THE ‘B’ WORD

Breech. A woman today whose baby is discovered to be presenting bottom or feet first (breech) will often be given no other option than elective caesarean.

The evidence that is used in directing mothers with breech babies at Term into the operating theatres was produced in a big multi-centre randomised controlled trial. It’s the most reliable type of quantitative evidence that is available. The research concluded that it’s safer for the baby to be surgically delivered than to be born vaginally.

There are several compelling reasons why I and some other midwives and medical practitioners are reluctant to submit to the breech-caesarean rule. We know that many babies in the past were born safely feet-first, and we know that many women have a strong preference for natural, non-surgical birthing options. We know that some breech presentations in advanced spontaneous labour will be undiagnosed, and that the skill of the midwife in attendance could be a deciding factor in the safety of that baby. The unintended and unfortunate reality of a professional terrain in which vaginal breech births are rarely seen is the de-skilling of the professions.

Another consideration that I will try to briefly outline here is the fact that a randomised controlled trial cannot truly reflect likely outcomes for women who want to work, undisturbed and unmedicated, with the power of their own bodies. So, even though I cannot challenge the results of the Term Breech Trial for the people who were involved, I consider that the very fact that pregnant participants agreed to be randomised into either the ‘labour’ or the ‘elective caesarean’ groups prevented them from engaging with their own natural resources needed for giving birth themselves.

The women enlisted in a randomised controlled trial are treated as though they have a medical condition, and the trial looks at different options for treatment. The hospitals and the maternity professionals who participated in the research could not have been committed to protecting and promoting wellness in childbirth, and many may have lacked the skills of midwifery in protecting natural birthing, particularly in breech vaginal birth. The results cannot apply to women who want to work with the wonderfully powerful natural processes in birthing their babies, as these women would have refused to be enlisted in the research.

Perhaps writing for my blog gives me an unrealistic sense of my own authority. This medium allows me to declare my opinion for the world to hear.

I have two birth stories to illustrate my current practice in relation to breech births.

‘Megan’ was about 39 weeks, carrying her second baby, when she became aware of a hard round lump under her rib cage. She found herself rubbing it from time to time, and thought it might be her baby’s head. She went to the Birth Centre for a checkup, and asked the midwife if she thought the baby might be presenting as breech. The midwife wasn’t sure, and called a more experienced midwife, who palpated and told Megan she was pretty sure the head was down. Megan phoned me a few days later to get my opinion. I visited her, and agreed with her - breech. The presenting part was not engaged, and moved easily. I encouraged Megan to seek ways of turning her baby, and to ask the hospital to attempt external cephalic version. She had an acupuncturist who she trusted, and suggested that she would ask for some acupuncture and moxibustion.

Megan went back to the Birth Centre, and this time the breech presentation was confirmed. She was told that she would no longer be able to keep her booking at the Birth Centre, as she would be booked for elective caesarean. She was already close to her due date, so an appointment was made with an obstetrician.

Megan asked if the baby could be turned. The midwife phoned a doctor at the hospital, who is involved in a trial of external cephalic version (ECV). The doctor said it was too late – the pregnancy was too advanced for her to try.

Megan was disappointed, and told me that she would rather plan a vaginal breech birth at home than have an elective caesarean. I agreed that that was a reasonable backup plan. Having palpated Megan’s abdomen, and felt how readily the baby’s bottom moved, I encouraged her to persevere with the quest for ECV. She made an appointment with the doctor who does ECVs. Megan is quite small and timid, but I admired her strength in this whole process. I encouraged her to go to the hospital with her partner, and ask the doctor to put her hands on her belly and feel her baby. If the doctor then said she could not attempt an ECV, then she would have to accept it and move on.

The doctor did agree to the ECV; the baby turned easily, and after monitoring Megan and her partner went home. Megan gave birth spontaneously to a healthy baby girl who came out head first, a couple of days later.

The lesson I learnt was to persevere. The hospital maternity care system may not automatically provide the options that the woman wants, particularly when those options are in supporting and protecting normal birth. But a woman is quite within her rights to request the sort of help that Megan received, even if that help is not readily available.

The second breech birth story does not have a happy ending. I learnt about this birth when I was asked to review the case on behalf of a law firm in Melbourne, and provide a report on the role of the midwives who provide care.

The mother arrived at a private hospital in strong labour with her second child, and was admitted by a midwife. The mother did not know her baby’s presentation was breech, as her doctor had checked her a couple of days ago and told her the head was presenting. Shortly after arrival the mother felt an urge to push, and the midwife arranged for the doctor to be called to attend for the birth. Before the doctor arrived the waters broke and baby’s legs and bottom were born. The baby’s body was initially pink, but after a few minutes the cord pulsation ceased and the baby became white. The midwives did what they could for the mother, but they did not have the skill or confidence to attempt to deliver the baby’s head. The doctor arrived and the baby’s head was born with assistance, followed immediately by the placenta which had probably separated at the time when cord pulsation ceased. The baby was resuscitated, and transferred to a neonatal intensive care unit. The baby’s brain had been damaged, and the lawyers were now acting on behalf of the child in suing the hospital and the doctor.

The question that was put to me was, should a midwife have been able to assist the birth of this baby?

This tragedy happened as a result of de-skilling of midwives. Today’s new midwives and obstetricians will possibly have had little or no experience in breech vaginal births, and this scenario is likely to be repeated from time to time.

When a baby's presentation is breech, the partnership between the mother and her midwife is put to the test. Various decision points are reached, and sometimes as in Megan's case, the baby can be turned and proceed to a normal cephalic birth. Such choices were not available for the second mother, because the breech presentation was not known until the birth was underway. Any midwife reading this story will do well to review the principles of an assisted birth of the after-coming head; a manoeuver that could have prevented the hypoxic brain damage to this baby.

Decision Points

The other evening a healthy baby boy was born vba2c to Julie (not her real name). For those who don't understand the abbreviation, that's vaginal birth after two caesareans. Words can't express the elation that we all felt as Julie held her new baby in her arms.

This birth took place in a private hospital, and I worked with an obstetrician and several shifts of hospital midwives in the labour. It was not a highly medicalised birth - Julie had stipulated in her birth plan that she did not want anyone to offer pain killing drugs, and at no time did she seem to be looking for medical pain relief. Electronic fetal monitoring (EFM) was used - the hospital's new telemetry monitor was put into use, enabling Julie to move freely, and spend all the time she wanted to in the bath. Julie's doctor had agreed to her plans with the understanding that if she did not progress in labour there would be no artificial stimulation of contractions. Julie was not asked to have an IV cannula in her vein.

Many of my stories are about women who give birth without any complications, in as close as we can to an 'undisturbed' state. The use of EFM is a disturbance, no matter how up to date and wonderful the gadgets are. But Julie had agreed to that disturbance, and was able to labour without letting it bother her. Julie's previous births had both been by emergency caesarean, early in the labours, when both babies had showed clear signs of distress.

Julie and I agreed to approach this birth with the intention of 'normal until proved otherwise'. I explained decision points - any time when a decision could be made. The 'default' decision was that Julie was giving birth. Plan A. At any time an alternative plan may be considered, if a valid reason for interference had arisen. This is the same basic plan that I encourage every woman to adopt.

It was not a simple journey from the first signs of labour to the birth, two days later. We reached several unexpected decision points, and each time, after careful consideration, agreed that Plan A was good. There was the high and very mobile head which did not engage until the second day. There was the vaginal loss, clear at first, then apparently meconium stained. There were subsequent concerns about infection and fetal distress. I called the loss a hindwater leak - the obstetrician disagreed. He did agree that the forewaters were intact, so as long as Julie's temperature remained normal, no treatment was required. At the end of the first day Julie was having contractions but not dilated, and the baby's head was still high. We assessed that she was not in labour; Julie agreed to stay in the hospital; the monitor was removed, and I went home to bed.

Julie's husband called me back to the hospital the next morning, as her contractions were becoming stronger. On palpation I was pleased to discover that the baby's head was engaged. Julie had not slept much, and was now putting all her focus into working with the labour. A dilute mixture of juice and water kept her well hydrated, with a little ready energy. By midday we were all delighted that Julie had progressed to 5-6cm dilatation, more advanced than she had been in either of her previous labours. Another decision point was reached in the afternoon, when the waters were broken artificially. The baby's head was still quite high. I was still concerned enough about that baby's high head that I wondered if we would have a caesarean at that late stage.

However, shortly after, Julie began pushing. Each step had been taken, and we all sensed the birth was near.

The baby's heart rate became very slow in second stage, and the doctor was consulted. Julie's baby's birth was assisted with the Ventouse cap - she pushed and the doctor pulled, for just one contraction. He went straight to Julie's abdomen, and I dried his body as he started to take some breaths then give out a strong cry.

I won't attempt to tell the story from Julie's perspective, or from her partner's. The midwifery lesson from this birth is that patience and consistent decision making enabled the mother to come into spontaneous labour, and to work through her own birthing journey. She can rightly say "We did it ourselves".

Knowing

Denise [not her real name] is a practical, down to earth young woman who lives with her two happy little boys and their father. When she booked me for homebirth she was sure that her baby would be born without too much bother, consistent with her previous birthing experiences. Denise asked me to visit her at home for a couple of prenatal checks - she doesn't own a car, and public transport between her place and mine is not easy. She had made a 'shared care' booking at the Women's, which means that most of her prenatal checkups were with the local doctor. I felt confident in Denise's knowledge of herself, her baby, and her trust in her own body, and I was happy to take her booking.

A couple of days before the due date Denise phoned me around midnight to tell me her waters had broken, but she was not in labour. She wanted to know if that was alright - it had not happened that way previously. In a brief conversation I reviewed a few important points - a small amount of clear liquor, and baby is kicking. The head had been presenting well last time I palpated her, so I reassured her and encouraged her to get some sleep before labour became strong.

The next phone call was after four in the morning, and Denise's husband asked me to come. I put on some easy clothes, brushed my teeth, and got my gear into the car without delay. It took 40 minutes or so as I drove towards the city, and across the flat docklands. I was conscious of the early light of dawn, and the movements of a city that is waking up, and I committed my work, and this family to God. I always ask for strength and wisdom as I go to a labouring woman.

The husband greeted me at the door, and told me she was still in bed - hadn't wanted to get up, in case the baby slipped out. I greeted Denise, who looked relaxed and well, and settled in. There was no rush, but I set up the basic equipment as is my routine.

I don't want to record here a blow-by-blow description of progress in labour. Denise was surprised that her contractions were irregular in their strength, and frequency. Her expectation of quick progress was not met. Yet she was well, and her baby was well, so I had no reason for concern. At one time she asked me if it was taking too long. No, I replied. Each baby has to find its own way through the birth canal.

Over the next few hours the labour became more powerful, and Denise moved into the isolation of her bedroom. Her cries indicated the intensity of the pain she was experiencing, yet her quiet confidence between contractions reassured us that she was well. She worried about her boys, who were watching a DVD - a rare treat for them. The younger one, who is about four, came to the door and checked his mother as her vocalisations became stronger. Each time she reassured him, and he seemed quite satisfied.

A change came eventually, and at the peak of a strong contraction there was a pop, as the bag of forewaters broke. The next contraction brought a strong urge to push. Denise was working intensely with her body as she progressed the baby through her birth canal, and into view. The brother checked once again from the doorway, saw the baby's head crowning, and went back to the television. It was just before 11 am when a beautiful, healthy baby girl was taken into her mother's arms. The two little boys came in, met their new sister, and left in a very matter of fact way. Their mother had had a baby. That's what mothers do!

Many times in the past I have experienced the 'knowing' that women have about their own birthing processes. I hear the woman's expectation through a critical ear, as I know that there are times when knowing is not what we think. Although Denise's knowing, or belief, that this baby was likely to be born very quickly, did not eventuate, that doesn't matter. Time takes on a different quality in uncomplicated, undisturbed birth, than in the world of measurements and calculations. As the labouring mother's mind progresses from neocortical activity to intuitive, hormone-mediated activity, the midwife protects the space around the woman so that she and her baby are free to take the journey. This is one of the secrets of midwifery.

First child

Lovely young woman,
your body firm and fresh.
Perfect.
A precious curtain was torn in two
from top to bottom,
making a way from the sacred place
into this broken existence.

Archetype of the primipara,
feel that deep pain;
mingle unshed tears with the wonder of life that has awoken.

The wound heals over.
The suckling child urges you on,
despite daily reminders.
In giving birth, you have given strength -
wholeness.
A scar remains.
A reminder of the open gape.

When another curtain was torn in two from top to bottom
the way was made into the holy place.
Ponder these things.
Treasure them in your heart.

Joy Johnston [I wrote this poem in my diary 30/6/2001]

[Photo: My niece Laura and her baby Elie, my husband Noel, and me, Joy]



THE OLD GREY MARE SHE AIN'T WHAT SHE USED TO BE
Today I am being very practical, thinking about the weariness I feel after being out all night. This old grey 'mere' (French for 'mother') used to work night shifts in a hospital - nowadays she likes to spend the whole night in bed. And when in bed she prefers to sleep - something else that has become more elusive with the progressive whitening of the hair.

The other day I received a call at midnight, and headed out to the home in the hills. Jane (not her real name) was very pleased to be in labour, and was walking around and enjoying her early labour. After a while I lay down, but did not sleep. Labour became stronger from about four, and Jane gave birth to a beautiful healthy boy at about 6.30 in the morning. I went home and spent a few hours in bed before getting on with what I could of the day's work.

Was I really stronger 20 years ago, was it really any easier then, or am I just more willing to be honest about how I feel now? I have a memory of those night shifts in the maternity wards at the Women's and St George's Hospital in the 80s and 90s: fighting off sleep in the wee hours; the horrible exhaustion that I often felt as I collapsed into bed in the morning; the legs and feet that stayed cold for what seemed like hours. The interruption to the body's usual diurnal processes brought on jet lag for a few days every week.

Working through the night is never easy, yet it was a choice I made while our children were growing up. It gave me the option of being at home when they returned from school, and it seemed the best option at the time. I enjoyed the uncomplicated quietness of hospital life in the night. The only people there were those who needed to be there. There were no 'politics'. Everyone had a job to do, and got on with that job. Over time I developed confidence in working with the natural processes in birth, and as I learnt to be 'with woman' I became assured of my midwife identity.

Since I have been working independently I have truly appreciated the fact that I am no longer working night shifts. Even if every woman booked were to call me out at night it would only be a few nights in the month. I know that night is a time when many women labour spontaneously, and I accept the need to be called out at night.

I believe that the best way midwives can provide appropriate primary maternity care is to take caseloads - to enable women to face childbirth in partnership with a known and trusted midwife. There is no easy way around the issue of sleepless nights on the job - each midwife needs to find the best and most sustainable way she can do it. The world of managed care in obstetrics, in which labours are induced at a time that is considered convenient is not in the best interests of mother or baby. There is no safer way for most women than to labour spontaneously.

I do not ask women to delay calling me so that I can get more sleep. My commitment to each woman means that she is the one who determines the best time to invite me to be with her. I like to have a chat with women in the days before they labour, so that they are confident in their knowledge of their bodies, and confident in their relationship with me.

In recognising the importance of a one-to-one midwifery partnership, I need to balance that with the woman's need to be sure that her midwife can be replaced if that becomes necessary. It's a fine balance - one that midwives are addressing in group practices and specific backup arrangements.

STUBBORN

‘Stubborn’ is the word that settles in my mind as I reflect on this mother who gave birth, who I will call Sally (not her real name). Sally was uniquely, beautifully, proudly, strongly, and wonderfully stubborn. She is a mother, and in her mother-role she is stubborn. She has three young children, born overseas, and a new baby born at home in Melbourne this week. Sally grew up in USA, and her husband grew up here.

Sally stubbornly prepared for this birth, finding the people and the type of care that she wanted. She stubbornly ignored the custom of her community as she made her plans. She stubbornly informed me of what she wanted from her midwife. I don’t think she really believed, until after the birth, that what she wanted was the same as what I wanted.

Birthing, the quintessential female state, transcends culture: Sally’s culture, and my culture. That’s why as her midwife I can know, without doubt, how to be ‘with woman’, no matter what her, or my, culture, religion, or place in a society.

Sally’s knowledge, upon which she confidently built her birth plan had been set down in the experiences she had had in her birthings. She had gathered the best of women’s knowledge over the past seven years. She knew what was good because she had tried it and it had worked for her. She knew what was not good from experiences of being disturbed and distracted in labour, being unable to progress as her time of surrender drew near. She understood, and planned to avoid, separation anxiety that had come when her new baby was taken from her for hospital procedures like weighing. Her stories of the three previous births included signing herself and her baby out of the hospital’s care, stubbornly demanding her own place as mother of these children.

I think of Sally as a she-wolf: independent and confident in her own role, and keeping any unwelcome intruders at bay.

Sally prepared her birth plan with the same stubborn authoritative spirit that I saw in her birthing. The memories of that birthing and the subsequent visits I have made to their home are fresh in my mind, and in writing this memoir I want to honour this strong woman. But rather than writing what I experienced, Sally has given me permission to share excerpts from her birth plan, and I know these statements will tell something of Sally’s story. She had written:

“This baby was planned and made with love; the birth is very much an expression of the culmination of our love for each other. It is very meaningful to us that our love can be so powerful as to bring a new person into this world. Please respect our need to make this birth an intimate and spiritual experience by reading through our birth plan. …

“I want to have a baby and that’s why I’m pregnant and going through the journey of labour and birth. Please let me do my job as a mother - just being present is supportive and it may be the only role I need from my support person or midwife. If a further role becomes needed, please act. …

“I trust in my midwife to follow a non-interventionist birthing approach as we’ve discussed. In the event that another midwife or doctor is present at the birth, please note that I don’t want my baby pulled out: let my body birth the baby. I also don’t want the cord yanked: I want to give my body the benefit of the doubt that it will birth the placenta without intervention. Please don’t administer artificial hormones without justification. I will cut the cord when I’m ready: please don’t clamp the cord until then. Unless needed don’t suction the baby’s mouth: let the baby learn its own body. Establishing breast feeding is a priority for me.

“After birth any separation between me and my baby can be stressful. Please keep this in mind, when wanting to examine and weigh the baby.”

Sally’s plan was to give birth: “Please let me do my job as a mother”. Her expectation of me and my apprentice midwife was that we would be with her, and not interrupt or interfere without valid reason. The time we had spent together prior to the birth, learning how to listen and respond to each other, enabled the partnership between woman and midwife to function well at the time of birthing.

THERE'S NO MILK LIKE MUM'S MILK

There’s no milk so uniquely and beautifully right for a baby as his mother’s own milk. Yet we so readily find reasons to undervalue the breastfeeding bond.

There’s no way so uniquely and beautifully right to transfer the milk from mother to child than the simple act of nursing at the mother’s breast. Yet, we so readily reach for gadgets and concoctions that approximate breastfeeding in a crude and incomplete way.

Many expectant couples say “we want to breastfeed if we can.” Of course! To my mind the “if” in that statement has the same level of uncertainty as “we want to conceive a baby by our own efforts if we can”, or “we want to breathe unassisted if we can”. The other option is unlikely, and should be avoided if possible.

Yet so many new mothers, with babies only a couple of days old, are convinced that they are unable to meet the needs of their babies, and resort to bottle feeding for some or all feeds. There’s no single reason for failure and discouragement at breastfeeding. Babies are all individuals, with individual strengths and capacities. Mothers are a diverse group, physically, emotionally, and relationally. The relationships each mother has with her partner and her family and friends has great bearing on her ongoing choices and decisions.

We know some of the events that can lead to poor breastfeeding outcomes. These include separation of mother and babe in the early hours and days of life; use of formula, teats and dummies; imposing routines of time or frequency; and giving conflicting advice to new mothers. Yet some mothers who experience some or all of these adverse situations go on to breastfeed beautifully for extended periods, while others who face only the most minor challenges will easily relinquish their breastfeeding relationship.

Sally, who is expecting her second child, told me with pride that she breastfed her little girl Molly for two and a half years. She told me how, when the family moved for six months to a Pacific island, the indigenous grandmothers all congratulated her on breastfeeding Molly who was then a toddler. The grandmothers told her that’s what they had done. Their daughters are not breastfeeding – they have accepted the globalised baby formula sold at the supermarket.

Sally was not well when Molly was born by elective caesarean. Molly developed ‘wet lung’, a serious respiratory distress, and was quickly taken to the nursery where her oxygen levels were monitored in a plastic ‘isolette’ box. Molly’s first feeds were formula. It wasn’t until several days later when Molly began breastfeeding. She had to learn how to suckle from Sally’s breast rather than a firm silicone teat that was thrust over her tongue. Sally had to learn to trust her own intuitive knowledge: her baby’s behaviour, and the tension of her breasts, rather than the number of millilitres in a bottle, in knowing that Molly had had enough.

The challenges that are experienced in breastfeeding are no less complex than any other significant life event. Just as labour and birth can be protected within the healthy natural processes for most women, most mothers and babies are able to make the transition from placental feeding to breast feeding without medical intervention.

Yet the reality of our maternity world today is that most mothers will experience a cocktail of drugs, and a complex set of medical interventions concurrent with giving birth. Most mother-baby bonding will also be complicated by hospital processes and medical interferences. By the end of the first week, when most are at home, some are happy and feeding well, while many are not far from weaning.

Understanding breastfeeding is best done when we consider what the baby feels and thinks about it.

A baby at one week of age, who has only ever suckled from her mother’s breast, is becoming very confident in the process. She knows that when she is hungry she is taken into her mother’s arms, and instinctively seeks the nipple, smells the milk, opens her mouth wide, and sucks strongly. After a short time the milk flows quickly and she has to concentrate to coordinate the work of her tongue, jaw, and swallowing mechanisms. If the milk let down begins and she is not well attached, she will come off and quickly seek a better attachment, knowing that the milk is there.

Another baby, also one week of age, whose experiences have included several different people providing different forms of nourishment in different receptacles may not yet recognise his mother’s breast as the place where his hunger is relieved and he feels exquisitely peaceful. His attempts at the breast have resulted in less than satisfactory feeding, and his mother’s nipples have been squashed, blistered, and grazed, and are very sore. So when this little fellow wakes up hungry it might be his dad or his granny who awkwardly manages a bottle with his mother’s milk in it, while mummy tries valiantly to extract milk from her swollen breasts. The milk doesn’t come, and baby is still hungry, so a bottle of formula is prepared. Baby responds thankfully, and sleeps for three hours.

The challenge to help this mother and baby establish not only breastfeeding, but also restore normal bonding processes, is a much greater one that experienced by his little cousin who has taken every feed from her mother’s breast, and is now thriving on an abundance of the liquid gold.

NEXT GENERATION INDEPENDENT MIDWIVES

Today I experienced an encouraging glimpse into the future of midwifery, as five women sat with me at our kitchen table to plan their transitions from hospital midwifery into autonomous independent practice. This was the first of what I hope will be monthly meetings for the coming six months. Each woman is at a different place in her professional practice journey, and each one will need to find the way from where she is to where she wants to be.

I won't try to record their stories here - they are probably reading this blog, and I know I couldn't do them justice. A couple of these women, both recent graduates, are only a few years younger than I. They have adult children and one has a grandchild and have a wealth of life experience. Two are young - late 20s or early 30s, I'd say, without any children. They are both exceptionally committed to midwifery. Another has an interesting story of studying midwifery by distance education, while living in a remote town in Western Australia. In order to access the practical experience she needed in the course she would drive for five hours to Port Hedland, and work for ten days, before driving home again over roads on which she may not see another vehicle for several hours at a time.

There was a common thread of extra-ordinary lives. As each told her story, I wondered if the next could ‘top’ the previous ones! And they did.

We spent a couple of hours listening to each other, telling birth stories, and getting a feeling for what this group needs to do in order to support each one in her quest. I see myself as a facilitator at present, and I feel privileged to participate.

The plan that we are working on is that each midwife will set out her own plan for professional development, using the Australian College of Midwives MidPlus (2007) program as a guide. Each member will report back to the group on her progress, and any difficulties she is experiencing. These plans will identify specific learning needs, reflective practice, and a sense of accountability to the group. I would like to see each member find a professional mentor from whom she can learn, and to whom she can turn for specific guidance.

I am concerned for midwives who would like to participate, but who are not able to meet face to face with us due to distance and other factors. I would like these people to be able to link in to the dynamics of the group. Although face to face is an ideal way of peer group support, I believe we can use email, Skype, phone, blogs as well as the face to face meetings to achieve our goals. In this way we will create a virtual community that goes way beyond Melbourne’s eastern suburbs. The vision I have is that the ‘remote’ members will be partnered or buddied by one of the members of the face to face group, who will provide a link to the discussion and peer support. The use of webcams with Skype has revolutionised conversations – you can see the person at the other end of the line, and they can see you.

My own interest in this new group has led me to consider the possibility of setting up a course that is offered through a university distance education program. I plan to explore this, and set it as my professional development plan.

One might ask what’s the point of supporting midwives to set up autonomous practice in a society that expects midwives to be obstetric assistants in hospital. That’s a pessimistic outlook.

I have seen a great deal of change and development in midwifery in the past decade, and I believe this form of peer support for professional development and extended practice has a logical place in the profession. I believe there will be increasing numbers of midwives looking for courses which will support their transition from shift work to more woman centred models of midwifery care. I expect that once the ball starts rolling it will gather momentum. This past week has seen the announcement of a large trial at the Royal Women’s Hospital, recording the impact of the introduction of caseloads for midwives. Those midwives will be stepping out of the usual familiar territory of midwifery in this State.

I am optimistic that women are also opening their eyes to protecting and promoting their own healthy natural processes in birth and nurture of the newborn. Women will be increasingly asking for midwives who are expert in working with the natural process, rather than booking into impersonal systems of medical care.

Sure, there’s a lot to be done. But goals will be achieved as we set out taking steps towards them.

ANGRY MOTHERS

A friend recently sent me a rant from an email list, in which someone told the story of a recent birth in country Victoria. In almost every paragraph, as the story unfolded interspersed with the cyber-chat language of that generation, there was anger expressed toward the obstetrician, the other doctors, the hospital system, and the caesarean surgery. The comment by the writer was “Wasn't sure where to put this, but need somewhere to get angry! LOL.”

The story was that M (the mother-to-be) went to hospital when her waters broke one morning: she was at 40 weeks and 5 days’ gestation. Labour was beginning, but after a couple of hours the decision was made to augment labour with a drip (Intravenous Syntocinon).

After “travelling really well”, labouring without drugs, a “student obstetrician” (possibly a junior doctor, the hospital resident) told her she was fully dilated and could start pushing. M tried to comply, without success. The consultant obstetrician then examined her, and told her she was only 5cm dilated – had a long way to go.

At this point M “loses hope and asks for an epidural”. But the epidural does not work properly – one side of her body is numb, and the other side is in pain. At 2am the “Ob decides it is time to C-Sec because he needs to get home to bed. M is beyond it by this stage and kinda agrees. So they spend half an hour taking off her freaking toe nail polish and to allow the epi to wear off so they can do a spinal. Which also doesn't work so they give her a G.A.”

M woke up when her baby was two hours old, and was told that the baby was born with a low apgar score – 2 at one minute, and 5 at five minutes. “M is kinda happy she didn't see all the slapping around that has traumatised her DH.”

“… She feels like a failure. Was told by the Ob that on top of that she will HAVE to have C-secs with all subsequent births because her pelvis is too small (oh gagf!) and besides her uterus will definitely rupture if she even tries for a vaginal birth.”

What can I say? Unfortunately this story is all too common.

The obvious question is, could things have been done differently? Could this mother and her baby have somehow progressed safely to a normal vaginal birth?

In labour and birth there is a sequence of decisions that need to be made, but can only be made in relation to what is happening at that time. There is no turning back. Decision points in labour are times when the decision is made to either continue with the natural process, or to intervene. Once an intervention has taken place, such as induction or augmentation of labour, it is no longer ‘natural’ labour, and subsequent care may become more and more medical. This is often referred to as the ‘cascade of interventions.’

In this case some of the key decisions that were made were to go to hospital, to augment labour, to assess progress, to have epidural anaesthesia, to perform caesarean surgery under general anaesthesia. I will go through these decisions in reverse order, and comment where I consider it useful in understanding how a sequence of events like this one is likely to unfold.

Decision point 5: Caesarean surgery under general anaesthetic

By the time the baby was taken from the mother, the baby’s condition was poor – she needed to be born and start breathing on her own, and she was given expert resuscitation immediately. It appears from the account that the baby recovered well.

Attempts had been made to give firstly epidural then spinal anaesthesia, without success, so the only alternative at that point in time was a general anaesthetic. During the interval when the anaesthetist was attempting to achieve anaesthesia (numbness) there would have been observations made of the baby’s heart sounds, and it is likely, in view of the baby’s poor condition at birth, that the baby was becoming distressed. It can be assumed from the account that the caesarean surgery was life-saving for this baby.

The obvious question is, therefore, could this baby have been safely born vaginally? The previous decision points may throw some light on the matter.

Decision point 4: to use epidural anaesthesia

As this case exemplifies, epidural anaesthesia is not necessarily a passport to pain-free birth. The treatment in itself may bring problems – in this case the torture of being numb and unable to move down one side of the body, and the pain of labour down the other side. In addition, the natural pain-relieving substances, endorphins, that build up in a woman’s body during unmedicated labour, are quickly rendered ineffective when medical management of pain is commenced. I do not have a physiological explanation for this – production of hormones and action on pain receptor cells is beyond my personal knowledge base - but I know it happens.

If the epidural had been successful, and the labour could have continued for several hours, a different conclusion could have been reached. The epidural in established labour will not, of itself, reduce the chance of vaginal birth.

We may wonder why some epidurals are ineffective. The skill of the anaesthetist is an obvious question. Also there may be some women whose inter-vertebral spaces make it easier for epidural to be administered than others.

There are serious risks to the epidural such as paralysis and infection. These, thankfully, are rare. However there is also the ‘minor’ morbidity which is probably under-estimated, and under-reported. Physiotherapists often see women with chronic lower back pain as a symptom after epidural in childbirth.

I cannot argue against the use of regional (epidural or spinal) anaesthetic in labour, because I know there will be some women who are not able to tolerate the pain for reasons such as obstructed labour. The only alternative management of severe pain is repeated doses of opiates, which also have unwanted consequences. Without regional anaesthesia the only surgical alternative is the general anaesthetic, which has potentially serious consequences for mother and baby.

It appears that in this case the decision to use epidural was made by the mother in response to her disappointment over being ‘only 5’ centimetres dilated, after having been told she was fully dilated. It is truly discouraging when a mistake like this is made. Yet the decision to ask for epidural was probably the point in this labour at which the cascade of interventions became overwhelming to the mother.

The lesson to women contemplating birth, and to midwives providing care for these women, is surely to value unmedicated birth, and to do all we can to protect and support the natural processes in birth.

Decision Point 3: to assess progress

The decision to assess progress is a standard protocol in maternity services. The people providing the care are responsible to assess and record the condition of the mother and baby, and this includes progress in labour. Yet the woman is the person who gives permission for the observation or assessment to be made. I can’t even take your pulse without permission, let alone put my fingers in your vagina and reach up to make contact with your baby’s head, and cervix.

We must not overlook any assessment or recording of observations as a point at which decisions need to be made.

The skill of the person who makes an internal assessment of dilatation is crucial. It seems that in this case there was an error made by the junior doctor: not an unexpected event in teaching hospitals.

My comment to midwives is to challenge any assessment that seems unbelievable. The midwife who was at that hospital must surely have doubted the doctor’s assessment.

My comment to mothers is also to challenge – to remain sceptical. If you don’t feel like pushing and someone tells you to push, ask them to convince you as to why that’s the best thing to do.

Decision Point 2: to augment labour

Augmentation is a decision that is often used in medically managed maternity care, with the rationale being the need to progress before the labouring woman and her baby become exhausted. This is particularly the case with primiparous (first baby) women. When the membranes have ruptured, as in this case, there is the additional consideration of increasing risk of infection being passed from the mother’s vagina to her baby. M was in early labour, with her first baby, with ruptured membranes.

Decision Point 1: to go to hospital

It is usual for women to go to hospital, or to be seen by their midwife, when their membranes rupture. Had M been able to stay at home, unobserved and active, it is likely that her labour would have progressed well. It is clear from the story that the baby was well until the later stages of labour. M would have been aware of her baby’s movements and the tone of her baby’s body, and this would have given her confidence to go on.

Where’s the midwife?

I can’t argue that women ought to know this; and somehow be a DIY midwife. The woman’s midwife is the person who is missing from the story. The midwife could have spoken to M on the phone; could have ascertained that all was well with the labour; could have visited her at home, and encouraged her without taking over or interrupting in any way. The midwife would have assessed progress at an appropriate time for M, rather than the junior doctor learning from his/her mistakes. The midwife who acts to protect and support the healthy natural processes in birthing has skills that obstetricians and other doctors do not have.

The midwife also recognises complications, and refers the woman to an appropriate care provides when complications arise. M may have needed medical support in birthing her baby: we don’t know. But without the partnership of a trusted and competent midwife, M did not have much chance at all to attempt normal birth.

HER DEATH WAS PREVENTABLE

Today’s newspaper carries a report on the coroner’s findings after investigating the death of a young mother, six hours after the birth of her first child. The coroner found that the cause of death was “post partum haemorrhage complicating amniotic fluid embolism”, and considered that there was a good chance that the death could have been prevented with better medical and nursing management.

Having read the coroner’s report, which is a public document, available at http://www.theage.com.au/ed_docs/coroner.pdf , I want to make a few comments. Several people have told me that they read this blog in order to obtain a better understanding of maternity issues, and I know that we all have big questions in our minds when we hear of a tragic death such as this one. I hope you find my comments useful. You may contact me joy@aitex.com.au or in the comments section of this page.

The only information I have on this case is the coroner’s report. However every midwife and doctor who attends births must be prepared to deal with post partum haemorrhage, and to that extent the coroner’s report is useful in focusing our thoughts on the topic.

Amniotic fluid embolism

Some readers may wonder about the significance of amniotic fluid embolism in this sequence of events. Expert opinion provided in the coroner’s report is worth reading. There is no doubt that amniotic fluid escaped from the baby’s sac to the mother’s blood stream. It is known that this event, though very rare, is likely to cause catastrophic consequences in the mother’s body.

How did the amniotic fluid embolism occur? The report states that there was “probably” a lower uterine segment rupture. This could have allowed amniotic fluid to pass into the mother’s blood stream.

Uterine rupture

How did a uterine rupture occur? This question is not addressed, and I don’t have enough information to form an opinion in this particular case. We are not told any details of the actual birth, whether it was spontaneous or assisted. The assumption is that it was a vaginal birth. We know that the labour was induced at 41 weeks’ gestation. Induction of labour is usually achieved by artificially rupturing the membranes, and administering an artificial oxytocic, Syntocinon® intravenously, gradually increasing the dose over time.

The women today who are most likely to be confronted with concerns about uterine rupture are those with previous uterine surgery – usually a caesarean birth. The scar itself can dehis or ‘buttonhole’, something that may even happen prior to the onset of labour. This is a serious complication, but may not lead to catastrophic haemorrhage. The rupture of the upper uterine segment in obstructed labour or following prior classical caesarean surgery is the most life-threatening complication in this group, as the muscle of the upper segment is thick and has a large blood supply. Tearing of the lower segment may occur in an assisted birth in which a tear in the cervix which was not fully dilated and taken up extends to the lower segment.

Post partum haemorrhage

The severity of the haemorrhage described in this account is far greater than most midwives will ever experience. In the six hours after the birth, from the description of events in the report, there would have been no time when this new mother would have felt well. Her blood pressure was low, her pulse weak, and when conscious she would have been aware that her life’s blood was flowing from her. Whether she experienced the joy of holding her baby or not, we will never know.

Large doses of oxytocics were administered to keep the uterus contracted, without success. It appears that there was no thought of possible uterine rupture in all the decision making and treatment that ensued. Even when the mother’s uterus was examined under anaesthetic, the doctor was looking for retained placenta as the possible cause of haemorrhage.

Coagulopathy

As the haemorrhaging continued over the hours after the birth, the mother’s ability to form clots became progressively worse. This is to be expected in serious haemorrhage of any kind, and requires expert medical management.

Model of care

The model of care in which this mother gave birth, with a specialist obstetrician being the primary carer in a private maternity unit for a healthy thirty-three year old primipara, received no comment from the coroner. It’s so *usual* that noone thinks critically of it in this country. The woman chose to have her baby in Melbourne, probably as ‘safe’ as any other place in the world from a maternity outcome point of view, and she chose the doctor. What more could one want?

In no other life event is there an expectation that well women will be given basic care by a specialist doctor. Yet this is the case in Australian maternity care, due in a large part to the government’s tax incentives to encourage private health insurance, and financial incentives through Medicare and the Medicare safety net.

An informed observer would ask “where was the woman’s midwife?” In this particular model of care the midwife who was present during labour would have been a stranger to the woman, and would not have acted autonomously in providing intrapartum care. Midwives working in private maternity hospitals in Australia usually work as assistants to the obstetrician, informing him or her of progress, administering treatments ordered by the doctor, and maintaining the record of observations. The baby girl was born at about eight in the morning, so a new midwife, rostered to work the day shift, would have taken over the care at about that time.

Perhaps the doctor had been called out to the hospital during the night, and was tired by the time the baby was born? We don't know - that's only conjecture. But had this woman's care been in the hands of a midwife, and everything else been the same, it's to be expected that a specialist obstetrician would have been called to manage the care as soon as the haemorrhage had been seen. Or, if the woman was in a primary care unit such as a birth centre without surgical facilities, or at home, a transfer would have been organised to a suitable backup hospital as soon as the haemorrhage had been seen. (note that a birth centre or midwife at home would not have provided induction of labour on maternal request, and that's a major difference in risk management.)

The point I am making is that when primary care is in the hands of the specialist, there is no further specialist to refer to when complications arise. The model of care put this woman at greater risk than another model, in which a specialist would have looked with fresh eyes at a woman who had experienced a severe post partum haemorrhage, and who was still in shock, and would have instituted aggressive measures to support the woman's circulation, and to stop further haemorrhage.

When a midwife attends a birth as primary carer, and the woman experiences excessive blood loss, the midwife acts quickly to prevent further loss. The uterine fundus is rubbed up and any blood expelled - an empty uterus does not bleed. The midwife administers oxytocics - my usual dose would be Syntocinon 10units intramuscularly, followed by Syntometrine 1ml intramuscularly if the first dose is inadequate. A woman who is still bleeding, with signs of low volume shock, would be transported to hospital by ambulance as soon as possible. An IV infusion would be started, and transfer of care to a backup medical team would occur without delay. This action would usually take place within an hour or so of the birth.

It's easy to be wise in hindsight. Errors of judgment clearly happened in this case, and the coroner described the decision making process as a "study in chaos". Whether the doctors concerned will be judged by their peers as having been professionally negligent or incompetent is up to the statutory body to decide. We expect the ‘eye for an eye’ – someone has to be punished. The lawyers will no doubt organise to sue for compensation, and the insurer will no doubt pay out. Yet nothing has been done to address the underlying cause, which had more to do with the model of care than the actual people involved. A precious life was lost; a baby began her life without her mother; and a new father lost the woman he loved, and who gave birth to their child. It's so sad.

A PLACE OF QUIETNESS
We have sought a place of quietness
resting mind, body, and spirit.
Relative solitude.
Separation from business and busyness.

Quietness opens a door for other sounds -
I hear the hum that rises and settles as the wind works its music in the multiple reeds and strings made up of leaves and branches and wires around me.
I hear the sound before feeling the breeze.
Bird sounds come and go: some bright and clear, and others soft and almost incidental.
A buzzing insect, a mosquito's whine, the croaking of frogs, and even the harsh flapping of a piece of corrugated iron that has come loose on the roof of the old shed - these are players in the orchestra of quietude.
These are the sounds I am hearing.

J Johnston. 5 January 2007
[This little piece was written a year ago, when we were having a holiday in Roma, Queensland.]

Today I am bringing two poems from my stored files to this blog. Two mothers; two families; two births. Two babies, but only one living. I hope the thoughts expressed here are helpful to others in coming to terms with the big questions of life and death. Joy Johnston

Tears

Salty tears fall from swollen eyes
as the woman mourns for her child.

In the day and in the night
surges of pain and sorrow
are reminders of her loss.

White milky tears flow from firm tender breasts
that never will feel those rosebud lips.

Deep pain of heart and breast and womb
is soothed a little by the warm and generous torrent from the shower above.

Tears, milk, and dark drops of blood
mingle at her feet
and are washed away.

J Johnston, January 2003

Uneventful

I called it an uneventful birth.

There was no time of fear or doubt,
no place for concern.

Progress was swift as you opened and gave up your treasure into my hands.

Uneventful?

How could I call it that?

When heaven opened a little
and a sunbeam in the night showed an angel the way to your home.

When your beautiful pink babe was ushered into your arms.

When heaven’s host watched on in awe,
and a little cherub said “ah - ah - ah!”

When your heart swelled to pour out its love.

As mother and father, and the whole circle of family and dear ones greeted and welcomed the newest member.
As you and your loved ones watched
an unfolding miracle.

Uneventful?

The rush of waters.

The surges of power from within, urging the little one forward.

The need to be ready, as fullness and heaviness preceded her arrival.

The moment between times – still within, and yet without,
and a small cry before the release.

Warm, wet, and glistening in my hands
held over the welcoming mat.

Could this be called uneventful?

Arms stretched wide, and air filled the little lungs for the very first time.

The baby heart undergoes the miracle of changing from the placental circulation
to its own supply.

The baby skin feels warm at mother’s breast
and the baby lips search for sweet warm milk.

The mother’s arms encircle her soft baby child.

Senses are fully alert, as sight, touch, smell and sound
imprint on the mother memory.

Others are reverently quiet, unwilling to interrupt this falling in love.

And her womb gives up the afterbirth.

What great mysteries we have witnessed!

A child has been born.

Events too momentous for description.

The early light of dawn can be seen above the hills to the East
as a family settles down to rest
before the new day begins.

Uneventful – yet extraordinary!

“Praise God, from whom all blessings flow.

Praise Him all creatures here below.

Praise Him above ye heavenly host.”

J Johnston

January 2003

MIDWIFE AUTONOMY

Case Summary

A primigravid woman, ‘Tracie’ (not her real name) aged 36 years asked me to be her midwife. At 26 weeks’ gestation I recorded that Tracie wanted to labour at home, and was questioning whether she would go to the local public hospital Birth Centre or stay at home for the birth. Tracie told me she wanted to keep both options open, and she decided to make two bookings – one for birth in hospital, and one for homebirth.

Tracie was working full time, and assured me that her job did not give her any undue stress. She planned to finish work a month before her baby was due. I saw Tracie at 33 weeks, and she was well. I recorded that her fundal height was at about the 32 week level. I palpated the baby, and assessed its size between my hands. Small-ish baby, I thought. There had been no elevated blood pressure or other condition that may compromise fetal growth. The fetal head was presenting nicely, and the back to the left.

I made a booking for a home visit for ‘birth preparation’ at about 36 weeks’ gestation.

Early Sunday morning I was woken by the phone, and was surprised to hear Tracie’s partner say “It looks as though we won’t be having the birth preparation meeting tomorrow”. He went on to tell me that Tracie’s waters had broken at three, and she was now labouring strongly. Only a couple of hours ago, I thought, as I began to discuss the implications of labour before 37 weeks, and the special needs of pre-term babies. Then I heard the sounds of Tracie’s labour in the background.

“Ask Tracie if she wants to go to hospital now, or if she would like me to come to the house,” I said.

“She would like you to come here,” was the reply.

“No worries. I’m on my way.”

It was cold and windy out. It took me about 30 minutes to get there, and I parked my car and went up to the house. As it was my first visit to their home, I was noting things that are usually noted at that preparation visit – the hilly terrain, the steps from the car to the house, and the flight of stairs from the entrance to the upper level where the bedroom was. There were big windows with superb views!

In the bedroom I found Tracie working strongly with each contraction, as the labour surged every couple of minutes. Checking mother and baby – both were fine! Waiting for another contraction to ease, I prepared in my mind to tell Tracie that we would need to go to hospital immediately, so that she could settle in before the baby was born. However, the sounds she made became lower.

“I felt like I needed to push that time,” Tracie said.

After a brief discussion we agreed to continue at home, rather than attempting the steep and exposed journey from the bedroom to the car, and on to the hospital. The birthing progressed beautifully, and soon we had a wee girl in excellent condition, resting on her mother’s abdomen; a proud new mother; and an elated father.

My usual practice at birth is to not intervene unless there is a valid reason. I did not clamp or cut the cord, or do anything to speed up the Third Stage. In the ensuing minutes we quietly watched this baby girl begin to respond in the instinctive way that healthy babies do. She began to lick and salivate, and make rooting movements with her mouth, and strong leg movements that moved her towards the breast [This process is known as the ‘breastcrawl’ – see http://breastcrawl.org ]. That evening I made a note in my journal:

“When baby was near the nipple she flopped her head to the other side. Mother gently put the head back where it was, and baby did the same movement again. After the second time I suggested she might want to be that way, and soon after, she began to take the breast. Strong contractions followed, and the placenta came with minimal blood loss.”

Baby was a couple of hours old when I weighed her, and noted that she was only 2.3 kilos. Despite the small size, her behaviour could not be faulted. She was warm, well fed, and a powerful bond was being forged between her and her mother. When I re-visited the question of transfer to hospital, Tracie reiterated her desire to stay at home, and I agreed.

Since she was a small baby, slightly premature, I set up a care plan of three-hourly feeds, at the breast, or with expressed colostrum if baby didn’t feed well. Each day as I visited I was thankful that Tracie and I were working together. Trust is a two-way process: she had to trust me and I had to trust her. Tracie kept a record of feeds, whether at her breast, or by cup. By 48 hours, baby was needing some expressed colostrum, and Tracie’s nipples were tender. The reality of broken sleep, and constant attention to the needs of a newborn was settling in, as the euphoria of birth subsided. Each day I looked carefully for any reason why this mother and baby should be under the care of a specialist team such as that available at the hospital. Each day Tracie confirmed that she wanted to stay at home in my care, unless I felt that they needed to go to hospital. Each day, as I observed that all was well, my conclusion was that we were acting appropriately.

By the end of that first week I saw a mother who was gaining confidence; her baby waking and feeding vigorously.

I reflected a lot during that first week on the issue of the size of the baby. Had we transferred to the hospital, this baby would have been taken to the Special Care Nursery, separated from the mother, and had her blood sugar levels checked frequently. When the blood sugar level was found to be low, it is most likely that artificial formula would have been given rather than relying solely on breastfeeding. This is a very different scenario than what was experienced by Tracie and her baby in their home, as there was no separation, and small but adequate amounts of colostrum were provided frequently either by baby’s efforts, or with expressed milk.

Despite being smaller than the usual ‘normal’ weight in Australian maternity services, this baby was well within the range of babies for whom weight alone is not an acceptable reason for interfering with the natural process in establishing breastfeeding. The Baby Friendly Hospital Initiative (BFHI) ‘Acceptable medical reasons for supplementation’, lists babies “born preterm, at less than 1500g or 32 weeks gestational age; or infants with severe dysmaturity with potentially severe hypoglycaemia, or who require therapy for hypoglycaemia, and who do not improve through increased breastfeeding or by being given breastmilk.” The guideline states that “For babies who are well enough to be with their mothers on the maternity ward, there are very few indications for supplements.”

[From Booklet 3 of the Global Baby Friendly Hospital Initiative in Australia, ACMI/BFHI, p10.]

The local hospital where Tracie had a booking is an accredited Baby Friendly hospital. Yet on this issue, I felt confident that the BFHI ‘Acceptable medical reasons for supplementation’ would not be followed.

I contacted the Maternal and Child Health (MCH) nurse, and discussed my care plan. When seen by the nurse at eight days of age, baby weighed only 2 kilos. A week later, baby was breastfeeding well with occasional ‘top-ups’ of expressed milk, and she had gained 50 grams, and all clinical signs were positive. Tracie took her baby to the local doctor at about two weeks of age, and he agreed that all was well. By three weeks of age, the baby was clearly thriving.

Reflective comment:

In providing postnatal midwifery care for Tracie and her baby at home I have acted autonomously, outside the National Midwifery Guidelines for Consultation and Referral (‘Guidelines’) (ACM 2004). This was not a pre-meditated decision to act ‘independently’ or to ‘push the boundaries’. It was an action plan that evolved during the first week as each decision point was reached, and as the care was reviewed each day.

The purpose of a systematic set of professional guidelines is to ensure “high quality and safe care” (ACM 2004, p5). However, guidelines should not be treated rigidly; they are guides. The wellness and safety of mother and baby are the primary concern of the midwife, who has the professional expertise to independently assess wellness, and to develop a professional care plan in which she can act confidently. Midwifery at the primary care level is health promotion rather than a treatment of illness or complication.

There are times when I and other independent midwives choose to act outside the Guidelines, such as in providing primary care for women who have had a previous caesarean birth, without consultation and transfer to medical care, and with a plan to give birth at home. When this decision is taken the midwife discusses with the mother the alternatives at that time, and what implications her choices may have as she progresses down the childbearing pathway. Informed decision making is an active process. The woman is encouraged to make her own choices at each decision point, taking into account the complexities of her own life and her knowledge of herself.

There would certainly be times when I would judge a small baby in a similar circumstance to be best cared for within a supportive multi-disciplinary collaborative framework of a maternity hospital. If I was not confident in the mother’s ability to act in the best interests of her vulnerable newborn; or her family support; or her own strength: many possibilities could have led to a different decision on my part.

Birth Trauma
I talk a lot about normal birth, and I aim to protect and support the natural process whenever possible. However, the other side to the 'normal' birth coin is the 'abnormal'. The midwife's job is not only to work with the natural process, but to identify any complications and to take appropriate action to protect wellness in mother and baby.

There is a young man who works at the local grocery store, who has Erb's palsy - the paralysis of the brachial nerve. He has limited function in his Right arm and hand, which are small and distorted compared with the other. He gathers the shopping trolleys and arranges them in the front of the store - a job he has been doing since he was a teenager. He always seems cheerful and energetic.

This was probably a birth injury. Those moments between the birth of the baby's head, and the rotation of the whole body to free the leading shoulder, can be critical. The midwife or doctor attending the birth can either facilitate a normal birth which protects health and wellness, or potentially allow damage to the baby in a way that will never heal.

My thoughts on birth trauma have been stimulated this past week since Marie (not her real name) gave birth to her baby boy at home. This baby weighed over four kilos, and Marie had to work with all her might to give birth to him. I assisted her birth the baby's shoulders, gently supporting the baby 's head after it had restituted from occiput anterior to the transverse plane. The shoulder was not obstructed - my intervention was more from a concern that the baby needed to be born, to fill his lungs with air. I didn't want any unnecessary moments' delay in the birth process.

Baby was floppy and pale initially, but the cord pulsated strongly. I was confident that he would resuscitate spontaneously. Marie was kneeling and he was on the mattress under her, as I used nappies to dry him and stimulate him. Soon a raspy cry came from him, followed quickly by improvement in his colour. I knew that all was well. As Marie reached for him and took him into her arms I had a moment of deep thankfulness to God for this blessing.

Marie was quite exhausted, and became chilled. Although the weather was mild, her room was cool, and there had not been any room heater set up. I worked on getting her more stable as she held her baby to her breast. She was trembling and weak. I wanted to see the placenta out, and be sure that she was not going into shock from blood loss. Marie agreed to an injection of the synthetic oxytocic Syntocinon, and soon the placenta was birthed as I exerted some traction on the cord. Marie felt huge relief, and rested quietly.

Over the next hour or so the baby found the breast and began suckling strongly, while the mother's strength returned. I felt confident once more that any potential crisis had been averted. Later that evening when I left them, the parents were proud and happy, and ready to introduce their other little son to his new baby brother.

A baby's transition from the womb to the outside world has many points at which damage or trauma can occur. These include physical - the passage through the birth canal; and physiological - the opening of the lungs to take in air for the very first time; and the closing down of the placental circulation, leaving the baby reliant on his own body's systems for circulation, excretion, and nourishment. This transition takes place in a very brief space of time, and although the transition is usually without incident, it is of profound importance to the baby.

When I visited Marie the next morning I found her well, and her partner busily attending to the household. The new baby was sleeping quietly. Marie had noticed that his skin was yellow, and had placed him next to the window to expose him to light.

Jaundice in a healthy Term baby is usually manageable at home, but this was obviously more serious than physiological jaundice. I quickly explained that we needed to take baby to hospital, so that he could receive appropriate care. A baby who develops obvious jaundice in the first 24 hours of life needs medical management without delay. I made a call to the local hospital, so that they would expect this baby in the emergency department.

A blood test confirmed that the level of jaundice was high, and the baby was admitted and put under phototherapy lights in the Special Care Nursery. Marie stayed as a 'boarder', and continued breastfeeding every three hours. Baby fed vigorously. The next day the serum bilirubin levels had increased, as expected. After 48 hours the level was falling, and they went home after three days in hospital.

Marie asked me what was the risk if we had not gone to hospital. A serious complication that occurs when severe jaundice in not treated appropriately is brain damage and deafness. In Marie's case there was no indicator prior to the birth that the baby was likely to become jaundiced. The subsequent care that the baby needed was the same whether he had been born in a birth centre, hospital, or home.

Why protect normal birth?

[Photo of our family, taken Christmas day 2007]

The idea that normal birth should be protected had not occurred to me when I was a young mother, back in the '70s. Protect from what, or whom? You only protect something that is under threat.
I was not idealistic about my own ability to engage in labour, and to give birth to my children.
There was an unspoken rule that medical and surgical interventions were only used when necessary, and everyone understood that the doctor would act in a way that protected the interests of the mother and her baby. I never considered that there was any choice other than to expect my body to do the work of childbirth. There was no notion of consumer choice, or discussion about decision making. The doctor/nurse/person in authority - knew best.
I don't want to imply by this that maternity care was particularly good when I studied midwifery, and became a mother myself, in the 70s. In fact it's difficult to find a time, or culture, where people have understood the power and rightness of normal birth. Perhaps if we look way back to the Biblical time described in Exodus 1, we find an example of civil disobedience that suggests both the midwives and mothers held birth as something that not even the king could interfere with.
"The king of Egypt said to the Hebrew midwives, one of whom was named Shiphrah and the other Puah, 'When you act as midwives to the Hebrew women, and see them on the birthstool, if it is a boy, kill him; but if it is a girl, she shall live.' But the midwives feared God; they did not do as the king of Egypt commanded them, but they let the boys live. So the king of Egypt summoned the midwives and said to them, 'Why have you done this, and allowed the boys to live?' The midwives said to Pharoah, 'Because the Hebrew women are not like the Egyptian women; for they are vigorous and give birth before the midwife comes to them.' So God dealt well with the midwives; and the people multiplied and became very strong. And because the midwives feared God, he gave them families." (Exodus 1:15-21)
The threat today to normal birth is quite different, but it calls for a similar degree of bravery on the part of those who are guardians of the natural processes.

PROTECTING NORMAL BIRTH

Thismorning I witnessed the birth of a healthy baby girl. A few hours later I returned home, leaving mother and baby resting quietly in bed. Baby had suckled strongly, and was now asleep. Mother had not slept much last night, and was happy to enjoy the sweetness of her new baby daughter. I will visit them tomorrow, and a few more times in the coming week, and check that all's well.

A couple of weeks ago this mother, who I will refer to as Lisa (not her real name) was facing the difficult choice of either elective caesarean, or vaginal breech birth against medical advice. Lisa had told me she thought her baby was presenting breech, and after palpating her belly I agreed. After visiting the hospital the presentation was confirmed, and Lisa was told that she would no longer be eligible for the Birth Centre, and would be scheduled for caesarean birth.

Lisa immediately visited her traditional Chinese medicine practitioner, who used acupuncture and moxibustion, to no avail. This process was repeated as the days passed.

I spoke to an obstetrician who is expert in external cephalic version. I outlined the situation that Lisa is a mother who has previously given birth, and is now at Term; she and her baby are healthy; the breech is mobile above the pelvic inlet, and there is plenty of amniotic fluid. The obstetrician confirmed my assessment, that external cephalic version should be attempted, and was likely to succeed. He gave me the name of the doctor who he knew would be able to turn the baby at the hospital where Lisa was booked. He knows that I am a homebirth midwife, and I commented that Lisa would consider breech vaginal birth at home, and his response was quick "so that's all the more reason why this baby should be turned!" I agreed.

Lisa went to the hospital and the midwife spoke on the phone to the doctor about arranging external cephalic version (ECV). The doctor said it was too late in the pregnancy. She usually does ECVs on Tuesdays, and next Tuesday she would not be at the hospital. I encouraged Lisa to persevere - I felt that the doctor needed to palpate Lisa's abdomen, and feel how ready this baby was to be turned.

After several visits to the hospital for monitoring, and a considerable degree of persistence, Lisa was seen in person by the doctor. The doctor agreed that a turn should be attempted, and told Lisa she could do it that day. The version took only moments, and was successful.

Attempting ECV for a breech at or near Term is a reasonable option in protecting normal birth.