Mother with daughter as daughter becomes mother: this is a timeless tradition that spans generations. It's a time when deep bonds are strengthened; when some of life's secrets are passed wordlessly from one generation to the next.
The older woman travelled to be with her daughter, and entered her home. She felt respect for her daughter's personal world, her husband and all that made up their lives. She experienced a sense of pride in her daughter's strength of character, and her desire to know and do what is good and right for her family; her child.
>>>>>>
And so we shared the days: preparing meals and carrying out ordinary tasks, all the time welcoming reminiscences. When pottering in the garden, or going to the shop for something that might be useful when the time came, we enjoyed the harmonising of two lives for a brief period of time. We shared words of faith in God, the giver and sustainer of life.
We remembered times with my mother. My daughter remembered her grandmother's gentle, loving care. She recalled the holiday at the Gold Coast, when she had helped Grandma make pumpkin scones and a baked jam roly-poly.
I also remembered my mother's gentle, loving care. I recalled how she had been a midwife to me when I gave birth to my second daughter; how the simplest act by her had nurtured me in the way that my lonely heart needed; how the simplest meal that she prepared had met a deeper need than hunger.
This time of birthing has brought three generations of women together, even though my mother's life journey was completed many years ago. She accompanied me, as I accompanied, and at times guided my daughter.
... Her womb prepared to give up its treasure.
... She gave birth, and took her child to her breast.
... She accepted and embraced the work of mothering.
Praise God from whom all blessings flow.
Friday, May 28, 2010
Thursday, May 13, 2010
the womb
The womb grows quietly,
surrounding and guarding the new life within,
sealed until the right time.
A single round window softens,
its fibers are thinned and taken up,
ready for the opening.
The womb gives up its charge, silently closing.
The one in the womb grows quietly
in a warm, watery world.
Secure in a closed and protected space.
The wee one hears sounds from outside,
feels mother's laughter, her song, and her sobs.
Two people: mother with child.
They are together, sharing each moment.
The wee one knows joys and sadness,
loving and longing;
learning life's patterns from within that womb.
At the right time the wee one is guided to a place of readiness.
The round window becomes a vast opening.
The womb that held its treasure so patiently finds new strength
to powerfully and completely expel its contents.
There is a second womb waiting to receive the wee one.
A womb that is bounded by mother's arms, her loving face, and warm strong body.
Within the new womb are her breasts with a bountiful provision.
The child grows, knowing safety, warmth, satisfaction and peace in mother's arms.
Joy Johnston (May 2010)
surrounding and guarding the new life within,
sealed until the right time.
A single round window softens,
its fibers are thinned and taken up,
ready for the opening.
The womb gives up its charge, silently closing.
The one in the womb grows quietly
in a warm, watery world.
Secure in a closed and protected space.
The wee one hears sounds from outside,
feels mother's laughter, her song, and her sobs.
Two people: mother with child.
They are together, sharing each moment.
The wee one knows joys and sadness,
loving and longing;
learning life's patterns from within that womb.
At the right time the wee one is guided to a place of readiness.
The round window becomes a vast opening.
The womb that held its treasure so patiently finds new strength
to powerfully and completely expel its contents.
A womb that is bounded by mother's arms, her loving face, and warm strong body.
Within the new womb are her breasts with a bountiful provision.
The child grows, knowing safety, warmth, satisfaction and peace in mother's arms.
Joy Johnston (May 2010)
Tuesday, May 04, 2010
Celebrating International Midwives' Day 5 May 2010
The second of these pictures is also my mother, holding our second daughter, Rebecca, in 1975. We were living in Haslett Michigan at the time.
Please join with midwives around the world as we celebrate our day.
If you would like to join in with others in a 24-hour global techno-feast of live online celebration, click here.
If you are able to join other Christian midwives in prayer for safe motherhood and safe childbirth, click here.
There's a global photo gallery here.
Midwives can join a forum at the Midwives Place
There are Facebook pages like this one.
AND LOTS MORE
"The world needs midwives now more than ever"
Monday, May 03, 2010
From routine episiotomy to routine caesarean
It's not easy to challenge accepted culture.
Dr Michael C Klein is a Canadian family physician who has challenged the accepted culture of routine episiotomy. I heard him speak on the topic at the Women's in Melbourne, probably 10 or more years ago. Recently Klein has published an article with the title From routine episiotomy to routine cesarean section: HOW SOCIETY CAME FROM REJECTING ONE TO EMBRACING ANOTHER. The link will take you to the article. Here are a few excerpts.
Klein writes:
"My views about episiotomy were formed by an experience in the early 1960s in Ethiopia, where I worked with midwives who attended births without routine use of episiotomy. Twenty years later while on sabbatical at Oxford University, I collaborated with midwives who rarely employed episiotomy yet obtained good results. Back in my usual setting in Montreal, our family practice maternity group employed the techniques and approaches that I had learned in England.
Our episiotomy rate was less than twenty-percent while the institutional rate was in excess of sixty-percent overall and greater than eighty-percent among women experiencing their first birth."
...
"In the 1980s many physicians still viewed the laboring woman with some suspicion, considering the female reproductive system as complex and intrinsically untrustworthy. It needed to be managed, controlled, and improved. Birth needed to be expedited, the fetus liberated from an unsafe environment. The place of episiotomy in this model was clear. In fact, labour can be slightly shortened by employing episiotomy. Those who felt this procedure was important often expressed concern about the negative effects of birth without episiotomy. In the absence of episiotomy, they were concerned about pressure on the fetal brain, maternal soft tissue support, and subsequent pelvic floor function, including delayed morbidity–such as urinary incontinence. Keep in mind that such thinking characterizes the thinking of the current proponents of elective Cesarean section."
...
"It turned out that episiotomy caused the very trauma that it was supposed to prevent, and those practitioners with the highest episiotomy rates had the highest rates of virtually all other procedures as well."
...
"Reconciliation of differing and often confusing views about normal childbirth among the maternity care disciplines and women is essential for the benefit of women and their families."
...
"Next Steps: At the age of almost seventy-two, I have now decided, along with my multidisciplinary colleagues, that we know pretty much what is going on in practice, education and training. And to correct the faults that have led to many of the problems uncovered will not be easy.
We cannot fiddle with such a flawed system and expect to improve it. But in the next few years, the dearth of obstetricians, family physicians and midwives available to serve pregnant and laboring women, will make it necessary to come up with major creative solutions. This will need to include new collaborative models of care, new interdisciplinary practice and teaching models, new financial arrangements and a whole new way of helping us partner with pregnant women in a way that supports and honors rather than frightens them. And of course we will have to control our own fears and anxieties or we will be unable to make the needed changes in a system that is poised to collapse.
Governments, policy-makers and educators will have to be helped to appreciate the ultimate financial and human costs to which the current path leads. It is rare to be able to help make a change that is both the right thing to do while also saving money for the system.
Hopefully we will not only study change but help make the changes that we will study."
Dr Michael C Klein is a Canadian family physician who has challenged the accepted culture of routine episiotomy. I heard him speak on the topic at the Women's in Melbourne, probably 10 or more years ago. Recently Klein has published an article with the title From routine episiotomy to routine cesarean section: HOW SOCIETY CAME FROM REJECTING ONE TO EMBRACING ANOTHER. The link will take you to the article. Here are a few excerpts.
Klein writes:
"My views about episiotomy were formed by an experience in the early 1960s in Ethiopia, where I worked with midwives who attended births without routine use of episiotomy. Twenty years later while on sabbatical at Oxford University, I collaborated with midwives who rarely employed episiotomy yet obtained good results. Back in my usual setting in Montreal, our family practice maternity group employed the techniques and approaches that I had learned in England.
Our episiotomy rate was less than twenty-percent while the institutional rate was in excess of sixty-percent overall and greater than eighty-percent among women experiencing their first birth."
...
"In the 1980s many physicians still viewed the laboring woman with some suspicion, considering the female reproductive system as complex and intrinsically untrustworthy. It needed to be managed, controlled, and improved. Birth needed to be expedited, the fetus liberated from an unsafe environment. The place of episiotomy in this model was clear. In fact, labour can be slightly shortened by employing episiotomy. Those who felt this procedure was important often expressed concern about the negative effects of birth without episiotomy. In the absence of episiotomy, they were concerned about pressure on the fetal brain, maternal soft tissue support, and subsequent pelvic floor function, including delayed morbidity–such as urinary incontinence. Keep in mind that such thinking characterizes the thinking of the current proponents of elective Cesarean section."
...
"It turned out that episiotomy caused the very trauma that it was supposed to prevent, and those practitioners with the highest episiotomy rates had the highest rates of virtually all other procedures as well."
...
"Reconciliation of differing and often confusing views about normal childbirth among the maternity care disciplines and women is essential for the benefit of women and their families."
...
"Next Steps: At the age of almost seventy-two, I have now decided, along with my multidisciplinary colleagues, that we know pretty much what is going on in practice, education and training. And to correct the faults that have led to many of the problems uncovered will not be easy.
We cannot fiddle with such a flawed system and expect to improve it. But in the next few years, the dearth of obstetricians, family physicians and midwives available to serve pregnant and laboring women, will make it necessary to come up with major creative solutions. This will need to include new collaborative models of care, new interdisciplinary practice and teaching models, new financial arrangements and a whole new way of helping us partner with pregnant women in a way that supports and honors rather than frightens them. And of course we will have to control our own fears and anxieties or we will be unable to make the needed changes in a system that is poised to collapse.
Governments, policy-makers and educators will have to be helped to appreciate the ultimate financial and human costs to which the current path leads. It is rare to be able to help make a change that is both the right thing to do while also saving money for the system.
Hopefully we will not only study change but help make the changes that we will study."
Friday, April 30, 2010
DANGEROUS DRUGS?
This US FDA website gives reliable guidance on codeine ultra-rapid metabolisers.
A baby's ability to breastfeed is one of the key 'performance indicators' that I observe after birth.
The majority of my work is with women and babies who are free of medication, giving birth to healthy babies at Term. Babies behave in the normal physiological fashion when the mother takes her child to her breast, and they remain together, skin to skin, for the next couple of hours. Babies seek the breast, making licking and rooting movements and moving in a distinctive way until they are in place and can take the breast and suckle effectively. This process is known as the breast crawl.
When a woman giving birth requires surgery she is given drugs. The anaesthetist and the obstetrician will prescribe whatever they consider to be necessary.
I am concerned about the current drug of choice for postnatal pain relief, Endone.
In the past year I have worked with three women who received Endone postnatally, and I believe I have observed a strong sedative effect of the drug on two of these babies. They became quite uninterested in the breast after the first breast feed, which had been unremarkable.
Recently another client of mine had a caesarean for obstructed labour, and I talked with her and the midwife in the postnatal ward 12 hours after the birth. The analgesia ordered was Endone (for 48 hours), Panadol and Voltarin. We agreed that if she was needing Endone she would breastfeed first, then take the drug. She has progressed very well with breastfeeding, went home on the third day - in fact this baby does a little breast crawl like a pro for every feed!
I am now checking for research literature specifically on Endone (oxycodone) and breastfeeding. Other midwives have said they share my concerns. A quick Google search came up with a very clear statement: "Do not take ENDONE during pregnancy or during breastfeeding as it may cause difficulty in breathing in an unborn or newborn child." [at http://www.mydr.com.au/medicines/cmis/endone-tablets]
A colleague who lives in regional Victoria told me that one of the local hospitals uses Endone less than the others, and that the local GPs, who provide anaesthetic services for the hospital, are still giving spinal morphine 1mg which works so well that very few women require more than Panadol and Voltaren.
I spoke to the pharmacist at a tertiary materntiy hospital in Melbourne, and he gave me some more information. He agreed that it's a very potent opioid that has a high transfer ratio into the milk, and variation from person to person as to how they metabolize Endone into morphine substances - hence variation in effect. He said the doses given appear to be pretty hefty.
The medical justification seems to be relatively short half life - 3-6 hours; that it's only used for 48 hours, claiming that the majority of babies are not sedated, and that the amount of colostrum the baby gets is pretty negligible anyway !!. Read here breastfeeding isn't something 'we' care much about!
The Lactmed site notes that "Newborn infants seem to be particularly sensitive to the effects of even small dosages of narcotic analgesics, particularly in the first week of life."
Dr Tom Hale, a world-respected expert and author on medications and mother's milk, has a forum
Hale states that "Oxycodone is a categoryL3... moderately safe, to be used only if the potential benefit to mother justifies potential risk to baby, and it has a half life of 3-6 hrs." Potential benefit to mother justifies potential risk to baby. I wonder how many mothers are given the opportunity to consider the risk/benefit before they swallow the tablet?
A newborn infant has important work to do, including learning how to breast feed. A newborn infant who is being systematically sedated through dangerous drugs that are passing from mother's blood to mother's milk, is being put at risk of breastfeeding delay leading to dehydration, jaundice, and a subsequent cascade of interventions, each with their own package of risks. The mother, receiving powerful sedation, is also likely to experience iatrogenic (physician-induced) difficulties with bonding and establishing breastfeeding.
I have often mused on the fact that "would you like something to help with the pain?" really means "would you like me to give you a dangerous drug?" I wish I knew a friendly cartoonist.
The anaesthetists and obstetricians really need to be questioned about this.
We live in a culture of acceptance of 'doctor knows best'. Women who undergo surgery for birth place an enormous trust in their surgeons and the other medical people - we need to act in their interests and on behalf of their babies.
I would like to ask that anyone reading this blog who works in the system, and who observes any cases where the baby of a mother receiving Endone in the early postnatal days appears sedated or performs poorly at breastfeeding, please draw attention to it. Speak to the obs and anaes departments, and point out what you observe. Ask them if they are aware of other such problems. Speak to the midwife manager of the unit, and ask her if she would support an internal audit of use of Endone. Find out what application is needed to get data from the general records. How often is it prescribed? What doses? (the pharmacy should be able to tell you this) Does the hospital have a protocol for the use of Endone? (you may find this on the hospital's intranet) What is the rate of supplementation of breastfeeding babies who were born by Caesarean (all the Baby Friendly hospitals should be able to give this data easily. Feeding on discharge is recorded on the Victorian perinatal statistics, so there could be some initial comparisons done.)
And while we're on the topic, I think some midwives are telling women in early labour to take some Panadeine and go to bed. Has anyone else heard this? In that case the codeine part of the drug will be added to the opioid soup in baby's system in the early days.
This is just not good enough!
Monday, April 19, 2010
when a baby needs to be born
There are many processes that midwives and others in the know about matters maternity are constantly checking. Today my thoughts are directed towards the first-time mother, known as a 'primip' from the Latin words primi (first) and para (birth), as she progresses through her pregnancy to that day when her labour will establish and her baby will be born.
It is normal/ usual for the baby's head to position itself deep in the mother's pelvic cavity from about 36 weeks of the 40 week gestation - weeks before the birth. The mother feels a sense of 'lightening', as there is a fraction more space under her ribs when the baby's head has engaged. When I palpate this engagement I am reassured that all is going to plan. This does not happen by chance. The mother's body is working in the way it was designed - wonderfully. It's as though the baby has discovered the door to this big world, and is waiting for it to open.
So what about the babies who haven't found the passage leading to the door? The baby who thinks she should come feet first, to start out running? The baby whose head stays high and mobile past 38, 39, even 40 weeks? What's the hurry, anyway?
Should the midwife just reassure the mother - we know a baby can be born spontaneously and safely in a breech presentation, and we know that occasionally a head does not engage until strong labour contractions direct it into the pelvic cavity - even in a primip!
Balancing this knowledge is another body of knowledge, which includes the standard of maternity care in the hospitals with which a midwife practising privately needs to collaborate occasionally. I cannot close my mind to the need for a smooth transfer and transition to medically led care from time to time.
I am constantly reflecting on the skills that promote, protect and support physiological processes that lead to spontaneous, safe birthing in the majority of cases.
Three primips in my care come to mind. I will call them A, B, and C. They are aged between 27 and 35, and are strong, healthy women, with caring husbands/partners. They are also normal height and weight - or normal BMI according to statistical charts. In other words, they are beautiful, healthy young women who would be expected to be able to give birth without complication.
A asked me to work with her for birth in a midwife-led Birth Centre attached to a large Melbourne hospital, Mercy Hospital for Women. When I palpated A's baby at about 38 weeks, I found the head engaged, with the fetal back on A's left side.
B asked me to work with her for planned homebirth, and has a booking at the Women's. At 36 weeks her baby was presenting head down, but the head was mobile. At 39 weeks the baby had turned to a breech presentation. I wrote a letter of referral to the hospital, and asked for review and consideration for external cephalic version (ECV). The ultrasonographer showed B that the baby was indeed presenting breech, and reassured her that there was plenty of amniotic fluid, which is considered necessary for ECV. B was told that the hospital preferred to do ECV at 37 weeks; that there was only about 20% chance that it would be successful at almost 40 weeks. B was determined, and she was invited to attend the next day for an ECV. She did not enjoy the sensation of tachycardia (fast pulse) that she experienced when Salbutamol was administered (to relax her uterine muscle). But the turn was successful. I visited her a couple of days later, and confirmed that the little head had stayed where we wanted it to be.
C is also planning homebirth, and her hospital backup is Monash Medical Centre at Clayton. The collaboration agreement with Monash is that the mother is seen in the hospital antenatal clinic at about 36 weeks, and if the midwife detects any issues of potential concern, an obstetrician also reviews the woman's care. As it happened, C's baby's head was high and very mobile. C was not concerned, as her mother had experienced the same situation and gone on to birthing spontaneously, but the doctor expressed his concern.
My midwifery ethos includes the statement "In normal birth there should be a valid reason to interfere with the natural process." (WHO Care in Normal Birth, 1996)
The question is, "Is there a valid reason in any of these cases to interfere with the natural process?"
Is there a valid reason to interfere with A's natural process? I think most midwives would say No, and I agree.
Is there a valid reason to interfere with B's natural process: baby presenting breech? If so, what should the interference be?
Is there a valid reason to interfere with C's natural process: baby's head high and mobile at Term? If so, what should the interference be?
[Any comments are welcome, of course!]
The birthing dance
One midwifery 'intervention' that I am currently asking my clients to consider, that I think may help that wee child find the way to the door in preparation for exiting her or his mother's womb, is a dance that brings on good 'practice' contractions of the womb. From about 37 weeks this dance will include upright movement, while intentionally increasing the release of natural oxytocin through loving body contact, including gentle nipple and clitoral stimulation with the purpose of bringing on a contraction.
It is normal/ usual for the baby's head to position itself deep in the mother's pelvic cavity from about 36 weeks of the 40 week gestation - weeks before the birth. The mother feels a sense of 'lightening', as there is a fraction more space under her ribs when the baby's head has engaged. When I palpate this engagement I am reassured that all is going to plan. This does not happen by chance. The mother's body is working in the way it was designed - wonderfully. It's as though the baby has discovered the door to this big world, and is waiting for it to open.
So what about the babies who haven't found the passage leading to the door? The baby who thinks she should come feet first, to start out running? The baby whose head stays high and mobile past 38, 39, even 40 weeks? What's the hurry, anyway?
Should the midwife just reassure the mother - we know a baby can be born spontaneously and safely in a breech presentation, and we know that occasionally a head does not engage until strong labour contractions direct it into the pelvic cavity - even in a primip!
Balancing this knowledge is another body of knowledge, which includes the standard of maternity care in the hospitals with which a midwife practising privately needs to collaborate occasionally. I cannot close my mind to the need for a smooth transfer and transition to medically led care from time to time.
I am constantly reflecting on the skills that promote, protect and support physiological processes that lead to spontaneous, safe birthing in the majority of cases.
Three primips in my care come to mind. I will call them A, B, and C. They are aged between 27 and 35, and are strong, healthy women, with caring husbands/partners. They are also normal height and weight - or normal BMI according to statistical charts. In other words, they are beautiful, healthy young women who would be expected to be able to give birth without complication.
A asked me to work with her for birth in a midwife-led Birth Centre attached to a large Melbourne hospital, Mercy Hospital for Women. When I palpated A's baby at about 38 weeks, I found the head engaged, with the fetal back on A's left side.
B asked me to work with her for planned homebirth, and has a booking at the Women's. At 36 weeks her baby was presenting head down, but the head was mobile. At 39 weeks the baby had turned to a breech presentation. I wrote a letter of referral to the hospital, and asked for review and consideration for external cephalic version (ECV). The ultrasonographer showed B that the baby was indeed presenting breech, and reassured her that there was plenty of amniotic fluid, which is considered necessary for ECV. B was told that the hospital preferred to do ECV at 37 weeks; that there was only about 20% chance that it would be successful at almost 40 weeks. B was determined, and she was invited to attend the next day for an ECV. She did not enjoy the sensation of tachycardia (fast pulse) that she experienced when Salbutamol was administered (to relax her uterine muscle). But the turn was successful. I visited her a couple of days later, and confirmed that the little head had stayed where we wanted it to be.
C is also planning homebirth, and her hospital backup is Monash Medical Centre at Clayton. The collaboration agreement with Monash is that the mother is seen in the hospital antenatal clinic at about 36 weeks, and if the midwife detects any issues of potential concern, an obstetrician also reviews the woman's care. As it happened, C's baby's head was high and very mobile. C was not concerned, as her mother had experienced the same situation and gone on to birthing spontaneously, but the doctor expressed his concern.
My midwifery ethos includes the statement "In normal birth there should be a valid reason to interfere with the natural process." (WHO Care in Normal Birth, 1996)
The question is, "Is there a valid reason in any of these cases to interfere with the natural process?"
Is there a valid reason to interfere with A's natural process? I think most midwives would say No, and I agree.
Is there a valid reason to interfere with B's natural process: baby presenting breech? If so, what should the interference be?
Is there a valid reason to interfere with C's natural process: baby's head high and mobile at Term? If so, what should the interference be?
[Any comments are welcome, of course!]
The birthing dance
One midwifery 'intervention' that I am currently asking my clients to consider, that I think may help that wee child find the way to the door in preparation for exiting her or his mother's womb, is a dance that brings on good 'practice' contractions of the womb. From about 37 weeks this dance will include upright movement, while intentionally increasing the release of natural oxytocin through loving body contact, including gentle nipple and clitoral stimulation with the purpose of bringing on a contraction.
Saturday, April 10, 2010
Scope of practice
The midwife's scope of practice is a topic that has become central in many discussions as we approach the introduction of the government's reforms into maternity care. I have written a lot about the countdown to 1 July in another blog.
Midwifery requires skill and wisdom - knowing how to work in harmony with normal physiological processes in pregnancy and birthing. The midwife who works independently, as the professionally responsible primary maternity care provider for a group of women and their babies, has the opportunity to work to the extent of her scope of practice. There are boundaries, and defining these boundaries also requires skill and wisdom.
It's no secret that a midwife is confident and delighted when a birth proceeds without incident, and a strong mother takes her baby joyfully to her breast. This birth is truly within the midwife's scope of practice.
But what about the birth that has some complexity? Is a breech birth, or twin birth, or even a birth at 36 weeks' gestation, or birth to a woman who has had previous caesarean surgery ... - are these within a midwife's scope of practice? Does that midwife, and that woman, have the *right* to choose the setting for the birth: the woman's own home? Or is there some line over which the midwife must not step?
I would be foolish to try to define a midwife's scope of practice in this blog. My hope is that by raising the issue, readers will reflect and learn in the way that is most useful to them.
The Australian College of Midwives has, since 2004, published National Midwifery Guidelines for consultation and referral (which can be downloaded as a .pdf file). The Guidelines claim to be "internationally comparable and based on the latest available research evidence at the time of publication." The Guidelines cannot, in themselves, set boundaries for a midwife's scope of practice.
The uniqueness of birth, and of midwifery, is that BIRTH IS NOT AN ILLNESS.
Birth is not an illness.
Certainly there are illnesses that can complicate birth: anything from a chest cold to life threatening diabetes or heart disease can and do result in risk to the mother's and her baby's ability to successfully and safely negotiate the birthing journey. No midwife has a guarantee of wellness or safety. Safety is achieved by enabling health and refraining from interfering in sensitive hormonally mediated processes, at the same time as being able to access relevant specialist medical services in a timely and effective way when appropriate.
What we do as midwives is different from any other health profession - even obstetrics. The key is the woman's desire to give birth under physiological conditions, which is what a midwife's scope of practice is able to offer, rather than a medically managed birth, which is effectively the only way the doctor knows.
Midwives who work in medical settings are often prevented by service protocols from working to their scope of practice, sometimes to a degree of restriction that is ridiculous and not based on any evidence. I have been told that midwives providing homebirth services under a new pilot scheme for a hospital in Melbourne's outer suburbs have been told that they will be dismissed if they do not abide by the 'rules'. An example is the management of the third stage. The hospital's protocol requires the midwife to undertake active management of the third stage. Women are informed that if they do not agree to active management, they will not be allowed to proceed in the homebirth group. There is no discussion.
When a midwife and woman are working in a partnership based on trust and reciprocity, and there is an aspect of the care for which the midwife's scope of practice may be broader than that which falls under a set of guidelines, it's an opportunity for decision making. The woman needs to know where she fits within the ACM guidelines, and any other contemporary standards - written or assumed. She needs to know what her midwife can offer. She may need to investigate what the alternative model of care to which she may be referred can offer, and weigh up the potential and perceived benefits against the costs and risks. She needs to know this so that she can make her own decisions.
Decision points that arise at any time in the professional relationship can be addressed in this way.
Midwifery requires skill and wisdom - knowing how to work in harmony with normal physiological processes in pregnancy and birthing. The midwife who works independently, as the professionally responsible primary maternity care provider for a group of women and their babies, has the opportunity to work to the extent of her scope of practice. There are boundaries, and defining these boundaries also requires skill and wisdom.
It's no secret that a midwife is confident and delighted when a birth proceeds without incident, and a strong mother takes her baby joyfully to her breast. This birth is truly within the midwife's scope of practice.
But what about the birth that has some complexity? Is a breech birth, or twin birth, or even a birth at 36 weeks' gestation, or birth to a woman who has had previous caesarean surgery ... - are these within a midwife's scope of practice? Does that midwife, and that woman, have the *right* to choose the setting for the birth: the woman's own home? Or is there some line over which the midwife must not step?
I would be foolish to try to define a midwife's scope of practice in this blog. My hope is that by raising the issue, readers will reflect and learn in the way that is most useful to them.
The Australian College of Midwives has, since 2004, published National Midwifery Guidelines for consultation and referral (which can be downloaded as a .pdf file). The Guidelines claim to be "internationally comparable and based on the latest available research evidence at the time of publication." The Guidelines cannot, in themselves, set boundaries for a midwife's scope of practice.
The uniqueness of birth, and of midwifery, is that BIRTH IS NOT AN ILLNESS.
Birth is not an illness.
Certainly there are illnesses that can complicate birth: anything from a chest cold to life threatening diabetes or heart disease can and do result in risk to the mother's and her baby's ability to successfully and safely negotiate the birthing journey. No midwife has a guarantee of wellness or safety. Safety is achieved by enabling health and refraining from interfering in sensitive hormonally mediated processes, at the same time as being able to access relevant specialist medical services in a timely and effective way when appropriate.
What we do as midwives is different from any other health profession - even obstetrics. The key is the woman's desire to give birth under physiological conditions, which is what a midwife's scope of practice is able to offer, rather than a medically managed birth, which is effectively the only way the doctor knows.
Midwives who work in medical settings are often prevented by service protocols from working to their scope of practice, sometimes to a degree of restriction that is ridiculous and not based on any evidence. I have been told that midwives providing homebirth services under a new pilot scheme for a hospital in Melbourne's outer suburbs have been told that they will be dismissed if they do not abide by the 'rules'. An example is the management of the third stage. The hospital's protocol requires the midwife to undertake active management of the third stage. Women are informed that if they do not agree to active management, they will not be allowed to proceed in the homebirth group. There is no discussion.
When a midwife and woman are working in a partnership based on trust and reciprocity, and there is an aspect of the care for which the midwife's scope of practice may be broader than that which falls under a set of guidelines, it's an opportunity for decision making. The woman needs to know where she fits within the ACM guidelines, and any other contemporary standards - written or assumed. She needs to know what her midwife can offer. She may need to investigate what the alternative model of care to which she may be referred can offer, and weigh up the potential and perceived benefits against the costs and risks. She needs to know this so that she can make her own decisions.
Decision points that arise at any time in the professional relationship can be addressed in this way.
Friday, April 02, 2010
Plenty of love to go round
There are times when an ordinary person is able to experience such an overwhelming sense of love that we want to hold on to that moment for ever.
The uncomplicated birth of a healthy baby is a time when love literally abounds. The cup of love fills up and overflows from the mother, particularly, to her infant, her husband and other children, her midwife, and everyone else with whom she shares the intimate experience. In that awesome moment, a mother receives her child to her breast, accepting the work of mothering.
Since as recently as the 1990s, this love phenomenon has been understood as being related to a surge of the hormone of love, oxytocin. Oxytocin is the natural substance that causes the womb to contract in a systematic way that, at the right time, leads to the opening of the cervix and all the complex processes that are summarised in the simple word 'birth'. Oxytocin continues to orchestrate birth, with the successful separation and expulsion of the placenta, the emptying of the womb of all trace of the baby, and the closure of the mother's blood flow through the placental site.
A surge of oxytocin is repeated many times in ensuing days, months, and years, as the baby stimulates mother's breasts and achieves the let down of milk.
A surge of oxytocin is also felt with sustained loving physical contact, building to a peak in sexual climax. Oxytocin supports and directs the normal physiological activities that lead to mammalian conception, pregnancy, birth, and nurture of the young.
In the years since I began to learn to work as a midwife, in harmony with natural physiological processes in the birthing journey, I have learnt to enjoy oxytocin. I have come to a deep appreciation of this wonderful substance in the lives of those for whom I am midwife, as well as in my own life.
As a midwife I see, over and over again, a woman progress through childbirth. I see a woman become a mother, and a couple become a family. I am sometimes privileged to return to that family a few years later when they welcome a new member.
I don't want to sound idealistic about this transformation. While most progress well, I also see some who start out beautifully become hurt and scarred by unrelated events. I see some whose own ability to love has been deeply marred in their early life, and they struggle to trust even themselves, let alone anyone else. I see some for whom illness or fear or destructive social forces hinder the development of strong bonds within families.
Today is Good Friday, and Christians around the world are celebrating a totally different love; love that saves and redeems lost humanity. This morning, as I sat with my family in our Church and meditated on Christ's love, I reflected on the profound difference between oxytocin-love and, for want of a better term, divine love. The elements of bread and grape juice; flesh and blood; a broken body and blood poured out, are symbols representing love that goes beyond any human achievement.
The human physiological love processes directed by oxytocin require flesh to be broken and blood to flow in order for new life to emerge. The symbolic representation of divine love is also in a broken body and poured out blood. New life begins.
The human physiological love processes directed by oxytocin are fragile, easily interrupted. The work of divine love is completed.
The uncomplicated birth of a healthy baby is a time when love literally abounds. The cup of love fills up and overflows from the mother, particularly, to her infant, her husband and other children, her midwife, and everyone else with whom she shares the intimate experience. In that awesome moment, a mother receives her child to her breast, accepting the work of mothering.
Since as recently as the 1990s, this love phenomenon has been understood as being related to a surge of the hormone of love, oxytocin. Oxytocin is the natural substance that causes the womb to contract in a systematic way that, at the right time, leads to the opening of the cervix and all the complex processes that are summarised in the simple word 'birth'. Oxytocin continues to orchestrate birth, with the successful separation and expulsion of the placenta, the emptying of the womb of all trace of the baby, and the closure of the mother's blood flow through the placental site.
A surge of oxytocin is repeated many times in ensuing days, months, and years, as the baby stimulates mother's breasts and achieves the let down of milk.
A surge of oxytocin is also felt with sustained loving physical contact, building to a peak in sexual climax. Oxytocin supports and directs the normal physiological activities that lead to mammalian conception, pregnancy, birth, and nurture of the young.
In the years since I began to learn to work as a midwife, in harmony with natural physiological processes in the birthing journey, I have learnt to enjoy oxytocin. I have come to a deep appreciation of this wonderful substance in the lives of those for whom I am midwife, as well as in my own life.
As a midwife I see, over and over again, a woman progress through childbirth. I see a woman become a mother, and a couple become a family. I am sometimes privileged to return to that family a few years later when they welcome a new member.
I don't want to sound idealistic about this transformation. While most progress well, I also see some who start out beautifully become hurt and scarred by unrelated events. I see some whose own ability to love has been deeply marred in their early life, and they struggle to trust even themselves, let alone anyone else. I see some for whom illness or fear or destructive social forces hinder the development of strong bonds within families.
Today is Good Friday, and Christians around the world are celebrating a totally different love; love that saves and redeems lost humanity. This morning, as I sat with my family in our Church and meditated on Christ's love, I reflected on the profound difference between oxytocin-love and, for want of a better term, divine love. The elements of bread and grape juice; flesh and blood; a broken body and blood poured out, are symbols representing love that goes beyond any human achievement.
The human physiological love processes directed by oxytocin require flesh to be broken and blood to flow in order for new life to emerge. The symbolic representation of divine love is also in a broken body and poured out blood. New life begins.
The human physiological love processes directed by oxytocin are fragile, easily interrupted. The work of divine love is completed.
Monday, March 22, 2010
There's no milk like mum's milk - part 2
It was the third day after a caesarean birth in Melbourne's tertiary hospital which is also accredited as 'Baby Friendly'.
[For the first part of this discussion, click here]
Mother had received excellent midwifery support and care during and after the birth, and the midwife on duty had arranged to stay with the little family in the Recovery room so that baby could initiate breastfeeding immediately.
Baby breastfed well in the hour or so after the birth.
In the next 24 hours, baby made some effort at breastfeeding, without attaching and sucking. Midwives helped the mother massage her breasts, express colostrum and give it to baby. I visited them in hospital and encouraged mother in this plan.
The following day I was unable to visit, as I had come down with a nasty head cold which I did not want to share. I spoke to the mother on the phone. Baby was only about 30 hours old, and had had limited success at the breast. Mother was happy giving her expressed colostrum.
The next morning - the third day - the midwife announced that baby looked jaundiced, and was dehydrated. Baby was weighed, and of course had lost weight. Although the loss was not excessive, that did not seem to be taken into account in the new care plan. Without making any effort to support breastfeeding, the midwife announced that the baby needed a blood test for jaundice. This recorded jaundice at the lower limit of the range requiring phototherapy. The mother was informed that baby needed to go 'under the lights' and would be given formula milk to complement the expressed breast milk.
The parents reluctantly agreed to the formula - there was really no alternative. They asked that they be able to give it via a cup or syringe, to avoid using a teat. The nurse's response was that that takes too long, and there's no problem with a teat anyway!
...
That nurse undermined the good work by midwives and the medical team in the preceding days, who had worked to promote, support and PROTECT breastfeeding.
Not only did the mother receive conflicting advice; she had reached a point where she was no longer able to trust the guidance of the midwives and other hospital staff. Breastfeeding was compromised by the formula, which took away the baby's appetite and interest in the breast, the enforced separation that came about with phototherapy, and the use of a teat.
...
Someone may be asking, "What alternative plan was there?" "What would a truly 'baby friendly' maternity service have done in this instance?"
At the very least, giving the supplement by cup or syringe, as requested by the parents, would have minimised the risk of nipple confusion.
Secondly, there was scope for more effort to help the mother with breastfeeding, while continuing to observe the baby for any medical problems such as jaundice and dehydration. In this case there was no cause for concern: the baby was at term, and would not be harmed by a more conservative approach than was taken.
And finally, I need to challenge the acceptance of artificial formula as a suitable alternative to a mother's own milk. The first alternative is human milk from another mother - yet Australian health authorities have put their collective heads in the metaphorical sand. Human milk banking, providing donated and pasteurised human milk for human infants, is the best supplement when a mother's own milk is unavailable.
Yet babies are routinely exposed to the bovine milk, and all the other micronutrients derived from plant oils and any number of foreign and potentially allergy-forming sources, when donated human milk would be far more suitable.
"There's no milk like mum's milk!"
[For the first part of this discussion, click here]
Mother had received excellent midwifery support and care during and after the birth, and the midwife on duty had arranged to stay with the little family in the Recovery room so that baby could initiate breastfeeding immediately.
Baby breastfed well in the hour or so after the birth.
The following day I was unable to visit, as I had come down with a nasty head cold which I did not want to share. I spoke to the mother on the phone. Baby was only about 30 hours old, and had had limited success at the breast. Mother was happy giving her expressed colostrum.
The next morning - the third day - the midwife announced that baby looked jaundiced, and was dehydrated. Baby was weighed, and of course had lost weight. Although the loss was not excessive, that did not seem to be taken into account in the new care plan. Without making any effort to support breastfeeding, the midwife announced that the baby needed a blood test for jaundice. This recorded jaundice at the lower limit of the range requiring phototherapy. The mother was informed that baby needed to go 'under the lights' and would be given formula milk to complement the expressed breast milk.
The parents reluctantly agreed to the formula - there was really no alternative. They asked that they be able to give it via a cup or syringe, to avoid using a teat. The nurse's response was that that takes too long, and there's no problem with a teat anyway!
...
That nurse undermined the good work by midwives and the medical team in the preceding days, who had worked to promote, support and PROTECT breastfeeding.
Not only did the mother receive conflicting advice; she had reached a point where she was no longer able to trust the guidance of the midwives and other hospital staff. Breastfeeding was compromised by the formula, which took away the baby's appetite and interest in the breast, the enforced separation that came about with phototherapy, and the use of a teat.
...
Someone may be asking, "What alternative plan was there?" "What would a truly 'baby friendly' maternity service have done in this instance?"
At the very least, giving the supplement by cup or syringe, as requested by the parents, would have minimised the risk of nipple confusion.
Secondly, there was scope for more effort to help the mother with breastfeeding, while continuing to observe the baby for any medical problems such as jaundice and dehydration. In this case there was no cause for concern: the baby was at term, and would not be harmed by a more conservative approach than was taken.
And finally, I need to challenge the acceptance of artificial formula as a suitable alternative to a mother's own milk. The first alternative is human milk from another mother - yet Australian health authorities have put their collective heads in the metaphorical sand. Human milk banking, providing donated and pasteurised human milk for human infants, is the best supplement when a mother's own milk is unavailable.
Yet babies are routinely exposed to the bovine milk, and all the other micronutrients derived from plant oils and any number of foreign and potentially allergy-forming sources, when donated human milk would be far more suitable.
"There's no milk like mum's milk!"
Wednesday, March 17, 2010
A landmark day for midwifery in Australia?
Yesterday the federal government's spin doctors announced that the passing of legislation through the Senate "provides long deserved recognition of Australia's highly skilled midwives.
... giving "midwives access to the Medical Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) for the first time."
... improving the "choices for Australian women to access high quality, safe maternity care as well as providing support for our talented midwives."
... establishing "a new Government-supported professional indemnity scheme for eligible midwives."
"Today marks a new era for our health workforce - ensuring smarter use of our skilled workforce, and more encouragement to work in multi-disciplinary teams.
This will help deliver better health and better results for patients.
"As a Government, we are extremely proud to be delivering these changes - providing new and innovative options for thousands of women and the community."
The Health Minister's press release makes it all sound great. BUT?
The Australian College of Midwives also welcomes the legislation.
"From 1 November this year, women will be able to choose to see a community midwife, and receive Medicare rebates for their visits to the midwife. The midwives will provide pregnancy and postnatal care in the community, and women may have the option of birth care in hospital from their chosen midwife.
“We welcome Nicola Roxon’s support for women to receive Medicare rebates when they choose the care of a midwife’ Dr Gamble said.
... ‘But we remain concerned to see that access to professional indemnity insurance becomes available for all midwives, including those providing professional care for women who choose to labour and birth at home.”
It's POSSIBLY a landmark day for SOME midwifery. But for miwives like me, who have chosen to be employed privately by women for homebirth or for other private midwifery services, the legislation gives us little to cheer about. Even the promise of Medicare and prescribing rights, to be implemented by November this year, appears to be so wound up in bureaucratic micro-management that we wonder if we will ever be able to meet the criteria. We are doubtful that the Medicare-funded midwife will be able to provide any service that is acceptable to clients, at the same time as providing a reasonable livelihood for the midwife.
The Greens Senator Rachel Siewert spoke up about the systematic discrimination against a small group of midwives and the women who employ us, declaring that "Major parties unite against midwives and homebirths.
"The Federal Government and Coalition have united to ensure that homebirth in Australia will be further marginalised by rejecting amendments to provide midwives with access to indemnity insurance irrespective of the location or venue of the births that they attend
...
"In addition the government chose to reject Greens amendments that would have taken away the power of doctors to veto aspects of midwifery practice, such as homebirth, that they are philosophically opposed to, despite the near universal evidence that safe low risk homebirth has positive outcomes for mother and child.
"We have consistently said that the Government amendments to their Midwives legislation give doctors too much control over midwives practice," said Greens health spokesperson Senator Rachel Siewert.
"It is extremely disappointing to see the major parties side together against the interests of midwives in refusing a Greens suggestion to broaden the scope of collaborative arrangements between midwives and medical practitioners to include health services, thereby ensuring that doctors can't veto homebirths."
Time will tell whether these legislative 'reforms' actually do what the government is claiming they will do, or if the culture of medical dominance is further strengthened.
... giving "midwives access to the Medical Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) for the first time."
... improving the "choices for Australian women to access high quality, safe maternity care as well as providing support for our talented midwives."
... establishing "a new Government-supported professional indemnity scheme for eligible midwives."
"Today marks a new era for our health workforce - ensuring smarter use of our skilled workforce, and more encouragement to work in multi-disciplinary teams.
This will help deliver better health and better results for patients.
"As a Government, we are extremely proud to be delivering these changes - providing new and innovative options for thousands of women and the community."
The Health Minister's press release makes it all sound great. BUT?
The Australian College of Midwives also welcomes the legislation.
"From 1 November this year, women will be able to choose to see a community midwife, and receive Medicare rebates for their visits to the midwife. The midwives will provide pregnancy and postnatal care in the community, and women may have the option of birth care in hospital from their chosen midwife.
“We welcome Nicola Roxon’s support for women to receive Medicare rebates when they choose the care of a midwife’ Dr Gamble said.
... ‘But we remain concerned to see that access to professional indemnity insurance becomes available for all midwives, including those providing professional care for women who choose to labour and birth at home.”
It's POSSIBLY a landmark day for SOME midwifery. But for miwives like me, who have chosen to be employed privately by women for homebirth or for other private midwifery services, the legislation gives us little to cheer about. Even the promise of Medicare and prescribing rights, to be implemented by November this year, appears to be so wound up in bureaucratic micro-management that we wonder if we will ever be able to meet the criteria. We are doubtful that the Medicare-funded midwife will be able to provide any service that is acceptable to clients, at the same time as providing a reasonable livelihood for the midwife.
The Greens Senator Rachel Siewert spoke up about the systematic discrimination against a small group of midwives and the women who employ us, declaring that "Major parties unite against midwives and homebirths.
"The Federal Government and Coalition have united to ensure that homebirth in Australia will be further marginalised by rejecting amendments to provide midwives with access to indemnity insurance irrespective of the location or venue of the births that they attend
...
"In addition the government chose to reject Greens amendments that would have taken away the power of doctors to veto aspects of midwifery practice, such as homebirth, that they are philosophically opposed to, despite the near universal evidence that safe low risk homebirth has positive outcomes for mother and child.
"We have consistently said that the Government amendments to their Midwives legislation give doctors too much control over midwives practice," said Greens health spokesperson Senator Rachel Siewert.
"It is extremely disappointing to see the major parties side together against the interests of midwives in refusing a Greens suggestion to broaden the scope of collaborative arrangements between midwives and medical practitioners to include health services, thereby ensuring that doctors can't veto homebirths."
Time will tell whether these legislative 'reforms' actually do what the government is claiming they will do, or if the culture of medical dominance is further strengthened.
Thursday, March 11, 2010
There's no milk like mum's milk
You might have overheard a conversation in a playground in Melbourne's leafy Eastern suburbs.
"These are amazing pesticide-free organic bamboo nappies," said Jenny.
"All my baby's clothes are organic cotton with no artificial colours," replied her friend Jacqui.
"This baby sling is really the BEST"
...
Variations on this converstation are being played out across our land. The baby industry relies on youthful idealism when hawking its stuff to our new parents and parents to be. A new baby is the essence of newness and hope. Who would not want all that is good and pure and right for that little one?
Fabulous baby clothes, maternity fashions, prams, toys, books, and other consumables flood shops as well as the online market. Providers of products and services advertise their stuff by every possible means, lining up in booths at a baby expo, with glossy handouts and trivial gifts that will entice market share.
There is one product that cannot be bought or sold, yet its value to both mother and baby is beyond any dollar estimation.
There's no milk like mum's milk.
There's nothing in the market that comes within cooee of a mother's own milk, in terms of nutritional correctness for the individual child, disease prevention through antibodies and other unique biological substances, protection of the psychological bond between mother and child, optimal physical support of the growing child, protecting the mother's health, and much more.
There's no milk like mum's milk.
A couple expecting their first baby will have an impressive array of items ready to welcome their child. Family members and friends will contribute. The mother-2-B will lovingly wash and fold beautiful clothes and wraps in preparation for the birth.
They know breastfeeding is 'best', so they will plan that too.
Yet breastfeeding is an incredibly vulnerable entity, easily lost.
There is a discrete window of opportunity, around the time of birth, when breastfeeding is initiated and established. We have substantial relable evidence as to the maternity practices that either support or interfere with the establishment of breastfeeding. In simple terms, breastfeeding will be threatened when new mothers experience anything that interferes with their learning to breastfeed, such as:
Breastfeeding is a 2-way activity: a baby breastfeeds, and a mother breastfeeds, simultaneously.
Breastfeeding will be threatened when newborn babies experience anything that interferes with their learning to breastfeed, including:
Many maternity hospitals have, over the past 20 years attempted to change the way breastfeeding is supported and promoted and protected, for the wellbeing of babies and their mothers. The global Baby Friendly Hospital Initiative was established by World Health Organisation and UNICEF in response to the global threat to health that had arisen with the world-wide promotion of artificial milk formulas that are used as a substitute for mothers own milk.
Many Australian maternity hospitals have implemented the Baby Friendly Health Initiative (BFHI), and undergo periodic external audits by assessors appointed by the BFHI.
In my next post I will outline a case in which staff of a 'Baby Friendly' hospital failed to maintain the expected standard, and the impact that failure has on the mother and baby.
"These are amazing pesticide-free organic bamboo nappies," said Jenny.
"All my baby's clothes are organic cotton with no artificial colours," replied her friend Jacqui.
"This baby sling is really the BEST"
...
Variations on this converstation are being played out across our land. The baby industry relies on youthful idealism when hawking its stuff to our new parents and parents to be. A new baby is the essence of newness and hope. Who would not want all that is good and pure and right for that little one?
Fabulous baby clothes, maternity fashions, prams, toys, books, and other consumables flood shops as well as the online market. Providers of products and services advertise their stuff by every possible means, lining up in booths at a baby expo, with glossy handouts and trivial gifts that will entice market share.
There is one product that cannot be bought or sold, yet its value to both mother and baby is beyond any dollar estimation.
There's no milk like mum's milk.
There's nothing in the market that comes within cooee of a mother's own milk, in terms of nutritional correctness for the individual child, disease prevention through antibodies and other unique biological substances, protection of the psychological bond between mother and child, optimal physical support of the growing child, protecting the mother's health, and much more.
There's no milk like mum's milk.
A couple expecting their first baby will have an impressive array of items ready to welcome their child. Family members and friends will contribute. The mother-2-B will lovingly wash and fold beautiful clothes and wraps in preparation for the birth.
They know breastfeeding is 'best', so they will plan that too.
Yet breastfeeding is an incredibly vulnerable entity, easily lost.
There is a discrete window of opportunity, around the time of birth, when breastfeeding is initiated and established. We have substantial relable evidence as to the maternity practices that either support or interfere with the establishment of breastfeeding. In simple terms, breastfeeding will be threatened when new mothers experience anything that interferes with their learning to breastfeed, such as:
- receiving conflicting advice
- not being able trust the guidance of the midwives and other hospital staff
- being unnecessarily separated from their newborn babies
Breastfeeding is a 2-way activity: a baby breastfeeds, and a mother breastfeeds, simultaneously.
Breastfeeding will be threatened when newborn babies experience anything that interferes with their learning to breastfeed, including:
- being given anything to suck that is not mother's breast (including teats, dummies, and fingers)
- not being able to satisfy their need for mother's milk when they feel hungry
Many maternity hospitals have, over the past 20 years attempted to change the way breastfeeding is supported and promoted and protected, for the wellbeing of babies and their mothers. The global Baby Friendly Hospital Initiative was established by World Health Organisation and UNICEF in response to the global threat to health that had arisen with the world-wide promotion of artificial milk formulas that are used as a substitute for mothers own milk.
Many Australian maternity hospitals have implemented the Baby Friendly Health Initiative (BFHI), and undergo periodic external audits by assessors appointed by the BFHI.
In my next post I will outline a case in which staff of a 'Baby Friendly' hospital failed to maintain the expected standard, and the impact that failure has on the mother and baby.
Friday, March 05, 2010
Maternity reform hijacked 2
Consumer choice
The women who employ midwives privately do so for many reasons. In most instances a midwife is employed with the intention of promoting and supporting physiologically normal processes in birth. Since midwives do not have visiting access/ practising rights at hospitals, planned homebirth is the main setting in which Victorian midwives practise. Some women employ midwives privately to accompany them to hospital for the birth. The main reason is that with a private midwife a degree of partnership and trust are able to be formed, and the woman's preference for continuity of carer. While no-one can predict the course of events, the process of making informed decisions in labour and birth can be enhanced.
Evidence from Victorian and other Australian data collections, and international peer reviewed publications supports the effectiveness and safety of planned home birth in the care of a midwife, with access to specialist medical services when the need arises.
Normal midwifery practice includes the ability to refer and make timely decisions about the need to transfer care from home to hospital, or from a primary care facility such as a birth centre or hospital that does not provide emergency obstetric surgery to a higher level hospital. Victorian independent midwives, who have demonstrated accountability and transparency in their private midwifery practice over many years, have exemplary statistics, as recorded by the Health Department's Perinatal Data Collection Unit (PDCU). Planned homebirth, with a midwife as the responsible professional in attendance, is at least as safe a choice in Victoria as planned hospital birth, and the rate of interventions such as caesarean or other operative birth is very low. For example, the PDCU Performance Indicator analysis for standard first-time mothers who planned homebirth showed that 6.5% have caesarean births (DoH Letter dated 15 October 2009) which compares favourably with the statewide public hospital rate of approximately 15%, and the statewide private hospital rate of approximately 27% for standard primiparae in 2007-08 [Source: Victorian Maternity Service Performance Indicators, 2009].
The end result of this reform is likely to be that private midwifery practice will be further marginalised, forced into a grey zone, on the edge of legal practice, or even underground. The outcome of unrealistic restriction to private midwifery practice is that women who plan homebirth may look to unregulated maternity care providers, who are prepared to work outside the law. This cannot be considered safe or acceptable.
Who will be held accountable for adverse outcomes that could have been prevented, with a little bit of a sense of fairness in protecting the choice of consumers who wish to plan to give birth at home?
Competition considerations
Under the Trade Practices Act, government is required to promote competition in health policy, to ensure reasonable choice for consumers and defensible cost for government; that regulations stand or fall on whether benefits can be shown to be greater than costs.
The privileged monopoly that has been granted by successive Australian governments to the medical profession is indefensible in maternity services. While midwives are quite capable of providing primary maternity services for the majority of pregnant women, continuing as the responsible professional carer throughout the labour, birth, and postnatal period, this model of care is largely unavailable in our communities.
There is no public funding for private midwifery care.
Funding arrangements between federal and state health departments fragment maternity care, which is not good practice.
Medicare rebates apply to services provided by GPs or specialist obstetricians, while there is no broad access to midwife led models of care.
The Medicare safety net uses public funds to further privilege the private obstetric market.
Tax rebates on private health insurance also privilege the private obstetric market.
Despite repeated calls by midwives' associations, there has been no serious attempt to apply a public benefit test to maternity-related policies which provide a monopoly for the medical profession, and stifle competition by midwives.
Competition considerations include the need for public funding for consumers who choose maternity services provided by a private midwife, equity and parity with doctors in access for midwives to public funding support for private indemnity insurance, which would likely lead to visiting access for midwives to practise in public hospitals.
Policies for which a public benefit cannot be demonstrated must be repealed or modified so that they do not reduce competition.
For more comment on this topic, go to
Part 1 Background
Part 3, Professional Indemnity Insurance, and Collaborative Arrangements
The women who employ midwives privately do so for many reasons. In most instances a midwife is employed with the intention of promoting and supporting physiologically normal processes in birth. Since midwives do not have visiting access/ practising rights at hospitals, planned homebirth is the main setting in which Victorian midwives practise. Some women employ midwives privately to accompany them to hospital for the birth. The main reason is that with a private midwife a degree of partnership and trust are able to be formed, and the woman's preference for continuity of carer. While no-one can predict the course of events, the process of making informed decisions in labour and birth can be enhanced.
Evidence from Victorian and other Australian data collections, and international peer reviewed publications supports the effectiveness and safety of planned home birth in the care of a midwife, with access to specialist medical services when the need arises.
Normal midwifery practice includes the ability to refer and make timely decisions about the need to transfer care from home to hospital, or from a primary care facility such as a birth centre or hospital that does not provide emergency obstetric surgery to a higher level hospital. Victorian independent midwives, who have demonstrated accountability and transparency in their private midwifery practice over many years, have exemplary statistics, as recorded by the Health Department's Perinatal Data Collection Unit (PDCU). Planned homebirth, with a midwife as the responsible professional in attendance, is at least as safe a choice in Victoria as planned hospital birth, and the rate of interventions such as caesarean or other operative birth is very low. For example, the PDCU Performance Indicator analysis for standard first-time mothers who planned homebirth showed that 6.5% have caesarean births (DoH Letter dated 15 October 2009) which compares favourably with the statewide public hospital rate of approximately 15%, and the statewide private hospital rate of approximately 27% for standard primiparae in 2007-08 [Source: Victorian Maternity Service Performance Indicators, 2009].
The end result of this reform is likely to be that private midwifery practice will be further marginalised, forced into a grey zone, on the edge of legal practice, or even underground. The outcome of unrealistic restriction to private midwifery practice is that women who plan homebirth may look to unregulated maternity care providers, who are prepared to work outside the law. This cannot be considered safe or acceptable.
Who will be held accountable for adverse outcomes that could have been prevented, with a little bit of a sense of fairness in protecting the choice of consumers who wish to plan to give birth at home?
Competition considerations
Under the Trade Practices Act, government is required to promote competition in health policy, to ensure reasonable choice for consumers and defensible cost for government; that regulations stand or fall on whether benefits can be shown to be greater than costs.
The privileged monopoly that has been granted by successive Australian governments to the medical profession is indefensible in maternity services. While midwives are quite capable of providing primary maternity services for the majority of pregnant women, continuing as the responsible professional carer throughout the labour, birth, and postnatal period, this model of care is largely unavailable in our communities.
There is no public funding for private midwifery care.
Funding arrangements between federal and state health departments fragment maternity care, which is not good practice.
Medicare rebates apply to services provided by GPs or specialist obstetricians, while there is no broad access to midwife led models of care.
The Medicare safety net uses public funds to further privilege the private obstetric market.
Tax rebates on private health insurance also privilege the private obstetric market.
Despite repeated calls by midwives' associations, there has been no serious attempt to apply a public benefit test to maternity-related policies which provide a monopoly for the medical profession, and stifle competition by midwives.
Competition considerations include the need for public funding for consumers who choose maternity services provided by a private midwife, equity and parity with doctors in access for midwives to public funding support for private indemnity insurance, which would likely lead to visiting access for midwives to practise in public hospitals.
Policies for which a public benefit cannot be demonstrated must be repealed or modified so that they do not reduce competition.
For more comment on this topic, go to
Part 1 Background
Part 3, Professional Indemnity Insurance, and Collaborative Arrangements
Saturday, February 27, 2010
How amazing is this?
How does an intelligent, active woman who has experienced lots of freedoms and is highly respected for her employed work, change (overnight) into a mother who is satisfied with being just that: a mother?
And why is it that some new mothers don't quite find that place of satisfaction in the role, and long for the day when they can hand the mother role over to someone 'more qualified' in a purpose-built facility?
This amazing phenomenon is a metamorphosis that takes place under natural, physiological cues, and the result is a mother who is so focused on her new baby that she doesn't miss the late nights with friends, or the cafe culture of her previous job, or the mental stimulation of a challenging business meeting.
I assert that:
The amazing, awe-inspiring truth is that in God's created world both a mother and a child are the beautiful new creatures who emerge out of the coccoon of pregnancy. She takes her child into her arms and into her heart, and she recognises the uniqueness of her place in the life of that little one. Call it attachment, bonding, maternal instinct: it's one of the miracles that happens at birth.
As with birthing, there is no safer way, or more staisfying way, to be a mother than to find and follow the time-tested normal physiological path. As with birthing, our society today offers many alternatives that did not exist, or that existed to a lesser degree, in previous generations. As with birthing, most of us will at some stage fall short of some imagined ideal. That's life! And as with the rest of life, coming to terms with 'good enough', and doing our best with what we have, is a very reasonable goal.
A couple of days ago I was writing about families in communities - the supports and protection within communities that enable new mothers to find their feet, 'put down roots', and become resillient as individuals, and as families.
Today's new mothers have options for connecting with others that their mothers, and previous generations would not have imagined. Easy access to the Internet has opened up chat rooms, blogs, email, VOIP telephone connections, Skype with a webcam, all those *friends* on Facebook, and whatever you call your Twitter crowd. It's a generation of connectedness. How could anyone be lonely? There's a lot of self-analysis, informing the world of how you feel about the minutae - it's old fashioned navel gazing.
The mothers of today's new mothers (I'm one of them) had the radio or the 'box' to keep us company, if we chose. The background in homes included morning chat shows, the soapies, mostly from the USA: in all a recipe for domestic mindlessness. We had most of the other time-saving 'mod cons' that our mothers did not have. But if we wanted to speak to another person we had to be there in person, except for phone calls. And there were no cordless phones or mobile phones. There was no virtual community.
I was living in Michigan, USA, when our first three children were born. We bought a house in a town called Haslett, which is near East Lansing. We had one car, which Noel usually drove to the university, so I must have had a lot of time at home. I don't recall being lonely, or dissatisfied in any way. The work of being a mother filled my life as long as the babies were small, and the next pregnancy followed once the breastfeeding demands on my body were reduced.
My own mother had been a great model for me to follow, and I am sure that being second of seven children prepared me in special ways for motherhood. But most of mothering is instinctual, going much deeper than the learning either in childhood, or from books or classes.
We know from laboratory animal work that the hormones of birth and breastfeeding set us up for mothering. Babies and young children require an enormous investment on the part of the mother firstly, and then on the part of the father, family, and community, in order to successfully negotiate the often hazardous terrain of childhood. Although there is no simple 'one size fits all' to this, the protection and support of a strong mother-baby bond sets up a family in a way that cannot be artificially immitated.
And why is it that some new mothers don't quite find that place of satisfaction in the role, and long for the day when they can hand the mother role over to someone 'more qualified' in a purpose-built facility?
This amazing phenomenon is a metamorphosis that takes place under natural, physiological cues, and the result is a mother who is so focused on her new baby that she doesn't miss the late nights with friends, or the cafe culture of her previous job, or the mental stimulation of a challenging business meeting.
I assert that:
- Every baby needs a mother.
- There is no better mother than the one who gave birth to the baby, in almost every situation.
- Mothering is a demanding, challenging role, whether the role is filled by the biological mother or a substitute.
The amazing, awe-inspiring truth is that in God's created world both a mother and a child are the beautiful new creatures who emerge out of the coccoon of pregnancy. She takes her child into her arms and into her heart, and she recognises the uniqueness of her place in the life of that little one. Call it attachment, bonding, maternal instinct: it's one of the miracles that happens at birth.
As with birthing, there is no safer way, or more staisfying way, to be a mother than to find and follow the time-tested normal physiological path. As with birthing, our society today offers many alternatives that did not exist, or that existed to a lesser degree, in previous generations. As with birthing, most of us will at some stage fall short of some imagined ideal. That's life! And as with the rest of life, coming to terms with 'good enough', and doing our best with what we have, is a very reasonable goal.
A couple of days ago I was writing about families in communities - the supports and protection within communities that enable new mothers to find their feet, 'put down roots', and become resillient as individuals, and as families.
Today's new mothers have options for connecting with others that their mothers, and previous generations would not have imagined. Easy access to the Internet has opened up chat rooms, blogs, email, VOIP telephone connections, Skype with a webcam, all those *friends* on Facebook, and whatever you call your Twitter crowd. It's a generation of connectedness. How could anyone be lonely? There's a lot of self-analysis, informing the world of how you feel about the minutae - it's old fashioned navel gazing.
The mothers of today's new mothers (I'm one of them) had the radio or the 'box' to keep us company, if we chose. The background in homes included morning chat shows, the soapies, mostly from the USA: in all a recipe for domestic mindlessness. We had most of the other time-saving 'mod cons' that our mothers did not have. But if we wanted to speak to another person we had to be there in person, except for phone calls. And there were no cordless phones or mobile phones. There was no virtual community.
I was living in Michigan, USA, when our first three children were born. We bought a house in a town called Haslett, which is near East Lansing. We had one car, which Noel usually drove to the university, so I must have had a lot of time at home. I don't recall being lonely, or dissatisfied in any way. The work of being a mother filled my life as long as the babies were small, and the next pregnancy followed once the breastfeeding demands on my body were reduced.
My own mother had been a great model for me to follow, and I am sure that being second of seven children prepared me in special ways for motherhood. But most of mothering is instinctual, going much deeper than the learning either in childhood, or from books or classes.
We know from laboratory animal work that the hormones of birth and breastfeeding set us up for mothering. Babies and young children require an enormous investment on the part of the mother firstly, and then on the part of the father, family, and community, in order to successfully negotiate the often hazardous terrain of childhood. Although there is no simple 'one size fits all' to this, the protection and support of a strong mother-baby bond sets up a family in a way that cannot be artificially immitated.
Thursday, February 25, 2010
Families within communities
The focus of midwifery is the mother-baby as a unit within a family. The midwife's scope of practice spans the pregnancy, birth, establishing breastfeeding and early parenting. We midwives often declare that, in the absence of complications these processes are normal, natural, physiological: that BIRTH IS NOT AN ILLNESS. We often point to the obvious similarities between the human mother and other mammalian mothers. No farmer would allow anyone to prod and poke the cows when they have separated themselves from the herd in preparation for giving birth. The farmer keeps a respectful distance, as do the other cows.
Lessons abound in nature.
As the simple drawing of trees suggest, today I am taking a lesson from trees.
Let's imagine the nuclear family unit, mother, father and children, as a tree. Some trees grow up in close proximity to others of their kind, while some are isolated. There is no one pattern that is right for all.
Families exist within communities, some are close and others more spread out.
A seedling tree - a new family - takes time to become strong. It sends down roots, and puts out branches and leaves.
Let's think about the roots of a tree/family. A young tree can be vulnerable to natural forces, as well as unnatural. It takes time and support for that tree to establish. In a garden we may put a stake next to a young tree, and possibly even a protective barrier around it. The tree will not thrive just by being propped up or protected. It has a lot of work to do itself, doing the work of a tree: its roots taking nourishment and water from the soil, and its green leaves photosynthesing light into plant energy.
A young family, similarly, has work of its own to do. The young family will not become strong merely by being placed in a supportive community with protection from difficulties.
Often after a storm we see trees that have been uprooted - destroyed in an instant. The huge canopy, and the system of limbs coming from the trunk can no longer be sustained. On the other hand a tree that has a tap root that penetrates deep into the soil is more able to withstand wind, storm, and drought.
In the tree/family analogy, that deep tap root could stand for strong values and standards that give resillience and a continuous supply of nourishment. A family that is secure in its beliefs, with clear principles to follow is able to stay whole in difficult times. Life's storms take many different forms; they may include illness or financial hardship or psychological threats. The family with good foundations, like the tree with strong, deep roots, comes through unharmed.
So, the question is, how does a new family establish roots in their community?
Monday, February 22, 2010
ABC TV: Q&A
For details of this program, link here.
Next Program: Monday 22 February 2010 at 9:35pm
Next Program's panellists
* Malcolm Turnbull - former Liberal leader
* Tanya Plibersek - Minister for Housing and Status of Women
* Mungo MacCallum - political commentator
* John Roskam - Institute of Public Affairs
* Jane Caro - social commentator
You can read questions submitted, and send your own question to the program.
My question could be put to several of the panellists, to answer from a social, political, or women's issues point of view. In maternity care throughout history the midwife has been the primary care provider who works with the woman. The government's new legislation is now set to give the medical profession veto power over which women can use midwifery services, potentially strangling private midwifery, and driving homebirth underground. Should this so called 'reform' be acceptable?
[ADDED LATER]
NOT ONE MENTION OF MATERNITY ISSUES, DESPITE HUNDREDS OF QUESTIONS BEING ASKED! Minister Plibersek looked unwell, and had a nasty cough - she should have stayed at home. A lot of time was given to Malcolm Turnbull; thinly disguised attempts to get him to speak against his replacement leader of the Opposition, and reignite the carbon debate. The show was not worth watching.
Next Program: Monday 22 February 2010 at 9:35pm
Next Program's panellists
* Malcolm Turnbull - former Liberal leader
* Tanya Plibersek - Minister for Housing and Status of Women
* Mungo MacCallum - political commentator
* John Roskam - Institute of Public Affairs
* Jane Caro - social commentator
You can read questions submitted, and send your own question to the program.
My question could be put to several of the panellists, to answer from a social, political, or women's issues point of view. In maternity care throughout history the midwife has been the primary care provider who works with the woman. The government's new legislation is now set to give the medical profession veto power over which women can use midwifery services, potentially strangling private midwifery, and driving homebirth underground. Should this so called 'reform' be acceptable?
[ADDED LATER]
NOT ONE MENTION OF MATERNITY ISSUES, DESPITE HUNDREDS OF QUESTIONS BEING ASKED! Minister Plibersek looked unwell, and had a nasty cough - she should have stayed at home. A lot of time was given to Malcolm Turnbull; thinly disguised attempts to get him to speak against his replacement leader of the Opposition, and reignite the carbon debate. The show was not worth watching.
Saturday, February 06, 2010
A birth story in pictures
Thanks to the family whose beautiful pictures tell the story eloquently.
Please note that midwives and other registered health professionals are not permitted to use testimonials to advertise our services.
Please note that midwives and other registered health professionals are not permitted to use testimonials to advertise our services.
Monday, February 01, 2010
what's in a midwife's bag?
A midwife sent a message to her colleagues who are members of a national email list, asking for people with experience to provide her a list of helpful herbal tinctures which may come in handy at a birth.
There were various responses, which can broadly be categorised into those who 'do' and those who 'don't'. Since I'm in the 'don't' group, I'll share my comments here. Readers are welcome to share your thoughts on the topic too.
THE DON'T GROUP SAID:
My thinking on this topic has been influenced by Maggie Banks in Home Birth Bound: mending the broken weave, Chapter 9. She describes 3 traditions of healing: the scientific, the heroic, and the wise woman tradition. Of course life is not black and white in any situation, and as a midwife there will be times when I use the scientific (as in collecting cord blood and administering anti-D to a Rhesus negative mother), and times when I reach (in a small way) for the heroic modalities (such as vitamin B6 supplement for fluid retention); but underpinning it all is the wise woman tradition - the knowledge and skill of working in harmony with normal physiological processes.
I will not attempt to present the case for those who 'do' use alternative medicines as part of midwifery practice. It's a complex and fascinating field of study. Some midwives have studied aromatherapy, homeopathy, reiki, herbal medicine, crystals, meditation, and various physical therapies (to mention just a few). At the end of the day the midwife's skill is in promoting health and harmonising her own life with that of the labouring woman, with the intention of supporting and protecting wellness in birth.
There were various responses, which can broadly be categorised into those who 'do' and those who 'don't'. Since I'm in the 'don't' group, I'll share my comments here. Readers are welcome to share your thoughts on the topic too.
THE DON'T GROUP SAID:
- Can I ask why a midwife would take herbal tinctures? If birth is not an illness, why do some midwives come along with a bag of 'medications', even if they are herbal or homeopathic or natural?
- Of course a lot of my clients use natural remedies, and in most cases I don't see any harm in them. But there are times when I ask a woman to stop looking for remedies - whether naturopathic, or even a tub of water - and get on with the job.
- Midwifery is about being 'with woman' rather than being a therapist of any kind.
- Herbals can have alkaloids and other substances that have very real effects on the function of the human body. Many mainstream drugs were herbals once upon a time. Unless the product is well tested for its potency and dose rate, it could cause unintended harm.
- Other 'natural' therapies, including homeopathy, may have a placebo effect, without having a direct medicinal effect.
My thinking on this topic has been influenced by Maggie Banks in Home Birth Bound: mending the broken weave, Chapter 9. She describes 3 traditions of healing: the scientific, the heroic, and the wise woman tradition. Of course life is not black and white in any situation, and as a midwife there will be times when I use the scientific (as in collecting cord blood and administering anti-D to a Rhesus negative mother), and times when I reach (in a small way) for the heroic modalities (such as vitamin B6 supplement for fluid retention); but underpinning it all is the wise woman tradition - the knowledge and skill of working in harmony with normal physiological processes.
I will not attempt to present the case for those who 'do' use alternative medicines as part of midwifery practice. It's a complex and fascinating field of study. Some midwives have studied aromatherapy, homeopathy, reiki, herbal medicine, crystals, meditation, and various physical therapies (to mention just a few). At the end of the day the midwife's skill is in promoting health and harmonising her own life with that of the labouring woman, with the intention of supporting and protecting wellness in birth.
Monday, January 25, 2010
What should we eat in pregnancy?
or the other question, what should we not eat?
I often counsel women to eat well. Eat the best food you can access.
Here's a blog with some good advice. (BTW I have no idea what link there is between phlebotomy - taking blood from veins - with a healthy diet in pregnancy.)
It's a good list. You'd have to be a pretty fussy eater not to be able to satisfy yourself from this.
Have a look at the list, and let me know if your favourite is not included. One I would add is dates. They are good, and take care of sluggish bowels at the same time. Anyone watching sugar intake would need to limit the number of dates you eat: they are very sweet.
You may also enjoy checking out the Food Standards Australia and New Zealand (FSANZ) website page Thinking about getting pregnant in 2010 – vital information about what's good to eat and drink.
Also the brochure
and the web videos
and translations
I often counsel women to eat well. Eat the best food you can access.
Here's a blog with some good advice. (BTW I have no idea what link there is between phlebotomy - taking blood from veins - with a healthy diet in pregnancy.)
It's a good list. You'd have to be a pretty fussy eater not to be able to satisfy yourself from this.
Have a look at the list, and let me know if your favourite is not included. One I would add is dates. They are good, and take care of sluggish bowels at the same time. Anyone watching sugar intake would need to limit the number of dates you eat: they are very sweet.
You may also enjoy checking out the Food Standards Australia and New Zealand (FSANZ) website page Thinking about getting pregnant in 2010 – vital information about what's good to eat and drink.
Also the brochure
and the web videos
and translations
Monday, January 11, 2010
Babies who need to be born at night
I was heading West along Burwood Highway in the morning traffic at about 8am, coming up to Springvale Road about 5 minutes from home when the dreadful realisation hit me in slow motion. I was heading for a post.
A near miss, I am thankful to report.
But this is an experience which is an integral part of the life of any midwife who accepts the need of women in her care to come into spontaneous labour, at any time of the day or night. The small number of midwives who practise privately in my part of the world, and the small number of women who plan homebirth, adds distance to the midwife's work terrain. A midwife has to accept travel: our 'village' is a virtual space that links the homes and lives of our clients with our own.
Those micro-second sleeps can kill. The risk potential is increased by the fact that I have a bottle of oxygen in the boot of the car, and other road users could also be at risk of fire in a collision.
The scenario about which I am reflecting now had several points of increased risk that were specific to this particular birth: I had been called out before midnight, and the mother had given birth around 5 am. The home was about 50 minutes' drive from my home. I followed my usual precautions for driving after a night's work: slowly eating an apple to keep some energy going into my body; listening to the radio; having the fan blow on my face ... After the 'scare' I phoned Noel and we talked until I drove into our yard.
I have no way of predicting which mothers will labour and give birth at night, and I discourage my clients from trying to 'know' this. One mother told me her five children had all been born in daylight hours. Her sixth was not!
This risk of falling asleep at the wheel is not about private practice or home birth. I remember a similar near miss about 25 years ago, when I was driving home after a night shift at the Women's hospital. That experience prompted me to explore ways of keeping my mind active and functioning when driving home after a 'night out'.
What have I learnt from this experience?
When I encounter combined risk factors of distance and sleep deprivation after a birth, I will consider other ways of getting home. This could include a taxi, or another person (who has slept the night) driving, or finding a place to sleep for a few hours before heading home.
I hope this post supports other midwives in their own understanding of our work, and planning for our own safety as well as that of mothers and babies in our care.
A near miss, I am thankful to report.
But this is an experience which is an integral part of the life of any midwife who accepts the need of women in her care to come into spontaneous labour, at any time of the day or night. The small number of midwives who practise privately in my part of the world, and the small number of women who plan homebirth, adds distance to the midwife's work terrain. A midwife has to accept travel: our 'village' is a virtual space that links the homes and lives of our clients with our own.
Those micro-second sleeps can kill. The risk potential is increased by the fact that I have a bottle of oxygen in the boot of the car, and other road users could also be at risk of fire in a collision.
The scenario about which I am reflecting now had several points of increased risk that were specific to this particular birth: I had been called out before midnight, and the mother had given birth around 5 am. The home was about 50 minutes' drive from my home. I followed my usual precautions for driving after a night's work: slowly eating an apple to keep some energy going into my body; listening to the radio; having the fan blow on my face ... After the 'scare' I phoned Noel and we talked until I drove into our yard.
I have no way of predicting which mothers will labour and give birth at night, and I discourage my clients from trying to 'know' this. One mother told me her five children had all been born in daylight hours. Her sixth was not!
This risk of falling asleep at the wheel is not about private practice or home birth. I remember a similar near miss about 25 years ago, when I was driving home after a night shift at the Women's hospital. That experience prompted me to explore ways of keeping my mind active and functioning when driving home after a 'night out'.
What have I learnt from this experience?
When I encounter combined risk factors of distance and sleep deprivation after a birth, I will consider other ways of getting home. This could include a taxi, or another person (who has slept the night) driving, or finding a place to sleep for a few hours before heading home.
I hope this post supports other midwives in their own understanding of our work, and planning for our own safety as well as that of mothers and babies in our care.
Sunday, January 03, 2010
"We are dealing with human biology, so ...
... inevitably things will not always go to plan."
This statement is attributed to Professor Euan Wallace, head of obstetric services at Southern Health (Melbourne) in a recent special report, 'Birth Pains' in the Age.
This seemingly innocuous comment by a respected obstetrician is in fact a significant example of a major difference in the philosophy of obstetric/medical maternity care, compared with midwife led maternity care.
It's an interesting perspective.
"inevitably" - there's nothing you can do about the inevitable
"things will not always go to plan" - nothing specific to human biology there!
My comment would be, "We are dealing with human biology (in birth), so our skills and systems need to be finely tuned to working with, and not against, the natural physiological process."
Medically managed maternity care treats the birthing woman+child as a potential disaster area. Strict surveillance is relied upon, using technology rather than 'fallible' human feelings. As the woman was told in Monty Python's classic 'The Meaning of Life', she can't do anything, because "You're not qualified."
It is no wonder, under these conditions, that human biology in childbearing can not be trusted.
The midwife who is skilled in promoting and protecting normal physiological (biological) processes in the birthing continuum engages in a partnership with the woman+child/ mother+baby, and seeks to work in harmony with human biology. This midwife knows that on occasion "things will not always go to plan-A", and has plan-B within reach. But the midwife does not have a defeatist attitude: there is nothing inevitable at all about the change of plans from A to B. That's just the way it works.
In childbearing we are dealing with human life, at its most basic and most rewarding.
This statement is attributed to Professor Euan Wallace, head of obstetric services at Southern Health (Melbourne) in a recent special report, 'Birth Pains' in the Age.
This seemingly innocuous comment by a respected obstetrician is in fact a significant example of a major difference in the philosophy of obstetric/medical maternity care, compared with midwife led maternity care.
It's an interesting perspective.
"inevitably" - there's nothing you can do about the inevitable
"things will not always go to plan" - nothing specific to human biology there!
My comment would be, "We are dealing with human biology (in birth), so our skills and systems need to be finely tuned to working with, and not against, the natural physiological process."
Medically managed maternity care treats the birthing woman+child as a potential disaster area. Strict surveillance is relied upon, using technology rather than 'fallible' human feelings. As the woman was told in Monty Python's classic 'The Meaning of Life', she can't do anything, because "You're not qualified."
It is no wonder, under these conditions, that human biology in childbearing can not be trusted.
The midwife who is skilled in promoting and protecting normal physiological (biological) processes in the birthing continuum engages in a partnership with the woman+child/ mother+baby, and seeks to work in harmony with human biology. This midwife knows that on occasion "things will not always go to plan-A", and has plan-B within reach. But the midwife does not have a defeatist attitude: there is nothing inevitable at all about the change of plans from A to B. That's just the way it works.
In childbearing we are dealing with human life, at its most basic and most rewarding.
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