supervision, part 2

Beautiful Brisbane, the city of my birth

continuing from yesterday's post, ...

[I have posted these comments on a social media site that might not be accessed by many of my readers, so have copied and expanded it here.]

A blog post by UK midwife-author-teacher Sarah Wickham, questioning the Australian regulation of midwives, provides comment on the UK model of supervision of midwives.

 
I share Sarah Wickham's concern, when midwives are subjected to "vexatious reporting and persecution in a number of ways, simply for supporting women’s choices."
 
Without pointing the finger at any person, and I wasn't at the recent homebirth conference in Brisbane, I think it's likely that Sarah has heard only a fraction of the story.  In my opinion there have been too many cases recently, some on public record, in which midwives have hidden behind a notion of the woman's choice, when in fact there was no discussion of escalation of care and appropriate intervention.  Midwifery partnership can only be achieved when the conversation between the midwife and the woman is ongoing, and informed *decisions* are made rather than choices.

An effective program of professional supervision of midwives could, theoretically at least, support the midwife in real time whose client is making an informed decision that does not follow usual professional advice.  This would apply whether the midwife was in private practice or employed in a hospital or other birthing facility.   The UK model of supervision of midwives is for all midwives.
 
A midwife can't afford to be a true believer, or to 'trust birth' in any idealistic way, even though we act to promote, protect and support normal birth and the physiological adaptation of the newborn to life out of the womb.
 
The setting/place of birth (home/hospital) has become an obstacle in this country to good midwifery practice, because privately practising midwives are restricted to homebirth.  The exclusion of PP midwives from mainstream hospital is not in the interests of wellbeing and safety of mother and baby, and probably contributes in complex (and unaccountable) ways to some adverse outcomes. The midwife's duty of care includes what we do in emergencies, and accessing medical (ie hospital) help in a timely manner. 
 
The introduction of the wonderful www, and social media, and digital communication ... has had a profound impact on some women's access to information about birth, and their choices. Anyone who remembers 20 years ago, when homes didn't have internet access, and mobile phones were great big clunky devices, will know what I mean. Now women tell me they have 'researched' their choices, as though it's done and dusted. The rise and rise of freebirthing is very much an internet phenomenon.
 
Please keep the conversation happening.

TWO YEARS LATER

It's two years since November 2010, when the Australian government announced sweeping maternity reforms that promised to give women a better deal in their maternity care.  The Report of the Maternity Services Review acknowledged that:

"... in light of current evidence and consumer preference, there is a case to expand the range of models of maternity care."

There are several posts on this site addressing the 2008 Review, and the subsequent recommendations and legislative reform.  For example, go to March 2010 Maternity Reform Hijacked, parts 1, 2, and 3; and the September 2010 one on Medicare funding: carrot or poisoned chalice.

Many midwives around this country have accepted the challenge, jumped through all the hoops, and achieved notation as Medicare eligible.  Our invoices for antenatal and postnatal midwifery services include the Medicare item numbers, and women are able to obtain Medicare rebate.  Some midwives are offering certain services at the Medicare bulk bill rate, which involves the swipe of a Medicare card in a little EFTPOS machine; the entry of a few details using the numbers on the machine, and the bulk bill payment shows up in the midwife's nominated bank account the next day.

The other major change that was brought about by the reform package was the ability of midwives to prescribe certain scheduled drugs: drugs that at present only a doctor can prescribe.  The first group of students in the Graduate Diploma of Midwifery from Flinders University are soon to receive their final scores for the Pharmacology exam paper, which we sat last Thursday, and which accounts for 50% of the mark.  For my journal as a student, go to this and subsequent entries.

On the positive side of the 2-year report of the 'reform' process we can record Medicare.  For example, Item number 82115, with a scheduled fee of $313.05 is

Professional attendance by a participating midwife, lasting at least 90 minutes, for assessment and preparation of a maternity care plan for a patient whose pregnancy has progressed beyond 20 weeks,...

[Health Insurance (Midwife and Nurse Practitioner) Determination 2011 - F2011L02162

]
The Medicare statistics website reveals that, in the 12 months October 2011 to October 2012, a total of $325,005 was paid out by Medicare for Item #82115.
The breakdown of amounts is (in order of magnitude):

Queensland $114,010
Victoria $63,944
South Australia $55,081
NSW $44,308
WA $40,720
ACT $3,241
Tas $2,912
NT $788

This is only one item number.  Other reports can be generated at the Medicare Item Reports site.


On the negative side of the leger, there are several points to note.  This list is my personal one, made from my experience.

1. Medicare Collaboration:
   It is becoming increasingly difficult in some areas to obtain collaborative arrangements that meet the requirements for midwives to provide Medicare rebates for women.
   
2. Access to practising in public hospitals: Despite expert multi-disciplinary committees and meetings and reports, it's clear that public hospitals do not welcome the idea of midwives practising privately within their confines.
3.  Access to practising in private hospitals: Are you kidding?
4. The homebirth problem: Midwives attending homebirth are doing so without indemnity insurance.  Surely the time of birth, regardless of place, is the very time when insurance may be useful. 
5. The future of private midwifery practice: I believe it is becoming more difficult over time to sustain private midwifery practice.  I believe some (probably well meaning) captains of the industry have an agenda to rid our society of homebirth.

Two years on, and the private midwifery profession is more restricted than it was previously.  There has been no expansion of the "range of models of maternity care" - the stated purpose of the maternity reforms.

*****

In conclusion, today I sat in a court room in Melbourne, as the case of complaints into the professional practice of a colleague was commenced by AHPRA.  The law under which the complaints are being heard prevents publication of the name of the complainant, and in this case the names of the women who employed the midwife have also been suppressed.

The legal inquiries and arguments will proceed over the coming days, and the midwife will eventually be told what findings have been made against her, and what conditions may be placed on her ability to practise her profession. [see MidwivesVictoria]

The issue that will, I believe, be at the centre of the case is whether a midwife is *allowed* to attend birth at home for a woman who has recognised risk factors.  The other side of that same coin is whether a woman who has risk factors, such as post maturity, previous caesarean, or twins, is *allowed* to give birth at home.  I have written *allowed* this way to highlight the statutory process that is being employed here, using the regulation of the profession to either permit or prevent certain activities, that are seen - rightly or wrongly - as 'operating on the fringe'.

I am not able in a blog to explore these issues fully.  I would like to make a clear statement that I consider the duty of care of the midwife who agrees to provide primary care for any woman, regardless of the risk status of that woman, to include the promotion of the wellbeing of mother and child, and where reasonable, the protection of spontaneous natural life processes.  The woman is the one who has the final choice on accepting or refusing any intervention.

The midwife practising privately brings skill and knowledge that may not be accessible or reliable in the hospital, where ad-hoc staffing issues often take precedence over the interests of the individual woman.

What progress have we made in the two years since the Maternity reform package was enacted?  Very little.  The only place most midwives are able to practise is the home.  The only way a woman can rely on a midwife is if she plans home birth.

BREECH

When I think about breech births the pictures that come to mind are women who I have attended for breech vaginal births, as well as a few other stories that have been preserved in my memory.

There's Sally, who gave birth unassisted to her 'feet first' baby one night in an ambulance.  I had palpated her abdomen that afternoon: head down, very mobile.  When she went to bed she felt a huge movement, and knew that baby had done a forward roll into a breech presentation.  She got up, went to the toilet, and as she sat down her waters broke, a foot and some umbilical cord presented.  Sally kept a cool head, gently put the loop of pulsing cord back into her vagina (to keep it warm), explained what had happened to her husband, who called the ambulance and me.  Sally's first baby had been born by emergency caesarean after finding that he was presenting breech.  Her second baby had been born (cephalic) at home in my care.  This was the third.

The paramedics arrived quickly, and they assisted Sally as she walked to the vehicle, pausing as she laboured strongly.  Sally told me later in detail how she waited for the head to be born, and supported her baby as he took his early breaths.  By the time I connected with them Sally and baby were resting at the nearby hospital emergency room.  After birthing the placenta, we went home again and had a cup of tea, with vegemite toast.

A few others of these mothers have already been written about in this blog.  [Thanks here to the blogger search function!]


In 2007 I wrote generally about vaginal breech birth, and the deskilling of midwives and obstetricians.  I noted that:

 The very real situation that presents itself today is the deskilling of midwives, and of obstetricians, in breech birth. A baby may be harmed or die simply because the midwife or doctor did not know what a more skilled person could have done to achieve the best outcomes.

In 2008 I wrote about The 'B'-Word, and told two breech birth stories, about one whose baby was born at home after ECV, and another mother whose baby developed a serious spastic brain injury from hypoxia, after abruption of the placenta some minutes before the birth.

In 2009 I wrote 'Thinking about vaginal breech births' in the leadup to the screening of a video 'breech in the system'.

In 2011 I wrote about normal birth for a breech baby, reflecting on the work of colleagues in bringing vaginal breech birth to the attention of the maternity professions and public.

In (March) 2012, reflecting on twin and breech births, I wrote about safer and better systems of care:

I am very distressed when women with twin pregnancies, or babies presenting breech, and their midwives, are so unable to trust hospital care that they see home as the only option. Home or hospital, spontaneous, managed, or surgical, there are no guarantees. The mother's choice of home or hospital for the birth of her babies is her choice, and she will face different challenges with each pathway.

“... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (ACSQHC National Action Plan, 2001).

Another memorable breech (first twin) birth took place in 2009, and has been noted in the post titled 'Why bother coming here if you won't let us manage you the way we think is best?' 
and the follow-up post 'Drive-through birthing'.


The purpose of today's essay is not just to collect stories, but to assert my belief that we can change, and put effort into making "our systems of care safer and better".  By "our systems of care", I include all aspects of professional maternity care, from the 'village midwife' primary carer, and the bush hospitals, to the big tertiary maternity units.

I believe this is happening.  Women's Healthcare Australasia and the University of New South Wales, Sydney have advertised a program 'Hands off the breech'[click here for speaker' profiles] to be held 30 November and 1 December.  Several of these speakers will be presenting their talks in Melbourne and Warrnambool in Victoria, also in early December - click here for program.  I plan to attend the session hosted by Monash Medical Centre - one of the 'big 3' maternity hospitals in Melbourne, and a strategic place to get the discussion about vaginal breech birth happening.

Social media is active in this regard, and many messages are being posted on a facebook site linked to the Breech Birth ANZ site.

For some, the changes are too little, too late.  Mothers have told me that they agreed to caesarean births for their breech babies because they were afraid.  Fear works against the protective intuitive forces in spontaneous birth.

Mothers have said to me, "Are you willing to attend breech births at home?"  That is a question that I can not give an immediate answer to.  I am committed to doing all in my power to protect the wellbeing and safety of mother and baby.  There are times when a breech birth (or twin) at home could come into that scope.  Other times there will be discussion and the decision may be made to go to hospital.

That's enough from me for today.  Thankyou for your comments.

PS
The following comment was left today (14 Nov 2012) on an earlier post about breech birthing.  I have included it here as it is relevant to the discussion:


motherwho (http://motherwho.wordpress.com/) has left a new comment on your post "THE ‘B’ WORD Breech. A woman today whose baby is...":

Hi Joy, thanks for writing this post! I enjoy reading your blog although this is my first comment.

My second baby was born last month (in Melbourne). My midwife first detected she was presenting breech at 29 weeks which was not a concern at the time, but as the weeks went on she stayed in the same position. At 36 and a bit weeks after much stress, acupuncture, moxibustion, massage, swimming, hypno-tracks, spinning babies.com, etc, etc, the little bub was still breech.

The hospital I had a [back up] booking at were most likely only giving me the option of an 'elective' caesarean (not really elective when it is the only option you are given?), so we went to another hospital and had a successful ECV. I went into labour spontaneously and had my baby girl at home last month.

I feel so lucky to have escaped the knife and terrified that it seemed to be the only option, had my baby remained breech, as we had decided we would prefer not to go ahead with our plan for a homebirth if she stayed in that position.

I still feel confused about the system we had to navigate and realise that if we had have been less educated we would not have questioned it. I can only imagine my recovery and the distress I would have felt now with a 5 week old baby and a toddler running around had things have been different.

My youngest sister is now a graduate midwife and I don't think she has ever seen a vaginal breech birth, nor has she been taught how to support a woman/baby should one arise under her care.

Definitely cause for great concern, in my opinion. 

Thankyou 'motherwho' for sharing your journey.

the death of a baby

I am writing with deep sympathy for the family who lost their baby in late 2010, and for the midwives and doctors who attended the mother.

I am writing about this because the Melbourne Coroner is currently hearing evidence from the various parties.  In time the Coroner's report will be published.  The Coroner's job is to find out what happened, in a respectful and unbiased way.  At present fragments of information have been published in newspapers and online news sites.  Some pieces of the information circulating in the media are factual, while others are contested.

I am writing because this case raises issues that are similar to a case that I wrote about a couple of months ago.

It is difficult for me to write.  I know the midwives; they are my colleagues, and we have shared in professional and personal journeys over the years.  I know the hospital; I have been there with women many times over the years.  I know the mother, who was a member of a peer support group I facilitated a few years ago.

The big issues as I understand this and similar cases are around a midwife's duty of care, a woman's decision-making, and the need for women to be able to feel respected in maternity hospitals.

The questions that I asked in my previous post are still pertinent:
"If a mother does not want to go to hospital, when overwhelming professional advice would want her to give birth in hospital, WHY?", and
"What can be done to make going to hospital a more acceptable choice for women for whom complex obstetric care may become necessary?"


I have many thoughts that I will not make public at present. 

safer and better systems of care

with my first baby 1973

Recently I have spent considerable time reflecting upon and writing about situations in which midwives face complaints of serious professional misconduct after attending home births.

See articles at the MiPP blog

Many of the complaints (notifications) that I am aware of relate to situations in which midwives attend women who have specific risk features of their pregnancy, such as having had caesarean surgery, or being classified as 'post mature', or having a breech birth or twins, for birth at home.

I do not want to seem to be guiding midwives to encourage 'at risk' women to see home birth as their only option. In my experience, a woman with twins, or breech presentation, or birth after caesarean, who is clear that she intends to hold onto 'Plan A' unless a valid reason is given for intervention whether she is at home or goes to hospital (with her midwife) to give birth; this woman will make an informed decision that she believes is in the best interests of her baby, her family, and her own wellbeing. This woman is enabled to take responsibility for her family's social, emotional, and physical health in a new way, in a special partnership with her midwife.

My personal approach to twins and breech births, after appropriate discussion and consultation, is to try to arrange support for a physiologically normal, unmanaged birth in a public hospital that has capacity for emergency obstetric intervention, if the woman believes that is the best way at the time of labour.

 This is not a simple task. It opens the door to a clash of opinion - medical vs social - in each situation. I wrote about that a few years ago - "Why bother coming here if you won't let us manage you the way we think is best?" - when a mother with twins near term followed my advice, and presented at the antenatal clinic of a large public hospital. She was told she had no option other than elective (scheduled) caesarean. The first baby was presenting breech. It's probably no surprise to readers that that mother rejected the advice of the big, well-equipped and well-staffed, public maternity hospital. We were able to engage the services of a smaller suburban public maternity hospital, and the babies were born one morning without incident, and the family returned home that afternoon - see Drive through birthing.

Another mother in my care gave birth to her twins at home. It was only after the first baby had been born, and the mother told me she was having contractions again that she placed her hand on her belly and said to me "Joy there's a lump here. Could it be another baby?" Yes, it could, and it was. By the time I had changed my gloves the second baby was ready to be born - beautifully!

Another mother in my care gave birth to her twins in hospital. The labour was powerful; mother knelt on the bed, and the first baby slipped out into my hands, cried, and went into mother's welcoming arms. The cord was clamped and cut to prevent any twin-to-twin transfusion. The mother's contractions returned quickly and intensely, and she maintained her crouched position, and passed the first baby to his dad. With the next contraction the second baby was born, about 6 minutes after his brother, with the placenta. The placenta had separated from the uterus (abbrupted) after the first birth and the second twin's life was immediately in danger as he had no oxygen supply. He needed to be born quickly, and he was. He revived spontaneously, without difficulty.

In telling this story, I am highlighting a situation in which the urgency for birth can be escalated in an instant, and specific action needed to protect, in this instance, a baby's life. After the birth of the first baby it is usual for the midwife or doctor to palpate the mother's abdomen to check the position of the second twin, and listen to the heart beat of the second twin. The mother, in this instance, refused to go onto her back, and proceeded very quickly, under natural intuitive knowing, to 'eject' the second twin. Had she been a compliant 'patient', and done as asked, and I believe it is possible that her baby's birth may have been delayed, with obvious negative consequences.

On the other hand, had there been no internal pressure to get that baby born, we would possibly have heard the slowing heart rate as the baby's oxygen supply quickly depleted, and an obstetric intervention to extract the baby would have been attempted. It's not helpful to speculate or ask 'what would have happened if?'. In this case the mother's decision to refuse a managed birth, which would have included epidural, was probably the factor that saved her baby's life, because she was able to do the job spontaneously.

I am very distressed when women with twin pregnancies, or babies presenting breech, and their midwives, are so unable to trust hospital care that they see home as the only option. Home or hospital, spontaneous, managed, or surgical, there are no guarantees. The mother's choice of home or hospital for the birth of her babies is her choice, and she will face different challenges with each pathway.

“... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (ACSQHC National Action Plan, 2001). 

The National Midwifery Guidelines for Consultation and Referral (ACM 2008) (the Guidelines) categorise women with twins and breeches as being ‘C’ (transfer). It is important to understand the place of the Guidelines in contemporary midwifery, and why after appropriate consultation, a woman and her midwife may chose to continue with the plan for homebirth.

The Guidelines were designed primarily for use across mainstream maternity services, outlining a risk management process by which midwives could act either autonomously, or in professional consultation with other maternity care providers, or by initiating transfer of care to a more appropriate maternity service. The Guidelines do not deal with situations in which women make an informed decision to seek out private midwifery services for home birth. The Guidelines do not deal with situations in which women choose care which is outside that which is recommended by the Guidelines, or by individual maternity care providers.

The Guidelines, in the preamble, indicate the purpose of these Guidelines, to address a significant gap that existed prior to their development, in helping “maternity services to meet national policy priorities aimed at improving the quality and safety of health care. When the Australian Council for Safety and Quality in Health Care launched its National Action Plan in 2001, its Chair Professor Bruce Barraclough argued that improving the safety and quality of patient care is one of the most important challenges facing health professionals: “... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (p 5) (emphasis added)

Systems of care that are safer and better than whatever Professor Barraclough referred to, and that are better than the system that told a mother "Why bother coming here if you won't let us manage you the way we think is best?", are systems that accept different levels of decision-making by different people.  A mother who values the spontaneous work of her own body in giving birth, unmedicated, to her babies, is a mother who the system needs to respect, and work hard to accommodate.

Systems of care that are safe and good for women and their babies will accept, at every level - not just the so-called 'low-risk' birth - that “Childbirth is a social and emotional event and is an essential part of family life. The care given should take into consideration the individual woman’s cultural and social needs." ICM Position Statement on Home Birth.

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. 

optimal space for birthing?

There is a special interest branch within midwifery and maternity care that overlaps with design and architecture disciplines, exploring the creation of optimal spaces for birthing. I have been reminded of this field of interest, when reading a recent post by my colleague and friend Carolyn Hastie, who writes the thinkbirth blog. Carolyn refers to, and provides a link to a presentation on optimal birth spaces by Maralyn Foureur, Professor of Midwifery at the University of Technology of Sydney (UTS). I wrote in the comments to thinkbirth:

I have seen some wonderfully designed spaces in which women can give birth. I have also seen women give birth beautifully (and, I would say, optimally) in settings that would seem to contravene every goal of the optimal birthing space ideology.

The woman's own nesting, which I believe is hormonally driven more than the result of intelligent planning and preparation, seems to be the key. Nesting can include the choice of setting, as well as the choice of people who make up that woman's birthing team. Nesting also enables the woman to change her plan if her situation requires it, without losing the ability to proceed normally.

I don't want to be critical of the optimal birth space ideology.

HOWEVER ...

The reality in my world is that each birth space is often very different from what the woman had planned or wanted, yet women are able to give birth in that wonderfully spontaneous way, without any regrets.

It would be naive to imagine that a woman's home is automatically the optimal birthing space for her.

I need to do a postnatal visit now, but hope to get back to this post later, and write some more.

[Melbourne readers may know that a private hospital in Hawthorn had recently set up a beautifully designed birthing facility, which has closed its doors after just a few months' operation, because the plan was not working, and there were too few women making bookings.]


NESTING and optimal birthing conditions
Nesting is one of those normal physiological functions that everyone knows about, but rarely pays much attention to.   While researchers have for a couple of decades looked seriously at the impact of the love hormone oxytocin, and the 'fight-or-flight' adrenal hormones, on the birth and mothering behaviours of laboratory animals, nesting doesn't seem to raise research interest or dollars.

A woman anticipating the birth of her child will usually have a 'to do' list, including stocking and preparation of food and other consumables, washing and setting out baby clothes, and packing a bag for herself and her baby in preparation for a stay in hospital, or 'birth kit' items in readiness for giving birth at home.  This process of getting ready would be recognised broadly as 'nesting'.  I have known some who feel the need to clean windows, and sweep, vacuum, and dust almost obsessively in the days leading up to the labour.  This is all intentional nesting, driven mainly by the woman's intellectual grasp of the enormity of the job that lies ahead.

With the establishment of spontaneous labour, physiological nesting becomes more pronounced.  Women who thought they would like to have the other children present for the birth of their sibling will often withdraw into a secluded space.  Women who have a plan to call a trusted midwife will often call her, just to check that she is able to come when called.  Nesting can continue until the peak of first stage, often called 'transition', when the woman must give up conscious control and surrender to the work of bringing her child out of her body. 

Women who plan to go to hospital to give birth face a nesting conflict.  It goes something like this:
"If I go to hospital too early my labour might fizzle.  If I stay at home I won't want to move when the labour becomes strong."  It's their natural nesting drive that makes them want to find the place where they will give birth - not the street address, but the actual room, with its contents, and the actual people with whom she will need to communicate.

Women who are booked at a modern hospital Birth Centre, where there are well-designed birthing rooms, often experience a conflict about the availability of a room.  They know that if the rooms are all in use when they arrive, they will be admitted to a standard hospital suite.  They have heard stories about how often this might happen.  Other matters of 'nesting' concern might focus on the times of shift changes in the hospital. 

I have, on occasion, been called to a 'planned' home birth, only to find that the woman and her home show no sign of nesting.  This dysfunctional nesting is, I think, a sign that the woman's sensitivity to natural instinctive urges has been in some way shut down.  The woman's labour can continue without nesting, and the baby can be born, "ready or not!"

Returning to the initial question of this blog: is there, and what is, an optimal space for birthing?
I would refine the question further, and add the word 'physiological' - the space for medically managed care in labour and childbirth must be very different from the space that enables and supports and protects physiological processes.  Here are a few ideals for that space:

• a place that the woman has chosen to be in
• a place that the woman is happy to continue in, as labour progresses
• a place where the woman can receive care, support, and guidance from a trusted midwife, and other chosen people
• a place where the woman is able to cover windows, dim lights, and make other physical adjustments when she wishes
• a place that allows the woman to feel private and unobserved
• a place where the midwife, as the responsible professional at the time, is confident that the wellbeing of mother and baby are being protected.

As with all other basic life events, "the best laid plans of mice and men ..."  There can be no guarantees.  The only people who we can be sure will be at a birth are the mother and her baby. 

The optimal space for physiological birthing in suburban Melbourne should not be very different from the optimal space for physiological birthing for Inuit women in Nunavik in the Arctic Circle.  The type of bed or birthing pool; the colour of the walls or the pattern of the furnishings - these things can be nice, but are of little significance to the woman giving birth.  The woman's feeling of unintruded privacy, as she reaches the point of surrender, knowing that her midwife is *with* her, is the essence of optimality. 


Your comments are very welcome.

midwives in the making

(c) Picture used with permission

Yesterday I had the privilege of presenting a 1.5 hour talk on private midwifery practice to the midwifery students at Deakin University in Burwood. I love having the opportunity to inspire the next generation of midwives.

I know some visitors to this blog are studying midwifery, in many countries. In today's post I want to give you an outline of my presentation, and links to some of the key documents.

The parts of the presentation were:

• Overview and introduction: developing a strong 'midwife identity'
• Private midwifery practice, changes in legislation with Medicare rebates and other changes for eligible midwives. Go to Midwives Australia for more information and links
• Planning for birth: philosophy of birth based on the statement that "In normal birth there should be a valid reason to interfere with the natural process" (WHO 1996); decision-making concepts of 'Plan A' and 'Plan B', birth preparation meeting handout
• DVD of a beautiful home/water birth [One picture used here with permission - the visual image is sooo powerful!]
• Highlighting aspects of midwifery practice that can apply only when the whole labour progresses under natural hormonal, unmedicated processes: physiological third stage, and baby's transition from the womb
• Questions

Please follow these links if you are interested in the topics mentioned. I intend to prepare a post on 'Planning for birth' at my private midwifery blog - will do that as soon as I can.

For the record, my relationship with the Deakin University School of Nursing and Midwifery is that I am employed as a casual lecturer, and as a tutor and marker for some of the midwifery Professional Development Unit Learning Packages. Several years ago I prepared one of the Learning Packages on the midwife in the community (PDU 323) and more recently I have written a Learning Package on Caseload and Homebirth midwifery, which is being processed in preparation for release.

"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.