the myth of choice

1983 - working night shifts a the Women's

For a couple of decades now, *choice* has been a pillar of the natural birth movement.

An organisation that I am a member of has the vision, that
"Every woman can choose how, where and with whom she births."

This vision has troubled me for some time.  Today I am attempting to critically explore the notion of choice, and whether it is desirable or imaginable that every woman choose "how, where and with whom she births."


Firstly, some historical considerations:

• The Fortelesa (Fortaleza) Declaration (1985) on appropriate use of technology in birth challenged interventions, from shaves and enemas, to inductions of labour.  This seminal document also declared that "The whole community should be informed about the various procedures in birth care, enable each woman to choose the type of birth care she prefers".  *CHOICE!*
• Changing Childbirth in the UK (early 1990s) declared that women want the 3C's: *choice*, control, and continuity of care.
• A call for *choice* of place of birth (home/hospital) and care provider (such as individual midwife or the maternity system) was clear in the Australian National Maternity Action Plan (2002).

At the same time,  twenty years ago,

• emerging trends in medical research led to the Cochrane Collaboration, defining the reliability of evidence;
•  UNICEF and World Health Organisation introduced the Baby Friendly Hospital Initiative, with a key document being the Innocenti Declaration  of 1990. 
•  various state and territory governments around this country were conducting broad reviews into birthing services, and producing their reports. (eg Having a baby in Victoria 1990)  These reviews sought consumer comment as well as professional.
•  WHO prepared a series of basic publications on maternity care, including Care in Normal Birth: a practical guide (1996).  This document brought a consensus statement that "In normal birth there should be a valid reason to interfere with the natural process"

During the past two decades the world has experienced the digital revolution.  Twenty years ago, in 1994, few households had computers: the world wide web and email had only just been invented.   This phenomenon exploded communication and access to reliable information.  Our home went 'on line' in the early 90s, with a (very slow, and unreliable) dial up connection, and we were leaders in the field.   Prior to that, if I needed to send an email, I would ask my husband Noel to send it from his office at the university.  He kept up with the expansion of knowledge via inservice education, and a very helpful secretary, Jean.  He became the 'IT' expert in our home, until our children absorbed the knowledge and quickly spoke the language, as children do.  (but I have digressed from my topic!)

Twenty years ago, professional peer reviewed scientific publications were held in libraries, and accessed by scholars and the intelligencia.  Today, there is an inexhaustible wealth of knowledge at the tip of our fingers, from our computers, tablets, and phones.

Twenty years ago, information about natural childbirth was passed from teacher to student couples in highly motivated childbirth education.  Today women join social media groups where they share everything from their nausea and indigestion, to ultrasound pictures.  These groups, as well as personal blogs and microblogging, have introduced a degree of sharing of opinions, and introspection ('navel gazing'), that would have been unimaginable when person to person communication was limited to a telephone or over the back fence or a tea room at work.

So, what about choice?

In discussing choice in childbirth with colleagues and other interested folk, I have been a little surprised to observe that the woman's right to decline (a treatment/intervention) is often perceived to be the same as a choice in maternity care.  A woman's autonomy in any care situation (whether it's her toe nails or the birth of her child) is often limited to the little word "No!"

By way of example:

Jill is in hospital, in labour with her first baby.  Jill has been told she needs a Caesarean, because she has been labouring without adequate progress, and the doctor is concerned that her labour is obstructed and her baby is becoming distressed.

Jill does not want a caesarean birth, but she has no other options at this time, other than to do nothing, and that may lead to injury/death to her baby.  She has planned for a natural birth, because she believes that's the best way for her and her baby.  Jill has written in her birth plan/preferences document that if she truly needs a caesarean birth, she wants her baby's umbilical cord to remain uncut, and the placenta delivered intact (known as 'lotus' placenta).  She wants her baby to be placed skin to skin on her chest, and to remain with her in the operating room and in recovery so that breastfeeding can be initiated without delay.  She is aware of 'natural' caesarean births, discussed on her social media forum, and likes the idea. 

Jill communicates her wishes to her doctor.  If that doctor has previously supported women's choices in this way, he/she might be willing to agree.  But Jill is a patient in a public hospital.  The doctor who is performing the surgery is being supervised by the consultant obstetrician, and does not feel able to accommodate such a radical plan.  The hospital's policy is to send the baby and the father to the nursery while mother is in recovery, and Jill is told that the hospital is not able to provide suitable staff to accommodate her choices.  Jill has run out of options.  She needs the help of the hospital to get her baby safely born, and she finds to her surprise that the notion of choice doesn't work in this situation.

 Jill thought, prior to coming into labour, that she had chosen:

how: a natural birth 
where: in the local public hospital
with whom: the hospital staff at the time

'how' Jill gives birth is something that cannot be predicted, whether she chooses a private hospital with the most popular obstetrician according to the online rating system, or the guru homebirth midwife who has amazing skill and, according to social media, can do all sorts of things to make birth work as it's supposed to.  The best Jill can find out when she is choosing her care provider is an approximate rate of spontaneous unmedicated births that person reports for woman in their care.

I (frequently) remind women that they have only one choice in childbirth - to do it themselves, or to ask someone else to take over. This is the case, whether it's avoiding induction, having a vaginal breech birth (vbb), a vaginal birth after caesarean (vbac), a physiological 1st, 2nd or 3rd stage. (Haemorrhage and death are also physiological). 

There's an obvious rationale for the skilled midwife in these equations. A primigravida who wants to have a natural unmedicated birth, booked at Caesar's Palace, in the care of a knife happy OB, may have chosen where and with whom she births, but doesn't have much chance of achieving the 'how'.  

Choice is also dependent on money $$$.

The woman who chooses a caesarean for her own (not clinically indicated) reason can get a private doctor to deliver her baby if she can pay the doctor's fee (Medicare + out of pocket) and the hospital fee. But she has very little say about who else is in the room - her partner is likely to be welcome but may be asked to step outside. 

If we have a vision that every woman should be able to choose how - including elective C/S - do we think our public health $ should be supporting that so that women who can't afford the co-payment are also able to rock up and *choose*?
 
I am very concerned about over-spending of health $.  

The only sustainable policy direction in maternity care is to protect, promote and support the natural processes in birth wherever that is reasonable. The workforce needed as experts in achieving this goal is midwives whose duty of care by definition includes "promote normal birth". This does not remove the woman's right to make an informed decision to decline or accept the plan. Medical and surgical options should of course be available to those for whom they are likely to lead to better outcomes, but that's not a matter of the woman's *choice*.


Your comments are welcome.

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.

...

Cultutal heritage in need of urgent safeguarding

Recently my attention was drawn to the UNESCO cultural project to develop a list of Intangible Cultural Heritage in Need of Urgent Safeguarding.

Intangible cultural heritage is knowledge and skill that, unlike monuments or collections of clay pots, cannot be touched.  The UNESCO list includes a fascinating range of human activities, from Mongolian calligraphy, to Watertight-bulkhead technology of Chinese junks, to many examples of traditional music and singing.

Readers of this blog may already have joined the dots, and wondered if some aspect of 'midwifery', or 'spontaneous, unmedicated *normal* birth' (or both) could be considered an under intangible cultural heritage in need of urgent safeguarding?

Is the reality of normal (natural unmedicated physiological) birth something that can be called a cultural heritage, and something worth protecting? I say "YES".

More evidence ...

... demanding action.

For many years the buzz word in maternity care has been 'evidence'.  'Evidence-based' maternity care guidelines can be found everywhere. 

Application of the evidence into mainstream maternity care is quite another matter.

From my perspective, it's great to see another piece of reliable evidence supporting midwifery continuity of care /caseload midwifery/ one-to-one midwifery.  This evidence is published in a respected professional journal, BJOG, and International Journal of Obstetrics and Gynaecology, reporting on research carried out under the strict rules of randomised controlled trials, by the La Trobe University team of midwifery academics, led by Associate Professor Helen McLachlan.

The title of the paper is:
Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.
Authors: McLachlan et al, BJOG (2012).


The team of authors of this paper includes midwife academics who were prominent in the 'Team Midwifery' research from LaTrobe Uni more than a decade ago.  'Team midwifery' was adopted into many mainstream maternity units, in an attempt to reduce the huge number of midwives who provided care for individual women during their prenatal, intranatal, and postnatal experience.  Women were allocated to the 'Green team' or the 'Pink team'.  Midwives work ordinary hospital nursing shifts.  Women under 'team midwifery' are usually attended in labour by midwives who are strangers. 

Two papers addressing Team Midwifery, authored by Professor Ulla Waldenstrom and others, and Mary-Anne Biro and others in 2000 in the journal BIRTH presented the research findings, and a commentary was written by Karyn Kaufman.  Kaufman, a midwife academic and a member of a community-based midwifery practice in Canada highlighted in her review the lack of difference between the control or ‘standard care’ and the intervention, team midwifery.  Kaufman commented that “midwifery care that follows strict medical protocols is not the same as midwifery care that is enacted from a philosophy of normal birth and is individually negotiated with labouring women.”  This statement sounds logical, yet many Australian midwives at the time may not have realised that midwifery care for well women can be enacted from a philosophy of normal birth.

The primary outcome of the continuity of care by a primary midwife (caseload midwifery) trial is that

"In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk shows promise for reducing caesarean births."  

Besides having fewer caesareans, women allocated to 'caseload' were more likely to have a spontaneous vaginal birth, less likely to have epidural or episiotomy, and their babies were less likely to be taken to the special care nursery than those who received standard care.  

Good for mother, good for baby.

Good for the midwife, too.

In the highly formal language of academia, the authors have boldly come to the conclusion that the midwives with caseloads "can make a difference by reducing the caesarean section rate."

When a reduced likelihood of caesarean can be demonstrated for women at low risk of complications, it's time for the midwifery profession to celebrate.  

Evidence demands action.

This is reliable evidence.

This research was carried out under strict controls.

Midwives and maternity services must be challenged to apply the evidence to practice.  The usual practise of midwifery should be in a caseload model, working autonomously in their scope of practice to promote, protect and support physiological processes in birth whenever possible ('Plan A').  Not as shiftworker nurses in hospitals who work as assistants to obstetricians.  

Only when midwives are willing to take action on evidence will we see improvements in birth outcomes: healthier mothers and babies.

24/7

"Within the [ ] health services financing structure, there is no room for financing the disutility of 24/7 availablity." [Mariel Croon, Human Rights in Childbirth conference, 2012]

One unavoidable feature of midwifery practice in primary maternity care is that a midwife needs to be accessible to a woman 24 hours a day, and 7 days a week, except, of course, if the birth is a medically scheduled and managed event.  If the midwife and the woman have agreed prior to the birth that they will work together when that time comes, that means the midwife is under a considerable degree of commitment.

I have often pondered the wastefulness, from an economic/time management point of view, of caseload midwifery. Of course I can understand the bean counters, who want midwives to be rostered to hospital wards, for shifts that can be predicted. Of course I understand why inductions of labour happen in hospital maternity systems, as managers attempt to match peak activity periods in the hospital with the times when adequate staff have been booked.  Of course I understand why midwives choose to work shifts in hospitals.

At present I am waiting for three babies: one 'due' last week, one this week, and the third in a week or so. Babies in my practice often cluster, and I can't worry about it because it is outside my control.  I must see each woman as an individual, and not allow stress about the time of onset of spontaneous labour to complicate our relationship.

The quote above, and particularly the phrase  "disutility of 24/7 availablity" caught my attention when I read it. 
The dictionary meaning is:

'disutility'
a. the shortcomings of a commodity or activity in satisfying human wants
b. the degree to which a commodity or activity fails to satisfy human wants
[Collins English Dictionary – Complete and Unabridged © HarperCollins Publishers 1991, 1994, 1998, 2000, 2003]

mmm!

My decision to work as a midwife, placing the 'activity' - the needs and wishes of a birthing woman above my need to 'satisfy human wants' - be able to plan my time for work and play and sleep and whatever else - is a decision on principle, not on economics.  The principle relates to my understanding of the unique trust relationship that can be established between a midwife and a woman, enabling the woman to proceed down the often unpredictable and challenging path that leads to the unassisted, unmedicated birth of her child. 

WHY I DISAGREE WITH THE CORONER'S RECOMMENDATIONS

Having written last week about some of the complexities of the decisions made by women about their birth-giving, and the roles of midwives, I would like today to briefly explore why I disagree with (most of) the South Australian Coroner's recommendations in the recent case.

I have summarised the recommendations as:
1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"
2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"
3) That the woman who is reported in (2) will receive "advice to be tendered to that person from a senior consultant obstetrician as to the desirability or otherwise, ..."
4) "establishment of a position known as the Supervisor of Midwives"
5) "establishment of alternative birthing centres" [note: not one of the three mothers of babies who died would have been eligible to go to 'alternative birthing centres']
6) education for public distribution on homebirths and risks
7) revised policy for Planned Birth at Home in South Australia "with an addition that current risk factors for shoulder dystocia be specifically identified;"
8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."

Rather than starting with #1 and plodding through this minefield, I will start with what I see as easier, and pick my way through the minefield, trying to state my opinions clearly. (And, dear reader, I must warn you that I often delete a great deal of what I write, so that you see the heavily edited version)

6) education for public distribution on homebirths and risks 

This is not a bad idea. My only hesitation relates to what sort of education, and who writes it, and who defines the risks, and ...

 5) "establishment of alternative birthing centres" 

Also not a bad idea - for the 1980s, that is. Midwifery theorists proposed that hospital rooms dressed as 'home-like' settings would help women to feel OK about birth.  Some women did well, while many were excluded by risk protocols, and moved into standard (the alternative to 'alternative') obstetric care.  I gave birth to my fourth child at the Women's Birth Centre in 1980, and that experience helped me come out of medically managed and dominated midwifery.  I know many other midwives who have learnt to work in harmony with physiology in unmedicated birth, and to trust their midwifery knowledge when detecting and acting upon complications, during their time working or giving birth in a birth centre.  Perhaps that's a good reason to establish birthing centres.

4) "establishment of a position known as the Supervisor of Midwives"

I need to sit on the fence for this one.  The role of Supervisor of Midwives is one that I don't fully understand.  How would these people be appointed?  What would their role entail?  Would all midwives be supervised, or only certain midwives?    The UK-style Supervisor of Midwives is different from the New Zealand system.  Psychologists work under a system of professional supervision.  I believe a thorough exploration of this proposal needs to be had by midwives, ethicists, psychologists, lawyers, and maternity consumer spokespeople, and some agreement reached, before yet another regulatory control be imposed on the profession.

1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"

NO!
Australia does not need to outlaw unregulated midwifery services.
Australia needs to protect and support the midwifery profession, so that midwives can provide midwifery services in homes and hospitals; so that women will feel safe in the professional care of midwives as primary carers, who are able to work seamlessly with specialist services when indicated.
Modern societies, and the legislators and coroners and others in positions of authority need to recognise that spontaneous labour and birth is a fact of nature, not something that a midwife controls or gives permission for, and that women under natural law are able to use the professional services provided in their community, or not.  It's their choice.

2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"

NO!
Midwives who understand the ethical and moral duties of our profession, who by definition work 'in partnership' with a woman, will REFUSE to report women on the grounds of a plan for homebirth.  My own practice for many years has been to encourage women to see the choice of place of birth as a decision they make as labour becomes established, and not before.  I believe this is best practice, as the midwife is committed to the woman, not to the planned setting for birth.

8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."

HOW would this work?  Will that woman be arrested and forced to listen to 'appropriate advice' being delivered?

I have not tried to tease out which risk factors the Coroner thinks would be used to initiate reports or the giving of advice.  There are few absolutes in midwifery.  Regardless of what risk factors may be attending a particular situation, physiological birth always starts with spontaneous onset of labour, and spontaneous onset of labour happens in the woman's own time, in her own world, in her own body.  The woman has to make a decision to call a midwife, or not; to go to hospital, or not.  This decision cannot be taken from her.

This set of recommendations exhibits a shallow and linear view of life, risk, and decision-making.  The question that the Coroner seemed to avoid is:

"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?"



Australia is a society which supports a wide range of freedoms for the individual.  I don't have the words to describe the legal and ethical framework that this is built upon, but I know that when a State (government-sanctioned authorities) is given power to control the most intimate relationships between a woman and her child, that comes with a great loss of basic freedom.

Civil disobedience by midwives has been recorded many times, when the midwives believed that the lives or wellbeing of the mother and/or her baby were at risk.  The Hebrew midwives, Shiphrah and Puah, who were prepared to disobey and deceive the autocratic, absolute authority of Pharoah, are our model.

The king of Egypt said to the Hebrew midwives, one of whom was named Shiphrah and the other Puah, "When you act as midwives to the Hebrew women, and see them on the birthstool, if it is a boy, kill him; but if it is a girl, she shall live.  But the midwives feared God; they did not do as the king of Egypt commanded them, but they let the boys live.  So the king of Egypt summoned the midwives and said to them, "Why have you done this, and allowed the boys to live?"  The midwives said to Pharoah, "Because the Hebrew women are not like the Egyptian women; for they are vigorous and give birth before the midwives come to them."  So God dealt well with the midwives; and the people multiplied and became very strong,.  And because the midwives feared God, he gave them families. (Exodus 1: 15-21, From the New Revised Standard Version (1989) of the Bible)

H+BAC=?

TROUBLE!
[H+BAC stands for Home + Birth After Caesarean]

I have written about births after caesarean from time to time on this and other blogs. Last August I focused briefly on 'A scarred uterus', in the context of guidelines that had been hastily put together by ACM, and which were subsequently adopted by the National Board as its regulatory position on homebirth [link].

Yes, according to this statement homebirth is contraindicated for the 'scarred uterus'. Just to put the 'scarred uterus' in perspective, the Australia-wide rate of caesarean birth is more than 30% of all births [See Australia's Mothers and Babies 2009 report, published Dec 2011]. That's a lot of scarred uteruses.

Q. When a woman who has one of those scarred uteruses wants to have another baby, and she wants to optimise her chances of vaginal birth (vbac), to whom does she turn for professional help?
A. An experienced midwife who is committed to working with each woman, protecting promoting and supporting healthy physiologically normal processes in pregnancy and childbirth.

Q. Where do you find a midwife like that?
A. A midwife in private practice is able to make a personal commitment to the individual woman, and work professionally with her as her primary carer.

Q. Where does the midwife work?
A. The midwife's work is limited to the home, because (except in a few cases) midwives in private practice are unable to be recognised as a woman's midwife once admitted to hospital.

Q. What does the woman with the scarred uterus need to do in order to plan vbac?
A. The woman who is healthy with a healthy fetus at Term, who experiences spontaneous onset of labour, and who progresses in labour under the natural hormonal environment without medical assistance (augmentation or analgesia), is most likely to give birth spontaneously without complication.

Q. So, coming into spontaneous labour - that happens best at home?
A. Correct.

Q. And progressing without medical assistance - that happens best at home?
A. Correct.

Q. And that's where the midwife is experienced and competent?
 A. Correct.

Q. So, why is homebirth contraindicated?

[But there's a hole in the bucket, dear Eliza ...]

Of course this little Q&A sequence is overly simplistic.

But the point I am trying to make is that 'home' is not the key issue.  The central issue is that a midwife is the most appropriate and expert primary professional care provider for any woman who intends to give birth under normal physiological conditions, using natural oxytocin, natural adrenalin and catecolamines, natural endorphins, natural anti-diuretic hormone, and all the other amazing substances that work together in the healthy body to bring a woman to safely and proudly give birth to her baby.  The woman who is able to proceed in labour with the confidence that her midwife is protecting the birthing space, and that her midwife will identify and act appropriately to protect the wellbeing of both mother and child if needed, is able to look forward to BAC, whether they are at home or in a supportive hospital environment.

Achieving vaginal BAC is core business of midwifery.  It's where the midwife's skill is most needed, and where an experienced midwife is confident and in her element.

Yet, BAC is 'contraindicated' in the one place where the woman is most able to proceed well, and the one place where the midwife is able to work without restrictions.

Midwives who are facing up to this dilemma that has come about as a result of hasty bureaucratic processes that failed to consult with the midwives or the women it affects most, do not have many choices.  Either we continue to attend women with scarred uteruses professionally, or we refuse to do so.  The latter alternative is likely to result in some women facing unnecessary repeat caesarean surgery, with the inherent compounding risks of abnormal placental implantation and severe haemorrhage; and some will take the other extreme pathway - freebirth.

The central issue is not about the big 'H' - homebirth.  The central issue is the midwife's right to engage in professional practice.  A midwife who is attending a woman in labour, with or without a scarred uterus or any other of the listed contraindications, or complication, is professionally able to work with the woman to make appropriate decisions.  In some cases that may mean going to hospital; in others it means staying at home.  At all times the wellbeing and safety of mother and baby guide the midwife's professional advice.  Home is only a setting.  Healthy mothers and babies are the outcome we desire.

Bungee jumping on a short cord

Midwives who attend strong, healthy women for their births are used to seeing mothers give birth unassisted, unmedicated, and with an ecstatic and triumphant cry. We are used to seeing labour establish and progress in a purposeful way. We are used to the power of the birthing process, which takes the woman beyond any limit that she imagined she possessed.

Occasionally we are surprised, even confused.

Especially when the woman has other babies who have all followed the standard 'normal' journey. ... when labour seemed to be established in the morning, so the midwife and the birthing team were summoned. After the greetings, and a cup of tea, and some conversation, and another cup of tea, and talk about what we should do for dinner, and mother lies down because she's feeling tired ... and the fetal head is still floating high and mobile. This mother has given birth previously, and there is nothing apparent in the size or presentation of the baby. Her contractions appear strong when she stands up and walks, but they become weak and infrequent when she rests. 

I could name several women who fit this picture, the most recent last week.  When I looked at the placenta with the mother we commented on the short cord.

The image I have in these 'slow start' multiparous births is that the baby was bungee jumping – pressing down on the cervix when the contraction’s there and mothers upright, and floating away when mother lies down or is not contracting. 

The cord may be short because of entanglement, or simply short.  The distance from the baby's umbilicus to the point of insertion of the placenta on the uterine wall does not change.  The distance between the placenta and the cervix can be reduced by amniotic fluid release, by contractions, and by the mother's position. The critical 'tipping point' will be reached only when that fetal head can dilate the cervix and enter the birth canal.  Then, it's "coming, ready or not!"

This is an article from Midwifery Today 

The Cord and the Strength of Life 
I have observed babies being birthed with the placenta detached and following right behind them for over 20 years. Throughout that time I have kept mental notes, observing, recording, pondering.

Then one day, finally, it all added up. The explanation is a short umbilical cord, a phenomenon that requires us to allow time for the baby, the cord and the placenta to descend slowly through the birth canal, in the wisdom of nature, for a healthy and natural birth. My first encounter with a short cord began with a false labor. The mother thought this was the day. She called me, and I stayed with her until labor ceased several hours later. The mother and baby were fine. There was no good reason to intervene, despite the fact that she was multiparous with 4 cm dilation and the baby was not engaged. I warned her of possible cord prolapse and asked her to be aware of her baby’s activity. A couple of days later she called me again. The birth was very quick and the baby was born with shoulders and body entangled in a barely pulsing cord. The newborn had some blood on his bottom because the placenta had separated at the time of birth. He required stimulation and oxygen, but it was all resolved quickly and within the realm of the normal. I have watched vigilantly for short cords ever since.

Two weeks ago, some twenty years after I noticed it for the first time, it happened again. This time it was with a mother who had had three babies. The last two had been very fast. She had always had mild contractions before going into labor, but this time she had more. As she was multiparous, I initially did not think there was a problem. About ten days after her due date I thought she was going to have her baby. Her uterus looked so low that it was “by her knees.” But it did not happen. “Something is strange,” I thought while checking her. I sighed. The baby was floating, even though the uterus was very low. It seemed the baby ought to be engaged, but he was not. I then listened to the baby’s heart tones and found normal heart tones but with minimal decelerations. The heart tones were at 140 and descended to 126 or so in the middle of mild contractions. I listened to the heart tones every three days. The mother was noticing movement. We decided she should try to induce herself through nipple stimulation and an enema of medicinal plants. I gave her an exam in which I stimulated the opening of the cervix. The contractions began, and she dilated another centimeter easily. The heart tones remained within normal ranges.

... However, everything stopped after a few hours. The mother was already at 5 cm, but the cervix remained inflexible. Although the baby’s head was in a good position, he was not engaged, and therefore was not exerting pressure. After the second attempt I sat down to think. I concluded that we were dealing with a short cord. In any other situation a vaginal exam, some nipple stimulation and an enema would have produced labor.

But beyond the mother and me, the wisdom lies between the baby, the cord, the placenta and the uterus. You can confirm that you are dealing with a short umbilical cord by observing the abdomen. During contractions, and sometimes without them, the baby appears engaged, even though a vaginal exam reveals that she is floating. It is important to avoid interventions that force the mother’s body to enter the birth process before the placenta and uterus are ready. The fundus has to descend with the baby. This process takes time. Contractions that cease despite dilation of 2–5 cm in a mother with previous fast births and no other complications indicate the possible existence of a short cord. Observation without intervention is important in these cases. 

—  Marina Alzugaray Excerpted from “The Cord and the Strength of Life,” Midwifery Today, Issue 70

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.

Normal birth for a breech baby

From time to time a presentation becomes available via this wonderful www that is really worth sharing.

Today I would like to direct my readers to the blogs of two colleagues, midwives who are committed, as I am, to sharing the knowledge and skill of authentic midwifery. I would encourage you to follow these two links, then come back and read my comments. Please feel free to make any comment here, or on the other blogs too. (You know that comments are very much appreciated by bloggers.)

Lisa Barrett has written about the Mechanisms of unassisted normal breech birth, with a superb set of photos.

Carolyn Hastie has presented this You-Tube video, which is in Spanish, with her own comments.