home midwifery in the (legal) spotlight

Melbourne in mid-winter is grey and damp and cold.  The tall concrete buildings block the weak, angled sunlight.

This week I have sat for two days in a tired meeting room in a city hotel that has passed its prime:  not old enough to be interesting; not fresh enough to be attractive.  The plate glass windows in the conference room revealed nothing more than the boarded up windows of a derelict multi-storey building on the other side of Little Collins Street.

The conference provided opportunities for comment on homebirth, and particularly homebirths that have gone wrong.  Lawyers presented papers on topics such as 'Managing the Risks inherent in Women's Choice in Obstetric Care', and 'Practical Obstetric Risk Management: defending your care'.  It sounded simple.    

Human rights in the childbirth process were eloquently discussed by other lawyers who drew from both their knowledge of the law and their personal experience.

'Open Disclosure' was discussed by two speakers, and I concluded that, in order to 'defend' oneself against potential legal or disciplinary action, an adverse event in a hospital is met with what seems to me to be a charade called 'open disclosure' that is not very open, and that doesn't disclose much.  Don't be too literal about the meaning of 'open' or the meaning of 'disclosure'.  A curious conundrum! 

A Coroner delivered, with barely an inflection in his voice, a keynote address on 'Lessons to be learned from the Home Birth Cases in Vic and SA.'  In this presentation, seven cases were reviewed, the common thread being that they had been planned homebirths, with either a registered midwife or a previously registered midwife in attendance.  When considering risk factors such as previous big babies, previous caesarean births, and a twin pregnancy, the conclusion was that most of these cases should not have been planned homebirths; that the midwife had a duty of care to transfer care to an obstetric unit.

In 6/7 cases, the baby deaths were declared by the Coroner to have been potentially preventable.  The Coroner does not attempt to apportion blame, merely to discover the facts, and to make recommendations.  The Coroner's filtering of the information presented at the inquest failed to notice any possible reason that a woman might have had for trying to avoid a medically managed birth; any mention of her desire to hold her baby to her breast within moments of birth; or even any recommendations that maternity hospitals provide pathways for women who want to have a known and trusted midwife providing continuity of care within the hospital.

I want to be perfectly clear here: I cannot speak for either the mothers or the midwives.  I am merely an onlooker, and I have read the Coroner's findings that have been put in the public domain.  I am also shocked at the tragedies that precipitated these cases into the Coroner's court.

The points made by those who spoke about women's rights were either ignored or not understood by those who spoke from the professional duty of care perspective.   The fact is that pregnant women have personal autonomy; that decisions do not have to be approved by, or even understood by, those who attend for birth.

***
The presentation following that by the Coroner was from the Victorian Perinatal Data Collection Unit.  I noted down a point that was briefly made, without any further comment, that, of the approximately 900 perinatal deaths in this State annually, 63% are found to have potentially avoidable factors.

The loss of a baby's life is, thankfully, uncommon in our world.  Yet it is one of the most heart-wrenching experiences imaginable.  Whether the death is linked to homebirth or not, everyone needs to take what lessons are available from the facts of the case.  I ask myself, what lessons have I taken from these seven tragic cases?

***
I believe the huge challenge that lies ahead for midwives and the whole maternity world is to find a balance between providing advice and care that protects the wellbeing and safety of the mother and child, while at the same time respecting the woman's decisions and choices.  This is not going to be easy.  It is an ongoing process, and demands trust and commitment between the midwife-woman, and the midwife-obstetric/hospital system. The paternalistic dictatorial style of hospitals has, in many instances, demanded submission to hospital policies and processes. This needs to change. The misunderstanding of risk in maternity care, as was clearly demonstrated in the cases reviewed, will likely continue to open the door for self-educated, internet-researched women to make the choice of birthing without a midwife in attendance.  This needs to change, to include intelligent dialogue and planning that is specific to the individual woman/pregnancy.  The misunderstood partnership between woman and midwife, as was also clearly demonstrated in the cases reviewed, may from time to time place unreasonable weight on the woman's choice, and devalue the midwife's skill and knowledge.  This also needs to change, enabling midwives to practise more autonomously and accountably.

Women who engage a midwife to attend them at home for birth, having an identified risk profile, such as a previous caesarean, a previous post partum haemorrhage, or multiparity, or any of the other features that are classified as risk - these women, and these midwives, need support rather than being driven underground.  The midwife who is ready to go with her client to the hospital, and continue supporting the woman's informed decision-making process within the hospital, will accompany that woman to the best birth that she can have.

And, we only want the best.



Your comments are welcome.

ps - this link to the story of a maternal death is, sadly, what we will see more of if we don't maintain a midwifery profession that is 'with woman'.

bleeding after birth

Today I am reflecting on experiences I have had with post partum haemorrhage, linking those clinical scenarios to my body of knowledge, reading reliable references that relate to appropriate interventions and drugs to treat bleeding, and applying learning to my practice.


The real test of primary maternity care is FIRST the safety and wellbeing of the mother, and SECOND the baby (even though the baby's birth usually comes first).

The aweful possibility of sudden dramatic bleeding after the birth, and what that can mean in terms of loss of life, is the spectre that hovers in the mind of many public health decision makers.  The burden of such loss, particularly in resource-poor parts of the world, has led to many initiatives that seek to make changes that will protect life and reduce harm.  An example is the Joint Statements on Prevention of Postpartum Hemorrhage, released in 2011 by the international peak bodies for midwifery (ICM) and obstetrics (FIGO).  The key recommendation, active management of third stage of labour, is explained in the joint statement released in 2003.

Active management of the third stage of labour should be offered to women since it reduces the incidence of post-partum haemorrhage due to uterine atony.

Recently released 3 Centres Guidelines, confirm the practice:

Active management of the third stage of labour is recommended practice worldwide, with an anticipated completion period of 30 minutes.

Midwives (and I am one) have learnt, over the past few decades, to value our knowledge of working in harmony with natural physiological processes. The third stage of labour is one of the key challenges that a midwife faces when attending a birth.  I do not fear the third stage.  If that were the case I would not be suitable to continue in the work that I do.


The discussion that I have around third stage with my clients in preparing for birth always includes consideration of our plan for the management (or non-management) of the third stage.  The clinical decisions that I will make in the minutes and hours immediately after the birth include my assessment of the need, or not, for drugs at that time. 

Midwives around the world work this way.  This is alluded to in a statement on physiological management of third stage  released by ICM in 2008 and reviewed in 2011.

The midwife's skill and competency resides in protecting the woman and her baby in healthy natural birth (PLAN A), and in recognising situations and conditions that may require medical interventions such as active management of third stage (PLAN B).

At a very practical level, I understand that the physiological separation and expulsion of the placenta without excess bleeding is a process so finely tuned that it can easily be interrupted.  Today's birthing community in my world has introduced all sorts of extraneous and potentially disruptive elements - clocks, bright lights, telephones, cameras, text messaging, men, children, other invited onlookers, ... 

Women giving birth are not a uniform, pristine group whose bodies all function at optimal levels.  Women may have internal uterine abnormalities from fibroids or procedures or terminations of pregnancy.  Women may have poor abdominal muscle strength, allowing their wombs to sag excessively, and putting unusual pressure on other supportive structures.  Women may be overweight, or poorly nourished.  Women may be emotionally drained or have specific painful deep memories that are triggered by labour and birth.  ... and so on!

So, you may ask, what's the problem?  What causes uterine atony in an otherwise uncomplicated situation?  Why does a woman bleed after a normal, unmedicated birth of a healthy baby (or babies)?

I won't attempt to give a text book answer here.  I would encourage students who are reading this post to review your text books, while reflecting on your own experience of haemorrhage, and seeking to learn from each situation.  You will need to decide, in practice, whether you follow the current recommendation of universal active management, which is not without risk, or if you are able to work competently with a woman who is intentional about natural, unmedicated birth.

I have looked through my birth register.  In the past few years several of the women who I have attended have had post partum haemorrhage of in excess of 500 mls.   I remember these women, and the setting of birth.  I remember the (thankfully rare) instances in which we called the ambulance and transferred to hospital.

The challenge that I return to, having reflected critically on my own practice and my experiences of bleeding after birth, is to continue to practise and learn my role in protecting the natural process.

"Western practices neither facilitate the production of a mother’s own oxytocin nor direct attention to reducing catecholamine levels in the minutes after birth, both of which can be expected to physiologically improve the new mother’s contractions and therefore reduce her blood loss."

  Dr Sarah J Buckley 2009 (page 179)

This topic will be continued here.