Monday, April 07, 2014

A midwifery half-truth: doing nothing

A couple of weeks ago I wrote about the myth of choice.

The midwife 'doing nothing' is a similarly misleading notion: not quite a myth, but definitely a half-truth. It's only one side of the coin.  It sets a potentially dangerous precedent, devaluing the expert professional activity of the midwife, being actively 'with woman' in the interest of safety and wellbeing of mother and child, to the point we have today: an epidemic of unattended births ("free births") in the community.  The rationale is like this: "If the midwife does nothing, then we don't need a midwife."

Today I want to critically explore what midwives are doing when we may appear to be 'doing nothing': what happens when I spend time on the couch in an almost dark room in the wee hours, with my eyes closed; what I am doing when I take up some simple knitting or crochet project as I wait for a baby to be born.

Let's consider the pregnant_woman/mother+baby to be central in this discussion.  What does that woman hear from her own intuition, from midwives, from other professional maternity care providers, from family, and from other sources?

There are many voices, and the value that the woman places on each of those messages varies from one to another.  Social media has, for at least the past decade, played an increasingly powerful role, as indeed this blog site offers information and discussion.  The current generation of mothers is the generation who uses online searches to 'research' a question, who follows multiple social media sites, who is prepared to ask questions.  Whereas previous generations had the 'disease of the month' prompted by an article in a publication (such as Reader's Digest), today's generation can search and often self-diagnose - with dubious effectiveness.  Gadgets can be bought: a pregnant woman can set herself up with a fetal heart rate monitoring device, a blood pressure machine, digital scales for the baby, and any number of other potentially useful, potentially useless pieces of equipment.

But I digress.

Back to the assertion I have made, that 'doing nothing' is a half-truth.  Further, I suggest the notion that the midwife does nothing, without taking into consideration the enormous and life promoting role of the midwife in any professional setting, could have negative consequences for idealistic, impressionable, inexperienced midwives, and for women in their care.

A woman who is labouring strongly, who has invited me into her home to attend her for birth, will have spent time with me during the pregnancy, discussing and planning and preparing for this climactic time.

I am in her home; I have moved quietly into her intimate space, and
  • I assure myself that mother and baby are well, through observation, active listening, and auscultation of baby's heart sounds after a uterine contraction
  • I communicate my assessment and any concerns to the mother, and support her, reassure her if appropriate 
  • I prepare the space so that I can maintain my written record 
  • I prepare equipment that may be needed, such as the newborn 'bag and mask', and oxytocic for mother
  • I recognise any idiosyncratic matters or instructions that are given, such as "don't open the door because the cat might escape"
  • I make a mental note of this woman's progress up to this point in time, how she is responding, what professional observations are reasonable, and what I expect to see happening
  • I assume a protective role of the space, knowing that interruptions and intrusions and interventions can be disruptive: for example, telephones are not welcome in the birthing room.
  • I may sit on a chair or rest on the couch in an almost dark room in the wee hours, with my eyes closed
  • I may take up some simple knitting or crochet project as I wait for a baby to be born.
Doing nothing?  No way!

Even if the labour and birth are 'uneventful', even if the baby is born quickly and easily (from an observer's point of view), without any instructions from me, my presence is the essence of my professional action.  I bring the capacity to intervene, when there is a valid reason.  I bring the ability to minimise interruption that may increase anxiety in the labouring woman, so that the woman is free to progress, unaware of what's going on in my mind or in the outside world.

Dear reader, if you know the ICM Definition of the Midwife, and other foundational statements and codes in our profession, you will understand what I am saying. 
"... This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures." (ICM 2011 - emphasis added)

Those who understand the promotion and support of normal, physiological processes in birth will know the masterly inaction of authentic midwifery.  This is not 'doing nothing'!

Midwives need to protect women from an idealistic message that tells only part of the midwifery story, and may confuse those who genuinely need the midwife to act in the interest of wellbeing and safety of mother and/or baby.  If that were not the case there would be no need for a midwife.

Your comments are welcome.

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