Monday, June 27, 2011

"When there are two midwives ...

... the baby's head is crooked."
[This is a saying from Persia, quoted by Michel Odent, in Childbirth in the Age of Plastics (2011), p63]
Here's the context:
Learning from home births
One of the main obstacles for easy births - particularly easy home births - is the common overuse of language. I have countless anecdotes of useless questions, comments, and advices from well-intentioned birth attendants.
Another obstacle is a deep-rooted tendancy to introduce without any caution several people around the labouring woman. This tendency is as old as the socialisation of childbirth. ... Traditionally the midwife is an autonomous, very independent person. There are proverbs, in places as diverse as Persia or South America, claiming that the presence of two midwives makes the birth difficult. In Persia, they used to say: "When there are two midwives, the baby's head is crooked".

And of course a crooked head means a painful, difficult birth. The optimal position for the fetal head is flexed at the beginning of labour in the occiputo-transverse to occiputo-anterior plane, well applied (evenly) to the internal os of the cervix, with continuing flexion of the fetal head as labour progresses. A head that is presenting posterior, or asynclitic (tilted to one side) is not well applied to the cervix, and dilation of the cervix can be difficult, and labour incoordinate.

A reader may wonder why traditional wisdom would warn that "Where there are two midwives a baby's head will be crooked." Is that just an old wives' tale, to be discarded by the modern, intelligent mind? Is there any possibility that the presentation of a baby in the womb is in any way influenced by the presence of a second midwife?

Assuming that there is something of universal worth in this saying, how can it apply to women and midwives in Melbourne, Australia, today?

Just for the record, my midwifery practice includes births at which I am the only midwife, and births at which a second midwife has been invited, and births at which I am in attendance as the second midwife.

The key: being woman-centred
Midwives understand that the woman who is giving birth is the central, focal point of everything that is happening in chilbirth. Within that woman, in her womb, is the baby. Woman-centred care is also baby-centred, because the woman and baby are one.

Midwives also understand that the woman and her midwife form a special partnership, based on reciprocity and trust. A one-woman-one-midwife partnership.

In the real world, despite the best laid plans, a midwife can never guarantee that she will be in attendance for a particular woman. The only people who can be sure they will be at the birth are that woman and her baby. In the real world, a good midwife is able to meet a labouring woman and work with her in such a way that the woman is able to optimise her birthing potential, feel safe regardless of the setting (home/hospital), and experience great satisfaction with the care. No crooked heads here.

In any physiological birthing relationship, there is room for only one birthing woman, one midwife, and one baby (at a time, in the case of multiples). If others are present with midwifery (or 'wannabe') skills; and 'others' may include midwives, lay birth attendants, doctors, alternative health practitioners, relatives, or even the labouring woman herself; these people must either step back from their professional roles, or work in harmony with *the* midwife. There is no place for different philosophies of care - they will make the baby's head go crooked.

Many midwife colleagues of mine, practising in the real world in which we live, tell me they would never intentionally attend a birth without a second midwife. There are many good reasons for the second midwife, including:
  • the possibility that mother and baby are both needing active midwifery interventions at the time of birth
  • a known midwife present if the other one is unable to attend
  • someone who will question or challenge practices if needed
  • 'tag team' if everyone is tired
  • a witness if something goes wrong
The first of these is perhaps the most compelling, and any midwife will need to address this possibility with the woman who is considering her choice of care providers for home birth.  What will be done if the baby is not breathing at birth, and the woman also requires attention?

In hospital births, and in some home births, the midwives have separate roles allocated - one for the woman, and the second for the baby.  If the baby needs resuscitation attempts to be made, the person who leads that is the second midwife.  The baby is often moved away from the mother to a resuscitation table in these situations.

When a midwife is working solo in the home, the woman knows that there is no second midwife.  If the baby needs resuscitation, this is done with the baby lying on his back on a towel on the floor, in front of the mother who kneels.  The umbilical cord is not cut.  The midwife also kneels, and has good access to the baby.  They work together, and the midwife is able to talk to the mother.  A baby who is born in a distressed state, not able to initiate normal breathing, may have a very slow, or absent pulse.  It's vital in this case that as the cardio-pulmonary resusciation proceeds, and the baby's pulse increases, the baby receives the full placental transfusion via the umbilical cord.  This will bring a proportionately large volume of blood, with the fetal haemoglobin that stores oxygen, perfusing the baby's central organs and brain, protecting the baby from hypoxia.  This, in my opinion, is a better model for initial resuscitation.

Women who plan to give birth under natural, physiological processes have access to natural, physiolocal support mechanisms.  The adrenal hormones that give the 'fight or flight' response are particularly valuable.  Not only does the mother experience a surge of adrenal hormones just prior to the birth; baby does also.  The mother gets a surge of energy, and her baby is ready to do what needs to be done.  Neither mother nor baby in the home birth situation have narcotics that would suppress their ability to respond, or to breathe.  Neither mother nor baby have synthetic oxytocics that would impede the mother's ability to expel the placenta safely without excess blood loss.

The safety and appropriateness of home birth is clearly demonstrable for women (and babies) who are well prior to the onset of spontaneous labour, and who progress without complications.


Anonymous said...

Interesting post. We in Hungary (EU) have a well-known version of this wisdom.
It can be translated as: "Among many midwives the baby get lost."
I know a lot about home and hospital births and I do agree with you!
The most important thing during the birth is not to try to start testing each other's strength, pushing the boundaries, etc. As you wrote, there must be one: "the" midwife. In this case the mother can be completely relaxed.
In Australia, on one of your Universities there is a scientist (Forgas, he has a Hungarian name :) ). He and his friends are researching the human race's communication abilities. They think, that our unbelievable ability of working together is our most important distinctive from animals. It means that one of our most important ability is to predict what our fellows are going to do! The more you can foresee the others intentions, the cleverer you are - as in chess. :)
During childbirth it is essential to "switch off" this base ability, because the mother must be completely relaxed.
For the mother it means not to be introduced to strangers, and to be completely safe with the people who are present.
They must have a clear domestic range amongst themselves, and a clear knowledge about who is responsible for what.
Thank you for your blog!
Best wishes

Joy Johnston said...

Thankyou, SBC, for this insightful comment. It's the same thought as "too many cooks spoil the broth", isn't it.
I think understanding the distinctive communication power that humans have, and the impact of this phenomenon in the birthing room is an area for new learning. Your analogy with a chess game is very good.
The woman who is labouring under optimal physiological conditions will become very focused. This often happens in the wee hours of the morning, when everyone who intended to 'support' her becomes weary and they curl up quietly in chairs or on couches. The labouring woman herself moves into the instinctive pattern of activity, because her thinking mind is also tired, and no-one in the room is doing or saying anything.
[And I'm recovering from a couple of all-night labours in the past week or so!]