Wednesday, December 28, 2011

optimal space for birthing?

There is a special interest branch within midwifery and maternity care that overlaps with design and architecture disciplines, exploring the creation of optimal spaces for birthing. I have been reminded of this field of interest, when reading a recent post by my colleague and friend Carolyn Hastie, who writes the thinkbirth blog. Carolyn refers to, and provides a link to a presentation on optimal birth spaces by Maralyn Foureur, Professor of Midwifery at the University of Technology of Sydney (UTS). I wrote in the comments to thinkbirth:
I have seen some wonderfully designed spaces in which women can give birth. I have also seen women give birth beautifully (and, I would say, optimally) in settings that would seem to contravene every goal of the optimal birthing space ideology.

The woman's own nesting, which I believe is hormonally driven more than the result of intelligent planning and preparation, seems to be the key. Nesting can include the choice of setting, as well as the choice of people who make up that woman's birthing team. Nesting also enables the woman to change her plan if her situation requires it, without losing the ability to proceed normally.
I don't want to be critical of the optimal birth space ideology.


The reality in my world is that each birth space is often very different from what the woman had planned or wanted, yet women are able to give birth in that wonderfully spontaneous way, without any regrets.

It would be naive to imagine that a woman's home is automatically the optimal birthing space for her.

I need to do a postnatal visit now, but hope to get back to this post later, and write some more.

[Melbourne readers may know that a private hospital in Hawthorn had recently set up a beautifully designed birthing facility, which has closed its doors after just a few months' operation, because the plan was not working, and there were too few women making bookings.]

NESTING and optimal birthing conditions
Nesting is one of those normal physiological functions that everyone knows about, but rarely pays much attention to.   While researchers have for a couple of decades looked seriously at the impact of the love hormone oxytocin, and the 'fight-or-flight' adrenal hormones, on the birth and mothering behaviours of laboratory animals, nesting doesn't seem to raise research interest or dollars.

A woman anticipating the birth of her child will usually have a 'to do' list, including stocking and preparation of food and other consumables, washing and setting out baby clothes, and packing a bag for herself and her baby in preparation for a stay in hospital, or 'birth kit' items in readiness for giving birth at home.  This process of getting ready would be recognised broadly as 'nesting'.  I have known some who feel the need to clean windows, and sweep, vacuum, and dust almost obsessively in the days leading up to the labour.  This is all intentional nesting, driven mainly by the woman's intellectual grasp of the enormity of the job that lies ahead.

With the establishment of spontaneous labour, physiological nesting becomes more pronounced.  Women who thought they would like to have the other children present for the birth of their sibling will often withdraw into a secluded space.  Women who have a plan to call a trusted midwife will often call her, just to check that she is able to come when called.  Nesting can continue until the peak of first stage, often called 'transition', when the woman must give up conscious control and surrender to the work of bringing her child out of her body. 

Women who plan to go to hospital to give birth face a nesting conflict.  It goes something like this:
"If I go to hospital too early my labour might fizzle.  If I stay at home I won't want to move when the labour becomes strong."  It's their natural nesting drive that makes them want to find the place where they will give birth - not the street address, but the actual room, with its contents, and the actual people with whom she will need to communicate.

Women who are booked at a modern hospital Birth Centre, where there are well-designed birthing rooms, often experience a conflict about the availability of a room.  They know that if the rooms are all in use when they arrive, they will be admitted to a standard hospital suite.  They have heard stories about how often this might happen.  Other matters of 'nesting' concern might focus on the times of shift changes in the hospital. 

I have, on occasion, been called to a 'planned' home birth, only to find that the woman and her home show no sign of nesting.  This dysfunctional nesting is, I think, a sign that the woman's sensitivity to natural instinctive urges has been in some way shut down.  The woman's labour can continue without nesting, and the baby can be born, "ready or not!"

Returning to the initial question of this blog: is there, and what is, an optimal space for birthing?
I would refine the question further, and add the word 'physiological' - the space for medically managed care in labour and childbirth must be very different from the space that enables and supports and protects physiological processes.  Here are a few ideals for that space:
  • a place that the woman has chosen to be in
  • a place that the woman is happy to continue in, as labour progresses
  • a place where the woman can receive care, support, and guidance from a trusted midwife, and other chosen people
  • a place where the woman is able to cover windows, dim lights, and make other physical adjustments when she wishes
  • a place that allows the woman to feel private and unobserved
  • a place where the midwife, as the responsible professional at the time, is confident that the wellbeing of mother and baby are being protected.

As with all other basic life events, "the best laid plans of mice and men ..."  There can be no guarantees.  The only people who we can be sure will be at a birth are the mother and her baby. 

The optimal space for physiological birthing in suburban Melbourne should not be very different from the optimal space for physiological birthing for Inuit women in Nunavik in the Arctic Circle.  The type of bed or birthing pool; the colour of the walls or the pattern of the furnishings - these things can be nice, but are of little significance to the woman giving birth.  The woman's feeling of unintruded privacy, as she reaches the point of surrender, knowing that her midwife is *with* her, is the essence of optimality. 

Your comments are very welcome.

Sunday, December 18, 2011

spontaneous birthing

There was no acceptable alternative; no short-cut or easy way.  The labour had established.
The young mother struggled with every surge of uterine activity.  "I can't do it!  I am too tired!", she cried in English, then lots more in another language.
If one of us had been able to step in as proxy; to labour and give birth, or even to do some of the work, and lessen her load, we would have.  Surely it's unfair that the woman has to do it all?

Each time I witness the massive effort that culminates in the unmedicated, unassisted birth of a baby - and particularly a first baby - I am in awe.   The journey that can have many unpredictable and unexpected turns in the path; many forks in the road.  At each decision point, only one way can be taken.  Is this the best way?

As midwife, I hear many voices.  The mother's body, the baby's body, my own mind, the voice of professional and scientific knowledge, and the words of others participating in the birthing journey.

When the mother's mind says "I can't do it! I'm too tired!" I can't just block my ears.

I ask, what does her body tell me?
There is power in these contractions, and I have seen progress over time.
There is strength in this young body.  Her pulse rate is steady and strong.
There is quietness in the moments of resting between contractions.
Is mother well?  At present, yes.
I know we can continue.

I ask, what does her baby's body tell me?
The baby's heart rate is strong and steady.
The contractions, although strong, do not bring any sign of distress in the baby.
The baby's station is progressing with time.
Is baby well?  At present, yes.
I know we can continue.

I ask, what does my own mind tell me?
It's the middle of the night, and my mind is also weary.
I hear the cries.  I know that she is sleep-deprived.
I seek to guide this girl who is being transformed into a mother through this rough terrain.
I will not interrupt or interfere with the amazing metamorphosis; the life-giving struggle that we are witnessing.

I ask, what does professional and scientific knowledge tell me?
Simply this: that there is no safer or more appropriate way for this baby to be brought into the world, than for the midwife to work in harmony with natural physiological processes in labour and birth.
That this woman's body is wonderfully made, that this baby's body is uniquely suited to this mother, and that the process of birth is so much more than delivery of a child from the womb to the outside world.
That the transitions which must take place shortly are best supported in strong, unmedicated birthing.
I know we can continue.

I ask, what do the others - the husband, the friend, the student - tell me?
We are working together, and I am responsible for so much.  These members of the team are looking to me for encouragement and strength.  They do not have the years of life experience that I have, and they are quietly learning to harmonise their actions with those of the labouring woman.
I know we can continue.

We moved to the birthing pool.  The pushing had been ineffective, and the voice "I can't do it, I'm too tired!" was becoming more persistent.

Then, as an expulsive urge was about to go, I saw some fine, thick black hair peep out between the labia, then disappear again.

"I can tell you what colour your baby's hair is" I said.  "Black."

We all laughed.  Babies from their people group all have black hair.

I don't know when the young mother realised that she actually could give birth, that she was giving birth.  But I know and hold onto the look of utter amazement and satisfaction as she took her child into her arms.