UNASKED QUESTIONS ABOUT SYNTHETIC OXYTOCIN

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PRIMAL HEALTH RESEARCH
A NEW ERA IN HEALTH RESEARCH
Published quarterly by Primal Health Research Centre
Charity No.328090
72, Savernake Road, London NW3 2JR
michelodent@googlemail.com
Summer 2010 Vol 18. No1
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www.primalhealthresearch.com
(Free access to the Primal Health Research Data Bank)
www.wombecology.com
(The importance of pre- and perinatal ecology)
BETWEEN THE MIDATLANTIC AND THE MIDPACIFIC CONFERENCES
(Topics for the future: see below)


UNASKED QUESTIONS ABOUT SYNTHETIC OXYTOCIN
A labouring woman was puzzled and even anxious when she received a drip of synthetic oxytocin, The midwife immediately reassured her that oxytocin is not like a drug: it is “natural”. Perhaps this is why we ignore many questions regarding what is undoubtedly the most common medical intervention in childbirth on all five continents. Today, all over the world, most women giving birth vaginally get such a drip (called Syntocinon or Pitocin) including those with an eventual operative delivery by forceps or ventouse. Most women who undergo a caesarean section during labour have had such a drip before the decision to operate, and this drip is usually continued for some hours after the surgery. Even during and after a pre-labour c-section, synthetic oxytocin is included in many hospital protocols to facilitate uterine retraction. Furthermore, the rates of labour inductions are currently high, and induction almost always involves the use of synthetic oxytocin.

Preliminary questions
This new situation raises important questions. We must first wonder why modern women need substitutes for the hormone that is naturally released by the posterior pituitary gland. Is it because their oxytocin system is disturbed? Is the capacity to effectively release oxytocin depleted from generation to generation, as a result of several aspects of modern life, particularly medicalised birth? This is a vital question for the future of civilisation, since the oxytocin system is involved in sociability, capacity to love, and potential for aggression. Is it mostly cultural conditioning in a context of industrialised childbirth? In this latter case the current situation might be reversible. If it is simply a matter of environment at birth, we need to improve our understanding of the birth process. In fact, we must explore the possible contribution of multiple factors.

Other questions address the substances that might cross the placenta and reach the unborn baby. For example, the kind of fluid used to transport synthetic oxytocin. In earlier times, glucose drips were routine during labour. These infusions were not benign because simple sugar molecules rapidly cross the placenta while the mother’s insulin—released in response—fails to reach the fetal bloodstream. There is thus a risk of excessive insulin production generated by the baby's pancreas in response to these circulating high blood sugar levels. Extensive research has confirmed the risks of neonatal hypoglycemia.(1 to 7) These studies led to the replacement of glucose drips during labour by other liquids, such as Ringer’s solution. The results of such studies also apply to labouring women without a drip of synthetic oxytocin if they are encouraged to consume sugar or soft drinks. This is not always understood by the natural childbirth groups. Furthermore, if labour progresses spontaneously, adrenaline type hormone levels are low, voluntary muscles are at rest, and these women don’t need added energy.8

Can synthetic oxytocin cross the placenta?

When we finally acknowledge that all over the world most women receive synthetic oxytocin while giving birth, we can no longer deny problems arising from the possible transfer of oxytocin via the placenta. One can wonder why it remains an unexplored issue. The main reason, as we have suggested, might be that oxytocin is not considered a “real” medication because chemically the synthetic form is no different from the natural hormone: it is a simple molecule (a nonapeptide). However, the problem is not simple because the amount of oxytocin reaching the maternal blood stream via an intravenous drip is enormous compared with the amount of natural oxytocin the posterior pituitary gland can release. Furthermore, natural oxytocin is released through pulsations, while synthetic oxytocin is delivered continuously. Another reason for ignoring this issue might be the discovery of enzymes that metabolize oxytocin (oxytocinases) in the placenta. This finding might have led to a hasty, tacit conclusion that synthetic oxytocin does not reach the baby.

Until now, there has been only one serious article published on this subject.9 A team from Arkansas concluded that oxytocin crosses the placenta in both directions—after measuring concentrations of oxytocin in maternal blood, in the blood of the umbilical vein and umbilical arteries, and also after perfusions of placental cotyledons. More precisely, the permeability is higher in the maternal-to-fetal direction than in the reverse. Eighty percent of the blood reaching the fetus via the umbilical vein goes directly to the inferior vena cava via the ductus venosus, bypassing the liver, and therefore reaching the fetal brain immediately: it is all the more direct since the shunts (foramen ovale and ductus arteriosus) are not yet closed.

Since there is a high probability that a significant amount of synthetic oxytocin can reach the fetal brain, we must investigate the permeability of the so-called blood brain barrier at this phase of human development. This “barrier” implies a separation of circulating blood from cerebrospinal fluid in the central nervous system. It restricts the diffusion of microscopic particles, including bacteria, and molecules such as oxytocin. However, Australian researchers presented evidence that the developing brain is more permeable to small lipid-insoluble molecules and that specific mechanisms, such as those involved in transfer of amino acids, develop gradually as the brain grows.10 Furthermore, it appears that the permeability of the blood-brain barrier can increase under the influence of oxidative stress11,12,13, that commonly results when a synthetic oxytocin drip is administered during labor.14 Therefore, we have serious reasons to be concerned if we consider the widely-documented concept of “oxytocin-induced desensitization of oxytocin receptors”.15,16,17,18 It is probable that, at a quasi-global level, we routinely interfere with the development of the oxytocin system of human beings at a critical phase for gene-environment interaction. Within the framework of accepted scientific knowledge, we must acknowledge the important role of oxytocin, particularly in sociability, the capacity to love (of others and love of oneself) as well as the potential for aggression (aggression towards oneself and towards others).19 Interfering in normal reproductive physiology raises critical issues. For example: “Is there a link between the increased incidence of disorders associated with documented alterations of the oxytocin system (such as autism20,21 and anorexia nervosa22,23) and the widespread use of intravenous drips during labour?” “What will be the impact on the evolution of our civilizations?” We may even wonder if the widespread use of synthetic oxytocin can induce an unprecedented cultural revolution.

Such questions should inspire a new generation of research.

Plastic related substances

Of course, one cannot ignore the toxic effects of phtalates, which are added to plastics such as polyvinyl chloride (PVC) to increase their flexibility, transparency, and longevity. The National Institute of Environmental Health Sciences and the National Toxicology Program began studying phthalates following a discovery that blood stored in PVC plastic bags for transfusions contained significant concentrations of phthalates.24 The most common phthalate is di-ethylhexyl phthalate, or DEHP. In bags for intravenous drips and tubing, additives like DEHP can make up 40 or 50 percent of the product.

There are several reasons why this issue is critical. The first is that the effects of phtalates on intellectual development have already been demonstrated, in particular by an authoritative South Korean study.25 The authors found that high urinary concentrations of phthalate metabolites were associated with lower intellectual quotients (IQ) among 667 children at nine elementary schools. Another reason for serious concern is that today most women spend hours with an intravenous drip while giving birth. There is an accumulation of data confirming the transplacental transfer of phtalates among mammals in general26,27 and humans in particular.28 Most babies probably receive some amount of phtalates during the critical period surrounding birth. Is this amount negligible or dangerous? What are the possible long-term consequences? It is essential to emphasize that these phtalates pass directly into the fetal bloodstream, with no possibility of degradation in the digestive tract. Very sensitive tests today can find a millionth of a gram, or even less, of certain substances in blood or urine. This measurement process is called biomonitoring. In July 2006, an expert committee of the National Academy of Sciences (NAS) published the results of a comprehensive study of biomonitoring. The committee stated that, “In spite of its potential, tremendous challenges surround the use of biomonitoring, and our ability to generate biomonitoring data has exceeded our ability to interpret what the data mean to public health.”

Today, even the experts confess that they are in the dark.

References
1 - Mendiola J, Grylack LJ, Scanlon JW. Effects of intrapartum maternal glucose infusion on the normal fetus and newborn. Anesth Analg. 1982 Jan;61(1):32-5
2 - Lucas A, Adrian TE, Aynsley-Green A, Bloom SR. Iatrogenic hyperinsulinism at birth. Lancet. 1980 Jan 19;1(8160):144-5.
3 - Kenepp NB, Kumar S, Shelley WC, Stanley CA, Gabbe SG, Gutsche BB. Fetal and neonatal hazards of maternal hydration with 5% dextrose before caesarean section. 1982 May 22;1(8282):1150-2.
4 - Carmen S. Neonatal hypoglycemia in response to maternal glucose infusion before delivery. J Obstet Gynecol Neonatal Nurs. 1986 Jul-Aug;15(4):319-23
5 - Grylack LJ, Chu SS, Scanlon JW. Use of intravenous fluids before cesarean section: effects on perinatal glucose, insulin, and sodium homeostasis. Obstet Gynecol. 1984 May;63(5):654-8.
6 - Kenepp NB, Shelley WC, Kumar S, Gutsche BB, Gabbe S, Delivoria-Papadopoulos M. Effects of newborn of hydration with glucose in patients undergoing caesarean section with regional anaesthesia. Lancet. 1980 Mar 22;1(8169):645.
7 - Singhi S, Sharma S. Neonatal hypoglycemia following maternal glucose infusion prior to delivery. Indian J Pediatr. 1991 Jan-Feb;58(1):43-9.
8 - Odent M. Laboring women are not marathon runners. Midwiferytoday
9 - Malek A, Blann E, Mattison DR. Human placental transport of oxytocin. J Matern Fetal Med. 1996 Sep-Oct;5(5):245-55.
10 - Saunders NR, Habgood MD, Dziegielewska KM. Barrier mechanisms in the brain, II. immature brain. Clin. Exp. Pharmacol. Physiol. 1999;26(2):85–91
11 - Noseworthy M, Bray T. Effect of oxidative stress on brain damage detected by MRI and in vivo 31P-NMR. Free Rad. Biol. Med. 1998;24:942–951
12 - Agnagnostakis D, Messaritakis J, Damianos D, Mandyla H. Blood-brain barrier permeability in healthy infected and stressed neonates. J. Pediatr. 1992;121:291–294.
13 - Noseworthy M, Bray T. Zinc deficiency execerbates loss in blood–brain barrier integrity induced by hyperoxia measured by dynamic MRI. PSEBM. 2000;231:175–182.
14 - Schneid-Kofman N, Silberstein T, Saphier O, Shai I, Tavor D, Burg A. Labor augmentation with oxytocin decreases glutathione level. Obstet Gynecol Int. 2009;2009:807659. Epub 2009 Apr 16.
15 - Robinson C, Schumann R, Zhang P, Young R. Oxytocin-induced desensitization of the oxytocin receptor. Am. J. Obstet. Gynaecol. 2003;188:497–502.
16- Gimpl G, Fahrenholz F. The oxytocin receptor system: structure, function and regulation. Physiol. Rev. 2001;81:642–643.
17 - Phaneuf S, Rodríguez Liñares B, TambyRaja RL, MacKenzie IZ, López Bernal A. Loss of myometrial oxytocin receptors during oxytocin-induced and oxytocin-augmented labour. J Reprod Fertil. 2000 Sep;120(1):91-7.
18 - Phaneuf S, Asboth G, Carrasco M, Lineares B, Kimura T, Harris A, et al. Desensitization of oxytocin receptors in human myometrium. Hum. Reprod. Update. 1998;4:625–633.
19 - Odent M. The Scientification of Love. Free Association Books. London 1999.
20 - Modahl C, Green L, et al. Plasma oxytocin levels in autistic children. Biol Psychiatry 1998; 43 (4): 270-7.
21- Green L, Fein D, et al. Oxytocin and autistic disorder: alterations in peptides forms. Biol Psychiatry 2001; 50 (8): 609-13.
22 - Demitrack MA, Lesem MD, Listwak SJ, et al. CSF oxytocin in anorexia.nervosa and bulimia nervosa: clinical and pathophysiologic considerations. Am J Psychiatry 1990 Jul;147(7):882-86
23 – Odent. Autism and anorexia nervosa: two facets of the same disease? Med Hypotheses 2010. doi:10.1016/j.mehy.2010.01.039
24 - Baker RW. Diethylhexyl phthalate as a factor in blood transfusion and haemodialysis. Toxicology.1978 Apr;9(4):319-29.
25 - Cho SC, Bhang SY, Hong YC, et al.. Relationship Between Environmental Phthalate Exposure and the Intelligence of School-Aged Children. Environ Health Perspect. 2010 Mar 1. [Epub ahead of print]
26 - Saillenfait AM, Payan JP, Fabry JP, et al. Assessment of the developmental toxicity, metabolism, and placental transfer of Di-n-butyl phthalate administered to pregnant rats. Toxicol Sci. 1998 Oct;45(2):212-24.
27- Kihlström I, Placental transfer of diethylhexyl phthalate in the guinea-pig placenta perfused in situ. Acta Pharmacol Toxicol (Copenh) 1983 Jul;53(1):23-7.
28 - Mose T, Knudsen LE, Hedegaard M, et al. Transplacental Transfer of Monomethyl Phthalate and Mono(2-ethylhexyl) Phthalate in a Human Placenta Perfusion System.0. International Journal of Toxicology 2007; 26(3): 221-229.

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BETWEEN THE MID-ATLANTIC AND THE MID-PACIFIC CONFERENCES
The Mid-Atlantic Conference on Birth and Primal Health Research – which attracted 1250 participants from 39 countries – has been a successful rehearsal before the Mid-Pacific Conference.
The Mid-Pacific Conference will occur on October 26-28, 2012, in Honolulu. The venue will be the prestigious Hawaii Convention Center, as the meeting point between Western and Eastern cultures.
Once more, the main objective of the conference will be to phrase new questions after presenting an overview of technical and scientific advances that will influence the history of childbirth. As in Las Palmas, the participation of Pr. Michael Stark, the “father” of the new simplified technique of cesarean, will symbolize technical advances, while the participation of Pr Kerstin Uvnas-Moberg, as an expert in behavioural effects of oxytocin, will symbolize scientific advances. The need to think globally will be emphasized by the participation of Dr Mario Merialdi, coordinator for maternal and perinatal health at WHO.
The Mid-Pacific conference will be characterized by the emergence of new important themes, such as the transgenerational effects of early experiences (during the “primal period”), the expected importance of economical factors in the evolution of medicine in general and obstetrics in particular, and also by the great diversity of renewed practical topics presented during the thirty concurrent sessions and through posters.
During these three days, inspired by our logo and surrounded by the foams of the oceanic waves, we’ll be in an ideal place to dream of and to work for the Rebirth of the Goddess of Love.
Aloha means Love!
Michel Odent and Heloisa Lessa

Bertha finds a midwife

"If you can type you can make movies"

.
That challenge was too much for me, so I have made this little 2-minute animation movie, in response to the one I posted below thismorning. Enjoy! JJ




NEW 17 Sept 2010 Bertha's first birth







BERTHA'S VBAC

midwife 'humor'

If you are able to think critically about midwifery, natural birth, women's choice in health care, advocacy, pain relief, ..., this quirky video clip is worth watching.

Yes, it's American, and we're different, aren't we?

Here's a thumbnail sketch of the clip:

The midwife talks with the anaesthetist and says the labouring woman needs an epidural.
The anaesthetist asks the usual medical questions.
The midwife says the woman feels fine - but no objective measurements of the woman's condition have been made.  The epidural is being ordered so that the cervix can be checked.  But the woman wants a natural birth, so she doesn't want all that medical stuff done, and the midwife is advocating for the woman's choice.
[Thanks to Caroline Hastie for this video clip]

Fathers

Happy Father's Day, from Poppy

Fathers are an integral part of a midwife's life, yet they don't often find themselves being the focus of my writings.

Today we have celebrated father's day, with a nice breakfast of pancakes, bacon and eggs, and a few little gifts including the standard 'sox-n-jocks'. Poppy has given me permission to use her drawing of herself, her daddy, and grandpa and granny.


Our society has changed in the past couple of generations, from excluding fathers from any involvement in birth to an expectation that they will be present and accounted for throughout the labour and birth.

Today the father's ritual of cutting the cord is almost comic relief after a highly medicalised birth. Occasionally a father says "no, thank you" when the scissors are being thrust in his direction, and someone else has to step up to the task.

What is a father's chief role in birth and early parenting?

Many aspects of a role come to mind, including encouragement, support, caring, looking after household chores, preparing meals, making cups of tea, ... These are like pieces of a puzzle - each one incomplete in itself. They only make sense when they fit together perfectly.

Looking beyond the individual pieces of the puzzle, the role of the father can be summarised as "to love the mother".

There are enormous adjustments that have to be made when a new baby is brought into a family. The father who loves the mother, in a gentle and unconditional way, is providing the strong cement that will hold that family together through sleep deprivation, and feeding challenges, and the many other unexpected journeys that come up in ordinary life.

Father's Day is to a great extent a product of materialism, and a great marketing opportunity. Today I encourage each father to truly love the mother of your children, and in that way you will be establishing strong bonds within your family, and protecting your children as well as their mother.

Unfortunately there is no plan that will guarantee that you will live 'happily ever after'. I simply encourage parents to commit yourselves to the work of parenting, to the best of your ability, and you will not regret the investment you make.

Families

In the past week or so my mind has been drawn into a family-related project that I call 'Pictures and memories from long ago'.

With a strong sense of purpose, I have scanned pictures and documents, and copied accounts of the lives of some of my forebears. These fragments of memories have been drawn together, as I have remembered people and stories from the past.

The two women pictured in this post are truly wonderful women, from whom I have learnt values and been inspired to follow their guidance. The stately old lady is Jane Eliza Harriet White, aged 95 when this picture was taken, I think. My Grandma lived in the old homestead overlooking the bay at Redland Bay, Queensland. The tall palm trees made the house visible from a mile or so away as we headed towards School of Arts Road. Grandma had given birth to, and cared for her eight children, through terrible times or war and the Great Depression.

The beautiful younger woman, with two little girls, is my mother, Ella White. Mum's story includes missionary work in China, where she met and married my father. She gave birth to, and cared for her seven children, through the 50s and 60s. I have written about my mother in this blog in the past, especially as I waited for my own daughter to give birth.

Both Mum and Grandma included twins amongst their children. Mum had trained as a triple certificate nurse: nurse, midwife, and infant welfare sister. Grandma had done lady-like preparation for life in the early 20th century, including learning to paint landscapes. These two women have given me my two passions that go beyond family: midwifery and art.

My work of collecting and collating pictures and stories has been inspired by my enjoyment of digital technology. A simple e-book format that I used for my first book, Midwifery from my heart, has been readily adapted to the job at hand. I am bringing out the old albums, scanning the pictures, and presenting them in a way that tells a very special story.

My children and grandchildren are not very interested in their heritage at present. They have busy lives. But one day they may find, as I have, great pleasure in remembering and adding to my memories.

IS HOMEBIRTH SAFE?

and,

IS THAT A VALID QUESTION?

I am not wanting to write at length about this very significant question today, but would like to direct readers to Amy Romano's comment and debate at the Lamaze blog.

In what appears to be a global race to discredit homebirth, people who should know better have shamelessly manipulated retrospective data from planned homebirth, and come up with conflicting and often confusing results that have been published in peer-reviewed literature.

Note in this context the critiques of the Australian Medical Association's publication of the Kennare et al (2010) Planned home and hospital births in South Australia, 1991-2006: differences in outcomes. The wild claims of increased risk of perinatal death or morbidity are just that: wild claims made on deeply flawed research.

Amy Romano writes:
The (in)famous Wax home birth meta-analysis hit the scene over a month ago. But the buzz doesn’t seem to be dying down. In the weeks since the original pre-publication and press release, editors at The Lancet and BMJ have both weighed in, and there’s a steady stream of media attention. While all of the media have dutifully quoted midwives in leadership positions saying the meta-analysis is flawed (an assessment with which I agree), I still keep coming back to the question I asked in my earlier post – did we need a meta-analysis to establish the neonatal outcomes of planned home birth? We had, after all, a very large, methodologically rigorous study on home birth safety involving over a half million women that was published less than 2 years ago. Won’t that suffice? ... (continued)

Collaborative arrangements for midwives

photo: Mizz with Josh

Readers who have been following the political developments in the world of midwifery will know that the Australian government has signed into law a requirement for midwives to have 'collaborative arrangements' in order to entitle their clients to claim Medicare rebates on their charges. Midwives may become eligible for Medicare provider numbers after 1 November this year, if all goes to plan.

Midwives have known since early in the maternity reform process that the Health Minister is committed to collaborative arrangements. Midwives and childbirth advocates have repeatedly lobbied the Health Minister and her bureaucrats about the fact that the requirement for collaborative arrangements for midwives, without any matching requirement that doctors should engage in such arrangements, was an effective veto of private midwifery practice. There is no incentive, no reason why any doctor would consider signing a collaborative arrangement with a midwife in private practice, who is, in a small way, competing with the doctor for business.

Press releases and discussion about the Gillard government's action in progressing the small piece of legislation, 'National Health (Collaborative arrangements for midwives) Determination 2010' under subsection 84(1) of the National Helath Act 1953 can be reviewed at recent posts to the MiPP blog.

My intention in commenting here on this matter is to work through a scenario that I, and a woman who sought my services, would encounter if we tried to comply with the requirement for collaborative arrangements as laid down in this piece of legislation.

Section 7 requires that (1) an eligible midwife must record the following for a patient in the midwife's written records:
(a) the name of at least 1 specified medical practitioner who is, or will be, collaborating with the midwife in the patient's care (a named medical practitioner);
(b) that the midwife has told the patient that the midwife will be providing midwifery services to the patient in collaboration with 1 or more specified medical practitioners in accordance with this section;
(c) acknowledgment by a named medical practitioner that the practitioner will be collaborating in the patient's care;
(d) plans for the circumstances in which the midwife will do any of the following:
(i) consult with an obstetric specified medical practitioner
(ii) refer the patient to a specified medical practitioner;
(iii) transfer the patient's care to an obstetric specified medical practitioner.

Under this section, the woman who is my 'patient' requires a named medical practitioner (a) of whom the woman has been informed (b), and who agrees in writing to be the collaborating doctor (c).

I don't know where to start looking for this doctor (or doctors). My clients at present come from as far away as Epping in the North, Point Cook in the S-W, and the Yarra Ranges in the East - from 20-50K in each direction. I do not know the local doctors. Most of my clients are healthy women who take good care of their bodies and their families, and who don't have much need for doctors.

I have no idea how the named medical practitioner of this section is going to make him/herself available 24/7. Midwives take small caseloads so that we can respond at any time, day or night. Critical decision making in maternity care, particularly when the midwife is committed to protecting, promoting and supporting the natural physiological processes, is not something that happens in office hours. Most doctors have work hours; many medical practices are closed out of hours. Is this doctor going to give me his/her private contact details, and engage with the midwife at any time, under this collaborative arrangement?

I can only imagine how the insurance company of the named medical practitioner of this section will respond to any potential claims. The indemnity issue alone will probably be off-putting enough for even those most supportive of midwifery practice.

The requrement (d), plans for consultation and referral and transfer of care are not a problem at present. A midwife, by definition, arranges medical referral when and if required.


The legislation continues:
(2) The midwife must also record the following in the midwife's written records:
(a) any consultations or other communications ...
(b) any referral ...
(c) any transfer ...
(d) when the midwife gives a copy of the hospital booking letter for the patient to the named medical practitioner - acknowledgment [signed -received]
(e) when the midwife gives a copy of the patient's maternity care plan to the named medical practitioner - acknowledgment [signed - received]
(f) if the midwife requests diagnostic imaging &c for the patient - when the midwife gives the results to the named medical practitioner - acknowledgment [signed - received]
(g) that the midwife has given a discharge summary to the named medical practitioner and the GP - acknowledgment [signed - received]


Reading this section makes me wonder how I would be able to comply with all the complexities of this system.  I don't have a secretary sitting at a desk and organising my letters and paperwork. I wonder if this doctor is going to be happy with faxes, or with results sent by mail from the pathology lab?

My conclusion is that the future looks unpromising for midwives who are hoping to set up Medicare - supported practices.



In the Radio National's Life Matters program today, midwife Liz Wilkes and obstetrician Ted Weaver spoke on "collaborative arrangements".

For those who'd like to hear the online audio, download the podcast, or make comment, the website is:
http://www.abc.net.au/rn/lifematters/

Liz spoke well. Ted Weaver has his head in the sand. He reckons doctors haven’t been asked if they would sign a collaborative arrangement so that a midwife’s clients can access Medicare. He suggested obstetricians will agree to increase their clinical load without being paid – he used the term altruism!

Midwives are regulated practitioners in our own right.  Yet the Medicare reforms put us not only at the mercy of the medical profession, but also asking for their generosity.  There is really no sense, from a doctor's point of view, in supporting someone in competition for business.

RANZCOG on trial

The new Statement on Planned Vaginal Birth after Caesarean Section (Trial of Labour) C-Obs 38, issued July 2010 by the College of Obstetricians and Gynaecologists, RANZCOG, requires critical review.

Yesterday I commented in another blog on the 'risk' picture presented in this Statement.

The ultimate statistic:
RANZCOG notes an "extremely low but clinically important frequency of adverse outcomes", notably maternal death, for women who have elective repeat caesarean surgery (ERCS). However, RANZCOG deftly attributes the reason for the "apparent association" to "women with complex medical and obstetric problems [who] are much more likely to feature in the ERCS". This statement is dishonest and misleading. Women with no medical or obstetric problems have added to maternal mortality and serious morbidity statistics after caesarean surgery that has been undertaken for non-medical reasons, or after a cascade of interventions that began with medical interference in an otherwise uncomplicated pregnancy.

Homebirth for VBAC
While the 'H' word is not prominent in the RANZCOG statement on VBAC, it is understood from a previous College Statement (C-Obs 2) that RANZCOG "does not endorse home birth". This position has been clear since 1987, and has effectively prevented any useful dialogue on home birth between midwives and most obstetricians.  It's a matter of joining the dots.

Having declared its standard for antenatal preparation; intrapartum care; contraindications to Trial of Labour (TOL), and TOL in risk-prone circumstances, the RANZCOG statement on VBAC has defined the option of "TOL" in "risk-prone circumstances" as "sub-standard care" [emphasis added].
"A TOL may become particularly risk-prone where: there is a lack of services for safe provision of emergency care (eg a TOL conducted at home, birth centre or centre without ready access to obstetric, anaesthetic and paediatric support); there is a failure to provide or accept adequate intrapartum maternal and fetal surveillance; and there are clinical circumstances such as outlined above (eg more than one previous caesarean section)"

It is pretty clear to me that RANZCOG's TOL is unlikely to proceed to a spontaneous vaginal birth, with a healthy mother and baby. This statement exposes the lack of recognition of childbirth as a physiological process that is normal and good; a process that is in delicate hormonal balance. Throughout the document the reader is reminded repeatedly of the risk of rupture. It comes up like an advertisement: "remember you might need an obstetrician".

How often is the risk of rupture likely to result in catastrophic outcomes?

About 1 in 2000 labours for planned vbac.

*****

There are many factors to be considered by women who have had one or more previous caesarean births. The Births after Caesarean INFOSHEET, available at the Maternity Coalition website, summarises the choices that these women may face.

Midwives who agree to provide primary care for women planning VBAC, whether the birth is planned for home or hospital, face potential criticism based on the RANZCOG Statement. The Statement advises that before a midwife agrees to "administer care in risk-prone circumstances, that the women agree to counselling by a senior obstetrician who should ... [read on, there's a real sting in the tail of this one! That selfish woman needs to know that she is potentially imposing "considerable demands on the limited resources of the health team, with potential adverse consequences not just for her and her baby, but also for other women and their babies"]

Feeling guilty now?

Why don't you just roll over?

*****

In this RANZCOG Statement on Planned Vaginal Birth after Caesarean Section I have found material for all the bullying and manipulation that is needed to force women into submission to the medical system. While acknowledging a woman's right to make choices, the Statement sets the stage to shackle those who have the ability and skill to recognise and address complications early if they occur, while working in harmony with the natural physiological processes that lead to safe and joyous birthing.  Under this Statement the rate of Caesarean births, and all the related complications, is likely to continue to rise in Australia and New Zealand.

Notes from my practice

A baby has been born, at home. After a couple of days of pre-labour, frustratingly coupled with winter colds being suffered by the whole family, the labour began. I was called at about 3 am, and headed out into the country, driving through towns, and past vineyards and farms.

The midwifery student arrived just after me, and we went into the home together.

The student has kindly shared her reflections with me:

"When we arrived the woman was upright, pacing with her ipod on and using lots of heat packs. The room was lit by candles and the fire was burning.
"Suprisingly we did not do an assessment on arrival but instead proceded to unpack things. I helped to test and check the emergency equipment and positioned everything in unobtrusive but accessible places in case they were needed (they weren't). After about 20mins of setting up we were ready to do an assessment. It the very first of many stark contrasts to hospital midwifery in that this only included a temperature and fetal heart rate. The midwife explained that as the woman's BP had been stable all along there was no evidence to support it being unstable in labour, in addition we already knew the baby was cephalic and well engaged (from our previous appointments) so a palpation was unnessessary. A VE [vaginal exam] was also unnessessary as it wouldn't change the course of action/treatment at that time. No timings either, as there is no syntocinon to put up. All in all our assessment was about observing behaviours."


It has been an interesting exercise for me to see this birth through the eyes of someone who is new to the profession. Someone who recorded, after the birth, 
"It was the first time I have seen:

• An upright first stage
• Labouring in water
• Birthing in water
• No meds to hurry labour
• No analgesia in labour
• A physiological 3rd stage
• A woman taking cues from her body, not from hospital staff
• Family and friends with active labour involvement
• A woman eating and drinking freely in labour
• Waters breaking without someone breaking them
• Kids in labour
• Video camera in labour
• A baby being swadled in sheets etc that the family had been using prior so it had their scent on it
• True woman-centre care"

My enduring memories from this birth centre on the normality of everything that happened, contrasting with the potential threat of illness. The illness that this mother, father, and family faced at the time was that they all had colds - common garden variety upper respiratory viral infections. Coughing, congestion, chills, sleeplessness ... they had it all.

By the time labour was established the mother was weary.
As the time for birth drew closer, and the mother became frustrated by her physical weakness, I asked her to rest quietly in the womb of warm water. Some would call it transition. The light from candels was dimmed. The support crew withdrew to the kitchen, and had cups of tea and pieces of toast.

The miracle of birth unfolded and a beautiful pink baby boy, with a shock of black hair, was lifted out of the water by his mother and taken into her arms.

The miracle of birth continued as the child transitioned from placental circulation to strong, normal breathing, and began his lifelong search for good food.

The miracle of birth continued as the mother stood and released her baby's placenta, with only minimal blood loss.

Mother and baby are well and happy.


Another mother is waiting for her baby to be born.

She is a mother who has experienced the cascade of interventions in her previous pregnancy, with induction of labour, epidural, caesarean birth, separation from her baby, the baby being given formula feeds, and weeks of distress, pain, bonding and breastfeeding difficulties.

She is a mother who is longing to give birth to her baby, and who is learning to face her fears and work with a simple decision making process as each day passes.

ANNOUNCING: Midwifery from my heart

Midwifery from my heart is the first in a new e-book series.

If you would like a copy of Midwifery from my heart, simply send a small donation of at least $10 to a charity providing services or relief for needy mothers and families, and let me know that you have done so when you request Midwifery from my heart. [email: joy@aitex.com.au ]

Charities to consider include
TEAR Australia
World Vision
CP Australia
ACM Scholarship fund for Aboriginal and Torres Strait Islander midwives


Introduction to the Villagemidwife e-book series

I am writing
To record my knowledge
To tell my stories
To teach others

I am a midwife. My words, thoughts and actions have been formed over many years and a unique set of experiences: the world into which I was born; the mother who bore me; the family that nurtured me; the towns and communities that have allowed me to be me, and this wide open land and its people.

I like to think that these are my thoughts, yet I know that much of what I say is my own filtering and organising of what I have absorbed from those around me. Although I am the speaker, I am not the source.

Midwifery belongs to women. The midwife is ‘with woman’, a companion for a distinct and definable childbearing event, in a special partnership. Midwifery does not belong to theorists, although the clear expression of the ‘with woman’ partnership by thinkers has helped set great value on this simple phrase.

Midwifery is women’s business, evolving and moving with women, in our own time and space, along with our joys and sadnesses, our changing bodies, our children who are sometimes wonderful, and sometimes bring us near despair, and our hopes always for a better future.

Midwifery from my heart is about the life I know and love. It’s from my heart because I have learnt it, deep in my own life, and in the homes and lives of the women who have taken me with them. It’s midwifery because it’s ‘with woman’.

...

The unexpected journey

"By choice, in our adult years, many of us choose to travel away from our home base, to go on journeys of various lengths, from the small to the epic. We seek adventure, novelty, change. We launch ourselves on ventures near and far, with the comfort of both a phone card and a return ticket in our hip pocket. From a secure base, we revel in being on the move, delight in the foreignness of our encounters and welcome the rejuvenation of self that accompanies these departures from our norm.
...
"When a journey is not of your choice, if you are ill prepared for the road, if you have little idea where you are going, how long you will stay, where or when you might find a place to rest, how to speak the language, the allure of travel fades." [Quoted from a paper 'The inside journey through care', given by Jennifer McIntosh, PhD, Clinical Psychologist, Family Therapist, Researcher, 2001]

The universal expectation of pregnancy is the birth of a baby. The 'knowledge' is not only knowing in our minds; it's also known and prepared for hormonally in every cell of the mother's body. Even the father's body may experience hormonal changes that are likely to prepare him for the anticipated change.

Just as the fact of a baby is hormonally heralded, the normal physiological process of childbirth anticipates a specific journey for the mother and her child. We know there is an intense (internal as well as external) period of nesting; then the onset of spontaneous labour which builds as oxytocin pulses, and uterine muscles contract and retract, and opioid-like substances surge, and the cervix is drawn up and opened to release the child. The peak of adrenaline just prior to the expulsive phase prepares the child for the huge transition he must make in leaving one world and entering another.

The journey that is physiologically anticipated includes the mother's recognition of newborn's cry; a babe in her arms; a babe with all the sounds and smells and movements that stimulate further surges of the love hormone; a babe who soon begins his life-long quest for food and proceeds to draw milk from her breast.


The unexpected journey shocks and confuses the mother in this finely balanced hormonal state.

Hours later she is numbly aware that her arms are empty; that her breasts have not been touched. Her mind searches for explanations; for a map to guide this journey that she did not choose.

Preterm labour

This document, Neuro-endocrinology Briefing 35: Preterm labour is available online at the British Society for Neuroendocrinology.

The briefing was sent to me by my friend and mentor, Wolfgang Jochle, who lives in New Jersey, USA. Wolfgang's life work has focused on understanding the physiology of animal reproduction. A conversation with Wolfgang always extends my thinking, even though my education in the biological sciences is very limited.

My interest in the topic of preterm labour was heightened just this morning, as a colleague and I discussed a recent experience of working with a woman in spontaneous labour at 35 weeks' gestation. The timely arrival (by air-snail-mail) of this document in today's mail was just one of life's interesting coincidences.

Here's a brief excerpt ...
"But why is birth difficult to delay long enough to reach term? The answer may lie in the recruitment of the oxytocin neurones which, once primed by the initial signals, then respond to any small trigger (including uterine factors/contraction and or psychological situations such as stress that activate parallel brain pathways). This results in an ever-increasing positive feedback that promotes oxytocin secretion in larger pulses which inevitably precipitate further uterine contraction and birth. So, far from uterine mechanisms sustaining labour, brain activity is crucial, and drugs targeting oxytocin neurone priming mechanisms may be an appropriate way forward for therapeutic intervention in preterm labour." (Author: Dr Alison J Douglas, Edinburgh, UK)


A midwife working with healthy, socially well supported, well nourished women planning homebirth does not see much preterm labour. In fact we worry more about pregnancies that extend beyond 42 weeks. (I wonder if the science of neuroendocrinology has a physiological explanation for prolonged pregnancy?)

The time, and nature, of the onset of labour hold many mysteries. The image of "ever-increasing positive feedback that promotes oxytocin secretion in larger pulses" fits well with my understanding of the vastly varied experiences women have as they approach that tipping point, which means their baby will soon be born.

A midwife is conscious of this intricate balance of physical and psychological factors in birthing.

A year in review

A year ago I wrote in this blog: "We (the community of independent midwives and homebirth parents) are all wondering what will happen to homebirth after July next year."

I encouraged my small group of readers to write submissions to inquiries, to attend rallies, to contact the radio stations .... 

I argued that the legislation which mandated something that was not possible to access (professional indemnity insurance) in order for a midwife to practise "denies a woman’s natural law right to give birth under natural physiological conditions, in the place of her choosing."

Now, with only a few days remaining before the new legislation comes into force, I am content that the time-honoured profession of the midwife attending a woman in her own home will continue. 

I am not suggesting that the government has managed maternity reform well.  They have not.  Concessions have been made in response to the unprecedented outcry by the small but resillient group of homebirth parents and the midwives who attend them, as well as other fair-minded supporters. Midwives attending homebirth have been given a temporary (2-year) exemption from the insurance requirement. This awkward exemption may in fact protect lives, by averting the alternative, of driving homebirth underground or into the hands of unregulated birth attendants.

I am not suggesting that the government will manage maternity reform better, now that Australia has our first female PM.  Julia Gillard was Opposition Health spokesperson a few years ago, and made all sorts of positive gestures to birth activists and midwives in the lead up to the election.  Julia Gillard appeared to be listening to reason; appeared to be impressed by evidence supporting the safety and importance of enabling women to make their own decisions about childbirth, in a partnership with a known and trusted midwife who provides primary care throughout the pregnancy-birth-newborn care periods.  Once Ms Gillard became deputy to the PM, the spirit of working together with women for better birthing was quickly forgotten.

Many midwives are not satisfied with the way things are. The cost of indemnity insurance that will meet the requirements of the national registration law is between about $2000 and $7,500. (see the MiPP blog for detail) A midwife whose private practice brings in less than $10,000 annually is required to have insurance, the same as the midwife who is earning $80,000 annually. The cost of insurance will either be passed on to the client, or some midwives will cease private practice because they can't afford to continue.


There have been some positives as well as many negatives in this past year of preparation for our brave new world.

On the positive side of the ledger,

• I have seen some independent midwives take action to lobby government agencies.  One particular midwife comes to mind; I won't name her.  She has made an exceptional contribution from which all private midwives stand to benefit.  She has brought together professional and political interests at great personal cost.  Many readers will know to whom I refer, and I thank her.
• I have seen midwives who had no experience in homebirth declare their intention to move into private caseload practice, and learn homebirthing
• I have seen people in the community - childbearing women as well as men and older folks - willing to reflect and discuss the importance of what happens when a baby is being born.

I will not list off negatives, but I have observed members of the midwifery profession acting as people under threat, and being ready to verbally attack others whose opinions differ from their own. I am looking forward to a period of healing within the midwifery profession.

Note: Part 2 of this review is at the Private Midwifery Services blog

Midwifery knowledge

A colleague who practises privately in a small and closely knit rural community told me the story of a recent birth; of what she, the midwife, experienced in the days and weeks prior to the birth; of the response of the local doctor who supported the homebirth plan; of the response of the various professionals in hospital, and of the parents themselves who are delighted with their beautiful child.

The details of this birth are not mine to tell.

As I listened to the story unfold, I commented "You know, there are two sets of birthing knowledge."  There's the general set that is understood by doctors and midwives who have had the most basic education in maternity care.  Then there's the specific midwifery knowledge.  The knowledge that midwives who practise in primary care, in partnership with each woman, learn from the women and from other midwives.

Midwifery knoweldge includes

• strategies for reducing anxiety in labour.  The midwife enters the woman's space and speaks only when the mother is able to listen, minimising interruption, quietly and confidently.
• strategies for being present without taking over.  The midwife settles quietly to wait in a place that's out of the way after satisfying herself that the labouring mother and baby are well, rather than positioning herself in a dominant or intrusive way near the woman.  This midwife may have knitting or crochet in her hand - repetitive work the does not demand a lot of concentration, but keeps the midwife observant and present.
• strategies for moving the baby in the womb.  Some midwives rely on physical manipulation of the pelvic bones.  Others have espoused the Rebozo technique taught by Mexican midwives.  My preference is to encourage exaggerated pelvic movement using the birth ball.  Each of these techniques, and probably others I haven't thought of at the moment, enable centering of the woman's body and the baby's head, the presenting part, to adjust its position in relation to the mother's cervix.  This brings progress.
• strategies for getting labour started.  The old fashioned castor oil and orange juice has been used to kick start many labours, but it comes at a cost of an irritated bowel for many women.  I would not recommend this method as a first line of action.  Some midwives encourage women to have acupuncture, or a spicy meal, a long walk, or repeated love-making, or all of the above.  My usual strategy is to encourage the woman to stimulate regular contractions for a period of time by touching the areola around her nipples.  This brings a uterine contraction in response to the natural oxytocin release from the nipple stimulation.  The woman is encourage to walk while having a contraction, then to sit on an exercise ball and do pelvic circles and tilts, then stimulate another contraction, walk, ...  In some instances the woman has progressed quickly into strong labour after stimulating only one contraction artificially.  It's as though her body was ready at the starting line, and the first contraction was the tipping point that got her going.
• strategies for enabling a woman to accept the work of labour.  The woman who asks a midwife to attend her, especially in home birth, knows that noone can give birth for her.  The woman knows that the midwife doesn't have dangerous drugs or procedures that will take away the sensations of birthing.  The woman's own hormonal mix of oxytocin, the love hormone, with endorphins, the natural opiates are used to advantage in the home where the woman feels safe and uninterrupted, unwatched.
• strategies for monitoring the progress of labour without performing frequent internal vaginal examinations.  An internal examination is a significant interruption to the hormonal flow of spontaneous physiological birthing, and is performed only when the information it gives is important.

The key to midwifery knowledge is the relationship between the midwife and the labouring/birthing woman.  The known and trusted midwife with whom the woman has spent substantial amounts of time prior to the onset of labour enables decision making that is appropriate for the individual mother/baby dyad.    The midwife's skill in working in harmony with the natural physiological processes in birthing is essential in promoting health.

mother and daughter

Mother with daughter as daughter becomes mother: this is a timeless tradition that spans generations. It's a time when deep bonds are strengthened; when some of life's secrets are passed wordlessly from one generation to the next.

The older woman travelled to be with her daughter, and entered her home. She felt respect for her daughter's personal world, her husband and all that made up their lives. She experienced a sense of pride in her daughter's strength of character, and her desire to know and do what is good and right for her family; her child.

>>>>>>

And so we shared the days: preparing meals and carrying out ordinary tasks, all the time welcoming reminiscences. When pottering in the garden, or going to the shop for something that might be useful when the time came, we enjoyed the harmonising of two lives for a brief period of time. We shared words of faith in God, the giver and sustainer of life.


We remembered times with my mother. My daughter remembered her grandmother's gentle, loving care. She recalled the holiday at the Gold Coast, when she had helped Grandma make pumpkin scones and a baked jam roly-poly.

I also remembered my mother's gentle, loving care. I recalled how she had been a midwife to me when I gave birth to my second daughter; how the simplest act by her had nurtured me in the way that my lonely heart needed; how the simplest meal that she prepared had met a deeper need than hunger.

This time of birthing has brought three generations of women together, even though my mother's life journey was completed many years ago. She accompanied me, as I accompanied, and at times guided my daughter.

... Her womb prepared to give up its treasure.

... She gave birth, and took her child to her breast.

... She accepted and embraced the work of mothering.

Praise God from whom all blessings flow.

the womb

The womb grows quietly,
surrounding and guarding the new life within,
sealed until the right time.

A single round window softens,
its fibers are thinned and taken up,
ready for the opening.


The womb gives up its charge, silently closing.

The one in the womb grows quietly
in a warm, watery world.
Secure in a closed and protected space.

The wee one hears sounds from outside,
feels mother's laughter, her song, and her sobs.


Two people: mother with child.
They are together, sharing each moment.

The wee one knows joys and sadness,
loving and longing;
learning life's patterns from within that womb.

At the right time the wee one is guided to a place of readiness.
The round window becomes a vast opening.
The womb that held its treasure so patiently finds new strength
to powerfully and completely expel its contents.

There is a second womb waiting to receive the wee one.
A womb that is bounded by mother's arms, her loving face, and warm strong body.
Within the new womb are her breasts with a bountiful provision.

The child grows, knowing safety, warmth, satisfaction and peace in mother's arms.

Joy Johnston (May 2010)

Celebrating International Midwives' Day 5 May 2010

These pictures are in memory of my mother Ella Davidson, who was a nurse and midwife in Brisbane during  the second world war.  After the war she went as a missionary nurse to China, where she met and married my father.  My sister Marion has written that story.
The second of these pictures is also my mother, holding our second daughter, Rebecca, in 1975.  We were living in Haslett Michigan at the time.


Please join with midwives around the world as we celebrate our day.




If you would like to join in with others in a 24-hour global techno-feast of live online celebration, click here.

If you are able to join other Christian midwives in prayer for safe motherhood and safe childbirth, click here.

There's a global photo gallery here.

Midwives can join a forum at the Midwives Place

There are Facebook pages like this one.

AND LOTS MORE

"The world needs midwives now more than ever"

From routine episiotomy to routine caesarean

It's not easy to challenge accepted culture.

Dr Michael C Klein is a Canadian family physician who has challenged the accepted culture of routine episiotomy. I heard him speak on the topic at the Women's in Melbourne, probably 10 or more years ago. Recently Klein has published an article with the title From routine episiotomy to routine cesarean section: HOW SOCIETY CAME FROM REJECTING ONE TO EMBRACING ANOTHER. The link will take you to the article. Here are a few excerpts.

Klein writes:
"My views about episiotomy were formed by an experience in the early 1960s in Ethiopia, where I worked with midwives who attended births without routine use of episiotomy. Twenty years later while on sabbatical at Oxford University, I collaborated with midwives who rarely employed episiotomy yet obtained good results. Back in my usual setting in Montreal, our family practice maternity group employed the techniques and approaches that I had learned in England.
Our episiotomy rate was less than twenty-percent while the institutional rate was in excess of sixty-percent overall and greater than eighty-percent among women experiencing their first birth."
...
"In the 1980s many physicians still viewed the laboring woman with some suspicion, considering the female reproductive system as complex and intrinsically untrustworthy. It needed to be managed, controlled, and improved. Birth needed to be expedited, the fetus liberated from an unsafe environment. The place of episiotomy in this model was clear. In fact, labour can be slightly shortened by employing episiotomy. Those who felt this procedure was important often expressed concern about the negative effects of birth without episiotomy. In the absence of episiotomy, they were concerned about pressure on the fetal brain, maternal soft tissue support, and subsequent pelvic floor function, including delayed morbidity–such as urinary incontinence. Keep in mind that such thinking characterizes the thinking of the current proponents of elective Cesarean section."
...
"It turned out that episiotomy caused the very trauma that it was supposed to prevent, and those practitioners with the highest episiotomy rates had the highest rates of virtually all other procedures as well."
...
"Reconciliation of differing and often confusing views about normal childbirth among the maternity care disciplines and women is essential for the benefit of women and their families."
...
"Next Steps: At the age of almost seventy-two, I have now decided, along with my multidisciplinary colleagues, that we know pretty much what is going on in practice, education and training. And to correct the faults that have led to many of the problems uncovered will not be easy.
We cannot fiddle with such a flawed system and expect to improve it. But in the next few years, the dearth of obstetricians, family physicians and midwives available to serve pregnant and laboring women, will make it necessary to come up with major creative solutions. This will need to include new collaborative models of care, new interdisciplinary practice and teaching models, new financial arrangements and a whole new way of helping us partner with pregnant women in a way that supports and honors rather than frightens them. And of course we will have to control our own fears and anxieties or we will be unable to make the needed changes in a system that is poised to collapse.
Governments, policy-makers and educators will have to be helped to appreciate the ultimate financial and human costs to which the current path leads. It is rare to be able to help make a change that is both the right thing to do while also saving money for the system.
Hopefully we will not only study change but help make the changes that we will study."

DANGEROUS DRUGS?

ps [added 17 November 2012]
This US FDA website gives reliable guidance on codeine ultra-rapid metabolisers.



A baby's ability to breastfeed is one of the key 'performance indicators' that I observe after birth.

The majority of my work is with women and babies who are free of medication, giving birth to healthy babies at Term. Babies behave in the normal physiological fashion when the mother takes her child to her breast, and they remain together, skin to skin, for the next couple of hours. Babies seek the breast, making licking and rooting movements and moving in a distinctive way until they are in place and can take the breast and suckle effectively. This process is known as the breast crawl.

When a woman giving birth requires surgery she is given drugs. The anaesthetist and the obstetrician will prescribe whatever they consider to be necessary.

I am concerned about the current drug of choice for postnatal pain relief, Endone.

In the past year I have worked with three women who received Endone postnatally, and I believe I have observed a strong sedative effect of the drug on two of these babies. They became quite uninterested in the breast after the first breast feed, which had been unremarkable.

Recently another client of mine had a caesarean for obstructed labour, and I talked with her and the midwife in the postnatal ward 12 hours after the birth. The analgesia ordered was Endone (for 48 hours), Panadol and Voltarin. We agreed that if she was needing Endone she would breastfeed first, then take the drug. She has progressed very well with breastfeeding, went home on the third day - in fact this baby does a little breast crawl like a pro for every feed!

I am now checking for research literature specifically on Endone (oxycodone) and breastfeeding. Other midwives have said they share my concerns. A quick Google search came up with a very clear statement: "Do not take ENDONE during pregnancy or during breastfeeding as it may cause difficulty in breathing in an unborn or newborn child." [at http://www.mydr.com.au/medicines/cmis/endone-tablets]




A colleague who lives in regional Victoria told me that one of the local hospitals uses Endone less than the others, and that the local GPs, who provide anaesthetic services for the hospital, are still giving spinal morphine 1mg which works so well that very few women require more than Panadol and Voltaren.

I spoke to the pharmacist at a tertiary materntiy hospital in Melbourne, and he gave me some more information. He agreed that it's a very potent opioid that has a high transfer ratio into the milk, and variation from person to person as to how they metabolize Endone into morphine substances - hence variation in effect. He said the doses given appear to be pretty hefty.

The medical justification seems to be relatively short half life - 3-6 hours; that it's only used for 48 hours, claiming that the majority of babies are not sedated, and that the amount of colostrum the baby gets is pretty negligible anyway !!. Read here breastfeeding isn't something 'we' care much about!


The Lactmed site notes that "Newborn infants seem to be particularly sensitive to the effects of even small dosages of narcotic analgesics, particularly in the first week of life."

Dr Tom Hale, a world-respected expert and author on medications and mother's milk, has a forum

Hale states that "Oxycodone is a categoryL3... moderately safe, to be used only if the potential benefit to mother justifies potential risk to baby, and it has a half life of 3-6 hrs." Potential benefit to mother justifies potential risk to baby. I wonder how many mothers are given the opportunity to consider the risk/benefit before they swallow the tablet?



A newborn infant has important work to do, including learning how to breast feed. A newborn infant who is being systematically sedated through dangerous drugs that are passing from mother's blood to mother's milk, is being put at risk of breastfeeding delay leading to dehydration, jaundice, and a subsequent cascade of interventions, each with their own package of risks. The mother, receiving powerful sedation, is also likely to experience iatrogenic (physician-induced) difficulties with bonding and establishing breastfeeding.

I have often mused on the fact that "would you like something to help with the pain?" really means "would you like me to give you a dangerous drug?" I wish I knew a friendly cartoonist.

The anaesthetists and obstetricians really need to be questioned about this.
We live in a culture of acceptance of 'doctor knows best'. Women who undergo surgery for birth place an enormous trust in their surgeons and the other medical people - we need to act in their interests and on behalf of their babies.

I would like to ask that anyone reading this blog who works in the system, and who observes any cases where the baby of a mother receiving Endone in the early postnatal days appears sedated or performs poorly at breastfeeding, please draw attention to it. Speak to the obs and anaes departments, and point out what you observe. Ask them if they are aware of other such problems. Speak to the midwife manager of the unit, and ask her if she would support an internal audit of use of Endone. Find out what application is needed to get data from the general records. How often is it prescribed? What doses? (the pharmacy should be able to tell you this) Does the hospital have a protocol for the use of Endone? (you may find this on the hospital's intranet) What is the rate of supplementation of breastfeeding babies who were born by Caesarean (all the Baby Friendly hospitals should be able to give this data easily. Feeding on discharge is recorded on the Victorian perinatal statistics, so there could be some initial comparisons done.)

And while we're on the topic, I think some midwives are telling women in early labour to take some Panadeine and go to bed. Has anyone else heard this? In that case the codeine part of the drug will be added to the opioid soup in baby's system in the early days.


This is just not good enough!

when a baby needs to be born

There are many processes that midwives and others in the know about matters maternity are constantly checking. Today my thoughts are directed towards the first-time mother, known as a 'primip' from the Latin words primi (first) and para (birth), as she progresses through her pregnancy to that day when her labour will establish and her baby will be born.

It is normal/ usual for the baby's head to position itself deep in the mother's pelvic cavity from about 36 weeks of the 40 week gestation - weeks before the birth. The mother feels a sense of 'lightening', as there is a fraction more space under her ribs when the baby's head has engaged. When I palpate this engagement I am reassured that all is going to plan. This does not happen by chance. The mother's body is working in the way it was designed - wonderfully. It's as though the baby has discovered the door to this big world, and is waiting for it to open.

So what about the babies who haven't found the passage leading to the door? The baby who thinks she should come feet first, to start out running? The baby whose head stays high and mobile past 38, 39, even 40 weeks? What's the hurry, anyway?

Should the midwife just reassure the mother - we know a baby can be born spontaneously and safely in a breech presentation, and we know that occasionally a head does not engage until strong labour contractions direct it into the pelvic cavity - even in a primip!

Balancing this knowledge is another body of knowledge, which includes the standard of maternity care in the hospitals with which a midwife practising privately needs to collaborate occasionally. I cannot close my mind to the need for a smooth transfer and transition to medically led care from time to time.

I am constantly reflecting on the skills that promote, protect and support physiological processes that lead to spontaneous, safe birthing in the majority of cases.


Three primips in my care come to mind. I will call them A, B, and C. They are aged between 27 and 35, and are strong, healthy women, with caring husbands/partners. They are also normal height and weight - or normal BMI according to statistical charts. In other words, they are beautiful, healthy young women who would be expected to be able to give birth without complication.

A asked me to work with her for birth in a midwife-led Birth Centre attached to a large Melbourne hospital, Mercy Hospital for Women. When I palpated A's baby at about 38 weeks, I found the head engaged, with the fetal back on A's left side.

B asked me to work with her for planned homebirth, and has a booking at the Women's. At 36 weeks her baby was presenting head down, but the head was mobile. At 39 weeks the baby had turned to a breech presentation. I wrote a letter of referral to the hospital, and asked for review and consideration for external cephalic version (ECV). The ultrasonographer showed B that the baby was indeed presenting breech, and reassured her that there was plenty of amniotic fluid, which is considered necessary for ECV. B was told that the hospital preferred to do ECV at 37 weeks; that there was only about 20% chance that it would be successful at almost 40 weeks. B was determined, and she was invited to attend the next day for an ECV. She did not enjoy the sensation of tachycardia (fast pulse) that she experienced when Salbutamol was administered (to relax her uterine muscle). But the turn was successful. I visited her a couple of days later, and confirmed that the little head had stayed where we wanted it to be.

C is also planning homebirth, and her hospital backup is Monash Medical Centre at Clayton. The collaboration agreement with Monash is that the mother is seen in the hospital antenatal clinic at about 36 weeks, and if the midwife detects any issues of potential concern, an obstetrician also reviews the woman's care. As it happened, C's baby's head was high and very mobile. C was not concerned, as her mother had experienced the same situation and gone on to birthing spontaneously, but the doctor expressed his concern.


My midwifery ethos includes the statement "In normal birth there should be a valid reason to interfere with the natural process." (WHO Care in Normal Birth, 1996)

The question is, "Is there a valid reason in any of these cases to interfere with the natural process?"

Is there a valid reason to interfere with A's natural process? I think most midwives would say No, and I agree.

Is there a valid reason to interfere with B's natural process: baby presenting breech? If so, what should the interference be?

Is there a valid reason to interfere with C's natural process: baby's head high and mobile at Term? If so, what should the interference be?

[Any comments are welcome, of course!]


The birthing dance
One midwifery 'intervention' that I am currently asking my clients to consider, that I think may help that wee child find the way to the door in preparation for exiting her or his mother's womb, is a dance that brings on good 'practice' contractions of the womb. From about 37 weeks this dance will include upright movement, while intentionally increasing the release of natural oxytocin through loving body contact, including gentle nipple and clitoral stimulation with the purpose of bringing on a contraction.

Scope of practice

The midwife's scope of practice is a topic that has become central in many discussions as we approach the introduction of the government's reforms into maternity care. I have written a lot about the countdown to 1 July in another blog.

Midwifery requires skill and wisdom - knowing how to work in harmony with normal physiological processes in pregnancy and birthing. The midwife who works independently, as the professionally responsible primary maternity care provider for a group of women and their babies, has the opportunity to work to the extent of her scope of practice. There are boundaries, and defining these boundaries also requires skill and wisdom.

It's no secret that a midwife is confident and delighted when a birth proceeds without incident, and a strong mother takes her baby joyfully to her breast. This birth is truly within the midwife's scope of practice.

But what about the birth that has some complexity? Is a breech birth, or twin birth, or even a birth at 36 weeks' gestation, or birth to a woman who has had previous caesarean surgery ... - are these within a midwife's scope of practice? Does that midwife, and that woman, have the *right* to choose the setting for the birth: the woman's own home? Or is there some line over which the midwife must not step?

I would be foolish to try to define a midwife's scope of practice in this blog. My hope is that by raising the issue, readers will reflect and learn in the way that is most useful to them.

The Australian College of Midwives has, since 2004, published National Midwifery Guidelines for consultation and referral (which can be downloaded as a .pdf file). The Guidelines claim to be "internationally comparable and based on the latest available research evidence at the time of publication."  The Guidelines cannot, in themselves, set boundaries for a midwife's scope of practice.


The uniqueness of birth, and of midwifery, is that BIRTH IS NOT AN ILLNESS.

Birth is not an illness.

Certainly there are illnesses that can complicate birth: anything from a chest cold to life threatening diabetes or heart disease can and do result in risk to the mother's and her baby's ability to successfully and safely negotiate the birthing journey.  No midwife has a guarantee of wellness or safety.  Safety is achieved by enabling health and refraining from interfering in sensitive hormonally mediated processes, at the same time as being able to access relevant specialist medical services in a timely and effective way when appropriate.

What we do as midwives is different from any other health profession - even obstetrics. The key is the woman's desire to give birth under physiological conditions, which is what a midwife's scope of practice is able to offer, rather than a medically managed birth, which is effectively the only way the doctor knows.

Midwives who work in medical settings are often prevented by service protocols from working to their scope of practice, sometimes to a degree of restriction that is ridiculous and not based on any evidence. I have been told that midwives providing homebirth services under a new pilot scheme for a hospital in Melbourne's outer suburbs have been told that they will be dismissed if they do not abide by the 'rules'. An example is the management of the third stage. The hospital's protocol requires the midwife to undertake active management of the third stage. Women are informed that if they do not agree to active management, they will not be allowed to proceed in the homebirth group. There is no discussion.


When a midwife and woman are working in a partnership based on trust and reciprocity, and there is an aspect of the care for which the midwife's scope of practice may be broader than that which falls under a set of guidelines, it's an opportunity for decision making. The woman needs to know where she fits within the ACM guidelines, and any other contemporary standards - written or assumed. She needs to know what her midwife can offer.  She may need to investigate what the alternative model of care to which she may be referred can offer, and weigh up the potential and perceived benefits against the costs and risks.  She needs to know this so that she can make her own decisions.

Decision points that arise at any time in the professional relationship can be addressed in this way.

Plenty of love to go round

There are times when an ordinary person is able to experience such an overwhelming sense of love that we want to hold on to that moment for ever.

The uncomplicated birth of a healthy baby is a time when love literally abounds. The cup of love fills up and overflows from the mother, particularly, to her infant, her husband and other children, her midwife, and everyone else with whom she shares the intimate experience. In that awesome moment, a mother receives her child to her breast, accepting the work of mothering.

Since as recently as the 1990s, this love phenomenon has been understood as being related to a surge of the hormone of love, oxytocin. Oxytocin is the natural substance that causes the womb to contract in a systematic way that, at the right time, leads to the opening of the cervix and all the complex processes that are summarised in the simple word 'birth'. Oxytocin continues to orchestrate birth, with the successful separation and expulsion of the placenta, the emptying of the womb of all trace of the baby, and the closure of the mother's blood flow through the placental site.

A surge of oxytocin is repeated many times in ensuing days, months, and years, as the baby stimulates mother's breasts and achieves the let down of milk.

A surge of oxytocin is also felt with sustained loving physical contact, building to a peak in sexual climax. Oxytocin supports and directs the normal physiological activities that lead to mammalian conception, pregnancy, birth, and nurture of the young.


In the years since I began to learn to work as a midwife, in harmony with natural physiological processes in the birthing journey, I have learnt to enjoy oxytocin. I have come to a deep appreciation of this wonderful substance in the lives of those for whom I am midwife, as well as in my own life.

As a midwife I see, over and over again, a woman progress through childbirth. I see a woman become a mother, and a couple become a family. I am sometimes privileged to return to that family a few years later when they welcome a new member.

I don't want to sound idealistic about this transformation. While most progress well, I also see some who start out beautifully become hurt and scarred by unrelated events. I see some whose own ability to love has been deeply marred in their early life, and they struggle to trust even themselves, let alone anyone else. I see some for whom illness or fear or destructive social forces hinder the development of strong bonds within families.



Today is Good Friday, and Christians around the world are celebrating a totally different love; love that saves and redeems lost humanity. This morning, as I sat with my family in our Church and meditated on Christ's love, I reflected on the profound difference between oxytocin-love and, for want of a better term, divine love. The elements of bread and grape juice; flesh and blood; a broken body and blood poured out, are symbols representing love that goes beyond any human achievement.

The human physiological love processes directed by oxytocin require flesh to be broken and blood to flow in order for new life to emerge. The symbolic representation of divine love is also in a broken body and poured out blood. New life begins.

The human physiological love processes directed by oxytocin are fragile, easily interrupted. The work of divine love is completed.