The young woman was labouring hard when I arrived. Hers was a better-than-textbook first labour: she got up at 4:30 am; was having mild contractions every 7 or 8 minutes by breakfast time; accelerated into 3 contractions every 10 minutes by mid-morning; and felt like pushing before midday. After quickly arranging my few pieces of equipment I knelt beside the birth pool, checked the fetal heart rate after a contraction, and waited with her. When her eyes met mine, she whispered, "I'm glad you're here."
The home, a lovely old inner-suburban Melbourne cottage, seemed to embrace and welcome this birth. There was harmony and warmth in the exposed brick walls. The baltic pine floor boards showed the wear of many occupants over the years. The mild summer day, and a gentle breeze, gave support and energy to the work of childbirth. I learned later that the young woman's parents had lived in this home when their first child was born, and that several of the babies of this family had either been conceived there, or were brought there after birth.
"I'm glad you're here."
The mechanisms of birth proceeded without delay. The strong, expulsive effort of the womb, brought the little head to the vaginal opening. We had no mirrors or torches - we worked by feel rather than by sight. The mother's hand gave her all the information she needed. After the head had fully emerged we waited, then supported the baby as she came to the surface of the water, opened her lungs, and took her first breaths of air. After a brief rest we assisted the mother and her baby out of the pool, and they rested as we awaited the after-birth. There was no bleeding. There was no cause for concern at any time.
I reflected on that simple statement, "I'm glad you're here", as I completed the day's work, writing my notes and preparing the official birth documentation. I reflected on them again as I visited the home the next day.
"I'm glad you're here" was firstly a statement of the rightness of home as the setting for this birth. The young mother told me later that she would have found it very difficult to know when to travel, if she had been required to go to hospital.
It was also a statement of the rightness of the 'with woman' relationship. The partnership I have with that young woman is a unique and special bond.
Clearly, this birth did not rely on any special skill or treatment that I might have offered. Apart from putting my hand gently on the woman's leg when she felt a muscle cramp, I did very little. A new graduate midwife could have done everything that I did. The midwife attending a home birth relies more on the wonderful spontaneous actions of the woman's body, than on any midwifery act. The essence of midwifery is being, rather than doing.
"I'm glad you're here" says it all.
Showing posts with label with woman. Show all posts
Showing posts with label with woman. Show all posts
Tuesday, January 29, 2013
Friday, September 07, 2012
availability of midwives for homebirths
Today I would like to explore a few issues around the availability of midwives to provide professional services for homebirth, and suggest what I see as a way forward.
These issues come under different headings, such as risk, cost, and practical matters such as distance the midwife needs to travel.
'Risk' - however defined - is a major obstacle. The narrow definition of risk declares that every birth carries substantial risk, and that the only responsible place for birth to take place is in hospital. This narrow mindedness is not informed by evidence or by logic.
The next level of risk puts it this way: It's OK to plan homebirth if everything is normal, and excludes significant numbers of women in the birthing population, such as those who have had a previous caesarean birth.
With the increased availability of publicly funded, hospital based homebirth programs, women who decline some 'standard' test or investigation are excluded. A woman who makes what she considers to be an informed decision to avoid exposing her unborn child to routine ultrasound is told she is not permitted to continue in the homebirth program. Similarly, a woman who indicates her desire to have an unmedicated/unmanaged third stage is told she can do that in hospital, but not at home.
Most readers of this blog probably realise that these restrictions that exist in our world today are based more on fear of birth than potential risk to the woman or her baby.
These distorted and uninformed responses to perceived risk should be discussed critically by midwives who understand the protective effect that is achieved when a well woman works in harmony with natural physiological processes. Yet midwives say very little.
These distorted and uninformed responses to perceived risk should be addressed logically and carefully by the maternity decision-makers in mainstream hospitals, providing suitable pathways for women whose risk status is not at the bottom of the ladder. An obvious pathway is that a midwife who the woman trusts is available to attend as primary carer throughout the episode of care. Yet the only place a woman can have her own midwife as her primary carer is in privately attended homebirth. Public hospitals in Melbourne seem to be more committed than ever to preventing midwives from having clinical privileges/visiting access. When midwives do attend a woman in a public hospital they often experience rudeness and disrespect towards the woman and themselves.
$$ Cost is significant in private homebirth. While the midwives need to make enough money to sustain their practices, the cost of the service needs to be acceptable to the women who employ midwives. Medicare rebates for antenatal and postnatal services are small by comparison with the fees that midwives are charging. For example, a woman in my care will pay me approximately $2,500 for the episode of care, and may receive $500-$700 in Medicare rebate. The Medicare rebate for intrapartum midwifery services is limited to hospital births with a Medicare-eligible midwife, and as mentioned, that is not an option.
The other factor in cost of private homebirth is the number of midwives. Traditionally midwives have often worked in pairs, and many of my colleagues, particularly around Melbourne, require two midwives to be booked for homebirth, bringing the expected cost of the booking to $5000 or more. A recent statement by a Sydney midwife-academic to a coroner's inquest indicated her belief that two midwives are an essential part of planned homebirth. I disagree. Strongly!
I have been told that some women who want to plan homebirth have chosen an unregulated woman (doula) as a cheaper alternative to two midwives. I cannot support this option - it scares me. I wonder if midwives who demand the 'two midwives' rule feel any responsibility for the apparently increasing rates of planned 'freebirth', either with or without a doula? A doula speaking to me recently indicated that a woman she has met is considering freebirth, "with me there just to support her".
Practical matters: the main one that comes to mind is the distance across this wide brown land. Gone are the days of the village midwife on her bike. Each time I visit a client, I am using precious fuel. Likewise, each time a woman comes to me. If a woman lives closer to another private midwife, I will always ask her to consider employing that midwife. (An exception is a few special women who I have attended on several occasions over the years. I have become a part of those families, and it's lovely to return for the birth of the next baby.)
Speaking practically, there's no reason why midwives in every town and city across this country should not be able and willing to attend women locally for birth, guiding the women as to their need to be attended in hospital, or at home. Ageing midwives like me should not be needing to drive an hour or two in our cars to get to the women.
Yet the culture of fear and distrust of birth has destroyed midwives' confidence in their own ability to be 'with woman'.
What am I saying?
I believe midwives need to take more assertive action to promote and protect normal birth, including homebirth.
These issues come under different headings, such as risk, cost, and practical matters such as distance the midwife needs to travel.
'Risk' - however defined - is a major obstacle. The narrow definition of risk declares that every birth carries substantial risk, and that the only responsible place for birth to take place is in hospital. This narrow mindedness is not informed by evidence or by logic.
The next level of risk puts it this way: It's OK to plan homebirth if everything is normal, and excludes significant numbers of women in the birthing population, such as those who have had a previous caesarean birth.
With the increased availability of publicly funded, hospital based homebirth programs, women who decline some 'standard' test or investigation are excluded. A woman who makes what she considers to be an informed decision to avoid exposing her unborn child to routine ultrasound is told she is not permitted to continue in the homebirth program. Similarly, a woman who indicates her desire to have an unmedicated/unmanaged third stage is told she can do that in hospital, but not at home.
Most readers of this blog probably realise that these restrictions that exist in our world today are based more on fear of birth than potential risk to the woman or her baby.
These distorted and uninformed responses to perceived risk should be discussed critically by midwives who understand the protective effect that is achieved when a well woman works in harmony with natural physiological processes. Yet midwives say very little.
These distorted and uninformed responses to perceived risk should be addressed logically and carefully by the maternity decision-makers in mainstream hospitals, providing suitable pathways for women whose risk status is not at the bottom of the ladder. An obvious pathway is that a midwife who the woman trusts is available to attend as primary carer throughout the episode of care. Yet the only place a woman can have her own midwife as her primary carer is in privately attended homebirth. Public hospitals in Melbourne seem to be more committed than ever to preventing midwives from having clinical privileges/visiting access. When midwives do attend a woman in a public hospital they often experience rudeness and disrespect towards the woman and themselves.
$$ Cost is significant in private homebirth. While the midwives need to make enough money to sustain their practices, the cost of the service needs to be acceptable to the women who employ midwives. Medicare rebates for antenatal and postnatal services are small by comparison with the fees that midwives are charging. For example, a woman in my care will pay me approximately $2,500 for the episode of care, and may receive $500-$700 in Medicare rebate. The Medicare rebate for intrapartum midwifery services is limited to hospital births with a Medicare-eligible midwife, and as mentioned, that is not an option.
The other factor in cost of private homebirth is the number of midwives. Traditionally midwives have often worked in pairs, and many of my colleagues, particularly around Melbourne, require two midwives to be booked for homebirth, bringing the expected cost of the booking to $5000 or more. A recent statement by a Sydney midwife-academic to a coroner's inquest indicated her belief that two midwives are an essential part of planned homebirth. I disagree. Strongly!
I have been told that some women who want to plan homebirth have chosen an unregulated woman (doula) as a cheaper alternative to two midwives. I cannot support this option - it scares me. I wonder if midwives who demand the 'two midwives' rule feel any responsibility for the apparently increasing rates of planned 'freebirth', either with or without a doula? A doula speaking to me recently indicated that a woman she has met is considering freebirth, "with me there just to support her".
Practical matters: the main one that comes to mind is the distance across this wide brown land. Gone are the days of the village midwife on her bike. Each time I visit a client, I am using precious fuel. Likewise, each time a woman comes to me. If a woman lives closer to another private midwife, I will always ask her to consider employing that midwife. (An exception is a few special women who I have attended on several occasions over the years. I have become a part of those families, and it's lovely to return for the birth of the next baby.)
Speaking practically, there's no reason why midwives in every town and city across this country should not be able and willing to attend women locally for birth, guiding the women as to their need to be attended in hospital, or at home. Ageing midwives like me should not be needing to drive an hour or two in our cars to get to the women.
Yet the culture of fear and distrust of birth has destroyed midwives' confidence in their own ability to be 'with woman'.
What am I saying?
I believe midwives need to take more assertive action to promote and protect normal birth, including homebirth.
- midwives need to think critically about risk
- midwives need to work to make primary maternity care by a known midwife affordable
- midwives need to wake up to their capacity to provide midwifery services in homes and hospitals, for all women.
Friday, July 13, 2012
hospitals and independent midwives
When a midwife walks into a hospital with a woman for whom she is providing private midwifery services, that midwife faces a complex and often challenging work environment.
Recently I went to hospital with a woman who I will call Melissa, who was planning VBAC. Melissa's first child had been delivered by emergency caesarean, after induction of labour at 42 weeks. This time Melissa was well informed, and intentional about all her decisions.
Melissa had experienced a difficult week 39-40 in her pregnancy. There were several nights without much sleep, and she had a cold. A couple of days after her expected due date, Melissa asked me to assess her internally, and consider a 'stretch and sweep' of the membranes at her cervix. I was pleased to report a well applied head, a very thin cervix, and about 1.5cm dilation. With very gentle stretching of the cervix, I felt confident that the labour was imminent.
Sure enough, Melissa called me a few hours later, and I went with her as she was admitted to the hospital birth suite. Melissa laboured strongly, and together we considered any decisions that needed to be made, following 'Plan A'. I continued 'with woman' through the labour and birth, and afterwards.
There is nothing remarkable about this little account. However, the matter that has prompted me to write about hospitals and independent midwives is the question of what to call a midwife who goes to hospital with a woman in her care.
I call that midwife a midwife.
Others call that midwife a 'support person', or a 'birth support person', or even 'only support'!
Why?
Because the independent midwife does not have visiting access/ clinical privileges/ credentialling in that hospital.
This is true - Victorian public maternity hospitals have dragged their feet on this matter. Despite government-supported indemnity insurance for private midwives providing intrapartum care in hospital, there is no likelihood of hospital visiting access in the near future.
So does a midwife cease to be a midwife, just because the hospital refuses to roll out the red carpet? Of course not! A midwife is 'with woman': not with a setting for birth. The midwife's registration is with the regulatory body, which is not under the management of the hospital. And, let's remember that if a midwife acted in a way that was considered unprofessional, she or he would expect to be reported to the regulatory authority as a midwife, not as a 'support person'.
The ICM definition of the Midwife
declares that the midwife's Scope of Practice is:
'Support' is listed in the definition as one of the elements of midwifery. I do not want to seem to devalue support. But the point I want to make is that support is a part of the midwife's scope of practice: not an alternative to midwifery practice, and definitely not an alternative to the title 'midwife'.
Thankyou for your comments.
Recently I went to hospital with a woman who I will call Melissa, who was planning VBAC. Melissa's first child had been delivered by emergency caesarean, after induction of labour at 42 weeks. This time Melissa was well informed, and intentional about all her decisions.
Melissa had experienced a difficult week 39-40 in her pregnancy. There were several nights without much sleep, and she had a cold. A couple of days after her expected due date, Melissa asked me to assess her internally, and consider a 'stretch and sweep' of the membranes at her cervix. I was pleased to report a well applied head, a very thin cervix, and about 1.5cm dilation. With very gentle stretching of the cervix, I felt confident that the labour was imminent.
Sure enough, Melissa called me a few hours later, and I went with her as she was admitted to the hospital birth suite. Melissa laboured strongly, and together we considered any decisions that needed to be made, following 'Plan A'. I continued 'with woman' through the labour and birth, and afterwards.
There is nothing remarkable about this little account. However, the matter that has prompted me to write about hospitals and independent midwives is the question of what to call a midwife who goes to hospital with a woman in her care.
I call that midwife a midwife.
Others call that midwife a 'support person', or a 'birth support person', or even 'only support'!
Why?
Because the independent midwife does not have visiting access/ clinical privileges/ credentialling in that hospital.
This is true - Victorian public maternity hospitals have dragged their feet on this matter. Despite government-supported indemnity insurance for private midwives providing intrapartum care in hospital, there is no likelihood of hospital visiting access in the near future.
So does a midwife cease to be a midwife, just because the hospital refuses to roll out the red carpet? Of course not! A midwife is 'with woman': not with a setting for birth. The midwife's registration is with the regulatory body, which is not under the management of the hospital. And, let's remember that if a midwife acted in a way that was considered unprofessional, she or he would expect to be reported to the regulatory authority as a midwife, not as a 'support person'.
The ICM definition of the Midwife
declares that the midwife's Scope of Practice is:
The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.
'Support' is listed in the definition as one of the elements of midwifery. I do not want to seem to devalue support. But the point I want to make is that support is a part of the midwife's scope of practice: not an alternative to midwifery practice, and definitely not an alternative to the title 'midwife'.
Thankyou for your comments.
Monday, April 02, 2012
Reflection on practice
 |
| Alena welcomes her baby brother, Christopher |
I want to assure readers that mother and baby are well. However, I am left with some difficult questions. I question my own actions as well as those of colleagues in the hospital.
1. What happened?
Linda was treated unnecessarily (imho) and aggressively for obstetric haemorrhage.
2. Feelings: What was I thinking and feeling?
I was shocked, surprised, and bewildered when I realised that there was a full-scale emergency 'code' being performed, with not only active management of the Third Stage, but additional oxytocic drugs intramuscular Syntometrine, intravenous Syntocinon (40 IU in 1 litre of fluid) administered urgently.
3. Evaluation: What was good and bad about the experience?
What was good? Having experienced respectful care from the doctors and midwives through the pregnancy, and engaged in carefully informed decision-making up to the moment of birth, this incident was an over-reaction to Linda's known risk factors (including multiparity, and a previous caesarean birth)
What was bad: I realised that I had facilitated this chain of events, because I encouraged Linda to agree in early labour to having the IV cannula sited in her arm.
4. Analysis: What sense can I make of the situation?
I can understand why this incident happened, because I know about other very difficult incidents that this group of midwives were dealing with.
5. Conclusion: What else could I have done?
At present a midwife practising privately is not able to have visiting access for clinical privileges in hospitals in Victoria. I cannot over-ride the clinical decision of another midwife, and when an emergency code has been called, I would be foolish to interfere. My long term hope is that I will be able to have clinical practice rights in public hospitals, and in this case I would be able to take responsibility for my own clients.
6. Action Plan: If it arose again, what will I do?
As I noted in #3 above, I had encouraged Linda to agree to the hospital's policy and have an IV cannula sited in preparation for an incident such as a post partum haemorrhage (pph). I believe Linda would have declined the offer if I had not spoken to her about it. In this case I think it was the fact that the cannula was in situ, and the hospital midwife was basically 'set up' for a pph, that somehow set the pathway.In another similar situation, I will be careful to inform the mother that once a cannula has been sited, it is easier for staff who may be on edge for totally unrelated reasons, to 'jump the gun' and treat her as though she is in an emergency, when this is not the case.
Thursday, October 20, 2011
what will the students think?
A few weeks ago I wrote about the interim Position Statement on Homebirth that appeared , with endorsement, on the website of the statutory body. The Position Statement and associated documents had been prepared by the College of Midwives.
Today I attended a meeting of members of the College, at which I and other members took the opportunity to speak about our concerns around these documents.
Today I attended a meeting of members of the College, at which I and other members took the opportunity to speak about our concerns around these documents.
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