Monday, June 27, 2011

"When there are two midwives ...

... the baby's head is crooked."
[This is a saying from Persia, quoted by Michel Odent, in Childbirth in the Age of Plastics (2011), p63]
Here's the context:
Learning from home births
One of the main obstacles for easy births - particularly easy home births - is the common overuse of language. I have countless anecdotes of useless questions, comments, and advices from well-intentioned birth attendants.
Another obstacle is a deep-rooted tendancy to introduce without any caution several people around the labouring woman. This tendency is as old as the socialisation of childbirth. ... Traditionally the midwife is an autonomous, very independent person. There are proverbs, in places as diverse as Persia or South America, claiming that the presence of two midwives makes the birth difficult. In Persia, they used to say: "When there are two midwives, the baby's head is crooked".

And of course a crooked head means a painful, difficult birth. The optimal position for the fetal head is flexed at the beginning of labour in the occiputo-transverse to occiputo-anterior plane, well applied (evenly) to the internal os of the cervix, with continuing flexion of the fetal head as labour progresses. A head that is presenting posterior, or asynclitic (tilted to one side) is not well applied to the cervix, and dilation of the cervix can be difficult, and labour incoordinate.

A reader may wonder why traditional wisdom would warn that "Where there are two midwives a baby's head will be crooked." Is that just an old wives' tale, to be discarded by the modern, intelligent mind? Is there any possibility that the presentation of a baby in the womb is in any way influenced by the presence of a second midwife?

Assuming that there is something of universal worth in this saying, how can it apply to women and midwives in Melbourne, Australia, today?

Just for the record, my midwifery practice includes births at which I am the only midwife, and births at which a second midwife has been invited, and births at which I am in attendance as the second midwife.

The key: being woman-centred
Midwives understand that the woman who is giving birth is the central, focal point of everything that is happening in chilbirth. Within that woman, in her womb, is the baby. Woman-centred care is also baby-centred, because the woman and baby are one.

Midwives also understand that the woman and her midwife form a special partnership, based on reciprocity and trust. A one-woman-one-midwife partnership.

In the real world, despite the best laid plans, a midwife can never guarantee that she will be in attendance for a particular woman. The only people who can be sure they will be at the birth are that woman and her baby. In the real world, a good midwife is able to meet a labouring woman and work with her in such a way that the woman is able to optimise her birthing potential, feel safe regardless of the setting (home/hospital), and experience great satisfaction with the care. No crooked heads here.

In any physiological birthing relationship, there is room for only one birthing woman, one midwife, and one baby (at a time, in the case of multiples). If others are present with midwifery (or 'wannabe') skills; and 'others' may include midwives, lay birth attendants, doctors, alternative health practitioners, relatives, or even the labouring woman herself; these people must either step back from their professional roles, or work in harmony with *the* midwife. There is no place for different philosophies of care - they will make the baby's head go crooked.

Many midwife colleagues of mine, practising in the real world in which we live, tell me they would never intentionally attend a birth without a second midwife. There are many good reasons for the second midwife, including:
  • the possibility that mother and baby are both needing active midwifery interventions at the time of birth
  • a known midwife present if the other one is unable to attend
  • someone who will question or challenge practices if needed
  • 'tag team' if everyone is tired
  • a witness if something goes wrong
The first of these is perhaps the most compelling, and any midwife will need to address this possibility with the woman who is considering her choice of care providers for home birth.  What will be done if the baby is not breathing at birth, and the woman also requires attention?

In hospital births, and in some home births, the midwives have separate roles allocated - one for the woman, and the second for the baby.  If the baby needs resuscitation attempts to be made, the person who leads that is the second midwife.  The baby is often moved away from the mother to a resuscitation table in these situations.

When a midwife is working solo in the home, the woman knows that there is no second midwife.  If the baby needs resuscitation, this is done with the baby lying on his back on a towel on the floor, in front of the mother who kneels.  The umbilical cord is not cut.  The midwife also kneels, and has good access to the baby.  They work together, and the midwife is able to talk to the mother.  A baby who is born in a distressed state, not able to initiate normal breathing, may have a very slow, or absent pulse.  It's vital in this case that as the cardio-pulmonary resusciation proceeds, and the baby's pulse increases, the baby receives the full placental transfusion via the umbilical cord.  This will bring a proportionately large volume of blood, with the fetal haemoglobin that stores oxygen, perfusing the baby's central organs and brain, protecting the baby from hypoxia.  This, in my opinion, is a better model for initial resuscitation.

Women who plan to give birth under natural, physiological processes have access to natural, physiolocal support mechanisms.  The adrenal hormones that give the 'fight or flight' response are particularly valuable.  Not only does the mother experience a surge of adrenal hormones just prior to the birth; baby does also.  The mother gets a surge of energy, and her baby is ready to do what needs to be done.  Neither mother nor baby in the home birth situation have narcotics that would suppress their ability to respond, or to breathe.  Neither mother nor baby have synthetic oxytocics that would impede the mother's ability to expel the placenta safely without excess blood loss.

The safety and appropriateness of home birth is clearly demonstrable for women (and babies) who are well prior to the onset of spontaneous labour, and who progress without complications.

Saturday, June 11, 2011

Midwives and the battle of the bulge

A new draft National Antenatal Care Guidelines has been released for public consultation. The consultation period ends on 27 June 2011. The guidelines can be found here.

Today's health care world relies heavily on guidelines, and this document is being developed with government funding under the AHMAC priority to "Ensure Australian maternity services provide high-quality, evidence-based maternity care."

If anyone has had an opportunity to read through these draft guidelines, you will find much that is accepted as good practice, presented clearly and referenced. However we need to read with our critical minds switched on: otherwise there's no point in reviewing the draft. Midwives and doctors who provide antenatal care need to ponder the impact on our practices that they might have when they are approved.

Routine weighing at each antenatal visit
Please take note of
Recommendation 4: Routinely weigh women at each antenatal visit. Excessive or inadequate weight gain may have negative effects on the woman and the baby. (p vii)

This recommendation is rated as Grade 'A', which means "Body of evidence can be trusted to guide practice."

I put a question out about this to colleagues, via a midwives' email list. "Do you routinely weigh women at each antenatal visit?" It appears that there is a general consensus in the group that midwives do not currently weigh women at each visit.

It’s clear that obesity in pregnancy is linked to poor outcomes, and the midwife’s duty of care is around promoting health through good diet and weight management. Obesity is the big current focus of health promotion. However it appears to require a great leap of faith to believe that routine weighing in pregnancy will result in better weight management, and better outcomes.

As I remember being pregnant in the ‘70s, when everyone was weighed at every visit, women were harming themselves in an attempt to control weight gain. Some women were restricting their intake to the point were they were nutritionally unbalanced, leading to a lot of fluid retention, and pre-eclampsia. The doctors (bless them) were prescribing a diuretic (Lasix) to get rid of the excess fluid, which did actually give ‘better’ weight gain, but at what cost? The routine weighing potentially led to adverse effects.

The Draft Guidelines Appendix D (p138) gives the UK National Institute for Clinical Excellence (NICE) recommendations, that Weight and height be measured at the first appointment, and BMI calculated. Then this second recommendation:
“Repeated weighing during pregnancy should be confined to circumstances where clinical management is likely to be influenced. [C]”

This second recommendation from NICE has been summarily dropped for the new Draft Australian guidelines, with some review discussion around ‘new evidence’ associated with a high or low pre-pregnancy BMI that has emerged since the NICE (2003).

It would seem wrong to impose routine weight monitoring on all women, when the new evidence, even if it is grade 'A' applies only to those at the ends of the spectrum.

It's good that maternity services seek to "provide high-quality, evidence-based maternity care." BUT, any guideline that claims to be evidence-based, with an A-grade "Body of evidence [that] can be trusted to guide practice." needs to be just that. In this case, there is no evidence that routine weighing of all women will do anything to address obesity and ill health, or under-nourishment for that matter, or improve maternity outcomes.

Comments from readers are welcome. If you refer to something in the Draft Guidelines, please quote the page.

Readers will be interested in the Science and Sensibility blog entries and discussion on maternal obesity.  The writer, Pam Vireday's blog is Well Rounded Mama.

Friday, June 03, 2011

career in midwifery?

wet and happy after a job well done!
[Thanks Miranda for the pic.]
Click here for Miranda's comments Why I Chose Homebirth
A young woman is considering a career in midwifery.

She is drawn by the ideas midwives write about:
  • forming a partnership based on reciprocity and trust with each woman; 
  • learning how to work in harmony with the woman's own natural processes; 
  • promoting health in a holistic way; protecting the woman's birthing potential; 
  • and providing a smooth interface between primary maternity care and medical intervention when there is a valid reason to interrupt the natural process.

The young woman has some doubts, recognising a potential clash between her own views on western medicine and the mainstream health system. She likes the idea of working as a private midwife attending well women in their own homes, but she realises that there is a journey that has to be taken in achieving a midwifery qualification, with study and experience that includes the medical/hospital system. She writes:

I'm worried that the "system" wont change, if not become even worse. Do you think it's going to become easier or even harder to practice midwifery in the way that you promote? IE- do you think i'll always be paddling up stream or, is there light at the end of the tunnel?

I have brought this discussion through to the blog, because these are questions that many are asking.

A slogan from the International Confederation of Midwives is
"The world needs midwives now more than ever"

even though ...
  • The system may become worse.
  • It may become even harder to practise midwifery in a woman-centred way.
  • We may feel as though we are always paddling up stream.
  • We may not be conscious of light at the end of the tunnel.

It is idealistic and unhelpful for midwives to focus only on the strong, healthy women and babies: women who are able to give birth spontaneously and joyfully in their homes.

Midwives, and authentic midwifery practice are needed in mainstream health care, which in this country means hospitals. True midwifery is needed for the women and babies who can't afford a private service, for women and babies in developing countries where the rates of maternal and perinatal deaths are many times that in Australia. True midwifery is needed for women who know they will need caesarean surgery in order to have the best chance of being 'delivered' safely.

The current batch of challenges in Australian midwifery are the result of a socialist government's attempt to improve maternity care. Socialist policy does not value the individual's concerns or iterests in the way that many people in the free world understand to be important. Centralised government regulation of midwives and other health professionals is likely to lead to bureaucratic red tape that restricts some midwives and women in the way the want to give birth. It is likely that we midwives will feel that we are always paddling upstream.

Governments will change. Regulations and laws will change. Women continue to need midwives who are 'with woman', regardless of the laws, regulations, or philosophies of the government.

"The world needs midwives now more than ever"

Today I received by email the picture of Miranda, with her newborn baby, and permission to use it in blogs. What a beautiful reminder that, for each midwifery partnership, there is light at the end of the tunnel. There is new life at the end of the hard work. There is beauty, and hope. Thankyou, Miranda.

If you are interested in the state of affairs for private midwifery in Australia, and links to search for a midwife online, please go to the APMA blog.