thoughts on motherhood

Women contemplating motherhood face enormous challenges.  Pregnancy and childbirth are just the beginning.

Many Australian women tell me that they are angry when the 'system' dictates what they can and can't do.
"It's my body; my baby", they say.
"Surely I know what's best for myself and my baby!"
"Surely you're not allowed to not allow me?"

Women also tell me that they have deep sadness as they remember and reflect upon their experiences in birth.  "I know I needed a repeat caesarean.  But I felt like a piece of meat on a slab.  My baby was taken to the Nursery, while I was in Recovery.  I didn't see him for a couple of hours, and that still makes me sad.  I was afraid for him, and wanted him with me.  If I could have had a natural birth, I would have."

Natural birth has become the ultimate, longed-for experience in childbirth.

Unmedicated, physiological birth; uninterrupted, ecstatic, even orgasmic.
No clamping of the umbilical cord.  No separation of mother and baby - at all!  Not just the first hour, but as long as it takes.

Achieved by only a few.

Who wouldn't want to join that exclusive club?

Not only does the mother appreciate the physical, emotional and hormonal bonuses of working in harmony with amazing natural processes in birth, but the baby also joins in, without any prompting, in this unique primal dance.  


The point I am trying to make, and the main reason I am writing this post, is that there's a problem - women can't pick and choose their maternity journey.  My comments may seem predictable.  How many times have I written this sort of thing, since I started blogging in 2006?  

• The choices or decisions in maternity are quite simple - to intervene or not.  The biological processes in pregnancy, birth and lactation will continue as time passes.  
• Once interventions have occurred it may be difficult to return to the natural, healthy process.
• Undesired outcomes including death may occur, with or without medical or surgical interventions.

I have heard childbirth educators who teach that women who really want natural birth need to surround themselves with a team of supporters who will not waver in their support.  "The chain is only as strong as its weakest link," they say.  "If your supporters (including friends, husband, photographer, carer for children, doula, midwives) stop believing in you, they will cause you to give up just when you should be strong!"

This sort of advice is appalling.

Noone can predict a childbearing journey.  Natural birth is not something that can be ordered like a saleable commodity.  Women can't pick and choose.  A woman's pain in labour may be an indication of serious complication which, if nothing is done to relieve it, has catastrophic consequences.  A woman who shuts down her own responses to pain, and blocks the empathy and care of her supporters is ignoring natural processes at her peril.  A midwife who is disengaged, and sits on her hands rather than guide a woman on in labour, or, make the call to escalate care, is negligent or incompetent.  This might be as 'simple' as, without words, guiding a labouring woman to change her position, thereby moving from the transition to the second stage.  It may be as profound as telling the woman that you are now advising medical intervention, with all that that means.


Advice on childbirth has multiplied in recent years, with social media and internet communications.  A childbirth blog that has (literally) thousands of 'like's, tells us that "The legal authority in childbirth lies with the woman giving birth, not the providers ..." [link]

That's nonsense. 

There is a legal and ethical 'duty of care' that providers (midwife or doctor or other health care providers) are required to take very seriously.   It's an ongoing responsibility that the care provider carries as long as they are in attendance or other relationship such as in phone contact with the recipient of care.

This doesn't mean that all advice or decisions by providers are necessarily 'best practice' or acceptable to the woman.  Some providers maintain practices that are out of date, and believe they should intervene when others consider the progress to be uncomplicated and not requiring intervention.  Some providers (midwives and doctors) take large caseloads that result in cutting corners and burnout.  Human error is a constant threat.  These factors are balanced, to a degree, by the legal right of a competent woman to decline any intervention on herself (but not necessarily on her baby after birth).

We can talk about the legal and ethical standard for informed consent, but the hospitals/doctors/midwives know that they are much more likely to be defending their actions to their indemnity provider or the coroner or AHPRA.  


And there's the uneven playing field. The provider does *it* many times every day, while the woman is doing it for the first (or whatever) time - and takes the 'outcomes' (including pelvic floor damage, surgical wounds, infection, and many other types of morbidity, not to mention mortality) home.
 

Becoming a mother - bearing and nurturing a child - is an awesome and privileged position for any woman to be in.  Our bodies are wonderfully made.  

But, we can't pick and choose what happens in our maternity journeys.

The most healthy and 'low risk' pregnancy can suddenly and unpredictably be subject to life-threatening complications.  Alternatively, a woman with recognised risk factors can proceed without any complication.

Decision-making in the childbearing continuum is an ongoing process.  The woman who can trust her care provider enough to challenge or seek further discussion when any decision point has been reached is, I believe, in the best position.  The woman who believes she is alone, and has to be strong  and resist intervention or professional advice 'no matter what', is likely to be overwhelmed with fear and may make decisions that are not in her best interest.

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".

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

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)

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

spontaneous birthing

There was no acceptable alternative; no short-cut or easy way.  The labour had established.
The young mother struggled with every surge of uterine activity.  "I can't do it!  I am too tired!", she cried in English, then lots more in another language.
If one of us had been able to step in as proxy; to labour and give birth, or even to do some of the work, and lessen her load, we would have.  Surely it's unfair that the woman has to do it all?

Each time I witness the massive effort that culminates in the unmedicated, unassisted birth of a baby - and particularly a first baby - I am in awe.   The journey that can have many unpredictable and unexpected turns in the path; many forks in the road.  At each decision point, only one way can be taken.  Is this the best way?

As midwife, I hear many voices.  The mother's body, the baby's body, my own mind, the voice of professional and scientific knowledge, and the words of others participating in the birthing journey.

When the mother's mind says "I can't do it! I'm too tired!" I can't just block my ears.

I ask, what does her body tell me?

There is power in these contractions, and I have seen progress over time.
There is strength in this young body.  Her pulse rate is steady and strong.
There is quietness in the moments of resting between contractions.
Is mother well?  At present, yes.

I know we can continue.

I ask, what does her baby's body tell me?

The baby's heart rate is strong and steady.
The contractions, although strong, do not bring any sign of distress in the baby.
The baby's station is progressing with time.
Is baby well?  At present, yes.

I know we can continue.

I ask, what does my own mind tell me?

It's the middle of the night, and my mind is also weary.
I hear the cries.  I know that she is sleep-deprived.
I seek to guide this girl who is being transformed into a mother through this rough terrain.

I will not interrupt or interfere with the amazing metamorphosis; the life-giving struggle that we are witnessing.

I ask, what does professional and scientific knowledge tell me?

Simply this: that there is no safer or more appropriate way for this baby to be brought into the world, than for the midwife to work in harmony with natural physiological processes in labour and birth.
That this woman's body is wonderfully made, that this baby's body is uniquely suited to this mother, and that the process of birth is so much more than delivery of a child from the womb to the outside world.
That the transitions which must take place shortly are best supported in strong, unmedicated birthing.

I know we can continue.

I ask, what do the others - the husband, the friend, the student - tell me?

We are working together, and I am responsible for so much.  These members of the team are looking to me for encouragement and strength.  They do not have the years of life experience that I have, and they are quietly learning to harmonise their actions with those of the labouring woman.

I know we can continue.



We moved to the birthing pool.  The pushing had been ineffective, and the voice "I can't do it, I'm too tired!" was becoming more persistent.

Then, as an expulsive urge was about to go, I saw some fine, thick black hair peep out between the labia, then disappear again.

"I can tell you what colour your baby's hair is" I said.  "Black."

We all laughed.  Babies from their people group all have black hair.


I don't know when the young mother realised that she actually could give birth, that she was giving birth.  But I know and hold onto the look of utter amazement and satisfaction as she took her child into her arms.