Understanding pain

There is something unimaginable about the pain that another person experiences. It's never easy to witness. My response is to want to do something that will end the pain.

But surely, I am a midwife, I should be used to the intense pain of labour. I tell women to work with their pain; to accept and use it. I know both the mental haze of narcotic drugs, and the total differentness and mental alertness of spontaneous unmedicated birth for myself, and for many of the women I have been with, and the latter is the winner without a doubt. I haven't personally experienced the numbness of regional anaesthesia (such as epidurals and spinals), but I cannot imagine anyone would choose that over the physical achievement and mental exhilaration of normal birth.

Yesterday I was at the home of a mother who was looking forward to the birth of her second child. She was strong and well, and had prepared beautifully, and was now in labour. Her husband gave unconditional personal support, and her sisters and whole family all had their support roles. The bedroom was quiet and almost dark; she spent time on the exercise ball, and resting as the hours lengthened. The birth pool was set up in the bathroom, and soft candle light made the space all the more special as an intimate place to welcome the precious newcomer. Labour had begun in the morning - a lovely clear sunny day in Melbourne. As the afternoon sun set, and the sounds of labour became more regular and stronger, I expected that undefinable change to occur, as a woman surrenders to the enormous power within her body, and her baby is brought forth.

But that didn't happen. The sounds became more distressed. We waited. I withdrew for a while, not wanting the mother to feel pressured. She told me today she wondered if I didn't believe she was really in a lot of pain. I did, and I was concerned about what I was hearing and feeling. I was intuitively sensing what we refer to as 'failure to progress', although intellectually that didn't make sense. It doesn't usually happen with a second labour, when the first baby was born at term, vaginally.

The minutes passed into hours, and the mother became more tired, and vomited. I checked internally for progress. Cervix about 5cm dilated; bulging forewaters; and a very high head that could be easily pushed away. I was careful not to rupture the membranes. The only advice I could give was that we should go to hospital. I hoped we would see progress of this baby, and my intuition would be proved wrong.

It was about six hours later that this family welcomed their new baby, with the help of the midwifery and obstetrics and anaesthetics and paediatric teams at the Women's. The hoped-for progress did not eventuate, and gradually the little one became more distressed. A caesarean birth was the best birth possible, and I was grateful.

I called this post 'Understanding pain'. My understanding of pain in labour includes the belief that there is a pain that is OK, and there is another pain that is intolerable. The distinction between the two is not easy to make, either by the labouring woman or by others. I think a midwife develops an intuition, but I am always ready to question my intuition. The labouring woman is the only person who can say, "this is OK" or "this is not OK". Many women have said, in effect, "this is not OK", in transition, and then gone through the paroxysm of pain, into the wonder of new life and love. But when "this is not OK" continues, without relief, the message is a different one.

By reflecting on an experience such as this one, I am reminded that I must hear what the woman is telling me, whether it fits with my perceived knowledge base or not. I must approach the decision points carefully, with clear thinking and without fear.

Promoting normal birth through BaBs

I have added babs-ies a new blog to my blog list, so I would like to tell my readers a little about babs.
BaBs stands for Birthing and Babies Support.

The Goal of BaBs is to be "a Health Promotion charity, which enables pregnant women and new mothers to increase control over, and to improve, their health in pregnancy and birthing, and in the nurture of their babies."

BaBs was born in 2006, after brainstorming meetings I had with two lovely young mothers, Erika and Deb. A quick stick-figure sketch that I did became the 'babs girls' At the time I was an executive member of Maternity Coalition (MC), and BaBs was set up as an organisation under the umbrella of MC, in a similar way to MIPP. Meetings began at Clota Cottage Neighbourhood House in Box Hill. Since then BaBs groups have been set up in other locations in Victoria and Queensland. BaBs is now incorporated, independent of MC, to enable growth.

The mission of BaBs is to "establish local peer support groups for pregnant and parenting women and their families in their own communities. We work to support women to make informed choices, take action about pregnancy, birth and parenting, to feel empowered and confident in their choices to improve their health, parenting, and life skills."

BaBs groups have been successful in obtaining small grants from local councils to buy books and other material, to print brochures, and to help with the costs of room hire. There is no attendance charge for BaBs groups - a donation is welcome, but not required.

BaBs groups depend on the voluntary support of mothers and midwives who work together to plan and facilitate the program in their own local neighbourhood. I am involved in the Box Hill group, which is close to my home.

I would like to encourage all midwives reading this blog to find a way by which you can make a commitment to mothers in your community - not just the mothers who pay you as their midwife, or the mothers at the hospital where you work. A midwife's duty of care includes to 'promote normal birth' [ICM Definition of a midwife]- and it's a bit late to do that when you arrive for a shift and are told to work with the woman in room 3 who has a Synt drip and an epidural.

I would like to enocourage all mothers who read this blog to find a way to meet with other mothers and midwives with the purpose of promoting health in birthing women and their babies. Normal birth includes a whole raft of 'normal' or physiological activities, including normal attachment and breastfeeding. There is no safer or better way to give birth than the way our bodies were designed, and there is no safer or better way to nurture a child than the physiologically normal way.

Birth Plan

A birth plan may be set down as Plan A and Plan B.
Plan A: "I am intending to give birth under my own power, and will do all I can to achieve the best outcomes for myself and my baby."
Plan B: "If a medical intervention is recommended in order to achieve the best outcomes for myself and my baby, I need to be given the following information in order to make an informed decision:

• what do you want to do? (procedure, test, intervention, ...]
• why do you want to do that?
• what is likely to happen if I say 'no' - if I don't allow you to do it?"

In this way you will only allow interventions - Plan B - that you believe are best for you and your baby.

See Preparing your birth plan at Maternity Coalition's INFOSHEETS site.

Understanding fetal monitoring

An article, 'Mother's plea after death of newborn' on p3 of the Saturday Age today has a sad tale, from which I have excerpted a couple of lines:
"[Jane] (the mother) said CTG machines, which monitor an unborn baby's heart rate, were not working properly and her partner had to alert staff when the heart rate dropped well below normal.
"Jane said it seemed obvious that 'our little girl wasn't coping', but she kept being told everything was OK. Shortly after the birth by caesarean, Jane's baby girl died."

I feel great sympathy for these parents. They were isolated in a hospital room, with monitor straps around Jane's belly and the machine that goes 'ping'. The alarm on the monitor would have started sounding when the baby's heart rate dropped - or was it just loss of contact [ie not working properly]? Why was the partner the one who had to alert staff? How did the partner know what was OK or what was not? Jane says it seemed obvious that 'our little girl wasn't coping', so where was the midwife?

The answer seems to be that the midwife was not in the room. It seems that the hospital did not have enough staff to keep a midwife in that room at that time.

Cardio Tocograph (CTG) machines are used consistently and often continuously in hospital births. As with any test, the information provided by the machine needs interpretation - not at some time in the future, but as it happens. That interpretation should not be the job of the partner, or the alarm function on the machine. It should be the work of the midwife who is in the room continuously with the woman.

I would encourage anyone who agrees to electronic fetal monitoring (EFM); having a CTG trace, that you agree ONLY if a person who is able to take responsible action on the results of the trace is present at the time.

Continuous EFM, or any other type of fetal monitoring, including doppler or pinard stethoscope, does not ensure the safety and wellbeing of the baby. It is useful only when appropriate action can be taken on the information that is provided, and the person who receives the information understands its meaning.

Continuous EFM can give a false sense of security, as well as a false sense of doom. The usual response to a non-reassuring CTG trace in today's maternity services is to rush to the operating theatre and have an emergency caesarean birth. In the case highlighted in this story, that did not happen soon enough, with tragic consequences.

The protection of the wellbeing and safety of mother and baby are the guiding principles in all midwifery. A midwife working in a hospital should not leave the room if she considers that a mother requires continuous EFM.

You might say that's unreasonable.
Midwives have to leave the room, to do paperwork, to go to the toilet, to have meal breaks, or whatever.
That's true. So turn off the CTG machine, and take the belts off the woman, before leaving the room. It's unreasonable to expect the mother and her partner to become defacto watchers of the EFM in the absence of a midwife. They are not able to understand what they are hearing and seeing. That's a professional act, and if there is truly a reason to keep the machine running, there must be a person in attendance and an intention to intervene.

midwifery debate in newspapers

I sent the following letter to The Age in response to a small article 'Doctors Attack Midwives Proposal' (most of this was published in Letters to the Editor 12 Sept)

The statements by the Australian Medical Association, reported in The Age (In Brief p10, 11/12/08) saying the Federal Government’s plans to extend the role of midwives “could threaten the lives of mothers and their babies” and “there was a greater chance of a baby dying during birth if born at home” are not based on any evidence.
Homebirths attended by midwives in Victoria are reported to the government’s Perinatal Data Collection Unit, and reports are published annually. The statistics for women who intended homebirth but transfer before or during labour are also available. Although these reports cannot give specific information on individual cases, the data do not suggest any cause for concern about the midwives’ competence in practising midwifery.
I am an independent midwife, so I obviously have an interest in asking for the right of reply. However, I do not want special treatment – I believe newspapers should look for and report on the truth. In this case the homebirth midwifery profession is small and poorly funded, threatened with extinction, and we are being attacked by a huge, well organised, and well resourced organisation.
Joy Johnston

Reflecting on a difficult birth

After visiting the new parents and their beautiful baby yesterday afternoon, only 12 hours after his birth, I have felt that I need to reflect carefully and write on this birth. Although I enjoy writing, this is not a simple task. The complexities of life, and of each birth, mean that I have to choose a small aspect of the whole experience and write on it. By reflecting on the experience that I had, within a professional partnership as midwife to this woman and her child, I am using the maieutic mode of enquiry. This is the essence of a midwife's work both as a teacher and as a student: enabling learning through reflection on experience.

The dictionaries explain the connection:

Maieutic = act as midwife. Pertaining to the Socratic method of bringing out ideas latent in the mind. [Webster's]

Gr maieutikos maieuomai = act as a midwife. [Concise Oxford]

In summary, the mother, who I will call M, was a primigravida at 41 weeks plus 3 or 4 days' gestation. For the previous week, and particularly for the past few days, M had been experiencing pre-labour contractions, day and night, every 7 to 10 minutes. Each time we spoke, I encouraged M to trust her body's signs, to rest when she could, and to be ready for the establishing of labour. I saw her on Tuesday, and found that her the baby's head was well engaged, and the cervix very thin. Very good! However, M was becoming discouraged. She did not think she could keep going. She had noted a reduction in fetal movements, and we were not sure of the significance of this.

M had chosen to give birth at the Mercy Hospital for Women in Heidelberg, and had an appointment at the hospital the next day. When offered induction of labour, M agreed to having her waters broken, but wanted to see how she could progress without IV oxytocic. Contractions became more frequent, and labour was underway.

Over the next few hours there was little dilatation of her cervix, and the doctor encouraged M to have the oxytocic. Having no alternative plan, this further step in 'Plan B' was agreed to, with an epidural.

It sounds trite to just say 'with an epidural'. Women who have planned for spontaneous unmedicated birthing, and who understand that an epidural comes with at a cost as well as having the apparent benefit of pain obliteration, express grief at this time. But when they see it as the best option, they make the decision. Well, there's no guarantee, and this epidural did not work, and had to be resited. Even when it was correctly placed, there was a persistent painful area in one of M's legs. The anaesthetist was patient and consistent in trouble-shooting, and eventually achieved the desired pain relief. By this time there were 'non-reassuring' fluctuations in the baby's heart trace.

The hospital midwife told M that it would be best to put a scalp clip on the baby's head, in order to monitor more reliably. M asked me what I thought. We agreed to make a decision after we knew what progress the baby had made, with several hours of oxytocin augmentation. Good news - M had dilated to 'fully'. M declined the scalp clip, and found a sitting position which allowed for better external monitoring.

With a deep anaesthesia from the epidural, M's efforts at pushing were insufficient to get this baby born. The heart rate continued to fluctuate. With M pushing, and the doctor pulling, using the Ventouse vacuum cap, the baby was born in good condition. With the baby came thick, heavily meconium stained liquor. He needed to be born, that's for sure.

When attending a complicated birth, with the increasing possibility of harm to the baby (as indicated by the baby's heart rate and rhythm), it is not possible to predict what may happen. In this case, I do not believe the baby would have been in good condition at birth, able to stay in mummy's arms, if the birth had been delayed much longer.

The matter I want to reflect on, and I hope my readers are also able to ponder, is that decision to move from 'Plan A' to 'Plan B' - in this case, accept induction of labour. Here are a few of the points I am conscious of in this decision:

• the woman is the one who makes the decision
  
• I am committed to being 'with woman' in her birthing
• I want to give the woman information so that she can make decisions that she believes are best for her
• obstetric and anaesthetic interventions in birth, although they are common, cannot guarantee good outcomes
• once we have moved to 'Plan B' we can't go back to 'Plan A'.

My question to myself is, was there something else M could have done, rather than accepting induction of labour? How will I advise a mother in a similar situation next time?

With the wisdom of hindsight in this case, I believe M's decision to accept 'Plan B' was the best option she had. Her body had been trying, for the past week, to get started. She was feeling discouraged, and exhausted. Her baby was showing signs of tiring too.

M asked me what I would have done if we had been planning homebirth. I believe my advice on key decisions would have been the same.

CONTESTED TERRAIN

I don’t want to over-dramatise the issue, but it’s an unavoidable fact: midwives who offer homebirth are in competition with doctors for the work. The contested terrain is the place of birth, and it’s not an equal contest. It’s one of those mad experiences from Alice’s wonderland, when she is either enormous and unable to fit, or so small that she’s likely to be stepped on and squashed.

Homebirth midwives who work independently don’t have ‘much’ to offer – except HOMEBIRTH, that is. And when professionally attended homebirth is not available any other way than through a private agreement between a mother and a midwife, independent homebirth midwives continue to work despite the social and professional restrictions we face each day. If it weren’t for the fact that homebirth makes so much sense to a small number of birthing women that they are prepared to pay for it, we would soon be out of work. We can’t buy insurance; we can’t get visiting access to the same hospitals that are very happy to employ us as ‘their’ midwives; we have to ask women to go to the local GP to request even the most basic blood tests and investigations, and to prescribe oxytocics that are considered essential in preventing or treating post partum haemorrhage.

I am referring only to professionally attended births. There is a steady trend, possibly growing, in which women give birth unattended. Some are surprised by the speed and intensity of their labours, while others consciously delay going to hospital, until the baby is ‘coming: ready or not’. These out of hospital, unattended births have always happened, and will continue. A few Australian women today make a decision to give birth at home without professional attention; possibly with an unregulated lay birth attendant.

Back to my initial statement, that midwives are in competition with doctors for the work of attending birth. There’s a complication that arises in looking at the contested terrain of birth. It’s not only homebirth. We have to include small birth centres and hospitals that are separate from 24-hour anaesthetic or obstetric care. These hospitals and birth centres, like homebirth, can ‘only’ support spontaneous birth. I say ‘only’, and ask, “What’s ‘only’ about that? Is that not enough? It’s huge.” Yet, how available is it? Many rural health services are sending these women to larger regional centres to give birth, because there is no obstetric or anaesthetic cover at a particular time. Do they have midwives? Of course they do. Why can’t those midwives take professional responsibility for the births? Because they never have been expected to work on their own authority, and in many cases they don’t want that responsibility. The hospital system, and those who work in it, expect doctors to be on hand to induce labours, and order narcotics and epidurals. The hospital system, in most cases, has women booked under the name of a doctor. The midwives work shifts, and the mother-to-be is not likely to know or trust the midwife who is working when she comes to the hospital in labour. The midwife is effectively, doctor’s assistant.

You would think that the leaders of a rational, sane society, like ours, committed to providing essential health services for all, would say “Right, there are going to be about 300,000 (and growing) babies born in Australia each year. At least half of these women (actually many more, but I’m not wanting to inflate the calculation) are likely to give birth to healthy babies without any complications. That means a midwife could provide the maternity care, and it means they can give birth wherever they choose.” If those 150,000 women were in the care of a midwife or group of midwives who were competent in attending birth on their own responsibility, which incidentally is what ALL midwives are declared able to do when they graduate, they could all give birth in primary level care, isolated from specialist obstetric or anaesthetic care. That is, almost all could give birth in the small country hospitals, freestanding birth centres, or in their own homes. The few who experience unexpected complication in labour would be transferred to a hospital that provides the service they need, in the same way that women and midwives planning homebirth make informed decisions as labour progresses.

The current annual rate for homebirth is 0.2%, approximately 600. I don’t have the number of babies born in primary maternity units without obstetricians and anaesthetists on call, but it’s also likely to be very small. The hospital based programs that have been offered in recent years have struggled to maintain management support. 600 out of 150,000.

Evidence of the contested terrain of homebirth is clear in the statement against home births by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZOG). The statement “The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) does NOT endorse home birth.” (http://www.ranzcog.edu.au/publications/collegestatements.shtml). This statement has been in effect since 1987, and was most recently updated June 2008. I suspect very few obstetricians have attended or seriously investigated homebirth.

The RANZCOG statement lists a set of recommendations for those women who are planning homebirth, including the statement that “Women choosing home birth should be cared for by both an experienced medical practitioner and a registered midwife, each of whom has agreed to participate”. This paternalistic recommendation is a curious one, as very few medical practitioners in Australia or New Zealand today are attending homebirths. It says: “Don’t do it, but if you do, here’s what you must do!” There does not appear to be any literature quoted in the RANZCOG statement to support this recommendation.

Midwives and obstetricians collaborate in providing expert maternity care for women and their babies. Obstetricians rely on midwives to admit women to hospital maternity units, assess progress, report to, and summon them at certain times. Obstetricians cannot provide maternity care without midwives’ support and collaboration. A RANZCOG statement such as this one imposes a wedge between the midwifery and obstetric professions. Some individual obstetricians support homebirth, having worked in countries where midwifery practice in offering homebirth is accepted and respected.

The midwife is the only professional who offers birthing services without requiring the support of other professional groups, and the only time that sort of birthing service can be offered is when the woman herself does the work. The healthy woman comes into spontaneous labour at term, progresses without artificial stimulation or analgesia, and works with her own body’s power to give birth to her unmedicated, healthy baby. The midwife works in harmony with the woman, and does not interrupt or intervene or disturb the wonderful process of birthing. There is no need in these births for hospital specialties: nursing, anaesthetics, obstetrics, paediatrics, or any other medical specialty. There is also no need for alternative therapies. The woman is not sick; she is giving birth. All she needs is a midwife.

This is the root of the contested terrain of birth.

I think that’s enough for today. Another time I will explore medical dominance of the terrain of birth, and how midwives have apparently accepted a subordinate position.

Lessons from homebirth

A midwife who starts attending homebirths with a more experienced independent midwife has an opportunity to learn all sorts of lessons, some predictable, and some unexpected. Yesterday as my colleague Karen was leaving the home, after attending a homebirth as 'second midwife', she commented on the difference between what we had just experienced, and what often happens in hospitals.

As I drove home yesterday afternoon, weary from a 3am call out, but thankful for and energised by the birth of another beautiful child, I was reflecting on the lessons we learn when we begin caseload and homebirth practice. Here are a few. Readers may want too add more in the comments section, or if you want to write a piece to add to this blog, please email it to me.

• Waiting for the spontaneous onset of labour. Does the midwife's commitment to the natural process mean that we wait passively, or is it an active waiting? How much checking and surveillance of the wellbeing of the baby is appropriate?
  
• Midwifery 'interventions' and advice for post Term pregnancies. When is it appropriate to recommend self-induction methods, such as nipple stimulation, or castor oil? Do you recommend acupuncture, or naturopathy, or other alternative medicine options?
• Technology. I sometimes call a second midwife in the middle of the night, and the phone goes to the message bank. If that happens I then call her on her mobile. I have had the experience of leaving messages on both home phone and mobile, and hoping for the best! Being on call means getting the telephones and other technology to work for you.
  
• Petrol. It's good to keep the petrol in the car above a certain point. It's frustrating and can be time consuming to have to put petrol in the tank in the wee hours.
• Directions. It's no fun getting lost, and trying to read the map in the half-light of a torch or the interior light of a car. In my practice I visit the home at about 36 weeks for the birth talk, or birth preparation meeting. This visit gives me the opportunity to think about the best roads, and check out parking and all those practical matters, when there is no pressure on my mind.
• Waiting. The father made the comment yesterday "A lot of what you do is waiting". That's right. It's very different waiting in a home than waiting in a hospital. In the hospital birthing suite there is a routine of shifts and rounds and client meals and staff meal breaks and reporting and meetings. In the home it's all about one woman. Many times the midwives move out of the room where the woman is labouring, but they don't move out of her space. Her sounds are the only sounds they hear.
  
• Finding the tea bags. This may sound too obvious to mention, but when you open cupboard doors, or rummage through a kitchen draw to find the tea bags, or a mug, or something else, there is an element of that special relationship between a woman and her midwives.
  
• Responding to pain. It's never easy to see someone else in pain. We would be heartless if we switched our minds off, and could not feel empathy. Yet the homebirth midwife does not carry pain relieving agents with her, and women who plan homebirth know it. Principles of active birthing, including movement, encouragement, massage, pressure, heat pacs, vocalisation, shower, and water immersion, are useful. Music, candles, a wood fire in the hearth, and aromatherapy may help create a personal intimate space. But it's the woman herself who decides how she can work with her own labour pain. It's the woman herself who decides when and if the pain is excessive or intolerable.
  
• When to assess internally for progress. I consider an internal exam an intervention, and there needs to be a valid reason for me to intervene/interrupt/disturb the progress of normal labour in this way. I will ask the woman for her permission to examine vaginally if I need the information that such an examination can provide. For example, a primigravid woman in advanced labour, who has some spontaneous urges to push over a period of a couple of hours, without bringing the baby on view, may have a lip of cervix. The vaginal examination will confirm this, and with permission, I can attempt to reduce the lip and push it back during a contraction. In my examination I feel for the baby's cranial sutures in order to visualise the position of the baby's head. An anterior lip, with the saggital suture off to the side, tells me that the baby's head is tilted, and is asynclitic. My advice to the mother is to walk through contractions, taking exaggerated steps that will move her pelvis, and adjust the fetal head in relation to the pelvis. Up and down stairs a couple of times is very helpful. Then as the baby descends, the mother can try kneeling on one knee, with the other foot on the floor, to tilt her pelvis, then change to kneeling on the other knee. These are fairly simple midwifery interventions, yet the woman's trust in her midwife is challenged, and they will need to work together in order to promote normal birth.
• Physiological birthing of the placenta. I think I am stating the obvious here, but physiological birthing of the placenta is probably only reasonable when the rest of the labour has also been physiological. Any stimulation or resuscitation of the baby is done with the umbilical cord intact. A midwife who makes a decision to administer an oxytocic to the mother is undertaking a professional intervention, and there is time to obtain the mother's consent for this act.
• Baby to the breast. It's wonderful to watch a healthy unmedicated newborn baby take the breast. Some do it without a second thought: some need to work hard at it. But they all love it. In homebirth the midwife needs to learn to trust the ability of mother and baby to manage this primal and essential act. Our advice is such that mother is encouraged and enabled to take responsibility, and to be confident in her own mothering.
• Leaving. A baby has been born; mother and baby are well; the paperwork has been done; and it's time for the midwife to leave - go home - get on with other work, or go to bed. This is another lesson.
• Completion. The time soon comes when no more postnatal visits are needed. I encourage the mother to call me if she has any questions, or is receiving conflicting advice and wants to know what I think. The invoice is paid, and I enter the information into my Quick Books program, in preparation for the next BAS and Tax statements. I ask the mother to come back for 'show and tell' at six weeks. After that visit I bundle her file into the filing cabinet, sorted alphabetically according to surname. Ready for next baby?
  

This list is not complete. I need to get dinner ready now, so will hit the publish button. I look forward to messages I may receive. What have you learned from home birthing?
Joy

Decision Points

Midwifery in Australia today can be one of the most satisfying occupations there is. When a midwife has a ‘caseload’, a group of women to whom she is committed through the pregnancy, birth, and postnatal period, the midwife and each woman are able to learn how to work together before the big event.

Usually the ‘big event’ is labour and birth. Occasionally it comes as a decision point before labour; sometimes there are several ‘big events’ or critical decision points.

Midwifery that is woman centred is neither woman-led nor midwife-led. Neither the woman nor the midwife dictate the terms; both recognise their own, and the other’s unique role and capability in the relationship. It is a dance in which there are separate, but interweaving and sensitive roles. And the dance is not just the woman and the midwife – there is the baby of course, whose presence is profoundly significant, as well as anyone else who the mother-to-be has invited into her presence at the time.

No matter how much research or preparation you, the mother, do, an uncomplicated labour and birth is likely to demand more physical and emotional energy than you thought you had; to take you to a place that you didn’t know existed. The time comes in most labours when you need to surrender any conscious control, and allow your body to do its work. This is the normal way babies are born, and it is usually the safest way for both mother and child. The midwife who is ‘with woman’ is with you in this often challenging and frequently demanding journey, and also has to harmonise with and in a different way surrender to the natural process. I usually come away from a birth emotionally and physically spent.

The trust a midwife has in the woman is that she, the woman, will accept the midwife’s professional partnership. The trust a woman has in her midwife is that she, the midwife, will not disturb or interfere with that deeply demanding process of birthing a child, unless ...

Unless?

Unless a decision point is reached where the mother-to-be is convinced that she is not able or safe to continue in ‘Plan A’ – doing it herself, and accepts an intervention in which she asks another person to take over – ‘Plan B’. It’s that initial decision point of handing over the controls that is the key to interference in normal birth.

This process of making informed decisions is the core of midwifery knowledge and skill. Midwives in all societies can work in harmony with a woman’s natural processes in pregnancy, birth, and nurture of the young – Plan A. Different cultures and different generations have had vastly different options for those who, for whatever reason, move out of Plan A.

The woman is free in our world to ask for, and will often receive, any intervention, including induction, dangerous drugs, regional anaesthesia, or caesarean surgery. In mainstream maternity care there does not seem to be any commitment to working in harmony with the natural process in birth. There does not seem to be any calling to account. Why does Hospital X have such a high rate of caesarean births? What are the midwives doing in Hospital X? Do they not know how to protect and promote normal birth?

A reader might think that the only people committed to working in harmony with the natural process in birth are those on the fringe – independent midwives, and midwives in birth centres or special midwifery caseload programs, who probably account for less than 5% of births. This is not so. By definition, every midwife has a set of requirements, including ‘partnership’ with women, and ‘promotion of normal birth’ (the International Confederation of Midwives’ Definition of the Midwife (2005) is copied below)

Every midwife’s duty of care can be summarised with statements from the Definition.

The midwife:

• Is a responsible and accountable professional, who
• works in partnership with women
• gives the necessary support, care and advice during pregnancy, labour and the postpartum period
• conducts births on the midwife’s own responsibility
• provides care for the newborn and the infant
• (implements) preventative measures
• promotes normal birth
• detects complications in mother and child
• accesses medical care or other appropriate assistance
• carries out emergency measures
• engages in health counselling and education

I commenced this piece with the statement “Midwifery in Australia today can be one of the most satisfying occupations there is.” A midwife has a scope of practice and a duty of care that is truly awesome. I hope that some midwives who have read this, and reflect on their own midwifery practice will find ways to make the transition to more woman-centred care in which the midwife and woman work in a partnership based on trust, respect, and reciprocity.

Definition of the Midwife

A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery.

The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.

The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.

A midwife may practise in any setting including the home, community, hospitals, clinics or health units.

Adopted by the International Confederation of Midwives Council meeting, 19th July, 2005, Brisbane, Australia. Supersedes the ICM “Definition of the Midwife” 1972 and its amendments of 1990.

Tennis on Thursday mornings

Each Thursday morning in school terms, weather permitting, a little group of women get together to play tennis in a back yard in Mont Albert. This group started more than 30 years ago. I have been in the group for about 20 years. The tennis court is situated in a lovely garden, and the owners have generously welcomed our little group.
Readers of this blog will probably wonder what that has to do with midwifery. The answer is nothing. But it has a lot to do with community, and it's one of the parts of my life that I enjoy and value. Being a member of a tennis group means that I have made a commitment to being with that group at a particular time, whenever I can. It's about being responsible to others, to the best of my ability. These women are not particularly interested in my midwifery practice - although they listen when I tell my stories, and they are accepting of my sometimes unpredictable hours. It's good that I can go to the tennis court and leave midwifery at arm's length (as far away as the mobile phone, that is) for a few hours each week.

A midwife with a personal caseload has a problem with commitment to other events - we are, at times, unreliable. We put the mothers and babies first. My children will tell you about their birthdays when I left the family to celebrate, while I headed out to a birth.
Last December, when our daughter Bec was getting married, I did the right thing and arranged for another midwife to cover my practice. On the afternoon before the wedding day I was enjoying the company of my sisters and other relatives who had come to Melbourne. We had 'open house' for tea that night, and I had prepared salads to go with meat done on the bar-b-q. The phone rang, and my client Paula said she thought her labour was getting started.
I phoned my backup midwife, Jan. Jan's reply when she answered the phone was, "You just caught me, I'm on my way to a birth." OK, plan B isn't going to work. There's no plan C, so I had better go back to plan A.
Of course my sisters and their families were able to manage without me, so I said a quick goodbye, and headed out. I had to make my way through peak afternoon traffic, and by the time I got to Paula's home she was holding a very beautiful newborn girl to her breast. The placenta came without difficulty, and I did the paperwork. By the time I got home the family were all enjoying each other's company, and someone had put aside a meal for me.

Readers of this blog probably realise that stories are my way of telling my midwifery knowledge to others. The point I want to make today is that each midwife needs friends and community linkages that are outside her commitment to mothers, babies, and birthing. For me, it's our Church, the tennis group, and of course, our wonderful family. It's not so much that they need me, as I need them.

What would the village midwife do?

My village is not an ordinary village. It has long busy roads, with lights at intersections and 40K zones outside schools. It has freeways that become very busy and clogged at certain times of the day. There are people and cars and trucks, buses and trains everywhere. It's the 'burbs of Melbourne. (I avoid the city if I can!)
So why do I call it a village?

The title 'village midwife' was given to me years ago when I was employed part time by RMIT University to provide supervision and mentoring for midwifery students at Birralee Maternity Unit (Box Hill Hospital). A hospital midwife discussing care of a woman with one of the students asked,
"What would the village midwife do?"
When the students and I sat down to reflect on the day's work in the afternoon, that question became the focus of our discussion. I was delighted to see the 'village' concept applied to a midwife's decision making. In today's globalised world, with amazing technology and communication, the challenge to give birth in harmony with nature's wonderful processes is the same as it has always been. Just as many of us value food grown in our own gardens, local grocers, schools, or clothes made in our own country, the village concept is readily applied to birth and nurture of our babies. "What would the village midwife do?" becomes a guiding question for me and others who are working to promote normal birth, whether they are out there in the 'village', or working in big modern hospitals.

My village is small, not in physical area, but in the number of mothers I can attend at any one time. This month I have three births booked. Those three women and their families become my neighbours for a brief period, and I join their lives in a special way as the midwife primary carer during their birthing experience.

Yesterday the mother called me in the morning and told me she was having 'niggles'. We spoke again after lunch, and she said nothing much was happening, but she knew her baby was coming. We anticipated the possibility of a rapid birth, as her first baby had been born minutes after I arrive at their home. I assessed the time it would take for me to get from my home to hers, up to 45 minutes, and we agreed that I should go to her home and wait. I put my gear in the car, with a MIDIRS journal to read, some wool and knitting needles, and an apple to eat on the way home (an excellent pick-up for a weary midwife), and headed out.

After a couple of hours the mother decided to have a rest in bed. Whether it was from tiredness or boredom, I don't know. The father went to his computer to check emails, and I nestled into a big red bean bag with the MIDIRS journal. The house was quiet. The bedroom door was ajar.

At about 4.30 the mother got up. Her waters had broken.
After listening to the baby's heart beat I noticed the wet undies on the bathroom floor.
"There's meconium in your baby's amniotic fluid" I said, and explained that this is a reason to consider transfer to hospital for monitoring.
However I was reluctant to cause unnecessary disturbance in this labour, which I expected to be strong and very demanding. It would take us about 30 minutes to get to the hospital, and then another 15 to settle in to a hospital birth room, if there were no delays. I decided to see what happened over the next 15 to 30 minutes - how the baby responded to contractions, and how the labour progressed. If there was fetal distress, or if the labour did not establish quickly, we should go to hospital. I called Katrina to come for the birth, and got my gear ready.

Soon the sounds coming from the bedroom were unmistakably those of strong labour. Contractions became long, with little resting period before the next contraction began. I listened again to the baby, and the heart sounds were strong and reassuring. What would the village midwife do? I was quickly confident that we needed to stay at home - that it would in fact be more harmful to try to move to hospital in this labour. The stress and anxiety of the trip, that would be added to a very demanding time of labour, with the potential for a birth in the car or in the hospital lobby, were more of a threat to this mother and baby than the meconium.

The bedroom was unlit, with a little light coming from the hallway. At about 5.30, only an hour from the time the waters broke, a beautiful baby boy lay on the floor under his mother. I untangled the cord, and wiped the fluids from his face. He was pink, but lay quietly, and I felt his chest - a good heart beat. With a bit more tactile and verbal encouragement he joined us with a lusty cry.

Katrina had just arrived, and heard this from outside the bedroom window. After a few minutes she knocked on the door and I went to bring her in.

As often happens with a very powerful labour, the strong contractions continued, and placenta came soon after. I was once again impressed with the ordinary-ness of an extra-ordinary event, as mother and baby rested in bed, with the proud daddy supporting and watching closely. I got on with the paperwork, and Katrina made a cup of tea and washed some dishes.

The village midwife today has the best of both worlds. When birth is spontaneous and normal, the home is the best place to give birth. When illness or complication is present, the village midwife links in with the team of experts in managing difficult births, and works to get the best possible birth for that individual woman and baby. There are, of course, grey areas. If in this instance I had felt anxious about proceeding with birth at home, because our guidelines say meconium stained liquor is an indication for referral, the birth of this particular baby would not have proceeded in the uncomplicated and undisturbed way that it did at home. This is the duty of care of the midwife - not just the village midwife: every midwife.

God bless you

I wrote this brief note a couple of years ago:

It was an hour or so after the birth, as we all relaxed in the quiet peaceful space that settles on a room as a mother rests and her baby takes his fill from her breast. I moved close to her and put my hand on her arm, and whispered, “God bless you, my dear.” I don’t know if she heard my hushed prayer. Then my hand rested on the small head covered with black hair, still glistening with moisture from the birth, and I said “God bless you, little one.”

I know no greater prayer. I have no deeper wish. If God blesses, what more could that one want?

“God bless you, my dear, mother of this child.
You have laboured and you have given birth in pain that went deeper than you could have imagined.
Your dark red lifeblood that sustained this little one
has spilled with the waters and meconium and your bowel’s emptying onto the white sheets.
The fears and pain left you cowering, having nowhere to hide, as the small child prepared to leave your womb.
What did you see as he struggled to take breath and become a separate living soul?
As you rest and begin to recover,
your breasts are now giving, and continuing to give.
Your baby is taking, and growing.”

Joy Johnston 2006

“Take care that you do not despise one of these little ones; for, I tell you, in heaven their angels continually see the face of my Father in heaven.” Matthew 18:10

Nipples that hurt

A mother who welcomes her newborn child to her breast is filled with a surge of love, a surge which is repeated each time they engage in this intimate act. The mother feeds her baby, and the baby feeds from her mother: a dance that takes two people working harmoniously.

Our nipples are beautiful, important, and highly sensitive parts, essential to mother-baby bonding and nurture. And because they are so important, they are also points of vulnerability in the establishment of strong mother-baby attachments. And when nipples become grazed, blistered, and cracked the relationship between that woman and her baby is truly tested. There is no easy option - a newborn baby needs milk from her mother every time she indicates interest or hunger. The act of giving and taking the milk is part of the life struggle that forges a strong bond between them.

Breastfeeding unites mother and baby in a health and wellness cycle. As in birthing, there should always be a 'valid reason to interfere with the natural process', and any interference carries a potential cost. Sometimes there is a valid reason. Bleeding, severe pain, horrible, deep pain. It's the antithesis of that serene Madonna and Child image that has been passed down over many generations.

Breastfeeding experts can list off many reasons why a mother's nipples are hurting. Often the mother gets advice from a variety of caring and concerned people, including family, friends, neighbours, and health professionals.

Damaged nipples usually present in the early postnatal days. There is no single solution to this problem. No matter what caused the initial damage, the process of recovery will require careful and consistent management by the mother, who needs strategies for healing as well as for ensuring that her baby is fed. The mother needs consistent advice from a midwife who she trusts, and who is competent in advising and making interventions that protect nature's goodness in providing the breastmilk for the baby. It's essential to keep the interests of both mother and baby in mind - baby needs frequent feeds that are sufficient to send her off to sleep. Mother needs the milk removed from her breasts, establishing the supply-demand cycle, and protecting the breasts from engorgement.

I have seen many mothers and babies struggle through the early days with painful nipples. My heart goes out to each one - each mother who feels the pain and the distress, and each baby who does all she or he can to get that precious milk from mummy. And I have seen them come through, days or weeks later, proud and confident, with healthy nipples, healthy lactating breasts, and healthy happy babies.

How many midwives do you need?

I was surprised when Sue, who is planning homebirth, told me that Karen, her midwifery student, was not 'allowed' to be present when she gives birth. Karen has come to several prenatal checks, and is doing the 'Follow Through Journey' with Sue.
"Why?" I asked.
"Karen's mentor from the University told her that she was not allowed to be there because you [referring to me] don't require a second midwife at the birth." was the reply. "She (Karen) said she thought it was a requirement of the Nurses Board, so that students aren't expected to stand in as the secondary midwife."

My surprise turned to annoyance. I felt I needed to defend myself. The logical implication was that I was in some way offering care that was of a lesser standard than those midwives who attend homebirths in pairs. In fact, there is NO requirement of the regulatory board, and there is definitely NO expectation that students will stand in as the 'secondary' midwife, whatever that may mean. I felt annoyed that an assumption had been made about my professional decisions in attending this birth. Anyone who has talked with me about my practice, or looked at the names on the calendar on the wall of my office, would know that whenever possible in homebirth I arrange to have a second midwife as an 'apprentice' - a midwife who is working on making the transition from hospital shiftwork to caseload practice. This is done at no cost to the woman, and is a wonderful opportunity for midwives to extend their knowledge and skill. But it's not done because I need the help, or because the birth becomes in any way safer in having another pair of hands. If I wanted that I would be working in a big hospital with emergency buzzers and operating theatres.

Karen's mentor, appointed by the University, is an independent midwife who does routinely book a second midwife for each planned home birth. That puts her practice and mine in competition for business - women may choose me because the fee they would pay two midwives is considerably greater than the fee I charge. The decision to require two midwives is a risk management strategy, in the same way that some people in Melbourne make a booking with a medical practitioner as well as one or two midwives. That doctor is able to extend the possible interventions that are available: antibiotics or Pethidine can be given, or a Ventouse extraction can be attempted - options that a midwife cannot offer. Women planning homebirth in Melbourne's leafy Eastern suburbs have the choice of a solo midwife, or two midwives, or a midwifery group practice, or a midwife and a doctor.

I want to make it clear that I do not intend to argue that a midwife working 'solo' is better than a midwife working with a partner. I do believe each woman planning homebirth needs to make the decision for herself as to what she needs. If a woman feels she will need a lot of 'support', she will probably not ask me to be her midwife.

One of the main arguments presented as the reason for requiring two midwives is that at the time of birth, both mother and baby may require professional attention. Without going into detail in this brief discussion, I would like to outline some major differences in homebirth as I know it, when compared with standard medical models of maternity care.

• mother and baby are usually well in the labour - no analgesic medications or stimulants of labour are used in homebirth
• the baby's umbilical cord is not cut at birth, and usually not cut until after the placenta has been birthed
  
• because the baby's umbilical cord has not been cut, any resuscitation of the baby must be done with the assistance of the mother. This would usually be done with the baby lying on a towel on the floor, and the mother kneeling near, and facing the baby. The midwife works to resuscitate the baby in this position
  
• if the mother is experiencing excessive blood loss after the birth, an injection of synthetic oxytocic may be used by the midwife in quickly managing the bleeding.
  

It is not possible to guarantee a particular outcome. However, when working 'solo', a midwife is relying on working with the mother in promoting normal birth, rather than relying on the number or the skills of people in attendance.

If I was setting up a maternity care program with government funding so that all prospective mothers could have access to services that are likely to promote the best health outcomes, that program would include the choice of homebirth. Each woman would be in the care of a midwife who is her primary or first midwife, and a second midwife, who backs up the leading midwife, and assists at the birth. These two midwives provide primary care throughout the pregnancy and birthing journey.

One aspect of working in a little team, with a second midwife, and a midwifery student, that I thoroughly enjoy, is the sharing of knowledge, and the reflecting together on events. Midwives learn from each woman, and from other midwives, each time we enter the intimate birthing space of a woman. Midwives learn to access our own intuitive knowledge, sensing the progress and the struggles that women must engage with as they in turn learn to work in harmony with their bodies.

NOT QUITE 24/7

On Sunday I was feeling quite unwell, and thought I was coming down with a cold, so I asked Karen if she could do a postnatal home visit for me. It was good to stay in my nightie and spend a quiet day, rugged up by the fire.

I had agreed to cover for Andrea on Sunday night and Monday, as she was taking the Lactation Consultant (IBCLC) exam. On Monday morning I woke up feeling stronger and was thankful that I had not been called out that night. Shortly thereafter the phone rang, and it was the husband of Andrea's client, who I will call Jen. Jen was having some contractions; her waters had not broken, and she had not noticed a show. She didn't want me to come yet - just wanted to know that I was available for her.
It was not long before Jen's husband rang again and asked me to come. I headed down the new East Link toll road, and found the house without difficulty.
This was Jen's second baby, and she progressed quickly and beautifully. After getting into the bath she asked me if I thought she had long to go. "Not long now" I said. "Are you just saying that?" she asked, with a look of surprise. The next contraction was strong and she felt the unmistakable bulge. I called her husband, and she gave birth in the bath tub to a healthy baby boy. The baby's bag of waters had not broken until after his body had birthed, so I lifted back the membrane as we welcomed the little one.

As I drove home I reflected on midwives covering for each other. We do our very best to be there 24/7, but there are times when we need to be somewhere else. I had conflicting emotions. I felt delighted to be asked to be able to stand in for Andrea, and I was also very happy to be able to ask Karen to cover for me the previous day; yet it was difficult for me to come to that point of acknowledging that I needed to ask for help.

I have chosen to be a solo practitioner, 'independent' within what I consider reasonable limits. It is uncommon for me not to 'be there' for women who book with me. I don't have any dependent children, and have sustained a caseload of 3 or 4 births a month, providing the continuity of care for each woman. The other fairly obvious fact in independent midwifery practice is that we are paid only for what we do. A midwife who misses a birth forgoes the fee that she would have charged. If we take a day 'off' work, we do so without pay.

Some midwives form group practices and agree to cover for each other at certain times, such as one weekend in three. There are obvious benefits, but disadvantages as well. I am happy to discuss this further if anyone wants to engage in discussion.

Circles of support for mothers

"Support a mother to provide a golden start for her child! With breastfeeding everyone wins!" These statements are themes that are being promoted by WABA for the World Breastfeeding Week 1-7 August [http://www.worldbreastfeedingweek.org/].

Thisafternoon I sat with a circle of women and their children at the Box Hill Birthing and Babies Support (BaBS) group http://birthingandbabies.info/
BaBS groups are sometimes chaotic, with toddlers and little children, babies, and mothers all being who they are.
Today we supported each other in being mothers, and members of families and communities, the way women have since time began. We listened to mothers speaking of their lives, and we grieved with those who spoke of emotional pain and frustration, and the one who shed tears. We talked about maintaining our emotional reserves so that we can cope with the often unpredictable ups and downs in ordinary life. We used butcher paper and drew pictures that recorded our feelings, and some of the children added their squiggles and lines and blotches to complete the picture. We acknowledged that a mother's life is never separate from her children - her life and theirs' are constantly interconnected.

The WABA World Breastfeeding Week program this year is promoting the Global Initiative for Mother Support, and is using the Olympic Games circles to remind us of the need for 'circles of support'. WABA states that:
MOTHERS DESERVE AND NEED

• empathetic listening
• basic, accurate and timely information
• skilled and practical help
• encouragement

These four points are the 'circles of support'.

Mothers don't just need circles of support for breastfeeding - they need it for all aspects of normal birthing and nurture. Breastfeeding is an absolutely important aspect of what I would call 'normal' parenting. Not necessarily 'usual' or 'most common' parenting - normal in that this is the physiologically normal, and the most basic way of enabling health and nourishing and nurturing the infant and young child.

The four WABA 'circles of support' apply equally to the promotion and support of normal birthing as they do to breastfeeding. In promoting normal birth, we are establishing the best set of circumstances for the initiation and establishment of a strong breastfeeding bond between mother and baby, and consequently strong emotional bonding. This is true even when the mother experiences complications or illness in her pregnancy or birthing or breastfeeding: the promotion of normal birth within a partnership between a woman and her midwife enables good decision-making, and protects the mother's sense of personal autonomy in her care.

Next month we will hear a lot about the world's best sporting performances. Let's also remember to: "Support a mother to provide a golden start for her child!"

When birthing becomes abnormal

I want to tell you, my readers, about Julie's birthing of her first baby. Julie asked me to be her midwife, and I worked with her obstetrician and the midwives at a Melbourne private hospital. We did not achieve normal birth, but I believe it was a very good birth.

I have heard some independent midwives saying that they don't accept bookings for private hospital births; that women who go down that track aren't trusting their bodies; that they, the midwives, feel unable to truly exercise their skill when they go into hospitals. I do not agree. All I ask is that a woman who engages me as her midwife is planning to do all she can to give birth, and will not interrupt or interfere with her natural processes without a good reason. I am not committed to either home or hospital - I believe the woman should be free to decide the right place for birthing when she is in labour. Sometimes women planning homebirth go to hospital, and sometimes women planning hospital birth make the intentional decision in labour to give birth at home.

Julie is a beautiful woman: healthy, fit, and in her late 20s. As we approached the due date her baby's head had not engaged, and we chatted about what that might mean. My usual advice is to remain active, but not to try to bring on labour until after 41 weeks. I planned to talk to Julie about a couple of 'self-induction' options such as a does of castor oil, and/or a program of nipple stimulation and pelvic movement. Julie's doctor talked about induction of labour at 10 days after the due date. However Julie's labour started spontaneously at 41 weeks. She was awakened with early contractions one night, and they continued irregularly through the next day.

Labour established that night, and Julie asked me to be with her. The sheer physical demand of a couple of sleepless nights was telling on her and her husband. I sent him off to bed, and Julie's mother and I kept her company. When I palpated I noticed that the baby's head was in a good position, well flexed, engaged, but high. An internal examination confirmed this assessment. There was a lot of work ahead - this baby was not going to slip out easily.

Labour progressed and we went to hospital. As often happens, contractions that had been close and strong became irregular and infrequent. It was frustrating as the hours rolled on, and the 'team' became more weary. By late morning Julie was nearly fully dilated, and the baby's head had progressed - a very encouraging sign. Someone (not I!) suggested a lunchtime birth. (in your dreams, I thought) Soon Julie was pushing, and got her baby deep into her pelvis. In the next couple of hours we tried different positions and all we could do to move that little one a bit further, without effect.

Some readers may think that Julie would have been able to do more if she wasn't in hospital, or if she was in a tub of water. I don't think so. This baby's head was such a tight fit and Julie was doing all she could, which was not enough.

The doctor was prepared to attempt an assisted birth, but warned that he may still need to do a Caesarean birth. This is a professional decision point that obstetricians face from time to time, and in today's private maternity system the die is often cast in favour of the surgery.

Julie pushed, and her doctor pulled, and after three good pulls the very elongated, molded head was birthed. Julie took her little boy to her breast as I and another midwife dried him, and after a couple of minutes he cried lustily - a wonderful sound.


Recently I have been reminded of the work of Dr Catherine Hamlyn, repairing obstetric fistulae in Ethiopia. The women with fistulae have had complicated births, and face dreadful incontinence and social exclusion. These women may have laboured for days in agony before their babies died, and were eventually stillborn. The link to the ABC TV interview is:

http://mpegmedia.abc.net.au/tv/talkingheads/vodcast/talkingheads_2008_catherine_hamlin.wmv

Catherine noted in the interview that they are now educating midwives to go into the communities and attend the women in birth.

Midwives are required, by definition, to promote normal birth. This duty of care must be understood alongside our knowledge of abnormal birthing, and our other duty to access appropriate care when complications occur. Always the wellbeing of the mother and child are foremost in our minds.

We live in a privileged society. Even if Julie had been planning homebirth I believe, with the benefit of hindsight, that we would have needed to go to hospital and ask for obstetric assistance with the birth. I also believe that we could have expected the clear decision making process and personal respect that Julie received, in a public maternity hospital. Good maternity care should not be linked to wealth or insurance status.

Safe motherhood in a safe country

I am sure I am not alone when I admit to being overwhelmed when I hear of the lack of safety for mothers and their little children in many of the poorest communities in this world. The tragedy of loss of the life of a baby is heartbreaking, while the loss of a mother cannot be comprehended.

Here I am, a midwife in Melbourne, Australia. Any time I am concerned about a woman in my care I can make a telephone call to a large, well equipped maternity hospital, and refer the woman for complex investigations, or for skilled management of whatever the problem is. Women can travel by car or, if needed, by ambulance, at any time of the day or night. Although there are no guarantees in this or any other life event I have no reason to fear. I can certainly find fault with the mainstream public hospital system, and I believe it could be improved particularly in providing services for well women, but it is pretty good when women or babies are ill, or develop complications. Most of the women in my care give birth to healthy babies at home, without drugs to stimulate labour or to relieve pain, and with very little or no help from me.

A story in the World section of today's newspaper describes a woman in Peru, pregnant with her seventh child, who hiked for hours through the Andes mountains to a health clinic where she gave birth. The clinic's notable difference from hospital maternity care is that women are encouraged to give birth standing up. (Sunday Age, July 13 2008, p11) The program described in this article encourages mothers who had previously given birth at home to go to the health clinics in an effort to reduce Peru's awful maternal death rate of185 per 100,000 births. This compares with around 10 women per 100,000 births in Australia (http://www.aihw.gov.au/publications).

A call has recently gone out from World Health Organisation and other leading organisations to the G8 leaders to address maternal and child health. "We don't need a new cure to save the lives of 6 million women and children. What we need is political leadership and investment. The Partnership has issued a Global Call asking G8 Leaders to fund basic health services for women, newborns and children." http://www.who.int/pmnch/en/ This call is in concert with the UN Millennium Development Goals, particularly #4 and #5 http://www.un.org/millenniumgoals/
The Countdown to 2015 http://www.countdown2015mnch.org/ has been set up "to track progress made towards the achievement of the United Nations Millennium Development Goals 1, 4 and 5 and promote evidence-based information for better health investments and decisions by policy-makers regarding health needs at the country level."

The message I have heard, and that I want to send out to any readers of this blog is that "we don't need a new cure to save the lives of 6 million women and children." We need midwives who work at the primary care or basic level in all communities. For the majority of women we need to protect normal birth. That may be, as in Peru, saying it's OK to stand up to give birth. But you can't stand up to give birth if you are loaded with narcotics or if you are numbed by epidural. You can only stand up and give birth actively, or kneel, or choose to lie down, if your mind and body are strong and working in harmony with your God-given birthing power.
For the minority of women and babies who experience complications or illness we need health clinics and referral hospitals that are accessible when they are needed.

Alice’s adventures giving birth

Alice looks radiant as she soaks in the golden beams of afternoon light. Not long ago she was that little girl in a Wonderland inhabited by the strangest of creatures and a Queen and things great and small. I can now see Alice in the after-time, herself a grown woman, as she awaits the birth of her first baby. She finds herself in another Wonderland, also inhabited by strange creatures and people with incredible powers that can make her feel great or very small, and she follows the White Rabbit into the hole in another mystery journey.

There are three strong voices competing for Alice’s attention as she approaches her special time. Voices 1, 2 and 3: Prima, Secunda, and Tertia (in Latin, making them seem so much more important than they really are.)

“Imperious Prima flashes forth

Her edict “to begin it”;

In gentler tones Secunda hopes

“There will be nonsense in it!”

While Tertia interrupts the tale

Not more than once a minute.”

Prima, the first, is direct and clear – there is one way, the right way, the normal way. Like the Queen of Hearts she gives her pronouncement. But is ‘normal’ what is normally done, or is it something else? Having never been there before Alice wonders how she will know the right way when she sees it.

The second voice Secunda is less sure, and more pragmatic, expecting she will somehow find a way through the underground maze. With a label that says ‘Drink me’, she offers all the choices as if they were of equal worth. Alice wonders if it is safe. “the wise little Alice was not going to do that in a hurry. “No, I’ll look first,” she said, “and see whether it’s marked ‘poison’ or not”; for she had read several nice little stories …”

“Would you like something to help with the pain?” Secunda inquires, and Alice says “Yes, please”. “This bottle was not marked “poison” so Alice ventured to taste it….” She did not see the locked cupboard where it was stored, with “Dangerous Drugs” on the front.

Tertia, meanwhile, has the oversight of all things obstetric, and considers herself in charge. With stop watch in hand, and pointing to (Capital E) Evidence, she demands that the times and calculations be correct. Alice becomes quickly confused with Tertia’s arguments:

“If you knew Time as well as I do,” said the Hatter, “you wouldn’t talk about wasting it. It’s him.”

“I don’t know what you mean,” said Alice.

“Of course you don’t!” the Hatter said, tossing his head contemptuously.

Being very keen to please, Alice listens to all the voices. !,2 and 3; 3, 2 and 1; 2,1 and 3 and in whatever order they speak.

Alice found her way out of Tertia the Mad Hatter’s Tea Party; escaped Secunda’s potions and cakes that made her alternately very large and very small; and stood up to Prima, the Queen.

“Stuff and nonsense!” said Alice loudly. “The idea of having the sentence first!”

“Hold your tongue!” said the Queen, turning purple.

“I wo’n’t!” said Alice.

“Off with her head!” the Queen shouted at the top of her voice. Nobody moved.

“Who cares for you?” said Alice (she had grown to her full size by this time). “You’re nothing but a pack of cards!”

Alice returned to the grassy bank in the golden afternoon light and decided not to go down that rabbit hole again. She stayed above ground and with her sister accompanying her, they took the path that was ahead of her. The path became steeper in places, and at times there were forks in the road that appeared to offer an easier way. Accepting her sister’s wisdom they stayed on the main path. They could see the goal, and knew that they must persevere. Alice’s mind and body became strong: she accepted the demands of each climb. Alice’s sister stayed with her, and encouraged her to keep the goal in sight. Then, as Alice began to doubt and cried out for help, her child was born. Alice rested a moment as the little one gave its first cry, then triumphantly and with her heart almost bursting with joy, took her child to her breast.

Joy Johnston, 11 July 2008.

[Note: Quotations are taken from Alice’s Adventures in Wonderland, by Lewis Carroll. First Published 1865 by Macmillan & Co Ltd.]

"Thanks, Noel!"

When lactating breasts become blocked in the early weeks and months after birth the mother feels very unwell, very quickly. A fever, severe flu-like aches and pains, a red painful quadrant of the breast, a very sore nipple - and often at a very inconvenient time.
This happened to 'Annie', whose baby is six weeks old, and she phoned on Sunday evening when I was out and another birth was imminent. Noel, my husband and No1 helper/supporter, took the call and said he would contact me. "'Annie' has a temperature of 39.5 and wants to know what to do."
I didn't have time to ask questions about other symptoms, and assumed that it might be mastitis.
Noel gave my instructions - "keep on feeding baby, massage the blocked part of your breast, take 2 Panadol, and a big drink, and have a bath. Then go to bed."

The next day I received an email from Annie:
"Thank you and Noel for bringing me to health again. Just talking to Noel decreased my temperature one degree! and then it started slowly getting back to normal. I feel better today, the temperature is normal, the breast hurts less. I'm little bit weak after a high temperature, but still can do all my usual things. I am happy to continue breastfeeding S... - she needs it very much. Thank you for your advice very much."

Breasts are one main point of vulnerability in an otherwise healthy woman postnatally. A blockage can occur very quickly. If the blockage is relieved quickly there is no need to treat with antibiotics, and the mother is able to recover naturally.