Friday, April 30, 2010


ps [added 17 November 2012]
This US FDA website gives reliable guidance on codeine ultra-rapid metabolisers.

A baby's ability to breastfeed is one of the key 'performance indicators' that I observe after birth.

The majority of my work is with women and babies who are free of medication, giving birth to healthy babies at Term. Babies behave in the normal physiological fashion when the mother takes her child to her breast, and they remain together, skin to skin, for the next couple of hours. Babies seek the breast, making licking and rooting movements and moving in a distinctive way until they are in place and can take the breast and suckle effectively. This process is known as the breast crawl.

When a woman giving birth requires surgery she is given drugs. The anaesthetist and the obstetrician will prescribe whatever they consider to be necessary.

I am concerned about the current drug of choice for postnatal pain relief, Endone.

In the past year I have worked with three women who received Endone postnatally, and I believe I have observed a strong sedative effect of the drug on two of these babies. They became quite uninterested in the breast after the first breast feed, which had been unremarkable.

Recently another client of mine had a caesarean for obstructed labour, and I talked with her and the midwife in the postnatal ward 12 hours after the birth. The analgesia ordered was Endone (for 48 hours), Panadol and Voltarin. We agreed that if she was needing Endone she would breastfeed first, then take the drug. She has progressed very well with breastfeeding, went home on the third day - in fact this baby does a little breast crawl like a pro for every feed!

I am now checking for research literature specifically on Endone (oxycodone) and breastfeeding. Other midwives have said they share my concerns. A quick Google search came up with a very clear statement: "Do not take ENDONE during pregnancy or during breastfeeding as it may cause difficulty in breathing in an unborn or newborn child." [at]

A colleague who lives in regional Victoria told me that one of the local hospitals uses Endone less than the others, and that the local GPs, who provide anaesthetic services for the hospital, are still giving spinal morphine 1mg which works so well that very few women require more than Panadol and Voltaren.

I spoke to the pharmacist at a tertiary materntiy hospital in Melbourne, and he gave me some more information. He agreed that it's a very potent opioid that has a high transfer ratio into the milk, and variation from person to person as to how they metabolize Endone into morphine substances - hence variation in effect. He said the doses given appear to be pretty hefty.

The medical justification seems to be relatively short half life - 3-6 hours; that it's only used for 48 hours, claiming that the majority of babies are not sedated, and that the amount of colostrum the baby gets is pretty negligible anyway !!. Read here breastfeeding isn't something 'we' care much about!

The Lactmed site notes that "Newborn infants seem to be particularly sensitive to the effects of even small dosages of narcotic analgesics, particularly in the first week of life."

Dr Tom Hale, a world-respected expert and author on medications and mother's milk, has a forum

Hale states that "Oxycodone is a categoryL3... moderately safe, to be used only if the potential benefit to mother justifies potential risk to baby, and it has a half life of 3-6 hrs." Potential benefit to mother justifies potential risk to baby. I wonder how many mothers are given the opportunity to consider the risk/benefit before they swallow the tablet?

A newborn infant has important work to do, including learning how to breast feed. A newborn infant who is being systematically sedated through dangerous drugs that are passing from mother's blood to mother's milk, is being put at risk of breastfeeding delay leading to dehydration, jaundice, and a subsequent cascade of interventions, each with their own package of risks. The mother, receiving powerful sedation, is also likely to experience iatrogenic (physician-induced) difficulties with bonding and establishing breastfeeding.

I have often mused on the fact that "would you like something to help with the pain?" really means "would you like me to give you a dangerous drug?" I wish I knew a friendly cartoonist.

The anaesthetists and obstetricians really need to be questioned about this.
We live in a culture of acceptance of 'doctor knows best'. Women who undergo surgery for birth place an enormous trust in their surgeons and the other medical people - we need to act in their interests and on behalf of their babies.

I would like to ask that anyone reading this blog who works in the system, and who observes any cases where the baby of a mother receiving Endone in the early postnatal days appears sedated or performs poorly at breastfeeding, please draw attention to it. Speak to the obs and anaes departments, and point out what you observe. Ask them if they are aware of other such problems. Speak to the midwife manager of the unit, and ask her if she would support an internal audit of use of Endone. Find out what application is needed to get data from the general records. How often is it prescribed? What doses? (the pharmacy should be able to tell you this) Does the hospital have a protocol for the use of Endone? (you may find this on the hospital's intranet) What is the rate of supplementation of breastfeeding babies who were born by Caesarean (all the Baby Friendly hospitals should be able to give this data easily. Feeding on discharge is recorded on the Victorian perinatal statistics, so there could be some initial comparisons done.)

And while we're on the topic, I think some midwives are telling women in early labour to take some Panadeine and go to bed. Has anyone else heard this? In that case the codeine part of the drug will be added to the opioid soup in baby's system in the early days.

This is just not good enough!

Monday, April 19, 2010

when a baby needs to be born

There are many processes that midwives and others in the know about matters maternity are constantly checking. Today my thoughts are directed towards the first-time mother, known as a 'primip' from the Latin words primi (first) and para (birth), as she progresses through her pregnancy to that day when her labour will establish and her baby will be born.

It is normal/ usual for the baby's head to position itself deep in the mother's pelvic cavity from about 36 weeks of the 40 week gestation - weeks before the birth. The mother feels a sense of 'lightening', as there is a fraction more space under her ribs when the baby's head has engaged. When I palpate this engagement I am reassured that all is going to plan. This does not happen by chance. The mother's body is working in the way it was designed - wonderfully. It's as though the baby has discovered the door to this big world, and is waiting for it to open.

So what about the babies who haven't found the passage leading to the door? The baby who thinks she should come feet first, to start out running? The baby whose head stays high and mobile past 38, 39, even 40 weeks? What's the hurry, anyway?

Should the midwife just reassure the mother - we know a baby can be born spontaneously and safely in a breech presentation, and we know that occasionally a head does not engage until strong labour contractions direct it into the pelvic cavity - even in a primip!

Balancing this knowledge is another body of knowledge, which includes the standard of maternity care in the hospitals with which a midwife practising privately needs to collaborate occasionally. I cannot close my mind to the need for a smooth transfer and transition to medically led care from time to time.

I am constantly reflecting on the skills that promote, protect and support physiological processes that lead to spontaneous, safe birthing in the majority of cases.

Three primips in my care come to mind. I will call them A, B, and C. They are aged between 27 and 35, and are strong, healthy women, with caring husbands/partners. They are also normal height and weight - or normal BMI according to statistical charts. In other words, they are beautiful, healthy young women who would be expected to be able to give birth without complication.

A asked me to work with her for birth in a midwife-led Birth Centre attached to a large Melbourne hospital, Mercy Hospital for Women. When I palpated A's baby at about 38 weeks, I found the head engaged, with the fetal back on A's left side.

B asked me to work with her for planned homebirth, and has a booking at the Women's. At 36 weeks her baby was presenting head down, but the head was mobile. At 39 weeks the baby had turned to a breech presentation. I wrote a letter of referral to the hospital, and asked for review and consideration for external cephalic version (ECV). The ultrasonographer showed B that the baby was indeed presenting breech, and reassured her that there was plenty of amniotic fluid, which is considered necessary for ECV. B was told that the hospital preferred to do ECV at 37 weeks; that there was only about 20% chance that it would be successful at almost 40 weeks. B was determined, and she was invited to attend the next day for an ECV. She did not enjoy the sensation of tachycardia (fast pulse) that she experienced when Salbutamol was administered (to relax her uterine muscle). But the turn was successful. I visited her a couple of days later, and confirmed that the little head had stayed where we wanted it to be.

C is also planning homebirth, and her hospital backup is Monash Medical Centre at Clayton. The collaboration agreement with Monash is that the mother is seen in the hospital antenatal clinic at about 36 weeks, and if the midwife detects any issues of potential concern, an obstetrician also reviews the woman's care. As it happened, C's baby's head was high and very mobile. C was not concerned, as her mother had experienced the same situation and gone on to birthing spontaneously, but the doctor expressed his concern.

My midwifery ethos includes the statement "In normal birth there should be a valid reason to interfere with the natural process." (WHO Care in Normal Birth, 1996)

The question is, "Is there a valid reason in any of these cases to interfere with the natural process?"

Is there a valid reason to interfere with A's natural process? I think most midwives would say No, and I agree.

Is there a valid reason to interfere with B's natural process: baby presenting breech? If so, what should the interference be?

Is there a valid reason to interfere with C's natural process: baby's head high and mobile at Term? If so, what should the interference be?

[Any comments are welcome, of course!]

The birthing dance
One midwifery 'intervention' that I am currently asking my clients to consider, that I think may help that wee child find the way to the door in preparation for exiting her or his mother's womb, is a dance that brings on good 'practice' contractions of the womb. From about 37 weeks this dance will include upright movement, while intentionally increasing the release of natural oxytocin through loving body contact, including gentle nipple and clitoral stimulation with the purpose of bringing on a contraction.

Saturday, April 10, 2010

Scope of practice

The midwife's scope of practice is a topic that has become central in many discussions as we approach the introduction of the government's reforms into maternity care. I have written a lot about the countdown to 1 July in another blog.

Midwifery requires skill and wisdom - knowing how to work in harmony with normal physiological processes in pregnancy and birthing. The midwife who works independently, as the professionally responsible primary maternity care provider for a group of women and their babies, has the opportunity to work to the extent of her scope of practice. There are boundaries, and defining these boundaries also requires skill and wisdom.

It's no secret that a midwife is confident and delighted when a birth proceeds without incident, and a strong mother takes her baby joyfully to her breast. This birth is truly within the midwife's scope of practice.

But what about the birth that has some complexity? Is a breech birth, or twin birth, or even a birth at 36 weeks' gestation, or birth to a woman who has had previous caesarean surgery ... - are these within a midwife's scope of practice? Does that midwife, and that woman, have the *right* to choose the setting for the birth: the woman's own home? Or is there some line over which the midwife must not step?

I would be foolish to try to define a midwife's scope of practice in this blog. My hope is that by raising the issue, readers will reflect and learn in the way that is most useful to them.

The Australian College of Midwives has, since 2004, published National Midwifery Guidelines for consultation and referral (which can be downloaded as a .pdf file). The Guidelines claim to be "internationally comparable and based on the latest available research evidence at the time of publication."  The Guidelines cannot, in themselves, set boundaries for a midwife's scope of practice.

The uniqueness of birth, and of midwifery, is that BIRTH IS NOT AN ILLNESS.

Birth is not an illness.

Certainly there are illnesses that can complicate birth: anything from a chest cold to life threatening diabetes or heart disease can and do result in risk to the mother's and her baby's ability to successfully and safely negotiate the birthing journey.  No midwife has a guarantee of wellness or safety.  Safety is achieved by enabling health and refraining from interfering in sensitive hormonally mediated processes, at the same time as being able to access relevant specialist medical services in a timely and effective way when appropriate.

What we do as midwives is different from any other health profession - even obstetrics. The key is the woman's desire to give birth under physiological conditions, which is what a midwife's scope of practice is able to offer, rather than a medically managed birth, which is effectively the only way the doctor knows.

Midwives who work in medical settings are often prevented by service protocols from working to their scope of practice, sometimes to a degree of restriction that is ridiculous and not based on any evidence. I have been told that midwives providing homebirth services under a new pilot scheme for a hospital in Melbourne's outer suburbs have been told that they will be dismissed if they do not abide by the 'rules'. An example is the management of the third stage. The hospital's protocol requires the midwife to undertake active management of the third stage. Women are informed that if they do not agree to active management, they will not be allowed to proceed in the homebirth group. There is no discussion.

When a midwife and woman are working in a partnership based on trust and reciprocity, and there is an aspect of the care for which the midwife's scope of practice may be broader than that which falls under a set of guidelines, it's an opportunity for decision making. The woman needs to know where she fits within the ACM guidelines, and any other contemporary standards - written or assumed. She needs to know what her midwife can offer.  She may need to investigate what the alternative model of care to which she may be referred can offer, and weigh up the potential and perceived benefits against the costs and risks.  She needs to know this so that she can make her own decisions.

Decision points that arise at any time in the professional relationship can be addressed in this way.

Friday, April 02, 2010

Plenty of love to go round

There are times when an ordinary person is able to experience such an overwhelming sense of love that we want to hold on to that moment for ever.

The uncomplicated birth of a healthy baby is a time when love literally abounds. The cup of love fills up and overflows from the mother, particularly, to her infant, her husband and other children, her midwife, and everyone else with whom she shares the intimate experience. In that awesome moment, a mother receives her child to her breast, accepting the work of mothering.

Since as recently as the 1990s, this love phenomenon has been understood as being related to a surge of the hormone of love, oxytocin. Oxytocin is the natural substance that causes the womb to contract in a systematic way that, at the right time, leads to the opening of the cervix and all the complex processes that are summarised in the simple word 'birth'. Oxytocin continues to orchestrate birth, with the successful separation and expulsion of the placenta, the emptying of the womb of all trace of the baby, and the closure of the mother's blood flow through the placental site.

A surge of oxytocin is repeated many times in ensuing days, months, and years, as the baby stimulates mother's breasts and achieves the let down of milk.

A surge of oxytocin is also felt with sustained loving physical contact, building to a peak in sexual climax. Oxytocin supports and directs the normal physiological activities that lead to mammalian conception, pregnancy, birth, and nurture of the young.

In the years since I began to learn to work as a midwife, in harmony with natural physiological processes in the birthing journey, I have learnt to enjoy oxytocin. I have come to a deep appreciation of this wonderful substance in the lives of those for whom I am midwife, as well as in my own life.

As a midwife I see, over and over again, a woman progress through childbirth. I see a woman become a mother, and a couple become a family. I am sometimes privileged to return to that family a few years later when they welcome a new member.

I don't want to sound idealistic about this transformation. While most progress well, I also see some who start out beautifully become hurt and scarred by unrelated events. I see some whose own ability to love has been deeply marred in their early life, and they struggle to trust even themselves, let alone anyone else. I see some for whom illness or fear or destructive social forces hinder the development of strong bonds within families.

Today is Good Friday, and Christians around the world are celebrating a totally different love; love that saves and redeems lost humanity. This morning, as I sat with my family in our Church and meditated on Christ's love, I reflected on the profound difference between oxytocin-love and, for want of a better term, divine love. The elements of bread and grape juice; flesh and blood; a broken body and blood poured out, are symbols representing love that goes beyond any human achievement.

The human physiological love processes directed by oxytocin require flesh to be broken and blood to flow in order for new life to emerge. The symbolic representation of divine love is also in a broken body and poured out blood. New life begins.

The human physiological love processes directed by oxytocin are fragile, easily interrupted. The work of divine love is completed.