Sunday, December 23, 2012

Christmas greetings

Thanks to Bec for the pic.
Loving greetings
from our home to yours
“Let us now go to Bethlehem, and see this thing that has taken place, which the Lord has made known to us.”
Luke 2:15

As we once again come together to celebrate our Saviour’s birth, we have chosen this lovely image of a precious young child, who is experiencing the Christmas celebration with eyes wide open, learning the stories, and singing the songs of our faith. 
The second reflection that I (Joy) would like to share from this picture is that time-honoured theme of mother and child, a theme that occupies my professional and personal life, and brings me a great deal of wonder.
Noel and I have come through 2012 with a wonderful sense of thanksgiving for life and love.
We pray that God will bless you in the coming year, and that you will know peace and strength in all of life’s challenges.
With love,
Joy and Noel

Saturday, December 15, 2012

hospital policy in the spotlight

Today as I write I have in mind a young midwife who is employed by a busy private hospital in Melbourne.  I hope that midwife comes to my blog, and reflects on the incident that I witnessed recently, and which I will briefly describe here.

The labouring woman had written a brief birth plan; the sort of plan that I call "Plan A".
Something like this:

I am intending to give birth under my own power, and will do all I can to achieve the best outcomes for myself and my baby.  At the time of birth, my baby’s cord should not be clamped or cut, and my baby must not be separated from me, except for clear medical reasons, and with my consent.  
I do not want any drugs to be administered to me or my baby without my consent. ...

"Yes, we do 'skin to skin', we do 'delayed cord clamping', and we keep babies with their mothers."
"But we can't do physiological third stage."
"The problem is," the young midwife said, "It's hospital policy that you have syntometrine.  I have checked with my manager, and we have to give you syntometrine for the placenta.  It's hospital policy."

The mother was labouring, wasn't saying much, so nothing was resolved.  The midwife brought the tray containing ampoules of the oxytocics into the room.

... fast forward  ...

A healthy baby made his grand entrance, and no drugs were used.  The woman birthed her placenta spontaneously about 30 minutes after the birth, with minimal blood loss.

I am recording this brief account because I want to comment on it.

  • A midwife became the pusher and enforcer of a hospital policy to administer a particular drug preparation.  This is not midwifery.  There was no professional discussion offered as to the implications of the use of this drug for mother or baby.  The midwife simply acted as an agent of her employer, demanding compliance with this policy.  
  • A midwife failed to recognise or uphold a woman's right to informed decision making, and ultimately her right of refusal.

I feel very concerned for this midwife, who is at the beginning of her career.   It seemed clear to me that the midwife considered it her job to enforce the policy.  The midwife gave no indication of any understanding of or interest in the physiology of birth.  Rather, she seemed set on carrying out a series of tasks that were, apparently, the essence of her professional practice. 

The midwife appeared to be ready to ignore a written statement by the woman, that she intended to give birth spontaneously, without drugs.  There seemed to be an assumption by the midwife that the woman's choice of working in harmony with physiological processes and avoiding unnecessary medications was a choice that could carry no weight in that particular hospital.   There was no discussion of the potential benefits or risks of either course of action.  'Hospital policy' was the big flashing light that apparently barred the woman from attempting her plan of action.

The prophylactic use of oxytocics in the third stage of labour, 'active management of third stage', is a process of routine intervention that comes under the banner of the 'evidence based practice' movement.  The uncritical adoption of active management by most hospitals, with the belief that it reduces blood loss and thereby reduces maternal morbidity, is rarely questioned.

In this birth, the mother was ideally suited to unmedicated, safe, physiological third stage because the following requirements had been met:
  • a woman in good health
  • at term
  • spontaneous onset of labour
  • good progress in labour
  • uncomplicated, unmedicated first and second stages of labour.

In contrast, there are good reasons why one might seek to avoid use of Syntometrine. 
Syntometrine is a preparation that combines synthetic oxytocin with ergometrine.
Syntometrine is an S4 drug - restricted to prescription by a doctor or an authorised midwife prescriber.  The idea that a hospital would make policy requiring the use of a restricted medicine is in itself suggestive of a breach of the basic rules of prescribing. 

Follow the link above to read consumer information about Syntometrine.  One small sentence stands out:  
Tell your doctor if you plan to breast-feed after being given Syntometrine. One of the ingredients in this medicine secretes into breast milk. Your doctor will discuss the potential risks and benefits involved.  ( )

Breastfeeding is an intrinsic part of physiological birth.
Further information on the use of Syntometrine in lactation comes from MIMS, the widely used medicines reference resource:
Use in lactation Of the two components, only ergometrine is known to pass into breast milk. The use of Syntometrine during lactation is not generally recommended.
Ergometrine is secreted into milk and the inhibitory effect of ergometrine on prolactin can cause a reduction in milk secretion. Syntometrine has the potential to cause serious adverse drug reactions in breastfed newborns/ infants. Postpartum women receiving Syntometrine should avoid breastfeeding at least 12 hours after the administration. Milk secreted during this period should be discarded. 
How many mothers are given this information prior to administration of Syntometrine?  Very few, I think.

I hope readers see the point I am making.  Today we are advocating a return to spontaneous breech birth, returing to the woman and her baby their right to unmedicated physiological birth.   Perhaps we also need a group of intelligent, well motivated consumers, to become activists for umnedicated, uninterrupted birth, from the onset of labour to the completion of the expulsion of the placenta and membranes and cessation of bleeding.

Your comments are welcome

Thursday, December 06, 2012

why breech births are important

I had a moment of clarity just the other day: Women who have breech babies, and for whom spontaneous vaginal breech birth (vbb) is an option, need MIDWIVES who are willing to be on call, and work with them to the full extent of midwifery as primary maternity care providers in their births.

But, I hear someone say, midwives have been deskilled in VBB,  Most breech babies in the past 20 years have been delivered by caesarean.  So how can a midwife consider herself competent?

And, I hear someone else say, surely the hospitals won't allow a midwife to 'manage' a breech birth.  Surely the senior obstetricians will take control?

Yes, these are valid points, but there's one other point - the point of my recent epiphany - that needs to be considered.  No matter how deskilled midwives and doctors are, the woman's body is, in many cases, ABLE to do the work.  Spontaneous birth, regardless of which pole is presenting, is just that: SPONTANEOUS.  Spontaneous means that the progress happens under the powers that are within the woman's body.

I don't want to sound ignorant or naive here, because I know there are specific complications with breech births that increase risk of neonatal morbidity.  An arm can impede progress: a midwife can manipulate the baby to free that arm.   A baby can be born with low Apgar scores: a midwife is able to provide resuscitation.   The knowledge that upright vbb works well has been circulated in midwifery circles for as long as I can remember.  I don't know when I first heard the old adages, "let the breech hang" and "hands off the breech".  One of the main questions in the exam I took in 1973, when I became a midwife, was all about breech births.  Yet the obstetric textbooks teach the lithotomy position; and the warmed towel to support the baby's body while the various manoeuvres which have the names of obstetricians (eg Lovesett, Mauriceau Smellie Veit ... - I haven't checked the spelling) are performed.

Since the publication of the Hannah (2001) Term Breech Trial, which had the almost immediate effect of channeling almost all breech babies to the operating theatre, midwives in my part of the world have had little experience with vbb.  Breech presentations occur at Term in about 4-5 of 100 births.  In my practice I have seen one or two most years, which is consistent with that rate.  I have followed the current best practice guidelines and sought out external cephalic version, which in at least half of the cases has done the trick.  I would be foolish to claim any special expertise in vbb.  Yet, with the information and drive I now have, I would now be prepared to discuss the option of spontaneous vbb at home in my care, or hospital, with any woman at Term with a breech baby on board. 

There are just a few birthing situations today that potentially challenge the skill, knowledge, and courage of a midwife.  These may be unanticipated.  They may occur with little warning.  And they require the midwife present at the time to act decisively in interests of safety of the mother and/or her baby.

A breech birth can be a big surprise.  The midwife can either act in harmony with the natural processes, and support uncomplicated birth of a healthy baby, or interrupt the processes and mechanisms of birth due to ignorance and fear.

Spontaneous birthing is the terrain in which midwives work best.  We watch and wait, and hold a cocoon of safety around the woman-child unit.  We know the subtle behaviours that indicate progress, and we know how to minimise adrenaline and other fear-related hormones.  We know how to leave well alone; how not to fiddle.  We know how to stay quietly with the woman, physically and emotionally, as she progresses on the pathway to bringing her child into this world.

Spontaneous birthing for vbb must be upheld and protected by midwives and women in all communities.  Sure, some of the big teaching hospitals need to set up breech clinics and have specialists strutting their stuff.  But the reality of childbearing is that women in small towns, and in outer suburbs, and on farms, will also occasionally need to give birth to breech babies.  Many won't have the $15,000 needed for a private hospital booking with the heavily booked breech doctor.  Many won't be within the catchment of the public hospital breech clinic.  They will need a midwife in their community who can work in harmony with a spontaneous and life giving process, and who has the skill to recognise complications in a timely manner and manage referral and transfer of care when it is indicated.

Does anyone out there see what I have seen?

Does anyone else feel deep sorrow for all the breech births for which we have not provided the option of midwifery care?

Midwives who are willing, we need to provide breech education for other midwives, and get the word out in women's groups that breech births can be great births. 

And, btw, we know that the promotion of spontaneous birth for breech babies will not necessarily be easy.  Midwives may need to provide arguments about women making informed choices in professional conduct hearings.   This is the world in which we live.

For more consumer-focused breech information, go to BBANZ

Saturday, December 01, 2012

Dueling Experts

This week, at the MIPP blog, I have recorded some of the questions asked in the course of a formal hearing into the conduct of a midwife.  The scene was a room in the County Court in Melbourne: formal, foreboding, and unfamiliar territory to the midwife whose actions in two particular cases were allegedly unprofessional.  The panel appointed to hear the case did not have anyone who could be called a peer.  Those three women also appeared to be in very unfamiliar territory.

Although formal hearings are open to the public, I have not identified the midwife or the witnesses who spoke for the Board or in the midwife's defense.  The name of the person who made the notifications (complaints) is suppressed by law, and the names of the women who received care from the midwife, leading to the complaints are also not allowed to be published.

In his opening address the lawyer acting for the Board ( Nursing and Midwifery Board of Australia ) commented that this case will probably come down to 'dueling experts'.  The second time he used that phrase it sounded more like 'drooling experts'!  Whether it was intended as a joke or not, it's difficult to see the funny side when a colleague is having to undergo such grueling questions about births that took place more than 6 years ago.

There were two experts called to answer the questions put to them by the two lawyers.  Both experts are Professors of midwifery: highly respected women who have impressive academic credentials.   The arguments become polarised between risk and the woman's choice.

Expert 1 told the panel hearing the case that the risk of a twin birth, or a postmature birth, was too great to be managed in the woman's home by midwives. 'Risk' and 'safety' appeared to be synonymous.
Expert 2 told the panel that safety can only be achieved when the woman's right to choose is upheld and supported - even if the woman is giving birth to twins, or the pregnancy is postmature.

Have you ever listened to dueling banjos?  Take a moment to listen to this one from Youtube, played by John O'Connell with James Meall.

That's the image that came to me when the barrister said we faced dueling experts.
They start out slowly, deliberately.
One makes a statement.
The second answers.
Another statement, slightly more complicated.
Another answer.
And it continues until they are in full swing, and I think one or both must surely be lost.  I do not understand how one or the other 'wins' the duel - I think banjo players must have some rules about that. 

And so it is for midwives.

Is a midwife *allowed* to agree to homebirth when one or more risk factors have been identified?
Is a woman *allowed* to plan homebirth when one or more risk factors have been identified?

This is the question, ultimately, that this panel are required to answer.  The NMBA has a two-fold statutory role, to protect the public and to guide the profession.  The protection of the public, in this case, is about putting limits on midwives, and thereby putting limits on the women who engage our professional services.  The guidance of the profession is, in this case, about attempting to define the boundaries of a midwife's practice.

I have come away from this episode of dueling experts without any solution.
I agree with the second expert, who strongly asserted that safety can only be achieved when a mother's right to informed decision making is protected and upheld.
Yet I know well that midwives will continue to be challenged if they agree to operate 'on the fringe'.