually is required to have insurance, the same as the midwife who is earning $80,000 annually. The cost of insurance will either be passed on to the client, or some midwives will cease private practice because they can't afford to continue.

There have been some positives as well as many negatives in this past year of preparation for our brave new world.

On the positive side of the ledger,
  • I have seen some independent midwives take action to lobby government agencies.  One particular midwife comes to mind; I won't name her.  She has made an exceptional contribution from which all private midwives stand to benefit.  She has brought together professional and political interests at great personal cost.  Many readers will know to whom I refer, and I thank her.
  • I have seen midwives who had no experience in homebirth declare their intention to move into private caseload practice, and learn homebirthing
  • I have seen people in the community - childbearing women as well as men and older folks - willing to reflect and discuss the importance of what happens when a baby is being born.

I will not list off negatives, but I have observed members of the midwifery profession acting as people under threat, and being ready to verbally attack others whose opinions differ from their own. I am looking forward to a period of healing within the midwifery profession.

Note: Part 2 of this review is at the Private Midwifery Services blog

Tuesday, June 15, 2010

Midwifery knowledge

A colleague who practises privately in a small and closely knit rural community told me the story of a recent birth; of what she, the midwife, experienced in the days and weeks prior to the birth; of the response of the local doctor who supported the homebirth plan; of the response of the various professionals in hospital, and of the parents themselves who are delighted with their beautiful child.

The details of this birth are not mine to tell.

As I listened to the story unfold, I commented "You know, there are two sets of birthing knowledge."  There's the general set that is understood by doctors and midwives who have had the most basic education in maternity care.  Then there's the specific midwifery knowledge.  The knowledge that midwives who practise in primary care, in partnership with each woman, learn from the women and from other midwives.

Midwifery knoweldge includes
  • strategies for reducing anxiety in labour.  The midwife enters the woman's space and speaks only when the mother is able to listen, minimising interruption, quietly and confidently.
  • strategies for being present without taking over.  The midwife settles quietly to wait in a place that's out of the way after satisfying herself that the labouring mother and baby are well, rather than positioning herself in a dominant or intrusive way near the woman.  This midwife may have knitting or crochet in her hand - repetitive work the does not demand a lot of concentration, but keeps the midwife observant and present.
  • strategies for moving the baby in the womb.  Some midwives rely on physical manipulation of the pelvic bones.  Others have espoused the Rebozo technique taught by Mexican midwives.  My preference is to encourage exaggerated pelvic movement using the birth ball.  Each of these techniques, and probably others I haven't thought of at the moment, enable centering of the woman's body and the baby's head, the presenting part, to adjust its position in relation to the mother's cervix.  This brings progress.
  • strategies for getting labour started.  The old fashioned castor oil and orange juice has been used to kick start many labours, but it comes at a cost of an irritated bowel for many women.  I would not recommend this method as a first line of action.  Some midwives encourage women to have acupuncture, or a spicy meal, a long walk, or repeated love-making, or all of the above.  My usual strategy is to encourage the woman to stimulate regular contractions for a period of time by touching the areola around her nipples.  This brings a uterine contraction in response to the natural oxytocin release from the nipple stimulation.  The woman is encourage to walk while having a contraction, then to sit on an exercise ball and do pelvic circles and tilts, then stimulate another contraction, walk, ...  In some instances the woman has progressed quickly into strong labour after stimulating only one contraction artificially.  It's as though her body was ready at the starting line, and the first contraction was the tipping point that got her going.
  • strategies for enabling a woman to accept the work of labour.  The woman who asks a midwife to attend her, especially in home birth, knows that noone can give birth for her.  The woman knows that the midwife doesn't have dangerous drugs or procedures that will take away the sensations of birthing.  The woman's own hormonal mix of oxytocin, the love hormone, with endorphins, the natural opiates are used to advantage in the home where the woman feels safe and uninterrupted, unwatched.
  • strategies for monitoring the progress of labour without performing frequent internal vaginal examinations.  An internal examination is a significant interruption to the hormonal flow of spontaneous physiological birthing, and is performed only when the information it gives is important.
The key to midwifery knowledge is the relationship between the midwife and the labouring/birthing woman.  The known and trusted midwife with whom the woman has spent substantial amounts of time prior to the onset of labour enables decision making that is appropriate for the individual mother/baby dyad.    The midwife's skill in working in harmony with the natural physiological processes in birthing is essential in promoting health.