searching for confidence

A young mother whose second pregnancy is at about 30 weeks phoned me, and we chatted for a while.   As I listened to her story, I felt enormous sympathy for her in her search for confidence. 

I have pondered the predicament of this young woman, who I will call Bea, and others in similar situations many times.  So, dear reader, I will share the story with you, and hope that those readers who are also searching for confidence as you approach your time to give birth will be given some useful tools.   If you think you know Bea, please read any of the more critical comments that I make as criticism of the system that leaves women dangling and lacking in confidence, rather than a criticism of any person.


Bea is booked to have her baby in a hospital, under the care of a team of doctors and midwives.  Bea is hoping to find someone who will palpate her abdomen (See RCM How to perform an abdominal examination) and tell her how her baby is growing, and whether she will be suitable for VBAC (vaginal birth after Caesarean).

Bea experienced an emergency Caesarean birth after a long and painful labour for her first child.  She felt traumatised, disappointed, confused, depressed; at times blaming herself and at times numb towards herself, her child, the child's father, and the world.

In preparing herself for this next birth, and in an effort to come to terms with her memories, Bea has had counselling.  One of the outcomes of that counselling is that Bea recognises a lack of confidence in the (nameless) people who will provide care for her in labour and birth.  Midwives, doctors, others: all with a role in the system that produces babies, yet Bea has no confidence in that system.

Bea is an intelligent woman who is used to researching every aspect of life, from the energy efficiency of white goods in her home, to the source of the food she buys.   She wants to know about pregnancy and birth specifically as it relates to her.  She reads posts from other mothers on social media.

Bea is particularly concerned about the size of her baby; whether he or she will 'fit'.  That's a big question.  It's a question that exercises the mind of every midwife.

Bea would like me to palpate her abdomen and (hopefully) tell her that her baby will fit through her birth canal.  I can palpate her abodmen, feel the fetal poles and hold her baby between my hands.  That gives me a good idea of the size of the baby - it's not much different holding a baby who is still in the womb to holding the baby in my arms.  But I can't tell if the baby will 'fit'! The only times when I would advise against progressing naturally and spontaneously into labour are when a complication presents - when the natural process would be likely to lead to damage or death.

Many times I have attended little women who have big babies.  Many of them have given birth spontaneously and quickly.  I have never tried to be a prophet, predicting events in the future.   The decision making processes in midwifery require the midwife to understand and work in harmony with the natural physiological processes, and only interfere if there is a valid reason to do so. 

Bea told me she has at least three birth plans: a vaginal birth; a caesarean after labouring; and an elective caesarean.

I told Bea that she should have only one birth plan: to do her best. 

You need to take ownership of your own natural processes which are essential if natural birth is to progress well. ...to make the best decision you can at any point when a choice or decision needs to be made.  Here are a few examples:

• The doctor tells you at 38 weeks that he assesses the baby to be large and advises an elective caesarean (without labour) at 40 weeks.  Do you think the best decision at this point is to say yes, to say no, or to make a decision closer to 40 weeks?
• It's a few days before (or after) that magical 40 weeks.  You think you are coming into labour - it's midnight and you woke up with a contraction, and felt baby make a few big moves.  Waters have not broken.   Do you get all excited and ring your support team, and ring the hospital, and wake your husband?  Or do you tell that baby to go back to sleep - you have a big day ahead if labour does begin, so you need to get some shut-eye!
• Later ... You think you are really in labour now.  Memories flood back each time your womb contracts, and you remember the early part of your first labour.  You remember using the labour ap on your phone to track the contractions.  You know you need to get organised - little Johnny will go to his granny after breakfast, DH will stay home from work, and the birth support friends will need to make arrangements for their families and work.  Contractions are coming every 10 minutes, and feel good.  You need to walk and rock through them.   Do you ask your team to come now, or to wait for another call?  Do you call the hospital now?

...

These 'decision points' might seem insignificant, but I say they are some of the most important decisions you will make.  Each decision is a fork in the road.  If you take one, you cannot take the other.  There is no turning back.  Can you feel confident about these decisions?  If you have that confidence, and you establish labour without any outside (medical or psychological) assistance, I know that you are well on the way to successful and healthy VBAC.   

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 about choice, decisions, and 'the birth you really wanted'

From time to time, as I read social media sites used by mothers, midwives, and others interested in the whole childbirth package, I come across messages such as:
"I was prevented by ... from having the birth I really wanted," or
"I'm so glad you got the birth you really wanted."

Women who feel physically and emotionally traumatised by experiences in previous births declare that they won't go near the hospital, because that's where and why it all happened the way it did.

More and more women are telling me that they are planning to give birth at home without professional support for various reasons - can't afford a midwife; no midwife or publicly funded homebirth program in the area; too 'high risk' for the midwives in the area ...  This really concerns me - it's scary!

Homebirth has resurfaced in the local media recently, with an article by Sydney midwives, Karol Petrovska and Caroline Homer, Beyond the “homebirth horror” headlines: some wider questions for the health system (and media).  This article was responding to a 'news' article on the mamamia blog, titled 'A hospital birth would have saved Kate's baby'.

The Coroner had identified internet-based research of risk as being central to the mother's choices and decisions in this instance
‘‘[This is] an example of the danger of untrained users utilising raw data or statistical information to support a premise as to risk, without knowledge and understanding of the complex myriad of factors relevant to the risk’’.[report]

The Coroner also found that delay in transferring care from home to hospital, after it should have been apparent to the midwives that Kate's baby was in distress, contributed to the death.

Midwives hold to a theory of 'partnership' with each woman in our care.  The midwife-woman partnership has been incorporated into the ICM International Definition of the Midwife.
This partnership, when correctly applied, places the woman at the centre of all decisions, with the intention of protecting the wellbeing and safety of mother and child.

Today I would like to briefly comment on the midwife-woman partnership, especially as it applies to choice, decisions, and achieving 'the birth you really wanted'.


Independent midwives, employed directly by women for birth in their own home, are in a privileged position because we are able to apply midwifery skill, knowledge and expertise directly without being hampered by the levels of bureaucracy and policy and protocol that exist in hospitals.  Women who are low risk and who plan to give birth at home with a midwife in attendance are in the most optimal maternity care situation that exists today.  A large study (de Jonge et al 2013) comparing maternal outcomes from (low risk) homebirths with a comparable group of (low risk) women giving birth in hospitals in the Netherlands concluded that:

"Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system."

Independent midwives practising in Australia are often asked to attend births that are not in the low risk category.  Women who are older, fatter, who have had a lot of children, or caesarean births, or who have been traumatised in previous births often seek a midwife who will plan homebirth with them, particularly those who want to avoid the hospital.

There is no calculation table that lists risk factors against chance of having an uncomplicated vaginal birth - and if there were, I doubt that it would be of any use.  The current 'odds' for serious adverse complications (such as death of a baby, or serious maternal haemorrhage from uterine rupture) in vbac is estimated at 1:2000. [for more on safety of vbac, click here]   There is no comparable statistical estimate that ordinary people face in daily living.  People who bet on horse races may have some understanding.  1:2000 seems remote, and meaningless.

A more useful guidance would be to define at what point in time does actual risk, rather than theoretical risk, escalate.  This appears to me to be a question that was not thoroughly explored in the tragic case referenced at the beginning of this post. This clinical judgment is within the scope of a midwife's practice.  Spontaneous, unassisted birth becomes less safe if there is anything that indicates compromise of the mother or the fetus: complications of pregnancy, including raised blood pressure or impaired glucose tolerance; prolonged pregnancy; antepartum haemorrhage. Complications of labour including poor progress over time; and fetal heart rate decelerations or other abnormalities.

When 'the birth I really wanted' focuses on place of birth, or even on the process of birth, a significant number of mothers are going to be disappointed.  A midwife cannot become so committed to homebirth, or natural birth, that she forgets to keep a keen, critical eye on what is actually happening.  There are a couple of significant hurdles that a woman needs to get over before the spontaneous, unmedicated homebirth can even be considered. These are:

• spontaneous onset of labour, and
• spontaneous progress in labour - to the point where natural expulsive forces can be applied.

As it happens, there is no safer way for most babies to be born, than for the mother to do it herself - spontaneously - irrespective of place.  Not with herbal stimulants or acupuncture or coaching or hypno/calm birth education or pelvic manipulation or olive oil being rubbed into the perineum, or the best midwife in town.  Spontaneous is from within.  As labour progresses, a mother's capacity to judge progress and safety decreases, as her calculating, educated mind closes down to permit intuitive activity from deeper brain structures.  As this altered state of consciousness becomes strong, her midwife maintains a skilled, watchful vigil.  A mother cannot do this for herself.

The midwife's role is clear: if the mother and baby are coping well with spontaneous labour, no interruption or interference is permitted.  On the other hand, if warning signs are present, the midwife's ongoing clinical judgment and assessment throughout the birthing process protect the interests of her clients, both mother and baby.

You might have a birth plan for 'the birth I really want'.  Please check that birth plan, and check with your midwife, to ensure clear decision points.  While you are able to spontaneously progress through labour and birth, the physiological process is magnificent.  But, if there is a valid reason to interrupt the natural process, be ready to get the best birth possible, using the best and most timely intervention that is accessible at the time.

'The birth I really wanted' is above all, one that protects my baby and myself.   

Thankyou for your comments.

Making the bed

I drove through crisp Autumn air, under blue sky, to visit the mother and her baby boy who was just 24 hours old.

Within minutes of laying eyes on them, and without touching either, I was satisfied that all was as it should be.  With early morning light filtering onto the bed, I noticed that the baby was sleeping quietly in his mother's arms; that his skin was a healthy pink; that his mother had a confident, oxytocin-induced smile.  A few questions confirmed my assessment: mother's blood loss was minimal; she was eating and drinking well; passing urine without difficulty; she had slept a little, and her baby was eagerly taking the breast.

It's difficult to describe the deep thankfulness that I feel as I witness the normality of birth.  Much of the preparation and discussion prior to the birth focus on what would happen if complications or difficulties arise in labour, or if the baby's condition at birth is not good.  The equipment and supplies I bring to the birth require skill and competence in assessment, resuscitation, and midwifery management of sometimes unpredictable, rare events.

Although the assessment was made with the confidence that comes from years of professional learning, at this postnatal visit I did not need to take any professional action.  I asked the mother if she had had breakfast yet, would she like a cup of tea?  Yes.  So the midwifery student went to the kitchen to prepare it.  We reflected on the exhaustion a mother feels after even an 'uneventful' spontaneous birth.  We laughed at the though that the father is often more spent!  We pondered the help given by the warm water in the birth pool; that the softness of the pool's inflated sides gave the mother a lovely soft surface upon which to drape her upper body in the most demanding part of the labour.  We chatted about the responses of the baby's brother and sister, building up a set of unique and very personal memories of this unique and very personal event.

I had noticed a small splatter of blood on the bed sheet.  "Would you like us to make the bed for you, with clean sheets?" I asked.

And while mother ate her toast and drank the hot herbal brew, we changed the sheets.

Making beds happens each morning in hospital, and it's not something that I would write about in a midwifery context.  Yet as we went away from this beautiful homeborn baby and his beautiful mother, I thought that making the bed was the main professional act that we had accomplished in that visit.

Submitting to the spontaneous

learning to breastfeed at an early age

This word, spontaneous, is repeated over and over again in my writing.  (you can check - do a word search using the search function on the right side of the screen)

Today I am thinking especially of the lovely young mother in my care, who is waiting for spontaneous onset of labour (and all that follows).

I am also thinking about the young midwife whom I am mentoring, and who hopes to attend the birth with me.  The work commitments that she has, together with other unpredictable factors, mean that each birth, each mother-baby consultation, needs to be negotiated in real time.

We are experiencing hot, dry weather, with hot nights in Melbourne at the moment. Energy is depleted as everyone goes about their tasks a little slower than usual.  Perhaps this baby is waiting for a cool change?

The challenge of waiting for spontaneous onset of labour, and working in harmony with natural physiological processes demands submission from the midwife as well as the woman.  Waiting and watching.  It's a discipline, in which the midwife supports and watches, and in which the woman makes preparation, nesting and waiting.

Submission to the natural order, as well as to social expectations, happens moment by moment in life.  Couples submit to each other, knowing that together they can achieve more than the sum of two lives.  We submit to the road rules, not because we enjoy driving slowly, but because that's the way we can reduce the risk of collision and harm in built up areas.  Parents submit to the needs of their young children, reorganising meal times, sleep times, ensuring healthy eating, and lots more to achieve harmony. 

Submission will, at times, include an element of frustration.  We all like to plan our days,  We all value knowing what we need to do, and when we need to do it.

A midwife is unusual in that she has an imperative to accept unpredictability, and submit her own will to the greater forces that are at work in childbirth.  A person cannot be an authentic midwife if, for whatever reason, they want to work 9-5, Monday - Friday.   In recent decades the progressive medicalisation of birth has led to increasing rates of induction of labour, business hours maternity services, elective caesarean births, and the like.  Medical management of the birthing process is the opposite of spontaneous birthing.  Managed birthing sets up processes that use the staff and facilities of a hospital in the most productive way.  Managed birthing tells midwives they don't need to submit to these unpredictable, wasteful, hormonally driven processes.

Yet it is the hormonal environment of spontaneous birth that sets a woman up for the next demanding steps in her journey: nurture, bonding, mothering.  Without respect for these finely tuned processes, mothers can feel as though they are being processed in a factory.  Without submission to and engagement with the natural processes. midwives become technicians who manage machines and who maintain the records for their employers.



Thankyou for your comments.

the after-glow

Picture the scene:

We are in the room where the baby was born, just over 24 hours earlier.
The mother is sitting quietly, with a sleeping baby in her arms.
The father is near her, and other children come and go - as they do.
The midwife and the midwifery student have returned for a postnatal visit, and as there is no pressing clinical activity to attend to, we are simply 'being' rather than 'doing'.

Gone is the inflated birth pool, the tarp that covered the carpet, and the protective drape and old beach towels that covered the chair where the mother waited for her placenta to birth.

Gone are the candles and other soft lights that provided a warm and intimate glow as we welcomed this little one into her family.

Gone are the simple midwifery tools: the absorbent 'blueys', the box of blue gloves, the doppler, the oxygen bottle, and other resuscitation gear, the syringe and needle and oxytocic to be used if required ...


The daylight of this summer morning enters the room through the large window. 

Another light, which I call 'the after-glow', rests on the faces of all who are present.


There was no camera to document the after-glow, and indeed, if someone had tried to capture that moment, I doubt the memory would have nestled so strongly in my heart, or urged me to write it down.   In many ways, it was an unremarkable moment.

Yet, the discussion that followed was full of awe and wonder.  The miracle of birth, by which a child is safely brought from the womb to the arms of the mother, never ceases to offer insight to anyone who has eyes to see and ears to hear.  The natural physiological process, spontaneous yet so very vulnerable to any interruption or interference, is somehow unnoticed by our society and particularly mainstream maternity services.

If I have learnt anything in these past 20 or so years of private midwifery practice, working closely with a few women, most of whom intend to give birth without medical intervention, it's that there is so much more to learn.

As we reviewed the experiences and events of this labour and birth, we were reminded that this mother would have been treated as 'at risk' if she had been in hospital.  A previous caesarean requires, in most maternity hospitals, continuous electronic fetal monitoring throughout active labour.  Parity greater than 5, as well as the caesarean scar, require an intravenous cannula to be in situ.  Active management of the third stage is the standard process in local hospitals for all women. 

Yet this birth proceeded spontaneously at home, without incident or complication.  The mother guided her baby's head over her perineum, without any instruction to 'pant' or 'give a push now'.  The baby came up out of the water, took air into her lungs, and made that great transition from placental oxygen to the bountiful air without any difficulty.  The cord was not clamped.  We supported the mother as she stepped out of the birth pool, holding her treasure to her chest, dried them off, and sat them quietly in the prepared chair.  As contractions returned, the mother stood, then squatted over a plastic bowl, all the time holding her naked baby against her naked body, and the placenta was expelled spontaneously.  Blood loss was minimal.  Baby took the breast eagerly - as they do.  After an hour or so the father took his daughter, and the mother achieved her next milestone, that of emptying her bladder.

Anyone reading this might ask, what's so special about that? 

It's the simplicity of uncomplicated, unassisted birth that I want to record here.  Simple, yet amazingly complex in the orchestration of hormones and the mechanics of the process.  Spontaneous, yet vulnerable to interruption or disruption.

Midwives must work to protect, promote and support birth in the natural framework that has been provided by our Creator, unless there is a valid reason to avoid the spontaneous normal process.

hospital policy in the spotlight

Today as I write I have in mind a young midwife who is employed by a busy private hospital in Melbourne.  I hope that midwife comes to my blog, and reflects on the incident that I witnessed recently, and which I will briefly describe here.

The labouring woman had written a brief birth plan; the sort of plan that I call "Plan A".
Something like this:

I am intending to give birth under my own power, and will do all I can to achieve the best outcomes for myself and my baby.  At the time of birth, my baby’s cord should not be clamped or cut, and my baby must not be separated from me, except for clear medical reasons, and with my consent.  
I do not want any drugs to be administered to me or my baby without my consent. ...

"Yes, we do 'skin to skin', we do 'delayed cord clamping', and we keep babies with their mothers."
"But we can't do physiological third stage."
"The problem is," the young midwife said, "It's hospital policy that you have syntometrine.  I have checked with my manager, and we have to give you syntometrine for the placenta.  It's hospital policy."

The mother was labouring, wasn't saying much, so nothing was resolved.  The midwife brought the tray containing ampoules of the oxytocics into the room.

... fast forward  ...

A healthy baby made his grand entrance, and no drugs were used.  The woman birthed her placenta spontaneously about 30 minutes after the birth, with minimal blood loss.


I am recording this brief account because I want to comment on it.

• A midwife became the pusher and enforcer of a hospital policy to administer a particular drug preparation.  This is not midwifery.  There was no professional discussion offered as to the implications of the use of this drug for mother or baby.  The midwife simply acted as an agent of her employer, demanding compliance with this policy.  
• A midwife failed to recognise or uphold a woman's right to informed decision making, and ultimately her right of refusal.

I feel very concerned for this midwife, who is at the beginning of her career.   It seemed clear to me that the midwife considered it her job to enforce the policy.  The midwife gave no indication of any understanding of or interest in the physiology of birth.  Rather, she seemed set on carrying out a series of tasks that were, apparently, the essence of her professional practice. 

The midwife appeared to be ready to ignore a written statement by the woman, that she intended to give birth spontaneously, without drugs.  There seemed to be an assumption by the midwife that the woman's choice of working in harmony with physiological processes and avoiding unnecessary medications was a choice that could carry no weight in that particular hospital.   There was no discussion of the potential benefits or risks of either course of action.  'Hospital policy' was the big flashing light that apparently barred the woman from attempting her plan of action.

The prophylactic use of oxytocics in the third stage of labour, 'active management of third stage', is a process of routine intervention that comes under the banner of the 'evidence based practice' movement.  The uncritical adoption of active management by most hospitals, with the belief that it reduces blood loss and thereby reduces maternal morbidity, is rarely questioned.

In this birth, the mother was ideally suited to unmedicated, safe, physiological third stage because the following requirements had been met:

• a woman in good health
• at term
• spontaneous onset of labour
• good progress in labour
• uncomplicated, unmedicated first and second stages of labour.

In contrast, there are good reasons why one might seek to avoid use of Syntometrine. 
Syntometrine is a preparation that combines synthetic oxytocin with ergometrine.
Syntometrine is an S4 drug - restricted to prescription by a doctor or an authorised midwife prescriber.  The idea that a hospital would make policy requiring the use of a restricted medicine is in itself suggestive of a breach of the basic rules of prescribing. 

Follow the link above to read consumer information about Syntometrine.  One small sentence stands out:  

Tell your doctor if you plan to breast-feed after being given Syntometrine. One of the ingredients in this medicine secretes into breast milk. Your doctor will discuss the potential risks and benefits involved.  (http://www.mydr.com.au/medicines/cmis/syntometrine-solution-for-injection )

Breastfeeding is an intrinsic part of physiological birth.
 
Further information on the use of Syntometrine in lactation comes from MIMS, the widely used medicines reference resource:

Use in lactation Of the two components, only ergometrine is known to pass into breast milk. The use of Syntometrine during lactation is not generally recommended.
Ergometrine is secreted into milk and the inhibitory effect of ergometrine on prolactin can cause a reduction in milk secretion. Syntometrine has the potential to cause serious adverse drug reactions in breastfed newborns/ infants. Postpartum women receiving Syntometrine should avoid breastfeeding at least 12 hours after the administration. Milk secreted during this period should be discarded.  ...

How many mothers are given this information prior to administration of Syntometrine?  Very few, I think.

I hope readers see the point I am making.  Today we are advocating a return to spontaneous breech birth, returing to the woman and her baby their right to unmedicated physiological birth.   Perhaps we also need a group of intelligent, well motivated consumers, to become activists for umnedicated, uninterrupted birth, from the onset of labour to the completion of the expulsion of the placenta and membranes and cessation of bleeding.


Your comments are welcome

why breech births are important

I had a moment of clarity just the other day: Women who have breech babies, and for whom spontaneous vaginal breech birth (vbb) is an option, need MIDWIVES who are willing to be on call, and work with them to the full extent of midwifery as primary maternity care providers in their births.

But, I hear someone say, midwives have been deskilled in VBB,  Most breech babies in the past 20 years have been delivered by caesarean.  So how can a midwife consider herself competent?

And, I hear someone else say, surely the hospitals won't allow a midwife to 'manage' a breech birth.  Surely the senior obstetricians will take control?

Yes, these are valid points, but there's one other point - the point of my recent epiphany - that needs to be considered.  No matter how deskilled midwives and doctors are, the woman's body is, in many cases, ABLE to do the work.  Spontaneous birth, regardless of which pole is presenting, is just that: SPONTANEOUS.  Spontaneous means that the progress happens under the powers that are within the woman's body.

I don't want to sound ignorant or naive here, because I know there are specific complications with breech births that increase risk of neonatal morbidity.  An arm can impede progress: a midwife can manipulate the baby to free that arm.   A baby can be born with low Apgar scores: a midwife is able to provide resuscitation.   The knowledge that upright vbb works well has been circulated in midwifery circles for as long as I can remember.  I don't know when I first heard the old adages, "let the breech hang" and "hands off the breech".  One of the main questions in the exam I took in 1973, when I became a midwife, was all about breech births.  Yet the obstetric textbooks teach the lithotomy position; and the warmed towel to support the baby's body while the various manoeuvres which have the names of obstetricians (eg Lovesett, Mauriceau Smellie Veit ... - I haven't checked the spelling) are performed.

Since the publication of the Hannah (2001) Term Breech Trial, which had the almost immediate effect of channeling almost all breech babies to the operating theatre, midwives in my part of the world have had little experience with vbb.  Breech presentations occur at Term in about 4-5 of 100 births.  In my practice I have seen one or two most years, which is consistent with that rate.  I have followed the current best practice guidelines and sought out external cephalic version, which in at least half of the cases has done the trick.  I would be foolish to claim any special expertise in vbb.  Yet, with the information and drive I now have, I would now be prepared to discuss the option of spontaneous vbb at home in my care, or hospital, with any woman at Term with a breech baby on board. 

There are just a few birthing situations today that potentially challenge the skill, knowledge, and courage of a midwife.  These may be unanticipated.  They may occur with little warning.  And they require the midwife present at the time to act decisively in interests of safety of the mother and/or her baby.


A breech birth can be a big surprise.  The midwife can either act in harmony with the natural processes, and support uncomplicated birth of a healthy baby, or interrupt the processes and mechanisms of birth due to ignorance and fear.

Spontaneous birthing is the terrain in which midwives work best.  We watch and wait, and hold a cocoon of safety around the woman-child unit.  We know the subtle behaviours that indicate progress, and we know how to minimise adrenaline and other fear-related hormones.  We know how to leave well alone; how not to fiddle.  We know how to stay quietly with the woman, physically and emotionally, as she progresses on the pathway to bringing her child into this world.

Spontaneous birthing for vbb must be upheld and protected by midwives and women in all communities.  Sure, some of the big teaching hospitals need to set up breech clinics and have specialists strutting their stuff.  But the reality of childbearing is that women in small towns, and in outer suburbs, and on farms, will also occasionally need to give birth to breech babies.  Many won't have the $15,000 needed for a private hospital booking with the heavily booked breech doctor.  Many won't be within the catchment of the public hospital breech clinic.  They will need a midwife in their community who can work in harmony with a spontaneous and life giving process, and who has the skill to recognise complications in a timely manner and manage referral and transfer of care when it is indicated.

Does anyone out there see what I have seen?

Does anyone else feel deep sorrow for all the breech births for which we have not provided the option of midwifery care?

Midwives who are willing, we need to provide breech education for other midwives, and get the word out in women's groups that breech births can be great births. 

And, btw, we know that the promotion of spontaneous birth for breech babies will not necessarily be easy.  Midwives may need to provide arguments about women making informed choices in professional conduct hearings.   This is the world in which we live.



For more consumer-focused breech information, go to BBANZ .