Understanding what's behind an adverse outcome

Today I am recording a few of my personal thoughts in relation to the (lengthy) Coroner's report that was released this past week, in Adelaide.  I have written about it from the perspective of Australian Private Midwives Association (APMA) at the privatemidwives blog.

Principles of accountability and transparency must be applied to professional practice.  When something goes wrong in birth, our society wants to know, and has a right to know what happened.  It's easy for me to say that the safety and wellbeing of mother and baby guide my professional advice and actions, but what about the times when things aren't clear?  How must I act when a woman in my care understands her personal risk differently from the mainstream?

A considerable proportion of my practice in the past 20 years has been with women who would not be graded 'low' risk, yet they want to give birth spontaneously, without drugs to stimulate their labours, or to ameliorate pain.  The most usual 'risk factors' that these women have include previous caesarean surgery, a previous large baby, a previous post partum haemorrhage, and grand-multiparity.  So, when I read in the SA Coroner's report that 

"All three infants died after complications that were experienced in the course of their deliveries. These were complications of a kind that from time to time occur in deliveries of the types involved in these cases, and were therefore not entirely unpredictable."

I wonder if a similar judgment is being made of my practice, as though a midwife who agrees to attend women with recognised risk profiles is playing a version of Russian Roulette, and the midwife in South Australia was just unlucky?

The recommendations made by the Coroner in this instance appear to be an [albeit superficial] attempt to prevent similar occurrences in the future.

This course of action - the statutory authority using its considerable muscle to regulate and control the practice of midwifery - would appear acceptable to the majority of maternity care providers and academics. The suggestion is that:

• if a baby is known to be large, the birth should be facilitated (presumably by repeat caesarean, because it's not safe to induce a BAC labour);  
• if the baby is known to be presenting breech, it would almost certainly be born alive by elective caesarean; 
• if a woman is known to have twins, the babies will probably be born alive in the care of an obstetrician (most of whom will strongly advise elective caesarean) 

That is a superficial, linear argument that fails to recognise the complexities of maternity care.  This suggested course of action ignores the increased risk that each caesarean places on the woman's reproductive future: a risk that does not really show up in the statistical reports.  It passes over the fact that many women who seek private midwifery care are consciously avoiding mainstream services.  It fails to notice that highly skilled, experienced midwives have been excluded from practising in any setting except the home.  And then there are all the issues of trust and continuity in providing optimal maternity care.

I cannot ignore the fact that some women in my practice who have agreed to go to hospital, following my advice, have told me how they suffered as a result.  The woman who gave birth spontaneously to twins in hospital told me she still grieved, several years later, that the first baby was taken from her, became chilled, and she deeply grieved that unnecessary separation.  She told me she felt exposed and a lack of respect when she realised that a gaggle of unknown extra people had quietly slipped into the room to watch her breech baby being 'delivered' by the obstetrician. [It could be argued here that public hospitals are training grounds, and doctors and midwives have become deskilled in breech vaginal births, so ...]

Another woman who agreed to have an IV cannula when she gave birth in hospital to her third baby after a previous caesarean experienced the shock of being treated, without any discussion or consent, for post partum haemorrhage immediately after the birth, despite the fact that her blood loss was not excessive.  The 'risk' factors - VBAC, multiparity, and large baby - seemed to precipitate an over-energetic response by the hospital midwives.  The emergency code had been rehearsed, prepared for, and was called into action.  Perhaps that group of midwives will be more ready and competent when it really is called for???

In each of these, and other situations, I have grieved my contribution to the 'harming' of women, even though what happened occurred as I tried to ensure wellbeing and safety.  I cannot control another person's actions.  I also cannot use these experiences as a reason to stay out of hospital in future situations.  The safety of mothers and babies in my care is linked in complex ways with my own attitude towards the hospitals, my own ability to facilitate a spirit of cooperation between hospital staff, myself, and my client.

I look forward to the day when midwives will be free to practise (midwifery) without restriction in any setting; home or hospital.
***********

The Coroner's recommendations are listed at the end of the 106-page report.  In this blog I am attempting to summarise the recommendations, for future reference:


1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"
2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"
3) That the woman who is reported in (2) will receive "advice to be tendered to that person from a senior consultant obstetrician as to the desirability or otherwise, ..."
4) "establishment of a position known as the Supervisor of Midwives"
5) "establishment of alternative birthing centres" [note: not one of the three mothers of babies who died would have been eligible to go to 'alternative birthing centres']
6) education for public distribution on homebirths and risks
7) revised policy for Planned Birth at Home in South Australia "with an addition that current risk factors for shoulder dystocia be specifically identified;"
8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."

TWO WHO ARE TWO

TOO good!

In this past month I have had many opportunities to enjoy the two little ones, James and Eve, who joined our family two years ago.

I have seen the two mothers go through amazing processes of learning to cope with the complexities of their lives, while mothering their babies.   I have seen two fathers adapt and learn how to love in a new way, and to become daddies.

I have reflected on the enormous investment of time, energy, money, and other entities that probably can't be described in a few words - investment by the child's parents, wider family, and community. Investment in a precious resource, a human life, and in the hope for a new generation.

Today I am posting a poem written my our beautiful daughter in law, Anna, celebrating Eve's second birthday. Anna has given me permission to share this tender love-poem with my readers. (Thankyou, Annie)

A Poem for Eve Dulcie - our La Dolce Vita (life is sweet), on your 2nd birthday..... 

I love your sense of humour-

Feeding breakfast to your toes

Declaring that it is "pickle day"

Or that you've lost your nose

I love your creativity, on paper (or on walls!)

The way you tell me stories

Or play dress-ups with scarves and shawls

You are my little encourager

Telling me that I'm good

At vacuuming or singing

Or playing Robin Hood

I love your little bird song

I could listen to your voice all day,

Singing songs in the bath

Or while you laugh and play

Your heart is so precious

Saying more than a love letter

You make me want to do my best

And as a mum, be better

The type of love you give is rare

So accepting and forgiving

An Evie filled life is one,

That is all the more worth living

I'm still learning to be your mum

I've made plenty of mistakes

But I'm head over heels for you kid

With every step we take

My curly headed rascal

My beautiful green eyed girl

Mummy's little hero, Daddy's little pearl

I love the way you love me

Always wanting to hold my hand

At breakfast or watching TV

Or playing in the sand

Your infectious belly chuckle

Your heart-warming grin

Your dainty royal wave

Your porridge covered chin

When I wake at morning

And when I sleep at night

I thank God for giving me you –

My Eve, my hearts delight."

Woolly warmth for babies

Ame meets the sheep not in the meadow

As the days and nights in Melbourne become cooler I am enjoying the warmth of wool.  Our world has been overtaken by fake fibres - the polyesters that never show a wrinkle and the lycras that stretch and the polar fleeces that are light and keep the cold out.  But I am convinced that nothing beats wool.

Recently a young mother, Brenna, has pointed me to her business, selling beautiful baby clothes at woollykins which are quite inspiring. 

If you share this love affair with wool and other natural fibers, I suggest you visit Brenna's blog, Cobbled together.

One of the essentials in a baby's 'layette' (I don't think anyone uses that word now-a-days) is a pure wool blanket.  The warmth from pure wool is good warmth, moisture is held without becoming hot or stifling.

Knitting and crochet are crafts that value wool.  Knitting and crochet are also activities that midwives have, over many generations, taken with us into the birthing space.  We need to be present, but we need to quietly and unobtrusively stay out of the labouring woman's way.  Lighting is dim - often a couple of candles, burning embers in the fire place, or a little daylight through the closed drapes.  Simple patterns are good - ones that can be interrupted at any stage.  We need to do nothing that will distract the labouring woman.  The repetitive nature of these wool crafts has the effect of keeping adrenaline and other stress hormones at minimal levels.  Women have often said to me that as their labours demanded more from them they felt reassured that I was quietly getting on with my crochet.

Years ago I went to Emma's home.  She wasn't labouring well - it was that frustrating preparatory stage.  I didn't want to go straight home, and it was a week-day, so I went to the local craft shop and bought a couple of balls of wool and a couple of crochet hooks.  I spent that afternoon teaching a couple of Emma's children the basics of crochet.  The next day Emma gave birth.  When I did my final postnatal visit I was delighted to see several of the children working on crochet projects.  They had found websites and learnt much more than I had showed them, and were already experimenting with colour and shape.

By the time Emma's next baby was born, the family had a couple of sheep, spinning wheels, and fleeces being spun, knitted and crocheted.  Emma gave me some of her homespun wool, the natural dark brown, as well as the white, and I have loved working with it, making shawls and squares.

Happy International Day of the Midwife

Today I am enjoying the global webinar
http://internationaldayofthemidwife.wikispaces.com/International+Day+of+the+Midwife+2012
[Recordings are posted at this site when the presentation has been completed]

At present there are 100+ guests logged in, and Prof Lesley Page has given the first lecture.
Lesley said:
The world needs midwives who can practise to the full extent of their power now, more than ever.

[I will add links and my comments as the program proceeds]
One world birth - Go to this site for video interviews with outstanding leaders in the childbirthing movement around the world, and much more!

http://www.facebook.com/HumanRightsInChildbirth/likes 

Lisa Barrett from Adelaide, South Australia addressed the topic Birthing at Home Regardless of Risk: Educated Choice or an Extreme Sport?. This presentation is significant in the homebirth midwifery terrain that we are progressing through today. Lisa's position is, in my opinion, one end of the spectrum that spans the childbirth-midwifery-obstetrics debate. Yet Lisa is paying the price for her idealism, in that she has relinquished her midwifery registration and is now identifying herself as a birth advocate.

Michelle Zimmerman from Sydney spoke about her vision for 'WOMBS' a Women’s Birth Society: the Social Maternity Model That Returns Childbirth to Women and Their Local Communities.  I envy anyone who can work to the principles that maternity 'care' should be provided in group settings, in which women gather around each other for support and nurture, and in which the midwives work alongside other women in a volunteer, non-heirachial, unstructured way.  This sounds like the ideal 'village'.  Unfortunately it's not the world in which I live and work!

Kate Emerson, presented Nuchal Cord: Ritual and Routine, in which she explored her own experience and the literature, looking at the training midwives receive to routinely check for, and then intervene in, the presence of nuchal cord - and how this may contravene the midwifery model of care and commitment to evidence-based practice. Women’s experiences of nuchal cord management are explored in this session, along with a discussion of the more serious outcomes associated with routinely cutting a tight nuchal cord.

The presentation by Dr Rafat Jan, Associate Professor, School of Nursing and Midwifery, Aga Khan University, Pakistan is a very worth-while presentation. Midwives in Pakistan would appreciate support from midwives in other countries. The wonders of technology are there to be used! I will add information here, and look forward to virtual meetings with some of my colleagues in Pakistan!

Anna Maria Speciale, Midwife, Research Associate, Instituto de Cooperación Social Integrare, Barcelona, Spain addressed the United Nations' H4+ High Burden Countries Initiative (HBCI) See the report Delivering health, Saving Lives
 

[I spent about 9 hours in the virtual meeting as it went to air, and I look forward to listening to the other presentations.]

H+BAC=?

TROUBLE!
[H+BAC stands for Home + Birth After Caesarean]

I have written about births after caesarean from time to time on this and other blogs. Last August I focused briefly on 'A scarred uterus', in the context of guidelines that had been hastily put together by ACM, and which were subsequently adopted by the National Board as its regulatory position on homebirth [link].

Yes, according to this statement homebirth is contraindicated for the 'scarred uterus'. Just to put the 'scarred uterus' in perspective, the Australia-wide rate of caesarean birth is more than 30% of all births [See Australia's Mothers and Babies 2009 report, published Dec 2011]. That's a lot of scarred uteruses.

Q. When a woman who has one of those scarred uteruses wants to have another baby, and she wants to optimise her chances of vaginal birth (vbac), to whom does she turn for professional help?
A. An experienced midwife who is committed to working with each woman, protecting promoting and supporting healthy physiologically normal processes in pregnancy and childbirth.

Q. Where do you find a midwife like that?
A. A midwife in private practice is able to make a personal commitment to the individual woman, and work professionally with her as her primary carer.

Q. Where does the midwife work?
A. The midwife's work is limited to the home, because (except in a few cases) midwives in private practice are unable to be recognised as a woman's midwife once admitted to hospital.

Q. What does the woman with the scarred uterus need to do in order to plan vbac?
A. The woman who is healthy with a healthy fetus at Term, who experiences spontaneous onset of labour, and who progresses in labour under the natural hormonal environment without medical assistance (augmentation or analgesia), is most likely to give birth spontaneously without complication.

Q. So, coming into spontaneous labour - that happens best at home?
A. Correct.

Q. And progressing without medical assistance - that happens best at home?
A. Correct.

Q. And that's where the midwife is experienced and competent?
 A. Correct.

Q. So, why is homebirth contraindicated?

[But there's a hole in the bucket, dear Eliza ...]

Of course this little Q&A sequence is overly simplistic.

But the point I am trying to make is that 'home' is not the key issue.  The central issue is that a midwife is the most appropriate and expert primary professional care provider for any woman who intends to give birth under normal physiological conditions, using natural oxytocin, natural adrenalin and catecolamines, natural endorphins, natural anti-diuretic hormone, and all the other amazing substances that work together in the healthy body to bring a woman to safely and proudly give birth to her baby.  The woman who is able to proceed in labour with the confidence that her midwife is protecting the birthing space, and that her midwife will identify and act appropriately to protect the wellbeing of both mother and child if needed, is able to look forward to BAC, whether they are at home or in a supportive hospital environment.

Achieving vaginal BAC is core business of midwifery.  It's where the midwife's skill is most needed, and where an experienced midwife is confident and in her element.

Yet, BAC is 'contraindicated' in the one place where the woman is most able to proceed well, and the one place where the midwife is able to work without restrictions.

Midwives who are facing up to this dilemma that has come about as a result of hasty bureaucratic processes that failed to consult with the midwives or the women it affects most, do not have many choices.  Either we continue to attend women with scarred uteruses professionally, or we refuse to do so.  The latter alternative is likely to result in some women facing unnecessary repeat caesarean surgery, with the inherent compounding risks of abnormal placental implantation and severe haemorrhage; and some will take the other extreme pathway - freebirth.

The central issue is not about the big 'H' - homebirth.  The central issue is the midwife's right to engage in professional practice.  A midwife who is attending a woman in labour, with or without a scarred uterus or any other of the listed contraindications, or complication, is professionally able to work with the woman to make appropriate decisions.  In some cases that may mean going to hospital; in others it means staying at home.  At all times the wellbeing and safety of mother and baby guide the midwife's professional advice.  Home is only a setting.  Healthy mothers and babies are the outcome we desire.

Bungee jumping on a short cord

Midwives who attend strong, healthy women for their births are used to seeing mothers give birth unassisted, unmedicated, and with an ecstatic and triumphant cry. We are used to seeing labour establish and progress in a purposeful way. We are used to the power of the birthing process, which takes the woman beyond any limit that she imagined she possessed.

Occasionally we are surprised, even confused.

Especially when the woman has other babies who have all followed the standard 'normal' journey. ... when labour seemed to be established in the morning, so the midwife and the birthing team were summoned. After the greetings, and a cup of tea, and some conversation, and another cup of tea, and talk about what we should do for dinner, and mother lies down because she's feeling tired ... and the fetal head is still floating high and mobile. This mother has given birth previously, and there is nothing apparent in the size or presentation of the baby. Her contractions appear strong when she stands up and walks, but they become weak and infrequent when she rests. 

I could name several women who fit this picture, the most recent last week.  When I looked at the placenta with the mother we commented on the short cord.

The image I have in these 'slow start' multiparous births is that the baby was bungee jumping – pressing down on the cervix when the contraction’s there and mothers upright, and floating away when mother lies down or is not contracting. 

The cord may be short because of entanglement, or simply short.  The distance from the baby's umbilicus to the point of insertion of the placenta on the uterine wall does not change.  The distance between the placenta and the cervix can be reduced by amniotic fluid release, by contractions, and by the mother's position. The critical 'tipping point' will be reached only when that fetal head can dilate the cervix and enter the birth canal.  Then, it's "coming, ready or not!"

This is an article from Midwifery Today 

The Cord and the Strength of Life 
I have observed babies being birthed with the placenta detached and following right behind them for over 20 years. Throughout that time I have kept mental notes, observing, recording, pondering.

Then one day, finally, it all added up. The explanation is a short umbilical cord, a phenomenon that requires us to allow time for the baby, the cord and the placenta to descend slowly through the birth canal, in the wisdom of nature, for a healthy and natural birth. My first encounter with a short cord began with a false labor. The mother thought this was the day. She called me, and I stayed with her until labor ceased several hours later. The mother and baby were fine. There was no good reason to intervene, despite the fact that she was multiparous with 4 cm dilation and the baby was not engaged. I warned her of possible cord prolapse and asked her to be aware of her baby’s activity. A couple of days later she called me again. The birth was very quick and the baby was born with shoulders and body entangled in a barely pulsing cord. The newborn had some blood on his bottom because the placenta had separated at the time of birth. He required stimulation and oxygen, but it was all resolved quickly and within the realm of the normal. I have watched vigilantly for short cords ever since.

Two weeks ago, some twenty years after I noticed it for the first time, it happened again. This time it was with a mother who had had three babies. The last two had been very fast. She had always had mild contractions before going into labor, but this time she had more. As she was multiparous, I initially did not think there was a problem. About ten days after her due date I thought she was going to have her baby. Her uterus looked so low that it was “by her knees.” But it did not happen. “Something is strange,” I thought while checking her. I sighed. The baby was floating, even though the uterus was very low. It seemed the baby ought to be engaged, but he was not. I then listened to the baby’s heart tones and found normal heart tones but with minimal decelerations. The heart tones were at 140 and descended to 126 or so in the middle of mild contractions. I listened to the heart tones every three days. The mother was noticing movement. We decided she should try to induce herself through nipple stimulation and an enema of medicinal plants. I gave her an exam in which I stimulated the opening of the cervix. The contractions began, and she dilated another centimeter easily. The heart tones remained within normal ranges.

... However, everything stopped after a few hours. The mother was already at 5 cm, but the cervix remained inflexible. Although the baby’s head was in a good position, he was not engaged, and therefore was not exerting pressure. After the second attempt I sat down to think. I concluded that we were dealing with a short cord. In any other situation a vaginal exam, some nipple stimulation and an enema would have produced labor.

But beyond the mother and me, the wisdom lies between the baby, the cord, the placenta and the uterus. You can confirm that you are dealing with a short umbilical cord by observing the abdomen. During contractions, and sometimes without them, the baby appears engaged, even though a vaginal exam reveals that she is floating. It is important to avoid interventions that force the mother’s body to enter the birth process before the placenta and uterus are ready. The fundus has to descend with the baby. This process takes time. Contractions that cease despite dilation of 2–5 cm in a mother with previous fast births and no other complications indicate the possible existence of a short cord. Observation without intervention is important in these cases. 

—  Marina Alzugaray Excerpted from “The Cord and the Strength of Life,” Midwifery Today, Issue 70

a career in private midwifery?

... continuing thoughts on this topic from the MIPP blog.

with Sue and baby Benjamin - photo taken by Amy, used with permission

Today I want to focus on questions that arise for midwives and midwifery students who are considering a career in private midwifery practice. If you want to practise privately, independent of the mainstream maternity hospitals (public or private) which provide employment for the great majority of midwives in this country, you need to find a sustainable way to work.

Most midwives who practise privately in this country rely for 'business' almost exclusively on individual women who seek the one-to-one midwife who will work with them when they labour and give birth.  Midwives in private practice have caseload bookings, with individual women, usually across the spectrum of pre-, intra-, and postnatal services.

Most births at which the woman's chosen midwife is the primary/leading professional in attendance - the one who takes responsibility for the conduct of the birth and ensuring the wellbeing of mother and child in that acute episode of care - are in the woman's own home. There are midwives with clinical privileges in hospitals in the South-Eastern corner of Queensland (Toowoomba, Ipswich, Brisbane, Gold Coast), and Sydney. I don't have the details, but can follow up if anyone wants to know more.

What does a private midwifery practice look like, from a business perspective?

We need to consider the practice (the acts and being of midwifery) separately from the business (structure and financial aspects).

The midwife's practice can be 'solo' (working as the only professional midwife booked by a woman for the episode of care) or in arrangements where two or more midwives work together to provide the primary care for each woman who is booked with them. This is often described as a 'group practice'.

The private midwife's business arrangements for earning a living can be a simple 'fee for service' in which the woman/client pays that midwife directly, or the fee may be paid to an employer/company which in turn remunerates the midwife for the work she undertakes. The employer in the latter instance could be a midwifery group practice, or another business such as a group of obstetricians. The midwife may or may not be a partner in the practice.  Whatever the arrangement, laws applying to tax, employment and superannuation must be complied with.

My system for management of payments is that any money that is transacted, whether by cash, credit card, cheque, or electronic transfer, and whether by the woman or by Medicare (bulk billing) is immediately recorded by hand in a small 'Cash Receipt' book with carbon copies.  This automatically generates a number for the receipt, as all the pages are numbered, and I add a prefix which refers to the number on the outside of the booklet - at present the prefix is 17.  The top page is placed in the client's file, and the carbon page stays in the receipt book.  The receipt number and information will be entered into my Quickbooks accounting system when I get to it.  This is the basis for my income tax, and quarterly BAS returns.  Midwifery services do not generate the goods and services tax (GST), but the GST charged on purchases by the midwife in carrying out her business can be claimed from the ATO.

Most of my midwifery practice is 'solo', with some bookings made in which I practise with another midwife.  Recently I have enjoyed working with my colleague and friend, Jan Ireland from MAMA, in providing midwifery services for a woman who was booked with Jan.  I will describe this case from the perspective of the new Medicare arrangements, as it demonstrates how midwives are able to work together within the collaborative arrangement and maternity care plan set up by the midwife who has made the primary booking.

In this case, from the Medicare perspective, the second midwife is able to act as a reliving midwife or locum for the primary midwife.  The locum is described in legislation
Health Insurance (Midwife and Nurse Practitioner) Determination 2011, Health Insurance Act 1973,

Part 4 Interpretation

(1) In this Part: collaborative arrangement, for a participating midwife’s patient, means a collaborative arrangement mentioned in regulation 2C of the Health Insurance Regulations 1975. delivery includes episiotomy and repair of tears.

(2) For this Part, a participating midwife is a member of a practice that provides a patient’s antenatal care if the midwife:

(a) participates (whether as a partner, employee or otherwise) in the provision of professional services as part of the practice; or

(b) provides relief services to the practice; or

(c) provides professional services as part of the practice as a locum.

The arrangement by which I have provided (b)'relief services to the practice' or (c) 'professional services as part of the practice as a locum' is under (a) 'otherwise', since I am neither partner nor employee of MAMA.



Midwives who are beginning private practice, and who have Medicare eligibility, may consider the 'relief/locum' model, either as partner, employee, or otherwise, as a means of getting started.  



I commenced this post with a question, 'a career in private midwifery?'.  I believe there is a great potential for midwives to aspire to extending their midwifery practice when they step out of hospital employment into private practice.  However there are also significant risks, which all would do well to consider. 

Midwives who practise privately in a community are able to support each other, with relief/locum services, on one hand, while on the other they may be competitors for business.  Being able to accept and work constructively with this dynamic is a key to sustainability in private midwifery practice, not just for the individual midwife, but also for the community served by midwives over generations.

Another reflection on practice

Photo used with permission

The mother in this picture, Cynthia, gave birth at home to her second child at home against medical advice. Her first child, born at a Birth Centre, had been too large, and she was told she had bled too much, so she was not permitted to book at the Birth Centre for her second birth: the advice was that she would require obstetric management.

This is a not uncommon situation, even when 'alternative' birthing services, such as midwife-managed birth centres, are accessible. It presents a challenge for midwife as well as mother, as we find our way through the often unpredictable terrain of pregnancy and birthing. Yet it could be argued that all home births are against medical advice.

Cynthia gave birth to baby Willa at home, early in the morning, as the first light of the new day filtered through the glass above the door on the Eastern wall.  I hold that memory of hushed ecstasy, as we who were witnesses to the miracle of birth watched the mother welcome her newborn daughter.

Cynthia has given me permission to use this beautiful photo, and to use her name as I tell a small part of her story. I am taking the opportunity to reflect on aspects of this birth, and the conversations I had with Cynthia in the months before the birth. Cynthia was strong in her resolve; she had discovered within herself a deep and precious knowledge of her birthing potential, and she asked me to accompany her through the most demanding part of this birthing journey.


With this recent birth in mind, I have been delighted to start reading a new book The Heart in the Womb, by Amali Lokugamage, an obstetrician who defied her profession's wisdom and gave birth to her son at home in the UK.  Amali writes:

I was prompted to write about this very personal experience because, prior to my pregnancy, I was never fully able to understand why a woman would actively choose to give birth at home, outside of a hospital safety-net." (p6)

The idea that being in a hospital for every birth provides a safety-net is one of the great 'lies' under which most Australian maternity services operate.  When a woman discovers her own strength, she arranges her life so that she will not be denied that potential when she is at the peak of her labour.  She chooses her team: midwife, sister, friend, and lover - each in a different partnership relationship with her, and each fully committed to being with her.

I cannot teach a woman how to discover her own innate birthing potential.  It is truly a discovery that she makes as she welcomes the hormonally mediated activity that her body leads her through.  I cannot predict who will progress unassisted to an ecstatic birth; who will gently guide the head of her own baby across the threshold of totally streched perineal tissues; who will enjoy that amazing dance of the breast crawl, and feel the pressure as the placenta presents for expulsion.

But I can reflect on my own memories of my birthings, many years ago, and I can confidently accompany women who are willing to engage in trust and reciprocity, and explore their own journeys as they give birth to their babies.

Reflection on practice

Today I am using Gibbs' reflective process in reviewing an experience I have had recently, attending a woman, who I will call Linda (not her real name), giving birth in hospital. I do not want to approach this from an idealistic standpoint, or to 'deamonise' the hospital. Birth, as with the rest of life, is full of unpredictable moments when those who are present are called upon to do their best.

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.

old-style midwifery

I have tried to capture the essence of the 'extraordinary'

The old-style ‘independent’ midwife, who has learnt autonomy and independence in practice and in decision-making from experience as the responsible primary maternity care provider for an individual woman, knows the value of working quietly and without fuss, in harmony with natural physiological processes, and enabling ordinary women to access their extraordinary strength and health in giving birth and caring for their babies.

[From APMA Blog]



Last week I was writing about the changes that I see taking place around me in Australian midwifery, as government and professional regulators make their efforts to improve the status quo - a task that all modern societies entrust to expert decision-making processes.

Other midwifery matters on my mind at present are the review of a university study module on postnatal midwifery care, for which I am tutor and marker, and a liability report I was asked to write in relation to a case in which a baby has cerebral palsy. These themes have influenced my thinking, as I engage with women in my care, at many points on the pregnancy-childbirth continuum.

Younger midwives may object to my comparing of 'old-style' midwifery with 'new'.  But the truth as I understand it is that midwifery today should be essentially the same at the primary care level as midwifery (by whatever name) in all societies and all times.  The new midwife who understands and is committed to 'old-style' midwifery, with linkages to the best and most effective medical services when needed, is practising midwifery well.

Since 'being' a pregnant-childbearing woman is not an illness, and never has been, the midwife with woman in the childbearing-nurturing time of that woman's life sees beyond the current fashions and time-related activities of a society.  That's what I mean by the 'old-style' midwife.

The debate around social and primary healthcare models, which aim to base all health care on the individual recipient of the care (in maternity care, the woman), compared with medical models of care that focus on illnesses or conditions, and the right treatment is readily applied to primary maternity care.  Sociologist Kerreen Reiger has contributed to this debate in The Conversation , in a commentary on 'Evidence-based medicine v alternative therapies: moving beyond virulence'. I am aware that some of my colleagues in midwifery look to alternative therapies, such as homeopathy, naturopathy, and traditional Chinese medicine in an attempt to provide a more holistic and woman-focused treatment option. This, in my mind, is not 'old-style' midwifery.

It might be 'old-style' treatment of illness, in the same way that people of previous generations concocted medicines out of plants that had medicinal properties. That 'old-style' treatment of illness has developed into the world of pharmaceuticals - a whole new terrain for discussion of ethics and power relationships in healthcare.

The basis I have for trusting 'old-style' midwifery is that the physiological and physical and psychological norms of health in the childbearing woman are consistent across time and culture. As long as it is reasonable to continue without interruption in that finely-tuned natural state, there is no better or safer way. The decisions around what is reasonable and what is unreasonable are quite different in a modern society from what our grandmothers experienced. Similarly women in Melbourne today are able to access a very different level of medical management for illness or complications than are women in tribal societies in developing parts of the world today.

'Old-style' midwifery, focused firmly on the woman in the midwife's care, together with the best available scientific, evidence based interventions when illness or complication are detected, is the recipe for best practice in primary maternity care. 

safer and better systems of care

with my first baby 1973

Recently I have spent considerable time reflecting upon and writing about situations in which midwives face complaints of serious professional misconduct after attending home births.

See articles at the MiPP blog

Many of the complaints (notifications) that I am aware of relate to situations in which midwives attend women who have specific risk features of their pregnancy, such as having had caesarean surgery, or being classified as 'post mature', or having a breech birth or twins, for birth at home.

I do not want to seem to be guiding midwives to encourage 'at risk' women to see home birth as their only option. In my experience, a woman with twins, or breech presentation, or birth after caesarean, who is clear that she intends to hold onto 'Plan A' unless a valid reason is given for intervention whether she is at home or goes to hospital (with her midwife) to give birth; this woman will make an informed decision that she believes is in the best interests of her baby, her family, and her own wellbeing. This woman is enabled to take responsibility for her family's social, emotional, and physical health in a new way, in a special partnership with her midwife.

My personal approach to twins and breech births, after appropriate discussion and consultation, is to try to arrange support for a physiologically normal, unmanaged birth in a public hospital that has capacity for emergency obstetric intervention, if the woman believes that is the best way at the time of labour.

 This is not a simple task. It opens the door to a clash of opinion - medical vs social - in each situation. I wrote about that a few years ago - "Why bother coming here if you won't let us manage you the way we think is best?" - when a mother with twins near term followed my advice, and presented at the antenatal clinic of a large public hospital. She was told she had no option other than elective (scheduled) caesarean. The first baby was presenting breech. It's probably no surprise to readers that that mother rejected the advice of the big, well-equipped and well-staffed, public maternity hospital. We were able to engage the services of a smaller suburban public maternity hospital, and the babies were born one morning without incident, and the family returned home that afternoon - see Drive through birthing.

Another mother in my care gave birth to her twins at home. It was only after the first baby had been born, and the mother told me she was having contractions again that she placed her hand on her belly and said to me "Joy there's a lump here. Could it be another baby?" Yes, it could, and it was. By the time I had changed my gloves the second baby was ready to be born - beautifully!

Another mother in my care gave birth to her twins in hospital. The labour was powerful; mother knelt on the bed, and the first baby slipped out into my hands, cried, and went into mother's welcoming arms. The cord was clamped and cut to prevent any twin-to-twin transfusion. The mother's contractions returned quickly and intensely, and she maintained her crouched position, and passed the first baby to his dad. With the next contraction the second baby was born, about 6 minutes after his brother, with the placenta. The placenta had separated from the uterus (abbrupted) after the first birth and the second twin's life was immediately in danger as he had no oxygen supply. He needed to be born quickly, and he was. He revived spontaneously, without difficulty.

In telling this story, I am highlighting a situation in which the urgency for birth can be escalated in an instant, and specific action needed to protect, in this instance, a baby's life. After the birth of the first baby it is usual for the midwife or doctor to palpate the mother's abdomen to check the position of the second twin, and listen to the heart beat of the second twin. The mother, in this instance, refused to go onto her back, and proceeded very quickly, under natural intuitive knowing, to 'eject' the second twin. Had she been a compliant 'patient', and done as asked, and I believe it is possible that her baby's birth may have been delayed, with obvious negative consequences.

On the other hand, had there been no internal pressure to get that baby born, we would possibly have heard the slowing heart rate as the baby's oxygen supply quickly depleted, and an obstetric intervention to extract the baby would have been attempted. It's not helpful to speculate or ask 'what would have happened if?'. In this case the mother's decision to refuse a managed birth, which would have included epidural, was probably the factor that saved her baby's life, because she was able to do the job spontaneously.

I am very distressed when women with twin pregnancies, or babies presenting breech, and their midwives, are so unable to trust hospital care that they see home as the only option. Home or hospital, spontaneous, managed, or surgical, there are no guarantees. The mother's choice of home or hospital for the birth of her babies is her choice, and she will face different challenges with each pathway.

“... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (ACSQHC National Action Plan, 2001). 

The National Midwifery Guidelines for Consultation and Referral (ACM 2008) (the Guidelines) categorise women with twins and breeches as being ‘C’ (transfer). It is important to understand the place of the Guidelines in contemporary midwifery, and why after appropriate consultation, a woman and her midwife may chose to continue with the plan for homebirth.

The Guidelines were designed primarily for use across mainstream maternity services, outlining a risk management process by which midwives could act either autonomously, or in professional consultation with other maternity care providers, or by initiating transfer of care to a more appropriate maternity service. The Guidelines do not deal with situations in which women make an informed decision to seek out private midwifery services for home birth. The Guidelines do not deal with situations in which women choose care which is outside that which is recommended by the Guidelines, or by individual maternity care providers.

The Guidelines, in the preamble, indicate the purpose of these Guidelines, to address a significant gap that existed prior to their development, in helping “maternity services to meet national policy priorities aimed at improving the quality and safety of health care. When the Australian Council for Safety and Quality in Health Care launched its National Action Plan in 2001, its Chair Professor Bruce Barraclough argued that improving the safety and quality of patient care is one of the most important challenges facing health professionals: “... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (p 5) (emphasis added)

Systems of care that are safer and better than whatever Professor Barraclough referred to, and that are better than the system that told a mother "Why bother coming here if you won't let us manage you the way we think is best?", are systems that accept different levels of decision-making by different people.  A mother who values the spontaneous work of her own body in giving birth, unmedicated, to her babies, is a mother who the system needs to respect, and work hard to accommodate.

Systems of care that are safe and good for women and their babies will accept, at every level - not just the so-called 'low-risk' birth - that “Childbirth is a social and emotional event and is an essential part of family life. The care given should take into consideration the individual woman’s cultural and social needs." ICM Position Statement on Home Birth.

maternity services survey

This is a high priority request to any readers who have had a baby in Australia since November 2010, or who hope/plan to have a baby in the near future. 

Please click HERE and follow the survey process. The survey will close midnight Sunday the 4th of March 2012. [The survey will accept one response only from an individual]

Please tell the survey why you want to have your own midwife, plan homebirth, promote normal birth, or whatever is important to you. Also, if you have friends who you think could spare 10 minutes to complete the survey, please pass it on to them.

Background
In 2010 the Australian Government introduced a series of reforms to improve access and choice in maternity services for women in Australia. The Australian Government Department of Health and Ageing (DoHA) is now seeking feedback from women on what their experiences have been with recent maternity service arrangements and whether they are aware of the reforms that are in place. Your important feedback will help to shape the future of maternity services in Australia.
Healthcare Management Advisors (HMA) has been engaged by DoHA as an independent organisation to conduct and collate the results of this short survey (3-5 minutes). All your responses will come directly to HMA and will be summarised so as not to be identifiable in any reporting. A report will be provided to DoHA for consideration by the Minister for Health regarding future arrangements for maternity services in Australia.
This short survey can be accessed through the following link http://www.surveymonkey.com/s/HMAmaternitysurvey The survey will be open until Sunday the 4th of March 2012. Please contact Justine Irving at HMA on justineirving@hma.com.au or (08) 8168 8000 if you have any questions or if you would like to complete the short survey over the phone or in hard copy. On completion of the online survey you will be directed to the Australian Government Maternity Services Reform website (www.health.gov.au/maternity) where you can find additional information on these reforms.

www.babyfriendly.org.au

The Australian Baby Friendly Health Initiative – NEW WEBSITE - now live!

You are invited to visit www.babyfriendly.org.au to hear an introduction by Tara Moss the UNICEF Australia Patron for Breastfeeding and BFHI. You can also view short clips from the new BFHI DVD about each of the Ten Steps to Successful Breastfeeding.

The website includes information about why and how your facility can ‘Go Baby Friendly’ and a list of Baby Friendly accredited hospitals in Australia.

Launch Special! The first 50 people to subscribe as a Baby Friendly Supporter will receive a copy of the new BFHI DVD signed by Tara Moss. The DVD is due to be launched in May 2012.

Seeking Testimonials: If you, or someone you know, has a Baby Friendly story or photo and are happy to share this on the website, please contact the BFHI Manager, Rachel Ford, on 1300 360 480 or info@babyfriendly.org.au. We are particularly interested in stories about working or birthing in a Baby Friendly hospital, undergoing Baby Friendly accreditation, or what Baby Friendly means to you.

A big thank you to UNICEF Australia for the hours of work and consultation that went into designing and developing the website, in particular the careful sourcing of all the fabulous images! Thanks also to the BFHI National Advisory Committee for their contributions and advice.
Ann Kinnear
Executive Officer
Australian College of Midwives

Welcome!

Our family has welcomed a beautiful little girl, Amélie Grace, who was born to Miriam and Neville yesterday.

Those who have the privilege of observing the work of birth will marvel at the miracles that are repeated over and over again. Here's a picture of the miracle of the newborn baby searching for, and finding, the breast. We call it the breast crawl. It's awesome!

Planning for birth

I have updated my little booklet, Planning for birth, which I have used for many years as a handout for women who visit me, making inquiries about having a baby, and for midwives and students of midwifery.

This booklet is self-published, and copies are printed as required. Readers who would like like a .pdf copy, please request by email joy@aitex.com.au [I have not hyperlinked this email address, as that may invite spam] I am happy to share my work. If you want to use copyrighted items such as the poem 'waiting' on page 8, please give reference.

waiting

You are waiting to give birth.

Your pregnancy is a statement of your wellness, life and strength.  New life is swelling your womb. 
 

You and your mate accept the gift of life with eager anticipation.

Your body tells you that change and growth are following nature’s course.   The cessation of your menstrual flow, the desire for good food and rest, the enlargement of your breasts - all external - accompany the private dreaming.

As your midwife I am committed to supporting you and your family through this wonderfully basic life event - the birth of your baby - your personal, intimate celebration of life and health.

 ©Joy Johnston

The pages of the booklet are also scanned here - 4 sheets with 2 pages per side. 

Finding a mentor - being a mentor

A mentoring agreement between two midwives can enrich and support both the mentor, and the one who is being mentored.
I have experienced this special relationship in the past two years, with a colleague who asked me to mentor her as she explored and experienced private midwifery practice as a career option for herself. During face to face meetings, phone calls, and email messages we discussed and questioned and reflected upon our shared and separate experiences as midwife, as woman, wife, mother, sister, and many other roles.

We each learnt to trust the other, and avoid defensiveness, when a question, such as "Why did you do that?", or, "... not do X" arose. Trust enables truthfulness, which leads to accountability and critical thinking, which can lead to changes in the way we behave in a given situation: the lifelong learning pattern that a midwife will always value.

I have titled this post 'finding a mentor, and being a mentor', as the midwife who is being mentored will quickly realise that she is able in turn to mentor others. The role of ‘mentor’ as it is commonly used in midwifery literature and discussion, is

mentor: a trusted friend, counselor or teacher, usually a more experienced person. ... Today mentors provide their expertise to less experienced individuals in order to help them advance their careers, enhance their education, and build their networks. [Wikipedia] 

Although there are no set ‘rules’, the following simple points may guide you in choosing a potential mentor:

• • The mentor should be a midwife who is practising or has recently practised in the scope of midwifery that you are entering; eg having a caseload 
• • In asking another midwife to be your mentor, you need to find ways in which you are able to work together, so that you are able to learn from your mentor, and she/he can observe your professional activity. This can be within a midwifery group practice, or as self employed midwives, or as volunteer members of a group, such as the local committee for the College of Midwives, or Maternity Coalition. 
• • The midwife who agrees to a mentoring agreement may ask you to do something as your side of the arrangement. She may ask you to be accountable to her, in giving regular updates on your learning goals, using the ACM MidPLUS professional development recording system. 
• • Review your situation from time to time, and be ready to become mentor.

$? What fee does a mentor charge? 

Of course there is no simple answer to that question.  A great deal of informal mentoring happens, without any fee and without being given any title, as midwives support one another within their communities. 

Sharing of skill and knowledge is a logical and accepted principle in health professional ethics.  Putting it another way, if there is insufficient sharing and passing on, that skill and knowledge will quickly be lost.

However, being a mentor requires commitment of time and interest. I have found that midwives who ask me to mentor them are happy to come to an agreement in which there is an exchange of money, and an expectation of commitment over a period of time. 


Here are a couple of examples of mentoring arrangements between midwives:

• Midwife A is an experienced independent midwife, who has established a midwifery business (or group practice) which enables other midwives to practise privately under the name of the business.  Midwife B asks A to mentor her, and comes into A's business as a partner.  The agreement between B and A's business is that B will pay an agreed percentage (eg 20%) of her earnings to A's business.  In return, B and A meet together for professional discussion each month; B is able to telephone A for direct support and advice at any time; and the advertising, book keeping, superannuation, and tax requirements of B's income are managed within A's business.  
• Midwife C is working part-time in a hospital, as she establishes her own midwifery practice.  C asks Midwife A to mentor her, but she does not want to become a partner in A's business/practice.  A and C come to an agreement that C will pay an amount for professional mentoring, and A will provide C with a receipt for that payment.  The support agreement between A and C is otherwise the same as between A and B.

Millennium Development Goals: How are we progressing with the maternity goals?

Millennium Declaration

In 2000, 189 nations made a promise to free people from extreme poverty and multiple deprivations. This pledge became the eight Millennium Development Goals to be achieved by 2015. In September 2010, the world recommitted itself to accelerate progress towards these goals.

The 8 Millennium Development Goals are:

1 Eradicate extreme poverty and hunger
2 Achieve universal primary education
3 Promote gender equality and empower women

4 Reduce child mortality

5 Improve maternal health

6 Combat HIV/AIDS, malaria and other diseases
7 Ensure environmental sustainability
8 Develop a global partnership for development

Each of these goals has a potential to improve maternity outcomes in the world's poorest countries.  Goals 4 and 5 give direct measures of maternity care.
If you would like to see the UN 2011 table summarising progress, click here.


Readers may wonder what significance the MDGs have in the context in which I practise midwifery.  Private midwifery in and around Melbourne is, surely, for a privileged minority, who are usually healthy, well educated women, and able to pay for the maternity care they choose.

This is true.

Women who plan homebirth in my practice understand that my role includes arranging transfer to hospital if complications are detected.  Well staffed and equipped maternity hospitals are within easy reach by car or ambulance, in most instances.  Availability of appropriate referral services is a key to safe and optimal outcomes, whether the referral is from planned homebirth, or from small primary maternity care units in rural towns.

Women in places where maternal mortality is high may not be within reasonable reach of emergency obstetric services; may face prohibitive costs if they do go to hospital; and often delay in seeking medical intervention.  Their bodies are often weakened by anaemia, malaria, HIV/AIDS, intestinal parasites, and other preventable conditions.  Mothers and babies die from Tetanus, because the mothers have never been vaccinated against Tetanus.   Women do not have access to acceptable family planning measures; child-brides are pregnant before their bodies are fully developed; too many women develop obstetric fistula; and the list goes on.

The challenge that I see in comparing maternity care here in Melbourne, with maternity care in some of the world's most disadvantaged settings, such as Sub-Saharan Africa, or the highlands of Papua New Guinea, is the continuing and increasing reliance on medical and surgical management of birth in the West.  This logically equates to a loss of knowledge, a loss of expertise, in working with natural processes in the childbearing continuum.  The excessive and unnecessary medicalisation of birth and everything related to maternity care, as is seen in mainstream maternity care in Melbourne, will not improve maternal or infant health in less developed countries. Melbourne hospitals are teaching doctors and midwives who will pass contemporary practices on to their students in all parts of the globe.  Melbourne, which has world-best facilities for those who need them, must set an example of best practice in protecting each woman's ability to give birth under her own amazing power - 'Plan A', unless there is a valid reason for 'Plan B'.

For decades we have seen the global impact on the lives of babies of the loss of collective confidence in breastfeeding.  Efforts to protect, promote, and support breastfeeding are required in the rich world if we want to have any impact in poorer countries.  The Baby Friendly Hospital Initiative (BFHI), which in Australia is known as the Baby Friendly Health Initiative, has the expectation of the same high standards in each of the '10 Steps to successful breastfeeding', whether the hospital provides care for those who pay big money, or those who are in low socio-economic settings.

Childbirth is not very different from breastfeeding.  The loss of confidence in natural physiological processes in childbirth, including the spontaneous onset of labour, progress in labour, giving birth without medical pain relief or physical assistance, expelling the placenta, and establishing breastfeeding, to name a few key points, needs to be recognised and rectified in Australian mainstream maternity care.  There is no safer or more reasonable way to proceed with childbirth, for most women, than to do so under the natural, hormonally-driven processes within each woman's body.  Only those for whom a valid reason to interrupt the natural processes will be better off with such intervention.

I expect any readers are likely to be already convinced of these facts, so I won't press on.   

Midwives, we carry the knowledge of normal birth!  We must value that knowledge, and hold on to the skills of working in harmony with women's natural physiological processes, whether in early labour, breastfeeding, birth, or the third stage. 

The 1996 'Care in normal birth' instruction from World Health Organisation, that
"In normal birth there should be a valid reason to interfere with the natural process" is as relevant when applied to the Millennium Development Goals, as it is in a Birth Centre in the rich world.

more thoughts on the birthing space

I have appreciated the recent thought-provoking discussion in connection with the previous post in this blog, which is also linked to Carolyn Hastie's thinkbirth blog.

In the past couple of weeks I have attended three births; two at home and one in hospital. These three mothers were 'first timers'; primipara; a special category worthy of consideration in any maternity setting.

Picture this scene:

A woman is labouring strongly and consistently in an inflated birthing pool, set up in her home.  It's 2 or 3 in the morning, the 'wee hours', when everyone is overcome by weariness.  Her man, whose sleep was interrupted by early labour the previous night, is asleep on a couch.  The midwife is nearby - within reach but dropping off to sleep between contractions, occasionally mumbling words of encouragement.  The student midwife is stretched out on another couch. There is a little light from a lamp or candle; the birthing space is quiet except for the sounds of the labour.  

After some time, the woman's sounds become deeper.  Her midwife encourages her "let your baby come down deep in your body; feel the fullness; you're doing well", and listens to the fetal heart after a contraction.  The woman does not notice that the 'period pain' she had been experiencing has gone.  In fact she has stopped thinking about her labour and has surrendered to the work that her body is doing.

By the time the early signs of daylight are peeping through the cracks in the blinds, the urge to push has become strong.  Daddy-to-be and student midwife are awake; midwife is awake and ready; and mother gives birth, through the water, to her first child.  Mother and child complete the mysterious dance of birth, as baby searches for the breast, and the placenta is expelled.

Today I would like to reflect on recent primipara births, and (without identifying individual women) discuss how the birthing space has supported these births. In the past 18 months, approximately, I have attended 10 women giving birth for the first time. 

Before looking at the birthing spaces, here is an overview of these births.  Of the 10 women:

• 10 came into spontaneous labour; which became strong as the night progressed (there's something special about night and birth!)
• 5 gave birth in water: 4 at home; 1 at hospital
• 2 planned hospital birth; both gave birth spontaneously to healthy babies
• 8 planned home birth
• 5 gave birth at home to healthy babies, without complication
• 3 who planned home birth transferred from home to hospital in labour
• 2 proceeded to spontaneous unmedicated births of healthy babies
• 1 was delivered of a healthy baby by emergency Caesarean surgery

The ages of these women ranged from 24 to 37.
The length of gestation ranged from 36 to less than 42 weeks.
The weights of these babies ranged from 2670g to 4250g.
All babies breastfed from birth.
The estimated blood loss for the 9 women who gave birth spontaneously ranged from 100 to 600ml.


I want to make a point here, which may be obvious to some, yet others may find it a challenging statement in the maternity environment in Australia.
Place of birth - home or hospital - is not a measure of good midwifery care.
Yet the decision to plan homebirth is a huge statement of intent, by the woman, that her plan is for spontaneous, unassisted, unmedicated birth.  Those who plan homebirth with an experienced midwife are able, I believe, to proceed down the path of physiological birth if that is feasible, with a high degree of safety.  Those who plan homebirth, then make an informed decision to transfer their care to hospital because there is an indication - a valid reason - are also able to protect their ability to give birth in harmony with the natural, hormonal, physiological processes that direct labour, birth, and the baby's transition from the womb to the outside world. 

In my previous discussion on birthing spaces I wrote about the physiological phenomenon of *Nesting*.  Understanding normal birth in terms of nesting, as the woman progresses under the influence of an amazing cocktail of hormones, provides a key to the mysteries of birthing.  Nesting supported each of these 10 women, as they came into spontaneous labour.  Nesting supported the three who made a decision in labour to move from home to hospital, and obtain special medical intervention that had become necessary for them.  Nesting supported the choice of position for birth, whether kneeling beside the bed, or squatting in the birth pool, or lying on the bed.

Cessation of nesting happens, I think, when the woman is able to surrender to the huge expulsive urges within her body.  Baby is "coming, ready or not".  Night time and weariness enables this transition to occur without question.  The woman, and her personal support team, have given up trying to understand what's going on; to do it the way they were taught in class.  The midwife is skilled at keeping watch, guiding when needed, without taking control from the woman.

The essential elements of the space for optimal birthing are few.  As long as the woman is able to proceed without interruption; as long as the woman is able to trust her midwife; as long as the woman and her support team are able to hold confidence in the process of birthing ...

... a baby is born.

It just happens.



Your comments are, of course, welcome.

optimal space for birthing?

There is a special interest branch within midwifery and maternity care that overlaps with design and architecture disciplines, exploring the creation of optimal spaces for birthing. I have been reminded of this field of interest, when reading a recent post by my colleague and friend Carolyn Hastie, who writes the thinkbirth blog. Carolyn refers to, and provides a link to a presentation on optimal birth spaces by Maralyn Foureur, Professor of Midwifery at the University of Technology of Sydney (UTS). I wrote in the comments to thinkbirth:

I have seen some wonderfully designed spaces in which women can give birth. I have also seen women give birth beautifully (and, I would say, optimally) in settings that would seem to contravene every goal of the optimal birthing space ideology.

The woman's own nesting, which I believe is hormonally driven more than the result of intelligent planning and preparation, seems to be the key. Nesting can include the choice of setting, as well as the choice of people who make up that woman's birthing team. Nesting also enables the woman to change her plan if her situation requires it, without losing the ability to proceed normally.

I don't want to be critical of the optimal birth space ideology.

HOWEVER ...

The reality in my world is that each birth space is often very different from what the woman had planned or wanted, yet women are able to give birth in that wonderfully spontaneous way, without any regrets.

It would be naive to imagine that a woman's home is automatically the optimal birthing space for her.

I need to do a postnatal visit now, but hope to get back to this post later, and write some more.

[Melbourne readers may know that a private hospital in Hawthorn had recently set up a beautifully designed birthing facility, which has closed its doors after just a few months' operation, because the plan was not working, and there were too few women making bookings.]


NESTING and optimal birthing conditions
Nesting is one of those normal physiological functions that everyone knows about, but rarely pays much attention to.   While researchers have for a couple of decades looked seriously at the impact of the love hormone oxytocin, and the 'fight-or-flight' adrenal hormones, on the birth and mothering behaviours of laboratory animals, nesting doesn't seem to raise research interest or dollars.

A woman anticipating the birth of her child will usually have a 'to do' list, including stocking and preparation of food and other consumables, washing and setting out baby clothes, and packing a bag for herself and her baby in preparation for a stay in hospital, or 'birth kit' items in readiness for giving birth at home.  This process of getting ready would be recognised broadly as 'nesting'.  I have known some who feel the need to clean windows, and sweep, vacuum, and dust almost obsessively in the days leading up to the labour.  This is all intentional nesting, driven mainly by the woman's intellectual grasp of the enormity of the job that lies ahead.

With the establishment of spontaneous labour, physiological nesting becomes more pronounced.  Women who thought they would like to have the other children present for the birth of their sibling will often withdraw into a secluded space.  Women who have a plan to call a trusted midwife will often call her, just to check that she is able to come when called.  Nesting can continue until the peak of first stage, often called 'transition', when the woman must give up conscious control and surrender to the work of bringing her child out of her body. 

Women who plan to go to hospital to give birth face a nesting conflict.  It goes something like this:
"If I go to hospital too early my labour might fizzle.  If I stay at home I won't want to move when the labour becomes strong."  It's their natural nesting drive that makes them want to find the place where they will give birth - not the street address, but the actual room, with its contents, and the actual people with whom she will need to communicate.

Women who are booked at a modern hospital Birth Centre, where there are well-designed birthing rooms, often experience a conflict about the availability of a room.  They know that if the rooms are all in use when they arrive, they will be admitted to a standard hospital suite.  They have heard stories about how often this might happen.  Other matters of 'nesting' concern might focus on the times of shift changes in the hospital. 

I have, on occasion, been called to a 'planned' home birth, only to find that the woman and her home show no sign of nesting.  This dysfunctional nesting is, I think, a sign that the woman's sensitivity to natural instinctive urges has been in some way shut down.  The woman's labour can continue without nesting, and the baby can be born, "ready or not!"

Returning to the initial question of this blog: is there, and what is, an optimal space for birthing?
I would refine the question further, and add the word 'physiological' - the space for medically managed care in labour and childbirth must be very different from the space that enables and supports and protects physiological processes.  Here are a few ideals for that space:

• a place that the woman has chosen to be in
• a place that the woman is happy to continue in, as labour progresses
• a place where the woman can receive care, support, and guidance from a trusted midwife, and other chosen people
• a place where the woman is able to cover windows, dim lights, and make other physical adjustments when she wishes
• a place that allows the woman to feel private and unobserved
• a place where the midwife, as the responsible professional at the time, is confident that the wellbeing of mother and baby are being protected.

As with all other basic life events, "the best laid plans of mice and men ..."  There can be no guarantees.  The only people who we can be sure will be at a birth are the mother and her baby. 

The optimal space for physiological birthing in suburban Melbourne should not be very different from the optimal space for physiological birthing for Inuit women in Nunavik in the Arctic Circle.  The type of bed or birthing pool; the colour of the walls or the pattern of the furnishings - these things can be nice, but are of little significance to the woman giving birth.  The woman's feeling of unintruded privacy, as she reaches the point of surrender, knowing that her midwife is *with* her, is the essence of optimality. 


Your comments are very welcome.