Saturday, February 23, 2013

working in harmony with great natural processes

back-yard bounty
Tomatoes, peaches, figs - summer bounty from our little garden yesterday.  The tomatoes are eaten fresh, and if there are any extras I will blanch and freeze them for later use.  The figs are either eaten fresh, or find their way into Noel's delicious fig jam (which is handed out in small jars to family members and special friends).  The peaches have done well this year, despite the few that have gone to support the local possum population, and the visiting rosella family (see pic below), and the few grubs that find their way into the fruit because we don't spray.  For many years now we have enjoyed poached peaches from the freezer, year-round, as our main dessert fruit.

The natural processes I am referring to include the wind and rain and sun; the soil; and the little group of brown-feathered cleaners (otherwise known as chooks) who maintain a weed-free and regularly fertilised soil wherever they go, but who are quite indiscriminate about what they scratch up and eat.

I work in harmony with these natural processes by choosing places that are exposed to enough sunshine, by watering when there is not enough rain, by adding natural fertilisers and root growth promoters to the soil, and by putting up fences to keep the hens away from plants that they would otherwise destroy.  Some of these measures are even 'interventions', to use language familiar to midwifery.  The end result is a healthy, bountiful harvest.
Two rosellas in a peach tree

We haven't always had good outcomes.  When young plants are not watered, or supported, or given adequate nourishment, or protected from snails, or ...

Sometimes the fruit trees blossom during a rainy spell, and there aren't many bees to do the work of pollination, so not many fruit develop.

The other great natural (even back-yard) process that I seek to work in harmony with, and to intervene carefully into if and when appropriate, is (of course) childbearing. 

It's not enough to simply declare my trust in natural birth; to admire the function of the woman's body; the integration of physical, emotional and hormonal energies that work so marvelously most of the time. 

I, the midwife, function in a similar way to the gardener.  I must understand and respect all the forces, internal and external, that are at play.  I must take measures that will prevent harm from illness (eg pests) or poor nutrition (eg by rotating plants to different garden beds), or physical forces (eg the chookies). 

A midwife colleague challenged me recently when I described a situation when I accompanied a woman in labour to hospital.   After what I considered to be a reasonable period of time had passed, during which the physical progress of the baby into the birth canal was minimal, the woman agreed to a caesarean birth.  I agreed with this decision.

My colleague questioned me sincerely: was I not concerned that the act of going (from home) to hospital could have interfered sufficiently with the labour to CAUSE the obstruction of progress?  Could this woman have given birth 'naturally' if her physiology had not been interfered with?

My answer: No.

I know this because I was there.  This woman's body did all it could, under the natural physiological processes and rules, and it was time to move to Plan B.

The sobering thought, that we must not forget, is that even wonderful natural processes can lead to death and mayhem.  Recognising the points at which timely, and relatively small interventions, such as health promotion through improving diet and activity in pregnancy, or major interventions, such as the need for a caesarean birth, is the work of the midwife.  Just as the back-yard bounty is evidence of many months of careful work, the healthy newborn baby, at the breast of the strong and healthy woman, is evidence of a woman's strength and care of herself and her baby, as well as appropriate maternity care.

Thursday, February 21, 2013

Petition: Human rights in Irish childbirth

Saturday, February 16, 2013

Informed or mistaken?

Informed choice
Informed decision
Informed refusal
In my world the adjective 'informed' is often used in an attempt to declare that the person who is making the 'informed' choice/decision/refusal/whatever is intelligent, and has carefully considered options.  My question is, often, who's kidding whom?

A woman who wants to make an informed choice about who provides her care, and other aspects of the model of care, can only choose from what is available to her. 

A woman who wants to make an informed decision, particularly about an aspect of natural, physiological birth, may say she does not want to be treated as the next number on the production line.  She does not want standard care, whatever that is.  She wants to be treated as an individual.

A woman who wants to make an informed refusal of, for example, pre-labour caesarean surgery for a baby presenting breech, can find herself up against a system that does not support or understand her intentions.

In the often complex and demanding journey that a woman takes in giving birth to and nurturing her baby, the information available can be only marginally relevant to the individual situation: the choices and decisions can appear as shades of grey, rather than good and bad.  The constant juggling of the interests of the woman and her child, within the multiple contexts of a marriage, a family, a maternity service, and a community, can change the options for decisions in a moment.  In fact, a woman who considers herself well informed, and who is intentional about proceeding with an unmedicated physiological birth, has very little choice when some person with authority says "We need to get your baby delivered now."  A woman in labour who is confronted with even the suggestion that her baby's condition may be compromised, without whatever intervention is being offered, can suddenly find herself submitting to something that she would otherwise have avoided.

Health care, and especially maternity care, has changed in recent decades, from a "doctor-knows-best"-no-discussion model, with a hierarchical knowledge-based framework, to a system that attempts to include and respect the wishes and values of the patient/client.   This is, I believe, to be encouraged in principle.  But, in practice, I am often frustrated at the absence of an appropriate conversation about decisions or choices that need to be made.

At present the Melbourne Coroner's office is inquiring into the circumstances around the death of a baby whose mother intended to give birth at home.  Newspaper reports of this inquiry highlight the fact that the mother had refused caesarean surgery a few days before she came into labour.  In a news paper report of the proceedings, a medical specialist is reported to have said that: 
the "inadequate, incomplete and at times misleading information" available, particularly on the internet, made it difficult for women to make an informed decision about their birth plans.
There is little doubt from the reports that the mother believed she had made informed decisions.  Yet, in the tragedy of loss of the life of a baby, it's easy to argue that there were seriously mistaken decisions that led to the events of that day.

Women who have had previous caesarean birth(s) may make choices and decisions about their carers, and their planned place of birth, early in their pregnancies.  By way of contrast, women who find that their baby is presenting breech as they approach Term are suddenly confronted with a bewildering array of decisions.  As they obtain information they become aware that there is no right way (eg elective caesarean) and wrong way.  There is increased risk in breech birth, regardless of the actual method of birth. At each decision point, they can feel exposed and uninformed, even misled - but decisions must be made and there is no turning back.  Each decision places the participants in a new context, which may lead to more decision-making.

A woman who had planned to give birth naturally in a hospital birth centre found that her baby was frank breech a couple of days after her due date.  The special set of decision points that she encountered after the breech diagnosis were:
  • attempt external cephalic version (ECV): the decision was made on Saturday that this baby was not suitable for ECV, and the mother was informed that she would be booked for a Caesarean on Monday.
  • spontaneous onset of labour: Mother laboured at home Sunday night, and called her midwife for support around midnight.
  • progress in labour: After several hours of established labour, the mother's cervix was dilated 6-7cm, and the presenting part was high.  The decision was made to go to hospital.  Labour continued strongly.  The obstetrics registrar at the hospital agreed that progress was good, but advised a caesarean birth.  The mother declined, and stated that she was intending to give birth vaginally.  All maternal and fetal observations were within normal range.
  • review of progress in labour: After several more hours of labour, full dilation of the cervix was confirmed, but no progress of the presenting part.  Once again the mother was advised that she needed caesarean surgery, and this time she agreed.  Her baby was born in good condition, and the hospital staff facilitated early skin to skin contact and breastfeeding in the recovery area of the OT. 

In discussion a week after the birth, this woman commented to her midwife, "You know, it's a totally different outcome, having a caesarean birth after labour, knowing that I couldn't do any more myself, than if I had agreed to it the first or second time I was told I needed it."

The midwife agreed.  The decision making process included an ongoing review of the progress of mother and baby through uncharted terrain.  The decisions were made on the best information available.  There was ultimately only one *choice* - for the woman to do it herself, or not.  This is the only informed birth plan a woman can make, and follow through with.

related posts:
decision making for breech
breech vaginal birth
messages about breech births

Saturday, February 09, 2013


The Day You Came

Wanda Ruby Bean

From a distance the sound of familiar footsteps enter, softly resonating the hallway boards. That long cool passage welcomes and grounds the energy of arrival, and those footsteps always speak to me of strength, confidence and calmness. They are slow, they are regular, and they belong, each time they place themselves down, yet there is a lightness to them that contains their energy, allowing them to change their course. These are the footsteps of my father. They are the rhythm.

There is a second set of footsteps proceeding, which skate and dance on the surface. They have the same base confidence whilst infusing a melody of willingness, playfulness and excitement, the footsteps of my mother.

As the footsteps reach the end of the passage, time and space briefly pause. The early afternoon sun has just begun to creep through the wooden blinds and open door, filling the room with the blissful warmth and breeze of a perfect day. From over backyard fences and beyond, a relaxed inhabited neighbourhood enters the room, joining us in building the sense of this gathering and impending celebration.

We are all here now, and it is soon to be that you will join us.

Joy is here – she kneels by the pool quietly guiding me to allow you to work your way down, and to allow my body to open by degrees until your head can come through. She squeezes a cramp from my thigh. I bury my face into the crook of her arm. Our eyes meet and I tell her ‘I’m glad you’re here’.
She gives me the practical confidence at this stage that I need to enjoy this moment and to trust the forces and the will of my body and yours.

Hamish is here – he has been on the edges, balancing between active support and giving me space. He has prepared the room in the final hours to absolute, in timing, function and style, invited the guests, thought about lunch, and even got the bins out in time for collection. And as only Hamish could, has peppered his day with a set of slightly mad but comical dramas.
He is beside me at the pools edge. He even offers up his flesh for my bite, a running joke we have had. I appreciate it but decline, briefly gnawing on the pool instead. He holds me, and I tell him ‘Beano is coming’. We exchange a look of excitement and bemusement, the humour we share about this realisation that has never yet really sunk in. I don’t need physical or emotional support from him, I need to include him in this moment and feel the union that we are in order to bring you into our world together.

Mum is here – she peeps shyly over to me holding a face and breath of thrill, anticipation and quietness. The same energy I recognise at times that I have been witness to an animal birthing. ‘Hello’ and my wide eyes greet her in smile. I am relieved she has made it in time, and relieved that this is the moment she has arrived. Before long she slips easily under Joys instruction to prepare warm towels and other things in preparation, as you are nearly here. The combination of gentle mothering and practical assistant is the perfect and natural balance of how I had wanted to share this journey of womanhood with her.
Dad is here – a welcome addition to the arrangements. He primarily came to deliver mum and take Velouer out for a walk. As it turned out Velouer is completely calm. It is so close to the time you will arrive th0at he stays quietly in the background. I am happy he is here, and want to tell him. Under my breath I invite him to stay. I don’t think anyone hears me but the atmosphere as it is, is enough for him to feel welcome and comfortable to stay. I feel an extra sense of love and significance that he does.

Velouer is here – my beautiful loyal dog. He has been with me throughout. In the early hours of the day he lay beside me, calmly and comfortably as I worked physically and vocally with the surges in my body. It had been thought by others that he would be distressed by the energy of my birthing. I knew that he would be fine, and I had wanted him here. We are part of each other and we understand on an instinctual level. He gives me comfort by just being, eyes to talk to, and an energy of calm. He gives me space but is there, there to protect me as people arrive, and there to accept and welcome the people as he knows them. He takes his place as he always does amongst the people and space in the room. I tell him ‘good boy’.

I am here – I have always been here with you, and until now had you all to myself… although you have kept yourself well as a little mystery, a quiet enigma.
In the hours of this day I have re-found the essential core connection to my body, brought my mind in and allowed and trusted the forces, the choices and the beings that surround me now.
Just one little wild card is you. As my body works in the final stages to release and expel you I embody a physical memory of a young goat birthing her first kid. She lays in the hay calmly allowing the process, as the head finally pops out beyond return, a brief flash of shock and then realisation of what this labour is all for comes across her face. Then the long glorious quiver as your body swims from me and comes up to land in the air, our bodies skin to skin.

You have arrived – a tiny little stranger person. Taking your first breaths with sleepy eyes blinking quietly, with little wrinkled hands you gently play and clutch at the air. You take a shy little peek up to me. I hold you to my belly and paddle the warm water over your body with my hand, letting us the time to readjust and take it in.

Everyone is having their own special moments with you around us. Like a conglomerate of prismatic bubbles floating gently in the earthly sun filled room.

Wanda Ruby Bean - we love you to pieces already.

Frances Martin

Saturday, February 02, 2013

I wonder if he reflected on what he said?

Today I want to look at the words of an obstetrician who was interviewed for an ABC TV story 'Call for wider availability of home birthing' on the 7:30 report last night.

The professional body representing obstetricians, RANZCOG, strenuously opposes homebirth, and appears to have no interest in opening pathways for midwives to have visiting access for clinical privileges in hospitals - public or private.  The midwife's place is working in hierarchical maternity care models in hospitals.  The obstetric dominated maternity care has no place for the sort of midwifery that I have practised for the past 2 decades: private midwifery practice in which I have a small caseload of 2-4 births per month.  Most of the mothers in my care are planning homebirth.  Others are planning to give birth at the hospital, and I become the primary carer working within a larger team, and a sort of 'event manager' during the hospital stay.

Back to the 7:30 report.

Two obstetricians were interviewed.  Euan Wallace is director of obstetrics at Southern Health, the large network that covers Monash Medical Centre, as well as Casey, Dandenong, and Sandringham hospital maternity units.  Dr Wallace spoke of the (publicly funded) homebirth program within Southern Health as "one of the jewels" in the program.  He compared the relative rarity of homebirth in Australia, less than 0.5% of all births, with the UK: that in Australia homebirth seems to have a "wackyness" about it!   His heavy Scots accent suggests that his life experience is less insular than many of his obstetric colleagues.  He called homebirth an appropriate choice for certain women, and a choice that women should have, wherever they live in Victoria.

The other obstetrician, Michael Permezel, spoke on behalf of RANZCOG.  It is his comments that have left me wondering if he has reflected on what he said.  In short, he said women can't be given the responsibility to make a choice about homebirth.

Patronising? Definitely. 

RANZCOG does not support homebirth because, he said, there are a few nasty things that can happen at home that would be better managed in hospital.  By some amazing stroke of [un-]logic, it follows that if homebirth was offered, women would get a false message about the safety of homebirth.  That it would somehow give out a wrong message, leading women to imagine that availability of the program implied safety.  [This is not a verbatum quote, but it's very close.]

Readers of this blog are probably mostly people who have heard all this before, and who do not think that women who choose homebirth are deluded or intellectually impaired.

In a brief response to the RANZCOG position as stated by Prof Permezel, I acknowledge that there are occasions when unpredictable events can quickly escalate into the need for emergency obstetric or neonatal medical treatment.  This is not a homebirth issue: it's a life issue.   It's something that maternity hospitals face every night when their operating theatre staff go home.  Even the big tertiary centres face the possibility of doctors and midwives being unskilled when a woman presents in spontaneous labour with a breech baby.

Women who sit down in my office to discuss homebirth are not ignorant; are not holding onto false notions about the safety of homebirth.  They are usually very well informed, and are making plans that give them the best options that are available to them.  These women, and I, the midwife, are deeply offended by the suggestion of this obstetrician that they somehow don't have the capacity to weigh the risks against the benefits of different options.