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'

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