more about choice, decisions, and 'the birth you really wanted'

From time to time, as I read social media sites used by mothers, midwives, and others interested in the whole childbirth package, I come across messages such as:
"I was prevented by ... from having the birth I really wanted," or
"I'm so glad you got the birth you really wanted."

Women who feel physically and emotionally traumatised by experiences in previous births declare that they won't go near the hospital, because that's where and why it all happened the way it did.

More and more women are telling me that they are planning to give birth at home without professional support for various reasons - can't afford a midwife; no midwife or publicly funded homebirth program in the area; too 'high risk' for the midwives in the area ...  This really concerns me - it's scary!

Homebirth has resurfaced in the local media recently, with an article by Sydney midwives, Karol Petrovska and Caroline Homer, Beyond the “homebirth horror” headlines: some wider questions for the health system (and media).  This article was responding to a 'news' article on the mamamia blog, titled 'A hospital birth would have saved Kate's baby'.

The Coroner had identified internet-based research of risk as being central to the mother's choices and decisions in this instance
‘‘[This is] an example of the danger of untrained users utilising raw data or statistical information to support a premise as to risk, without knowledge and understanding of the complex myriad of factors relevant to the risk’’.[report]

The Coroner also found that delay in transferring care from home to hospital, after it should have been apparent to the midwives that Kate's baby was in distress, contributed to the death.

Midwives hold to a theory of 'partnership' with each woman in our care.  The midwife-woman partnership has been incorporated into the ICM International Definition of the Midwife.
This partnership, when correctly applied, places the woman at the centre of all decisions, with the intention of protecting the wellbeing and safety of mother and child.

Today I would like to briefly comment on the midwife-woman partnership, especially as it applies to choice, decisions, and achieving 'the birth you really wanted'.


Independent midwives, employed directly by women for birth in their own home, are in a privileged position because we are able to apply midwifery skill, knowledge and expertise directly without being hampered by the levels of bureaucracy and policy and protocol that exist in hospitals.  Women who are low risk and who plan to give birth at home with a midwife in attendance are in the most optimal maternity care situation that exists today.  A large study (de Jonge et al 2013) comparing maternal outcomes from (low risk) homebirths with a comparable group of (low risk) women giving birth in hospitals in the Netherlands concluded that:

"Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system."

Independent midwives practising in Australia are often asked to attend births that are not in the low risk category.  Women who are older, fatter, who have had a lot of children, or caesarean births, or who have been traumatised in previous births often seek a midwife who will plan homebirth with them, particularly those who want to avoid the hospital.

There is no calculation table that lists risk factors against chance of having an uncomplicated vaginal birth - and if there were, I doubt that it would be of any use.  The current 'odds' for serious adverse complications (such as death of a baby, or serious maternal haemorrhage from uterine rupture) in vbac is estimated at 1:2000. [for more on safety of vbac, click here]   There is no comparable statistical estimate that ordinary people face in daily living.  People who bet on horse races may have some understanding.  1:2000 seems remote, and meaningless.

A more useful guidance would be to define at what point in time does actual risk, rather than theoretical risk, escalate.  This appears to me to be a question that was not thoroughly explored in the tragic case referenced at the beginning of this post. This clinical judgment is within the scope of a midwife's practice.  Spontaneous, unassisted birth becomes less safe if there is anything that indicates compromise of the mother or the fetus: complications of pregnancy, including raised blood pressure or impaired glucose tolerance; prolonged pregnancy; antepartum haemorrhage. Complications of labour including poor progress over time; and fetal heart rate decelerations or other abnormalities.

When 'the birth I really wanted' focuses on place of birth, or even on the process of birth, a significant number of mothers are going to be disappointed.  A midwife cannot become so committed to homebirth, or natural birth, that she forgets to keep a keen, critical eye on what is actually happening.  There are a couple of significant hurdles that a woman needs to get over before the spontaneous, unmedicated homebirth can even be considered. These are:

• spontaneous onset of labour, and
• spontaneous progress in labour - to the point where natural expulsive forces can be applied.

As it happens, there is no safer way for most babies to be born, than for the mother to do it herself - spontaneously - irrespective of place.  Not with herbal stimulants or acupuncture or coaching or hypno/calm birth education or pelvic manipulation or olive oil being rubbed into the perineum, or the best midwife in town.  Spontaneous is from within.  As labour progresses, a mother's capacity to judge progress and safety decreases, as her calculating, educated mind closes down to permit intuitive activity from deeper brain structures.  As this altered state of consciousness becomes strong, her midwife maintains a skilled, watchful vigil.  A mother cannot do this for herself.

The midwife's role is clear: if the mother and baby are coping well with spontaneous labour, no interruption or interference is permitted.  On the other hand, if warning signs are present, the midwife's ongoing clinical judgment and assessment throughout the birthing process protect the interests of her clients, both mother and baby.

You might have a birth plan for 'the birth I really want'.  Please check that birth plan, and check with your midwife, to ensure clear decision points.  While you are able to spontaneously progress through labour and birth, the physiological process is magnificent.  But, if there is a valid reason to interrupt the natural process, be ready to get the best birth possible, using the best and most timely intervention that is accessible at the time.

'The birth I really wanted' is above all, one that protects my baby and myself.   

Thankyou for your comments.

hospital policy in the spotlight

Today as I write I have in mind a young midwife who is employed by a busy private hospital in Melbourne.  I hope that midwife comes to my blog, and reflects on the incident that I witnessed recently, and which I will briefly describe here.

The labouring woman had written a brief birth plan; the sort of plan that I call "Plan A".
Something like this:

I am intending to give birth under my own power, and will do all I can to achieve the best outcomes for myself and my baby.  At the time of birth, my baby’s cord should not be clamped or cut, and my baby must not be separated from me, except for clear medical reasons, and with my consent.  
I do not want any drugs to be administered to me or my baby without my consent. ...

"Yes, we do 'skin to skin', we do 'delayed cord clamping', and we keep babies with their mothers."
"But we can't do physiological third stage."
"The problem is," the young midwife said, "It's hospital policy that you have syntometrine.  I have checked with my manager, and we have to give you syntometrine for the placenta.  It's hospital policy."

The mother was labouring, wasn't saying much, so nothing was resolved.  The midwife brought the tray containing ampoules of the oxytocics into the room.

... fast forward  ...

A healthy baby made his grand entrance, and no drugs were used.  The woman birthed her placenta spontaneously about 30 minutes after the birth, with minimal blood loss.


I am recording this brief account because I want to comment on it.

• A midwife became the pusher and enforcer of a hospital policy to administer a particular drug preparation.  This is not midwifery.  There was no professional discussion offered as to the implications of the use of this drug for mother or baby.  The midwife simply acted as an agent of her employer, demanding compliance with this policy.  
• A midwife failed to recognise or uphold a woman's right to informed decision making, and ultimately her right of refusal.

I feel very concerned for this midwife, who is at the beginning of her career.   It seemed clear to me that the midwife considered it her job to enforce the policy.  The midwife gave no indication of any understanding of or interest in the physiology of birth.  Rather, she seemed set on carrying out a series of tasks that were, apparently, the essence of her professional practice. 

The midwife appeared to be ready to ignore a written statement by the woman, that she intended to give birth spontaneously, without drugs.  There seemed to be an assumption by the midwife that the woman's choice of working in harmony with physiological processes and avoiding unnecessary medications was a choice that could carry no weight in that particular hospital.   There was no discussion of the potential benefits or risks of either course of action.  'Hospital policy' was the big flashing light that apparently barred the woman from attempting her plan of action.

The prophylactic use of oxytocics in the third stage of labour, 'active management of third stage', is a process of routine intervention that comes under the banner of the 'evidence based practice' movement.  The uncritical adoption of active management by most hospitals, with the belief that it reduces blood loss and thereby reduces maternal morbidity, is rarely questioned.

In this birth, the mother was ideally suited to unmedicated, safe, physiological third stage because the following requirements had been met:

• a woman in good health
• at term
• spontaneous onset of labour
• good progress in labour
• uncomplicated, unmedicated first and second stages of labour.

In contrast, there are good reasons why one might seek to avoid use of Syntometrine. 
Syntometrine is a preparation that combines synthetic oxytocin with ergometrine.
Syntometrine is an S4 drug - restricted to prescription by a doctor or an authorised midwife prescriber.  The idea that a hospital would make policy requiring the use of a restricted medicine is in itself suggestive of a breach of the basic rules of prescribing. 

Follow the link above to read consumer information about Syntometrine.  One small sentence stands out:  

Tell your doctor if you plan to breast-feed after being given Syntometrine. One of the ingredients in this medicine secretes into breast milk. Your doctor will discuss the potential risks and benefits involved.  (http://www.mydr.com.au/medicines/cmis/syntometrine-solution-for-injection )

Breastfeeding is an intrinsic part of physiological birth.
 
Further information on the use of Syntometrine in lactation comes from MIMS, the widely used medicines reference resource:

Use in lactation Of the two components, only ergometrine is known to pass into breast milk. The use of Syntometrine during lactation is not generally recommended.
Ergometrine is secreted into milk and the inhibitory effect of ergometrine on prolactin can cause a reduction in milk secretion. Syntometrine has the potential to cause serious adverse drug reactions in breastfed newborns/ infants. Postpartum women receiving Syntometrine should avoid breastfeeding at least 12 hours after the administration. Milk secreted during this period should be discarded.  ...

How many mothers are given this information prior to administration of Syntometrine?  Very few, I think.

I hope readers see the point I am making.  Today we are advocating a return to spontaneous breech birth, returing to the woman and her baby their right to unmedicated physiological birth.   Perhaps we also need a group of intelligent, well motivated consumers, to become activists for umnedicated, uninterrupted birth, from the onset of labour to the completion of the expulsion of the placenta and membranes and cessation of bleeding.


Your comments are welcome

The midwife

I have been enjoying the BBC series 'Call the Midwife', which has been shown on Australian ABC TV.  This week we will see the fifth and final episode in the series.

(If you go to You Tube you can apparently download and watch the full first series.)

Since I began writing my stories in the mid 1990s, in The Midwife's Journal,  I have hoped that I am setting down on the record something of the essence of midwifery, within the context of ordinary life, so that it is available to future generations of midwives, and anyone else who is interested.  The discipline of writing down the stories as they happen must have been similar for the writer, Jennifer Worth, who journaled her experiences in London in the 1950s.

Last week I wrote about women's rights in childbearing.  This is a very important topic, but is likely to lead to a skewed view of birth, unless there is an equal emphasis put on the midwife.  The partnership of midwife and woman, working in harmony with sensitive natural physiological processes, is precious, but easily disrupted.

Just as without a strong healthy mother the baby is unlikely to thrive; without a strong, confident, and capable midwife, the woman is unlikely to progress safely along the pathway to birth: a mystery journey each time.

Today's world offers women a potentially overwhelming burden of knowledge about aspects of birth, without preparing a woman for the real job, which includes giving birth and nurturing their young.  Women are bombarded with an array of mainstream and alternative treatments, for their bodies, their minds, their relationships ...
By the way, I am referring to the woman, because only the woman can give birth.

A woman (or couple) may attend childbirth education classes at a hospital, independent childbirth education, exercise classes on balls, exercise classes in a yoga studio, exercise classes in the local swimming pool, and video sessions with commentaries by consumers, professionals, and lay activists to name a few.  They may follow pregnancy-birth related social media groups and forums.  She may see her primary maternity care provider for basic check-ups, as well as a naturopath and homeopath and acupuncturist and chiro or osteo or any number of other therapists and healers, each of whom offer to have some part of her body in tip-top shape for the big event, but none of whom can offer what the midwife does.

I said it's a potentially overwhelming burden of knowledge about aspects of birth.  I rarely see women coming to birth with calm confidence in the wonderful processes that our minds can not fully grasp no matter how hard we try.  I see a father anxiously coaching the woman who is carrying his child, telling he how to move or what to relax.  I wonder where he obtained this knowledge.  I hear recorded voices of unknown strangers who guide visualisation of climbing a mountain or a flower opening.

One mother who gave birth about a week ago had confidence.  I have been with her for several of her babies.  She is a beautiful, gentle woman who invests herself fully in her family, and avoids the public gaze.  Her preparation for birth included good food, adequate rest, and work about her home.

As the labour became strong this mother withdrew from her children, knowing that they were all in bed and quiet.  I rested on the couch.  Then she invited me into her bedroom: "it won't be long now," she told me.

Quietly and steadily she guided her baby down and out.  There was a cry as the little one's head passed over the perineal threshold - the older children said they heard it.  Shortly afterwards there was another cry, as the newborn took air into her lungs and made that amazing transition from placental to lung circulation.  The third stage proceeded without the need for any medical intervention, and there was minimal blood loss.  When I visited this mother she was sitting outside in the gentle spring sunshine.  I saw a well mother, with a well baby at her breast. 


In telling this story I have not mentioned the buzz word of the day: collaboration.  Those in authority today will insist that collaboration is the key to safe maternity care.

Yes, there was a collaborative arrangement in place, a letter of referral from a suitably qualified doctor, enabling this mother to claim some Medicare rebate on my fees.  The birth plan was, as is usually the case in primary maternity care for planned homebirth, to proceed under normal physiological conditions, working in harmony with the natural processes, unless complications were to arise. We planned to go to the nearest suitable public maternity hospital without delay for urgent obstetric concerns, or to refer to a local doctor for non-urgent medical indications.  This is basic midwifery.  The baby is born safely; the mother recovers quickly; all without medical (or midwifery) intervention.


Thankyou for your comments.

Planning for birth

I have updated my little booklet, Planning for birth, which I have used for many years as a handout for women who visit me, making inquiries about having a baby, and for midwives and students of midwifery.

This booklet is self-published, and copies are printed as required. Readers who would like like a .pdf copy, please request by email joy@aitex.com.au [I have not hyperlinked this email address, as that may invite spam] I am happy to share my work. If you want to use copyrighted items such as the poem 'waiting' on page 8, please give reference.

waiting

You are waiting to give birth.

Your pregnancy is a statement of your wellness, life and strength.  New life is swelling your womb. 
 

You and your mate accept the gift of life with eager anticipation.

Your body tells you that change and growth are following nature’s course.   The cessation of your menstrual flow, the desire for good food and rest, the enlargement of your breasts - all external - accompany the private dreaming.

As your midwife I am committed to supporting you and your family through this wonderfully basic life event - the birth of your baby - your personal, intimate celebration of life and health.

 ©Joy Johnston

The pages of the booklet are also scanned here - 4 sheets with 2 pages per side.