Tuesday, April 26, 2011

The making of a midwife

I have recently finished reading Patricia Harman's memoir (pictured here), Arms wide open: a midwife's journey. I have enjoyed the journey.

As I progressed through the book I welcomed insight into the way Patsy, an idealistic hippy wild child in the early 1970s, learnt about life and in that learning, she found midwifery.

I welcomed insight into the realities of the American counter-culture, war resisters, commune life, living without what most of their peers would call the basic necessities of life.

I welcomed the honesty of statements by Patsy, now a grandmother with a nice home and a day job, no longer attending births, such as "You'd think by my age I'd have everything figured out, but I don't have a clue and I'm more confused than when I was thirty."  I concur.

I found to my surprise that Patsy's midwifery journey reminded me in many ways of my own. I was at the same time, learning about life, and discovering my midwife identity in a sort of mirror image journey.

Here's what I mean by a mirror image journey.

Patsy and I must be about the same age, and we gave birth to our babies at about the same time. I was living in Michigan in those formative years, the 1970s, in a little brick house with a basement, surrounded by tall oak trees that shed mountains of brown leaves each 'Fall'. I raked leaves in autumn, shovelled snow in the winter, planted spring gardens, and enjoyed home grown veges in the summer.

While Patsy learnt how to stay warm and well in an isolated primative log cabin, I, who had spent most of my life in the sub-tropics in Queensland, learnt how to live with central heating, and cook in a kitchen that had green carpet on the floor.

While Patsy and her companions had dropped out of education, I had already graduated as a midwife in my home country. Noel, my husband was a graduate student at Michigan State, working on the fascinating and previously unnoticed protective effect of colostrum in the newborn calf. I was absorbing scientific literature and knowledge as fast as I could, broadening my understanding of reproduction, and particularly the needs of mammalian newborns.

Like Patsy, I attended the local Lamaze birth preparation classes and learnt psychoprophylaxis and Lamaze breathing. Unlike Patsy, I did not discover homebirthing. I gave birth to my first three children in the local hospital, was moved in second stage to the delivery/operating room, positioned with legs in stirrups and hands held to boards by big pieces of velcro. I was told to "take a deep breath and push push push!"

While Patsy raised her children in a loosely knit 'family' of a commune, I was away from all my family, became a full-time mother, and was satisfied with that role. Apart from the help offered by a few neighbours and friends from our Church, I needed to be emotionally and physically self-sufficient.

While Patsy developed a sort of faith in the forces of nature, I continued in the Christian faith in which I had been nurtured.

My awakening in midwifery came later, in the early 1990s, when I thought that my four children no longer needed a parent to be at home for them all the time.

I was able to move without difficulty into homebirth, even though I had not given birth at home myself.  The knowledge that stood by me had been instilled in my mind over the years of my own childbearing, building on the foundation that I had learnt in my student days at the Royal Women's Hospital in Carlton.  The years of breastfeeding had given me insight into mother-baby bonding and nurture.  The years of parenting had given me an understanding of what it means to promote health, and work in harmony with natural processes.  The years of part time shift work, usually nights, in hospital maternity wards, had taught me that I wanted to be 'with woman' - that the 'one night stands' I was having in the hospitals were not optimal in any way.

Like a butterfly emerging from its quietness in the crysalis, I had metamorphosed, and came out of that space ready for action.

Enough from me for today.  Your comments are, as always, welcome.

ps Arms wide open is Hardcover, or eBook, 324 pages.  Publisher: Beacon Press. ISBN: 978-0807001387

Monday, April 18, 2011

When birth is no longer normal

Midwives consider ourselves the guardians or keepers of normality in birth. We attend conferences and repeat slogans about keeping birth normal. We talk about sitting on our hands, about trusting the natural process, about protecting the woman's space so that she can give birth naturally and safely.

Our definition declares that our duty of care includes the promotion of normal birth.

Here is an excerpt from that definition of the midwife (ICM 2005):

The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. 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.

Australian midwives need to know this definition well. It has been adopted by our regulatory agency AHPRA, and the Australian Nursing and Midwifery Council, and is foundational to current midwifery education, codes and standards.

The big challenge for the midwife is to balance each aspect of our professional duty. Our desire to promote normal birth must not be allowed to over-ride our responsiblity to carry out preventative measures, or to detect complications in mother or child, access medical care and other appropriate assistance in a timely manner, and the carrying out of emergency measures.

I have reflected many times on what it means for a midwife to be a responsible and accountable professional. In recent submissions to government inquiries, I and other midwives have written about the processes by which midwives are required to give an account of what we do, and this is especially so when there is an adverse outcome. Our society has an expectation that professional care will be in the public interest; that the safety and wellbeing of mother and child are the primary concern of the midwife and any other person who provides professional maternity care.

A recent report by the Queensland Coroner on the death of a baby Samara Hoy has been distributed in midwifery circles.  It is a public document.  The Coroner's findings were critical of both midwifery and obstetric care (or the lack thereof) in this case. Reading the report has left me with many questions about the standard of care and culture of maternity services in that hospital.

If this woman had been planning homebirth, and her midwife had taken her to the local public hospital when meconium, fetal tachycardia, decelerations ... were observed, there would have been no question about continuous electronic fetal heart monitoring (EFM), or offering a theoretical set of options, one of which was waiting for nature to take its course.

That's the essence of midwifery: that if complications are detected, we have a process to follow, including "accessing of medical care or other appropriate assistance".

The tragedy in this story in my mind is that the woman was so alone. Although there was a person there with the role and title of midwife, there was no person with whom that mother had a partnership based on reciprocity and trust. There appears to have been no informed decision making by the woman. The decision by various midwives, and the collaborating doctor, to not even use the facilities available for checking the baby's response to the contractions suggests either a misplaced reliance on natural processes, or just plain incompetence. The physical findings of the Coroner of strangulation marks left by a tight umbilical cord around the baby's neck, and meconium aspiration, suggest that severe fetal distress would have been observable, particularly with EFM, for some time prior to the birth.

I can only surmise that the midwife was committed to a skewed idea of keeping birth normal, by sitting on her hands and keeping her head in the sand.

A young mother who has engaged me as her midwife for planned homebirth asked me under what circumstances would I think she would need a Caesarean birth.  I don't have an easy answer, but we chatted about how I know when birth is no longer normal, and what would happen in such a situation.

I know it's easy for me to be an armchair critic, but I have written this post with the hope that other midwives who read it will also reflect on what we do when birth is no longer normal.

Saturday, April 02, 2011

Midwifery knowledge

click to enlarge

One of my current projects is to lead the review of the Maternity Coalition INFOSHEETs - see the APMA blog for more detail. I also headed the previous working group which put together these information sheets in about 2006. Our aim was, and is, to provide reliable information that supports informed decision making for women and midwives who seek to promote normal physiological birthing, and to work in harmony with the natural processes in pregnancy, birth the perinatal period.

It's a big project, and the working group is asked to consider current evidence and practice, and check the information provided on the INFOSHEET. Recently we completed the first to be reviewed, A Baby's Transition From the Womb to the Outside World, (see jpeg file above) and are now working on The Third Stage of labour. Unfortunately I do not know how to link a .pdf file to this blog, so if you would like a copy of the revised document emailed, please send a request to me joy[at]aitex.com.au

A midwife commented to me that "what we need to say loud and clear is that we use Midwifery Knowledge which is very different and definitely not less than obstetric and surgical belief."

Yes, I (sort of) agree – but remember that ‘midwifery knowledge’ is not well defined, as is also the case with some 'medical' practices, or 'alternative health' knowledge. If our knowledge embraces truth, it's true regardless of whose it is. Midwifery knowledge should not belong to midwives only - it should be common knowledge.

If 'midwifery knowledge' is to be accepted as reliable it has to be well articulated and put out to scrutiny. I believe that’s what these infosheets are trying to do.

Management (or non-management) of the Third Stage (S3) and the time interval from birth to clamping of the umbilical cord are two examples of what I would call 'midwifery knowledge', compared with rituals that have been widely accepted by modern obstetrics and midwifery, without any evidence to support them.

I am excited to see changes in the mainstream maternity attitudes to time of clamping the cord, and protocols for active management of S3. This has been in response to evidence, just as the virtual mandating of active management of S3 in hospitals was in response to flawed evidence.

We must continually engage in critical review of all that we do. Many hospital ‘guidelines’ require [that’s an oxymoron I know] immediate clamping of the cord, and none of them that I have seen have a reference linked to it.

Watch the APMA blog in the coming weeks for developments in the revision of this INFOSHEET. This is all voluntary work, and it is put out in the public domain to encourage involvement of anyone who is interested.

Today’s Age newspaper has an article about a research program for which ethics approval is being sought for a cord blood trial, and the relationship between a baby receiving its own placental transfusion and cerebral palsy. There are many questions that this research, if well done, may begin to provide answers to. The proliferation of private facilities that collect and store cord blood, without any reliable evidence that the baby will benefit from it - and without any evidence that the baby has not been harmed by the withholding of that placental blood at the time of birth - is evidence that many parents have taken a punt on this issue.

Your comments are welcome.