Another reflection on practice

Photo used with permission

The mother in this picture, Cynthia, gave birth at home to her second child at home against medical advice. Her first child, born at a Birth Centre, had been too large, and she was told she had bled too much, so she was not permitted to book at the Birth Centre for her second birth: the advice was that she would require obstetric management.

This is a not uncommon situation, even when 'alternative' birthing services, such as midwife-managed birth centres, are accessible. It presents a challenge for midwife as well as mother, as we find our way through the often unpredictable terrain of pregnancy and birthing. Yet it could be argued that all home births are against medical advice.

Cynthia gave birth to baby Willa at home, early in the morning, as the first light of the new day filtered through the glass above the door on the Eastern wall.  I hold that memory of hushed ecstasy, as we who were witnesses to the miracle of birth watched the mother welcome her newborn daughter.

Cynthia has given me permission to use this beautiful photo, and to use her name as I tell a small part of her story. I am taking the opportunity to reflect on aspects of this birth, and the conversations I had with Cynthia in the months before the birth. Cynthia was strong in her resolve; she had discovered within herself a deep and precious knowledge of her birthing potential, and she asked me to accompany her through the most demanding part of this birthing journey.


With this recent birth in mind, I have been delighted to start reading a new book The Heart in the Womb, by Amali Lokugamage, an obstetrician who defied her profession's wisdom and gave birth to her son at home in the UK.  Amali writes:

I was prompted to write about this very personal experience because, prior to my pregnancy, I was never fully able to understand why a woman would actively choose to give birth at home, outside of a hospital safety-net." (p6)

The idea that being in a hospital for every birth provides a safety-net is one of the great 'lies' under which most Australian maternity services operate.  When a woman discovers her own strength, she arranges her life so that she will not be denied that potential when she is at the peak of her labour.  She chooses her team: midwife, sister, friend, and lover - each in a different partnership relationship with her, and each fully committed to being with her.

I cannot teach a woman how to discover her own innate birthing potential.  It is truly a discovery that she makes as she welcomes the hormonally mediated activity that her body leads her through.  I cannot predict who will progress unassisted to an ecstatic birth; who will gently guide the head of her own baby across the threshold of totally streched perineal tissues; who will enjoy that amazing dance of the breast crawl, and feel the pressure as the placenta presents for expulsion.

But I can reflect on my own memories of my birthings, many years ago, and I can confidently accompany women who are willing to engage in trust and reciprocity, and explore their own journeys as they give birth to their babies.

more thoughts on the birthing space

I have appreciated the recent thought-provoking discussion in connection with the previous post in this blog, which is also linked to Carolyn Hastie's thinkbirth blog.

In the past couple of weeks I have attended three births; two at home and one in hospital. These three mothers were 'first timers'; primipara; a special category worthy of consideration in any maternity setting.

Picture this scene:

A woman is labouring strongly and consistently in an inflated birthing pool, set up in her home.  It's 2 or 3 in the morning, the 'wee hours', when everyone is overcome by weariness.  Her man, whose sleep was interrupted by early labour the previous night, is asleep on a couch.  The midwife is nearby - within reach but dropping off to sleep between contractions, occasionally mumbling words of encouragement.  The student midwife is stretched out on another couch. There is a little light from a lamp or candle; the birthing space is quiet except for the sounds of the labour.  

After some time, the woman's sounds become deeper.  Her midwife encourages her "let your baby come down deep in your body; feel the fullness; you're doing well", and listens to the fetal heart after a contraction.  The woman does not notice that the 'period pain' she had been experiencing has gone.  In fact she has stopped thinking about her labour and has surrendered to the work that her body is doing.

By the time the early signs of daylight are peeping through the cracks in the blinds, the urge to push has become strong.  Daddy-to-be and student midwife are awake; midwife is awake and ready; and mother gives birth, through the water, to her first child.  Mother and child complete the mysterious dance of birth, as baby searches for the breast, and the placenta is expelled.

Today I would like to reflect on recent primipara births, and (without identifying individual women) discuss how the birthing space has supported these births. In the past 18 months, approximately, I have attended 10 women giving birth for the first time. 

Before looking at the birthing spaces, here is an overview of these births.  Of the 10 women:

• 10 came into spontaneous labour; which became strong as the night progressed (there's something special about night and birth!)
• 5 gave birth in water: 4 at home; 1 at hospital
• 2 planned hospital birth; both gave birth spontaneously to healthy babies
• 8 planned home birth
• 5 gave birth at home to healthy babies, without complication
• 3 who planned home birth transferred from home to hospital in labour
• 2 proceeded to spontaneous unmedicated births of healthy babies
• 1 was delivered of a healthy baby by emergency Caesarean surgery

The ages of these women ranged from 24 to 37.
The length of gestation ranged from 36 to less than 42 weeks.
The weights of these babies ranged from 2670g to 4250g.
All babies breastfed from birth.
The estimated blood loss for the 9 women who gave birth spontaneously ranged from 100 to 600ml.


I want to make a point here, which may be obvious to some, yet others may find it a challenging statement in the maternity environment in Australia.
Place of birth - home or hospital - is not a measure of good midwifery care.
Yet the decision to plan homebirth is a huge statement of intent, by the woman, that her plan is for spontaneous, unassisted, unmedicated birth.  Those who plan homebirth with an experienced midwife are able, I believe, to proceed down the path of physiological birth if that is feasible, with a high degree of safety.  Those who plan homebirth, then make an informed decision to transfer their care to hospital because there is an indication - a valid reason - are also able to protect their ability to give birth in harmony with the natural, hormonal, physiological processes that direct labour, birth, and the baby's transition from the womb to the outside world. 

In my previous discussion on birthing spaces I wrote about the physiological phenomenon of *Nesting*.  Understanding normal birth in terms of nesting, as the woman progresses under the influence of an amazing cocktail of hormones, provides a key to the mysteries of birthing.  Nesting supported each of these 10 women, as they came into spontaneous labour.  Nesting supported the three who made a decision in labour to move from home to hospital, and obtain special medical intervention that had become necessary for them.  Nesting supported the choice of position for birth, whether kneeling beside the bed, or squatting in the birth pool, or lying on the bed.

Cessation of nesting happens, I think, when the woman is able to surrender to the huge expulsive urges within her body.  Baby is "coming, ready or not".  Night time and weariness enables this transition to occur without question.  The woman, and her personal support team, have given up trying to understand what's going on; to do it the way they were taught in class.  The midwife is skilled at keeping watch, guiding when needed, without taking control from the woman.

The essential elements of the space for optimal birthing are few.  As long as the woman is able to proceed without interruption; as long as the woman is able to trust her midwife; as long as the woman and her support team are able to hold confidence in the process of birthing ...

... a baby is born.

It just happens.



Your comments are, of course, welcome.

Reflecting on progress in midwifery

Hello Grandpa!

When I studied midwifery (in the early 1970s) we learnt about the hormones in the menstrual cycle and the physiology of conception. We learnt about FSH and LH and oestrogen and progesterone and testosterone. We knew that oxytocin existed, but it was just the hormone the caused contractions of the uterus. The synthetic copy of oxytocin, Syntocinon, was used liberally as it could be measured and given in a 'scientific' way. I don't know if oxytocin crucial role in milk let down and love making was mentioned. The action of endorphins as natural opiates, and adrenaline and nor-adrenaline were part of that complex mystery waiting to be better understood. I don't remember any mention of bonding or maternal behavioural adjustments.

When Noel (my husband for the past 37 years) studied veterinary medicine in the late 1960s he learnt the same physiology. Vets became fascinated with the world of artificially managed conception, ovum transfer, and surrogacy in the world of producing the fittest and most highly desired offspring.

Noel's Masters and PhD research explored the protective effect of colostrum in the newborn calf. He showed that colostrum protects the calf against diarrhoea (scours) and septicaemia (blood poisoning) in the early days after birth. This result sounded obvious to me, but was important scientific knowledge at the time. My journying with him through academic processes, including the literature review and carrying out the research, informed me a great deal and opened my mind to critical thinking.

... move through time to today.

Noel and I are now doting grandparents. We have seen huge changes in our own understanding of the physiology of all things to do with childbearing, reproduction, and a human mother's ability to love and care for her child.

Acquiring knowledge of natural physiological processes in childbearing and nurture of the infant has been a fascinating journey that has, for me, absorbed my mind over most of the past three or four decades. It's an incomplete process.

As long as I am able to call myself a midwife I will have a duty of care to promote normal birth. I hope that midwives around the world will also claim that purpose.