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.


Tabs said...

"Strategies for getting labour started" - that's an interesting part of pregnancy and birth to interfere with. When, or why, would you consider this necessary? Would you only do it to prevent a woman from going over 42 weeks and having the medical fraternity pressuring her to have an induction? Would you do it to satisfy a woman's impatience? I know you've spoken before of the importance of the baby choosing it's own time to enter the world.

I usually find it amusing when people try to bring on labour - they eat strange things, they do strange exercise, they do sex things, and it all seems like voodoo. Some people do these things for weeks and yet the baby takes his or her own time, others do them once or twice and the baby comes, some do none at all - and the baby still comes ;-) Although I'm sure there's a psychological component (and therefore physiological component - our emotions do stimulate endocrine secretions after all) to when labour starts, it also seems to me that babies generally come when they're ready. Of course this does nothing to explain still births and it may be that many "post term" births occur due to the woman not being in quite the right psychological, and therefore physiological, state.

It would be interesting to know re: nipple stimulation if women who breastfeed whilst pregnant go into labour earlier than women who don't.

Joy Johnston said...

This is a great comment Tabs, and I agree with much of what you have written.

I'll go to the last question first, re nipple stimulation and women who are breastfeeding an older child. This has been considered by physiologists, and we know that women who are feeding an older child are not at higher risk of premature labour/birth - any more than those who have frequent surges in oxytocin from other stimuli do. The role of the oxytocin receptors in the uterus is crucial in spontaneous onset of normal physiological labour.

I encourage nipple stimulation as an intervention when it appears that there may be pressure to undergo more invasive interventions if baby does not come soon. By stimulating a contraction every few minutes the woman is giving her body pulses of hormone, which often helps the process to move on.

We do not have a guarantee of health no matter how 'healthy' the woman appears. Most pregnancies that continue past 41 weeks will be just fine, but in the group, often where you don't expect it, is the one that will require specialist medical intervention for safe birth. The midwife's job is to identify that woman, and advise her as time passes.