Monday, March 05, 2018

MY body ...

Thoughts on choice, effective communication, and decision making in childbirth

Dear reader,
Now that I am retired from midwifery practice I don't have the same access to real life events that used to prompt me to write in the past.   I am 'restricted', so to speak, to my circle of friends, acquaintances, family, and what comes my way via the already-filtered social media the 'news'.  

Today I want to reflect on a very real, every day situation in the world of the midwife; a situation that I have recently been reminded of in real life.

A woman, aged 30 years, at Term, comes into labour with her first child.  She has been well through the pregnancy.  Her BMI is in the 'high' range, and she has followed dietary advice, maintaining minimal weight gain, and keeping blood sugars within the normal range.  Throughout the pregnancy she has stated clearly that she is planning a birth without interventions.

My body ...

Labour progressed well.  The pain became intolerable, and they went to the hospital where she had booked.  The hospital midwife focused on the baby's heart rate being too slow at times.  The labouring mumma just wanted a break!   Someone offered an epidural, and the mother accepted it. 
Everyone can relax now.  Baby's heart rate is fine - it must have been a problem with the pickup of heart sounds by the monitor.


My body, except that I can't feel anything below my waist. 

My baby ... 

Some time later the monitor declared that baby's heart rate was slowing down.  Doctors who mother hadn't previously met entered the room.  They had been watching the monitor trace at the ward desk computers.  
Brief introductions, 
legs go up in stirrups that appeared out of nowhere ... 
and a procedure to determine baby's blood gas levels. 

Consent form is signed

Rush to the operating theatre
Casearean surgery
Baby is fine!

... forward 5 days

Mother is overwhelmed.  The preceding days are just a haze in her mind, having received generous doses of opiate drugs to numb her pain.  She cries and sobs "Everything that I planned has gone wrong". 

The mother sits with a breast pump in the beautiful room that she had prepared so lovingly.  Somebody else gives the baby a bottle of expressed breast milk, and a 'top up' of artificial milk from a formula can.  Attempts at breast feeding have been less than satisfactory.  Baby just goes to sleep - out like a light.  Doesn't know what to do.  A couple of times baby did seem to be sucking at the breast, but left ridges and blisters on the nipples that quickly progressed to bleeding.  Now someone else changes baby's nappy, and cuddles her after the feed.  


I am reflecting on this birth, focusing on choice, communication, and decision making in childbirth

  • Choice:  From early pregnancy this mother had made what she considered to be an informed choice.  She wanted what was best for her baby, herself, her family.  She researched childbirth advice, went to classes, and spoke with friends.  It was a no-brainer.  She wanted to give birth without [that ugly thing, whatever it was] intervention.  Drugs are bad for mother and baby.  Drugs are dangerous.  No drugs.  Birth is natural.  Natural is best.

  • Communication: The words clearly communicated by the mother; "no intervention", became less meaningful as labour became established.  This is not news to a midwife or a doctor working in maternity.  Even as the night progresses and weariness sets in, some women become more and more distressed with the pain of labour.  The midwife can't ignore a woman's pain.   It can be a sign that everything is going well, and the mother is resisting the need to surrender neo-cortical control.  Or sometimes it may mean that the labour is obstructing.  This is one point at which a known and trusted midwife who is primary carer is able to either reassure the woman or prepare her for ongoing decision making in labour.  There was no such midwife for this mother. 

  • Decision making:  In all the prenatal preparation that this mother had done she had not grasped decision making as an ongoing, active process in pregnancy, birth, and all that childbearing entails.  She liked 'choice', and 'control'.  'Choice' gives the mirage of control.  Yet noone has absolute control of their own body's function, let alone control of the actions of other people such as the staff of a hospital.  This mother did not understand that each decision she made influenced the next option she would have.   

For some years now there has been a push by some midwives and birth activists to assert birth rights within a global human rights agenda.  A march planned in Melbourne is headed 'Birth Rights are Women's Rights'.  The promotional material for this march states:
"... Getting it right in the birth context could provide a strong platform from which to assert how vital it is that all women are treated as humans at all times, with the rights this should afford them.
By contrast, childbirth also provides the perfect opportunity to undermine those rights. Looking across the developed and developing world it is clear that the broad spectrum of women's freedoms is undermined daily in birth. If we don't value their experiences in an act that is particular to them, we make it an easy access point for those who seek to disrupt feminist process." - Rebecca Schiller Why Human Rights in Childbirth Matter

I don't think there was any intention in the case I am reflecting on, or the many others that take place daily in our maternity hospitals, to ignore or undermine the woman's rights or freedom.  When the mother declared that she wanted to give birth without intervention it wasn't a wish list.  She considered it her right to choose.  That's where she was misguided.  In choosing to give birth without intervention she needed to know how to give birth under physiological conditions.   She was a victim of her own ignorance, rather than a system designed to undermine her freedom and disrupt the female process. 

I believe there is a lot of mis-information doing the rounds of childbirth education classes - both those given by hospitals and those provided privately.  I have seen claims that the choice of place of birth, and choice of who provides midwifery care, are human rights.  No!  They are (in this part of the world at least) usually linked to a person's ability to pay, and occasionally linked to the person's access to a funded program.  It has nothing to do with being "treated as humans at all times" (Schiller, R. quoted above).  

In an ideal world, every pregnant woman would have access to, if they wished, a known and skilled midwife who facilitates effective maternity care for women planning homebirth, and hospital care for those for whom it is appropriate.   There is plenty of literature supporting this model as safe.  But it's not easy.

Dear reader, I am writing this because I am very sorry for the young mother and father and baby in the case I have described.  I am sorry that she feels so very disappointed.  

Yet, I am optimistic that there is hope for this mother to recover, and to become strong again.  As she and her baby learn breastfeeding and the hormones of love surge in their bodies, there will be healing for both of them.  Even in sub-optimal situations there are many blessings.  Young women become strong and resilient as they learn to deal with real life situations.  Children thrive in the care of strong, loving families.