midwifery: protecting health across generations

Maria Lactans (17th Century) Antwerp

One of the truly compelling reasons that I have for practising midwifery the way I do is the knowledge that there is no safer, no better way for a baby to be born and nurtured than the way our bodies have been wonderfully created to do it.  The marvels of science and medicine have not come up with a better process.  

I'll call it NORMAL birth: normal from a biological, physiological perspective in ideal conditions.
Not what *normally* happens today.
Not what is most common in birth today, or 100 years ago, or in a primitive society .... 

NORMAL birth requires a strong healthy woman who carries her pregnancy to term, and comes into spontaneous labour.  It requires the mother to accept and work with her body in labour, and to progress, without medication, to the climax of birth.  It requires the mother and baby to work together in establishing breastfeeding, within a nurturing family-community setting that supports the mother in these challenges.

This 'ideal' is what a midwife seeks to facilitate. "In NORMAL birth there should be a valid reason to interfere with the natural process." (WHO 1996)

At any point in the process we can face challenges, complication, illness, and the need to intervene.  That's when science, medicine, obstetrics ... become life-saving.


There are obvious and unquestioned benefits to a mother and her baby when the NORMAL processes are protected, promoted and supported.

• A mother's body and mind respond in unison to the changes in hormones in her blood, as she prepares, and progresses.  
• The mother's thinking brain is suppressed, in a quiet and unstimulating environment where she does not feel that she is being observed, so that her instinctive mind is free to proceed with the final nesting, and the surrender that accompanies strong labour.  
• The baby is born alert and healthy, ready to engage in the instinctive breast crawl as breastfeeding is initiated.   
• Early and effective suckling at the breast, together with the physical pressure of the baby's weight against the mother's uterine fundus, lead to strong contractions and completion of the third stage.  
• Once the placenta and membranes are completely expelled the risk of haemorrhage is minimised, and continuing breastfeeding supports the involution of the uterus.  
• Close physical contact from the time of birth supports the development of normal bacterial flora on the baby's skin and digestive organs, preparing the baby's immunological processes for ongoing function.  
• Bonding between a mother and her newborn proceed as they make eye contact, with uninterrupted close contact, and the mother's body is awash with love hormones.

I have not mentioned the midwife.  Yes, the midwife is present, working in harmony with the NORMAL processes, and guiding and supporting when things get difficult, but staying quietly and unobtrusively out of the limelight.  The midwife is guardian - protecting the mother and her child, and providing a safe space for them in NORMAL birth.

When there is a valid reason to interfere with the natural process, the midwife guides the woman, and provides appropriate explanations.  The midwife seeks only the health and wellbeing of mother and child.


Today I am looking further than the primary episode of care, spanning the nine months of the pregnancy, and the six weeks of the postnatal period.

I am looking at future generations.


The study of epigenetics: "the study of heritable changes in gene activity that are not caused by changes in the DNA sequence" offers huge challenges in health care, and particularly at the beginning of it all; conception, pregnancy and birth.  Emerging within this field of science is a new respect, for example, for the effect of nutrition during a woman's pregnancy on the health of her grand-children - the children of the child forming in her womb.

I have no claim to expert knowledge in biology, but would encourage readers to keep exploring this field.

Our bodies are wonderfully made.

I have recently become aware of a new film project,
micro birth

"MICROBIRTH" is a feature-length documentary looking at birth in a whole new way, through the lens of a microscope.
The film explores the latest scientific research into the microscopic events that occur during and immediately after birth.
This compelling, brand new science is starting to indicate that if the natural processes of childbirth are interfered with or bypassed completely, this could have devastating consequences for the long-term health of our children.
Just to be clear, this film is not calling for an end to interventions as many times they are essential and they can be life-saving.
But as this new science is starting to indicate, the use of synthetic oxytocin to induce or speed up labour (Pitocin / Syntocinon), antibiotics, C-section, the routine separation of mother and baby immediately after birth and formula feeding, could significantly raise the risk of our children developing serious disease later in life.
And as the film shows, the medicalisation of childbirth could even be contributing to a potential global human catastrophe predicted to happen by the year 2030.

...

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.

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.