Tuesday, January 29, 2013

"I'm glad you're here."

The young woman was labouring hard when I arrived.  Hers was a better-than-textbook first labour: she got up at 4:30 am; was having mild contractions every 7 or 8 minutes by breakfast time; accelerated into 3 contractions every 10 minutes by mid-morning; and felt like pushing before midday.  After quickly arranging my few pieces of equipment I knelt beside the birth pool, checked the fetal heart rate after a contraction, and waited with her.  When her eyes met mine, she whispered, "I'm glad you're here."

The home, a lovely old inner-suburban Melbourne cottage, seemed to embrace and welcome this birth.  There was harmony and warmth in the exposed brick walls.  The baltic pine floor boards showed the wear of many occupants over the years. The mild summer day, and a gentle breeze, gave support and energy to the work of childbirth.  I learned later that the young woman's parents had lived in this home when their first child was born, and that several of the babies of this family had either been conceived there, or were brought there after birth. 

"I'm glad you're here."

The mechanisms of birth proceeded without delay.  The strong, expulsive effort of the womb, brought the little head to the vaginal opening.  We had no mirrors or torches - we worked by feel rather than by sight.  The mother's hand gave her all the information she needed.  After the head had fully emerged we waited, then supported the baby as she came to the surface of the water, opened her lungs, and took her first breaths of air.  After a brief rest we assisted the mother and her baby out of the pool, and they rested as we awaited the after-birth.  There was no bleeding.  There was no cause for concern at any time.

I reflected on that simple statement, "I'm glad you're here", as I completed the day's work, writing my notes and preparing the official birth documentation.  I reflected on them again as I visited the home the next day.

"I'm glad you're here" was firstly a statement of the rightness of home as the setting for this birth.  The young mother told me later that she would have found it very difficult to know when to travel, if she had been required to go to hospital.

It was also a statement of the rightness of the 'with woman' relationship.  The partnership I have with that young woman is a unique and special bond.

Clearly, this birth did not rely on any special skill or treatment that I might have offered.  Apart from putting my hand gently on the woman's leg when she felt a muscle cramp, I did very little.  A new graduate midwife could have done everything that I did.  The midwife attending a home birth relies more on the wonderful spontaneous actions of the woman's body, than on any midwifery act.  The essence of midwifery is being, rather than doing.

"I'm glad you're here" says it all.

Monday, January 28, 2013

midwife-centred language

We midwives have theories about woman-centred care.  The woman and her baby are the focus, and their individual needs guide the planning and providing of maternity care.  The provision of basic primary maternity care through the months of the pregnancy, birth, and neonatal period from a known midwife facilitates, in theory at least, the development of a unique partnership between the woman and her midwife, and supporting woman-centred care.

Many times, in reality, 'woman-centred care' is a hollow and meaningless phrase.   Aspects of the care are dictated by the service providing maternity care, limited by staff numbers and funding arrangements, and fragmented into 'items' that can be entered as numbers into databases.

My attention was piqued the other day when a midwife in a hospital used the word 'passive' in relation to the third stage.  The mother who was about to give birth spontaneously, without medication, had indicated that she did not want synthetic oxytocin to be injected into her after the birth.  The midwife, correctly, informed the woman that the hospital's policy required her to perform active management of the third stage.  The woman replied "No, thankyou."  The midwife then referred to what proceeded as 'passive management'.

  • ... passive [management], as opposed to active management

Before you nod your head and say, "OK, passive means not administering the oxytocic, not applying cord traction, not checking the fundus for evidence of separation of the placenta (and whatever else, such as cord clamping, is considered part of active management)", let me explain what is wrong with the concept of 'passive' third stage.

  • midwife-centred language
Active management, or passive [non-]management are terms that refer to the midwife's actions.  The woman is virtually invisible.  This is not woman-centred care.

  • ignorance
I witness appalling ignorance within the mainstream midwifery and obstetric community with regard to the uninterrupted physiological processes that lead to safe and optimal completion of the third stage of labour.  The 'broad brush' approach, treat everyone, regardless of the need, as required by the hospital's policy, leads to the deskilling of midwives who ought to be competent in protecting and supporting the physiological processes in childbirth.  This is also not woman-centred care.

  • denial of a woman's ability to make an informed decision
A woman who is progressing spontaneously in birth, and who indicates that she prefers a spontaneous and unmedicated third stage, can easily be denied the opportunity to proceed when the midwife uses the 'hospital policy' card. 

What is a physiological third stage?
Put simply, a physiological third stage is the spontaneous and unmedicated completion of the birthing process, after the birth of the baby (second stage), resulting in the expulsion of the placenta and membranes.

The Women's Hospital guidelines* defines physiological management of third stage as:
Physiological management: The birth of the placenta and membranes are expelled by maternal effort only and without using uterotonic agents or controlled cord traction.
[note the midwife-centred language: turning the focus from the woman, whose body is achieving a significant and healthy function, to the midwife.]

This is a totally inadequate definition, and is evidence of my previous assertion that midwives and obstetricians have become de-skilled in supporting physiological processes in birth.

I have described aspects of physiological third stages in recent posts, for example:

... The cord was not clamped.  We supported the mother as she stepped out of the birth pool, holding her treasure to her chest, dried them off, and sat them quietly in the prepared chair.  As contractions returned, the mother stood, then squatted over a plastic bowl, all the time holding her naked baby against her naked body, and the placenta was expelled spontaneously.  Blood loss was minimal.  [from The After-Glow]

... 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. [from Hospital policy in the spotlight]

What is the midwife's role in physiological third stage?

Having accepted that a woman who gives birth spontaneously and unmedicated, and who is intentional about continuing in the natural physilogical mode unless there is "a valid reason to interfere with the natural process" (WHO 1996. Care in Normal Birth: a practical guide),  the midwife's role is (obviously) to support and protect that natural process.

In the two birth accounts that I have referred to above, the midwife's role included assisting the mother into a supported position, such as sitting upright on a chair, with warm, dry wraps around herself and her baby.  The midwife manages the environment, rather than the labour, encouraging the mother to focus exclusively on her baby who rests quietly in her arms before seeking the breast.  The midwife ensures any activity around the mother is kept to a minimum.  If photos are being taken, this is done in an unobtrusive way.  The midwife notices signs of separation of the placenta, and instructs the baby's father on how to support the mother as she stands or squats over a bowl to expel the placenta, if she needs to.

There is nothing at all passive about the midwife's role in supporting and protecting the natural physiological processes in birth. 

I need to sign off now, as a mother is in labour and I expect to be called soon to attend.

The message of this post is that when we, the midwives, focus on the woman, we are able to work with her.  Our language reveals the focus of our care: either the woman, or ourselves.

*Active Management: go to the Women's Hospital guidelines and click on 'Labour-Third Stage Management'

Saturday, January 26, 2013

celebrating 40 years

yes, we were young and beautiful!

Thursday, January 17, 2013

the after-glow

Picture the scene:

We are in the room where the baby was born, just over 24 hours earlier.
The mother is sitting quietly, with a sleeping baby in her arms.
The father is near her, and other children come and go - as they do.
The midwife and the midwifery student have returned for a postnatal visit, and as there is no pressing clinical activity to attend to, we are simply 'being' rather than 'doing'.

Gone is the inflated birth pool, the tarp that covered the carpet, and the protective drape and old beach towels that covered the chair where the mother waited for her placenta to birth.

Gone are the candles and other soft lights that provided a warm and intimate glow as we welcomed this little one into her family.

Gone are the simple midwifery tools: the absorbent 'blueys', the box of blue gloves, the doppler, the oxygen bottle, and other resuscitation gear, the syringe and needle and oxytocic to be used if required ...

The daylight of this summer morning enters the room through the large window. 

Another light, which I call 'the after-glow', rests on the faces of all who are present.

There was no camera to document the after-glow, and indeed, if someone had tried to capture that moment, I doubt the memory would have nestled so strongly in my heart, or urged me to write it down.   In many ways, it was an unremarkable moment.

Yet, the discussion that followed was full of awe and wonder.  The miracle of birth, by which a child is safely brought from the womb to the arms of the mother, never ceases to offer insight to anyone who has eyes to see and ears to hear.  The natural physiological process, spontaneous yet so very vulnerable to any interruption or interference, is somehow unnoticed by our society and particularly mainstream maternity services.

If I have learnt anything in these past 20 or so years of private midwifery practice, working closely with a few women, most of whom intend to give birth without medical intervention, it's that there is so much more to learn.

As we reviewed the experiences and events of this labour and birth, we were reminded that this mother would have been treated as 'at risk' if she had been in hospital.  A previous caesarean requires, in most maternity hospitals, continuous electronic fetal monitoring throughout active labour.  Parity greater than 5, as well as the caesarean scar, require an intravenous cannula to be in situ.  Active management of the third stage is the standard process in local hospitals for all women. 

Yet this birth proceeded spontaneously at home, without incident or complication.  The mother guided her baby's head over her perineum, without any instruction to 'pant' or 'give a push now'.  The baby came up out of the water, took air into her lungs, and made that great transition from placental oxygen to the bountiful air without any difficulty.  The cord was not clamped.  We supported the mother as she stepped out of the birth pool, holding her treasure to her chest, dried them off, and sat them quietly in the prepared chair.  As contractions returned, the mother stood, then squatted over a plastic bowl, all the time holding her naked baby against her naked body, and the placenta was expelled spontaneously.  Blood loss was minimal.  Baby took the breast eagerly - as they do.  After an hour or so the father took his daughter, and the mother achieved her next milestone, that of emptying her bladder.

Anyone reading this might ask, what's so special about that? 

It's the simplicity of uncomplicated, unassisted birth that I want to record here.  Simple, yet amazingly complex in the orchestration of hormones and the mechanics of the process.  Spontaneous, yet vulnerable to interruption or disruption.

Midwives must work to protect, promote and support birth in the natural framework that has been provided by our Creator, unless there is a valid reason to avoid the spontaneous normal process.

Sunday, January 13, 2013

how to promote midwifery?

I have often pondered this question, how to promote midwifery. 

Although midwifery is my livelihood, promotion of midwifery goes way beyond making a living and paying the bills.

Today I have drafted this sign, through which I hope to promote midwifery.  Although this sign has my contact phone number, my intention is to provide this as a template for other Medicare-participating midwives.

I have used colours and fonts that are consistent with the official Medicare signage and posters.  (unfortunately the quality of my printer's colours atm is not very good)  The colours and font should elicit a recognition response from the general community.  The fact that a midwife can offer Medicare rebates will be 'NEWS' to many in the community.

The key message is: "protecting the wellbeing of mother and child".  This is foundational to midwifery, and to the provision of expert primary maternity services in communities.

Another new initiative on my part is to start up a facebook group, which I have named 'villagemidwife'.  I do not particularly enjoy facebook, and its reliance on thumbs up 'like' votes about anything that is posted.  However, I am conscious that facebook is the social medium used by many young women of childbearing age, and therefore important.

For the record, other facebook professional groups that I belong to are:
breech birth ANZ
eligible midwives
graduate certificate of midwifery at Flinders
Australian College of Midwives

Thankyou for your comments.

Friday, January 04, 2013

Looking ahead: midwife-led primary maternity care

Today is a hot day in Melbourne, and I am taking this moment to set down my thoughts on how I and other midwives can continue to practise our profession.

Prior to the holiday break I wrote a progress report, two years after the introduction of reforms to government funding of maternity care.

There was clearly an expectation within the government, and the midwifery profession and the maternity advocacy community that the injection of $$ to fund midwifery would also open up greater acceptance of the work of the midwife.   It was assumed that private midwifery would ease the work of the over-burdened hospital system, public and private.  I cannot see evidence of this.  In fact, the money from the public purse has probably increased over-servicing by multiple service providers, rather than any cost shifting from the state (hospital) to the federal (Medicare) health budgets.


The unique product that midwife-led primary maternity care offers a woman is a midwife who is the primary or first contact throughout the episode of care.  This is, in my opinion, the ideal option for any woman, and the ideal model in which a midwife can practise.  This ideal requires the midwife to be flexible in the time she will attend the mother, particularly during the labour, birth, and the early postnatal days.  The midwife's caseload is usually described by the number of bookings she has each month.  This ideal is supported by expert opinion and research, in the interests of the wellbeing and safety of mother and baby. 

Caseloads for midwives mean that the mother is in the care of a known midwife who intends to be the leading care professional through pregnancy, birth, and the postnatal period, unless care is referred to a specialist obstetrician (or hospital obstetric service).  In this case, the midwife may continue to provide midwifery care, in consultation/cooperation with others (doctors, midwives, nurses, and other health services as required).

In reality, this ideal is rarely achieved.  This ideal should not be linked to planned place of birth, but in reality it is.  The only way most women can plan to have a known midwife as their primary carer throughout the episode of care is to plan homebirth. 

In reality, Australian hospitals and midwives are resistent to the changes that would be needed to make caseload midwifery options work for midwives in mainstream maternity services.  Women receive fragmented care that comes with all sorts of names attached: shared antenatal care, team care, obstetric clinic, midwives clinic, and many more.  Maternity wards and staff are used to midwives as shift workers, who are allocated to provide care for the women in the ward at the beginning of a shift.  The mother receives antenatal, perinatal and postnatal care from a group of midwives, doctors, and others, without knowing who will attend her at any time.

The maternity 'reforms' seem to be fragmenting the maternity care a midwife can provide, under a skewed concept called collaboration.

Midwives don't always agree on the way forward.
One midwife might be a pragmatist, and make an arrangement with the hospital maternity ward that she will be employed as a casual staff member when her clients are ready to be admitted. 

Another midwife is holding out, and hoping, for visiting access to the hospital.

One midwife might be an idealist, who will only make bookings to provide care for women who are committed to home birth. 

Another midwife is not interested in where the woman is intending to give birth ...

I have come to this latter position.  I recognise and respect the choice that a woman has to make, in the world in which we live, as to the intended place of birth.  I also know that this decision can change in a flash, for all sorts of reasons.  There are times when a woman who plans hospital birth reconsiders her options, perhaps in the weeks leading up to birth.  I am happy to work through this process.

One change that I and some of my colleagues have made, in response to the current climate of disrespect for the work of the private midwife, is to encourage women who intend to give birth in hospital to make a deliberate choice about the package of care they receive.  A woman can choose to receive primary care from a midwife, without having to plan home birth.  In some situations the hospital accepts a booking, but in others the woman will be unbooked.  This should not be a problem.   The administrative burden on the hospital of admitting an unbooked woman, especially in well staffed city and suburban hospitals, is not great.  The private midwife provides copies of any relevant tests and investigations, and a handover to the staff member who admits the woman.

Some midwives who have had Medicare provider numbers since 2010 have not yet established viable private midwifery practices.  They continue to juggle shift work in part-time or casual work at hospitals, while they seek private work.  Women are being discharged from public and private hospitals before they are confident in caring for themselves or their babies.  Many of these women would, I believe, appreciate home visits from a private midwife who has Medicare.  This is not happening.  The hospitals do not refer women to midwives.  They are happy to say "See your GP if you have a problem", but not "See your local private midwife before problems arise."

In conclusion, we still have a lot of work to do.