Those who have been reading my blogs over the years probably realise that a great deal of what I write comes out of reflection on actual recent experiences in my midwifery practice. Today I want to write about a placenta.
As I sit down at the computer I am conscious of my weariness, overlaid with the 'buzz' of good cup of coffee that I have just consumed. I was called out at midnight last night; the baby was born at about 2:30; and I returned to my bed for a few hours at about 6:30. I accept this weariness and irregular sleep pattern that comes with the territory, and my heart is content and thankful to God the creator of life, because once again I have witnessed the awesome yet unremarkable event of a healthy woman giving birth to a healthy baby.
I have headed this post 'an observation of a placenta's healing property'. That's what I think I observed, and will try to document here.
Last week I attended another spontaneous birth at home. Uncomplicated; great 'outcomes'. But there was one unusual feature that set my reflective mind in action: a considerable amount of fresh bleeding during the labour. I have estimated 50-100ml in total, which is considerably more than a bloody show. It would be classed an antepartum haemorrhage (APH). The show usually comes from the cervix, while this APH must have come from the placenta.
Anyone who is familiar with my midwifery practice will probably ask, how did this baby come to be born at home? If the woman was having an abnormal blood loss, is that not an indication for transfer to hospital, continuous electronic fetal monitoring, and closely managed obstetric care?
Yes. That is what would usually happen.
The realisation of what had just happened only settled in on my mind after the baby had been born, when I went to the bathroom and saw a collection of blood-stained toilet paper not yet flushed away. When I spoke with the mother about it she confirmed that there had been a significant amount of bleeding through the labour. By the time I arrived, and she was ready to get into the birth pool, already feeling a strong urge to push, there was no bleeding; the fetal heart sounds were good; so we proceeded with the birth.
The second realisation that I had in this case was when I took the placenta to the kitchen sink, and checked it under the bright light (rather than the dull light of the birthing area).
The placenta was complete, with no unusual features. However the membranes were clearly torn into the placenta at one edge. The interesting observation I made was that the torn edges of the membranes, for 2-3 cm from the edge of the placenta, appeared to have shrunk slightly as though an astringent had caused them to pucker. [I wish I had taken a photo of this, but I didn't, so words will have to suffice].
Ummm. Interesting, I thought, and completed my check of the placenta, placed it in the bowl provided by the mother, and went on with my work.
I had not previously observed this phenomenon that I have described as astringent, or drawing together of the tissue. But as I turned it over in my mind, this is what I have wondered. The bleeding obviously came from the point at the placental edge where the membranes had torn. The bleeding did not compromise either mother or baby's condition. There appears to have been something that had an astringent effect on the torn part of the placenta and membrane, that worked to heal the tear and reduce blood flow. That is what I mean by the placenta's healing property.
Friday, October 26, 2012
Saturday, October 13, 2012
bleeding after birth
Today I am reflecting on experiences I have had with post partum haemorrhage, linking those clinical scenarios to my body of knowledge, reading reliable references that relate to appropriate interventions and drugs to treat bleeding, and applying learning to my practice.
The real test of primary maternity care is FIRST the safety and wellbeing of the mother, and SECOND the baby (even though the baby's birth usually comes first).
The aweful possibility of sudden dramatic bleeding after the birth, and what that can mean in terms of loss of life, is the spectre that hovers in the mind of many public health decision makers. The burden of such loss, particularly in resource-poor parts of the world, has led to many initiatives that seek to make changes that will protect life and reduce harm. An example is the Joint Statements on Prevention of Postpartum Hemorrhage, released in 2011 by the international peak bodies for midwifery (ICM) and obstetrics (FIGO). The key recommendation, active management of third stage of labour, is explained in the joint statement released in 2003.
Midwives (and I am one) have learnt, over the past few decades, to value our knowledge of working in harmony with natural physiological processes. The third stage of labour is one of the key challenges that a midwife faces when attending a birth. I do not fear the third stage. If that were the case I would not be suitable to continue in the work that I do.
The discussion that I have around third stage with my clients in preparing for birth always includes consideration of our plan for the management (or non-management) of the third stage. The clinical decisions that I will make in the minutes and hours immediately after the birth include my assessment of the need, or not, for drugs at that time.
Midwives around the world work this way. This is alluded to in a statement on physiological management of third stage released by ICM in 2008 and reviewed in 2011.
The midwife's skill and competency resides in protecting the woman and her baby in healthy natural birth (PLAN A), and in recognising situations and conditions that may require medical interventions such as active management of third stage (PLAN B).
At a very practical level, I understand that the physiological separation and expulsion of the placenta without excess bleeding is a process so finely tuned that it can easily be interrupted. Today's birthing community in my world has introduced all sorts of extraneous and potentially disruptive elements - clocks, bright lights, telephones, cameras, text messaging, men, children, other invited onlookers, ...
Women giving birth are not a uniform, pristine group whose bodies all function at optimal levels. Women may have internal uterine abnormalities from fibroids or procedures or terminations of pregnancy. Women may have poor abdominal muscle strength, allowing their wombs to sag excessively, and putting unusual pressure on other supportive structures. Women may be overweight, or poorly nourished. Women may be emotionally drained or have specific painful deep memories that are triggered by labour and birth. ... and so on!
So, you may ask, what's the problem? What causes uterine atony in an otherwise uncomplicated situation? Why does a woman bleed after a normal, unmedicated birth of a healthy baby (or babies)?
I won't attempt to give a text book answer here. I would encourage students who are reading this post to review your text books, while reflecting on your own experience of haemorrhage, and seeking to learn from each situation. You will need to decide, in practice, whether you follow the current recommendation of universal active management, which is not without risk, or if you are able to work competently with a woman who is intentional about natural, unmedicated birth.
I have looked through my birth register. In the past few years several of the women who I have attended have had post partum haemorrhage of in excess of 500 mls. I remember these women, and the setting of birth. I remember the (thankfully rare) instances in which we called the ambulance and transferred to hospital.
The challenge that I return to, having reflected critically on my own practice and my experiences of bleeding after birth, is to continue to practise and learn my role in protecting the natural process.
The real test of primary maternity care is FIRST the safety and wellbeing of the mother, and SECOND the baby (even though the baby's birth usually comes first).
The aweful possibility of sudden dramatic bleeding after the birth, and what that can mean in terms of loss of life, is the spectre that hovers in the mind of many public health decision makers. The burden of such loss, particularly in resource-poor parts of the world, has led to many initiatives that seek to make changes that will protect life and reduce harm. An example is the Joint Statements on Prevention of Postpartum Hemorrhage, released in 2011 by the international peak bodies for midwifery (ICM) and obstetrics (FIGO). The key recommendation, active management of third stage of labour, is explained in the joint statement released in 2003.
Active management of the third stage of labour should be offered to women since it reduces the incidence of post-partum haemorrhage due to uterine atony.Recently released 3 Centres Guidelines, confirm the practice:
Active management of the third stage of labour is recommended practice worldwide, with an anticipated completion period of 30 minutes.
Midwives (and I am one) have learnt, over the past few decades, to value our knowledge of working in harmony with natural physiological processes. The third stage of labour is one of the key challenges that a midwife faces when attending a birth. I do not fear the third stage. If that were the case I would not be suitable to continue in the work that I do.
The discussion that I have around third stage with my clients in preparing for birth always includes consideration of our plan for the management (or non-management) of the third stage. The clinical decisions that I will make in the minutes and hours immediately after the birth include my assessment of the need, or not, for drugs at that time.
Midwives around the world work this way. This is alluded to in a statement on physiological management of third stage released by ICM in 2008 and reviewed in 2011.
The midwife's skill and competency resides in protecting the woman and her baby in healthy natural birth (PLAN A), and in recognising situations and conditions that may require medical interventions such as active management of third stage (PLAN B).
At a very practical level, I understand that the physiological separation and expulsion of the placenta without excess bleeding is a process so finely tuned that it can easily be interrupted. Today's birthing community in my world has introduced all sorts of extraneous and potentially disruptive elements - clocks, bright lights, telephones, cameras, text messaging, men, children, other invited onlookers, ...
Women giving birth are not a uniform, pristine group whose bodies all function at optimal levels. Women may have internal uterine abnormalities from fibroids or procedures or terminations of pregnancy. Women may have poor abdominal muscle strength, allowing their wombs to sag excessively, and putting unusual pressure on other supportive structures. Women may be overweight, or poorly nourished. Women may be emotionally drained or have specific painful deep memories that are triggered by labour and birth. ... and so on!
So, you may ask, what's the problem? What causes uterine atony in an otherwise uncomplicated situation? Why does a woman bleed after a normal, unmedicated birth of a healthy baby (or babies)?
I won't attempt to give a text book answer here. I would encourage students who are reading this post to review your text books, while reflecting on your own experience of haemorrhage, and seeking to learn from each situation. You will need to decide, in practice, whether you follow the current recommendation of universal active management, which is not without risk, or if you are able to work competently with a woman who is intentional about natural, unmedicated birth.
I have looked through my birth register. In the past few years several of the women who I have attended have had post partum haemorrhage of in excess of 500 mls. I remember these women, and the setting of birth. I remember the (thankfully rare) instances in which we called the ambulance and transferred to hospital.
The challenge that I return to, having reflected critically on my own practice and my experiences of bleeding after birth, is to continue to practise and learn my role in protecting the natural process.
"Western practices neither facilitate the production of a mother’s own oxytocin nor direct attention to reducing catecholamine levels in the minutes after birth, both of which can be expected to physiologically improve the new mother’s contractions and therefore reduce her blood loss."
Saturday, October 06, 2012
The midwife
I have been enjoying the BBC series 'Call the Midwife', which has been shown on Australian ABC TV. This week we will see the fifth and final episode in the series.
(If you go to You Tube you can apparently download and watch the full first series.)
Since I began writing my stories in the mid 1990s, in The Midwife's Journal, I have hoped that I am setting down on the record something of the essence of midwifery, within the context of ordinary life, so that it is available to future generations of midwives, and anyone else who is interested. The discipline of writing down the stories as they happen must have been similar for the writer, Jennifer Worth, who journaled her experiences in London in the 1950s.
Last week I wrote about women's rights in childbearing. This is a very important topic, but is likely to lead to a skewed view of birth, unless there is an equal emphasis put on the midwife. The partnership of midwife and woman, working in harmony with sensitive natural physiological processes, is precious, but easily disrupted.
Just as without a strong healthy mother the baby is unlikely to thrive; without a strong, confident, and capable midwife, the woman is unlikely to progress safely along the pathway to birth: a mystery journey each time.
Today's world offers women a potentially overwhelming burden of knowledge about aspects of birth, without preparing a woman for the real job, which includes giving birth and nurturing their young. Women are bombarded with an array of mainstream and alternative treatments, for their bodies, their minds, their relationships ...
By the way, I am referring to the woman, because only the woman can give birth.
A woman (or couple) may attend childbirth education classes at a hospital, independent childbirth education, exercise classes on balls, exercise classes in a yoga studio, exercise classes in the local swimming pool, and video sessions with commentaries by consumers, professionals, and lay activists to name a few. They may follow pregnancy-birth related social media groups and forums. She may see her primary maternity care provider for basic check-ups, as well as a naturopath and homeopath and acupuncturist and chiro or osteo or any number of other therapists and healers, each of whom offer to have some part of her body in tip-top shape for the big event, but none of whom can offer what the midwife does.
I said it's a potentially overwhelming burden of knowledge about aspects of birth. I rarely see women coming to birth with calm confidence in the wonderful processes that our minds can not fully grasp no matter how hard we try. I see a father anxiously coaching the woman who is carrying his child, telling he how to move or what to relax. I wonder where he obtained this knowledge. I hear recorded voices of unknown strangers who guide visualisation of climbing a mountain or a flower opening.
One mother who gave birth about a week ago had confidence. I have been with her for several of her babies. She is a beautiful, gentle woman who invests herself fully in her family, and avoids the public gaze. Her preparation for birth included good food, adequate rest, and work about her home.
As the labour became strong this mother withdrew from her children, knowing that they were all in bed and quiet. I rested on the couch. Then she invited me into her bedroom: "it won't be long now," she told me.
Quietly and steadily she guided her baby down and out. There was a cry as the little one's head passed over the perineal threshold - the older children said they heard it. Shortly afterwards there was another cry, as the newborn took air into her lungs and made that amazing transition from placental to lung circulation. The third stage proceeded without the need for any medical intervention, and there was minimal blood loss. When I visited this mother she was sitting outside in the gentle spring sunshine. I saw a well mother, with a well baby at her breast.
In telling this story I have not mentioned the buzz word of the day: collaboration. Those in authority today will insist that collaboration is the key to safe maternity care.
Yes, there was a collaborative arrangement in place, a letter of referral from a suitably qualified doctor, enabling this mother to claim some Medicare rebate on my fees. The birth plan was, as is usually the case in primary maternity care for planned homebirth, to proceed under normal physiological conditions, working in harmony with the natural processes, unless complications were to arise. We planned to go to the nearest suitable public maternity hospital without delay for urgent obstetric concerns, or to refer to a local doctor for non-urgent medical indications. This is basic midwifery. The baby is born safely; the mother recovers quickly; all without medical (or midwifery) intervention.
Thankyou for your comments.
(If you go to You Tube you can apparently download and watch the full first series.)
Since I began writing my stories in the mid 1990s, in The Midwife's Journal, I have hoped that I am setting down on the record something of the essence of midwifery, within the context of ordinary life, so that it is available to future generations of midwives, and anyone else who is interested. The discipline of writing down the stories as they happen must have been similar for the writer, Jennifer Worth, who journaled her experiences in London in the 1950s.
Last week I wrote about women's rights in childbearing. This is a very important topic, but is likely to lead to a skewed view of birth, unless there is an equal emphasis put on the midwife. The partnership of midwife and woman, working in harmony with sensitive natural physiological processes, is precious, but easily disrupted.
Just as without a strong healthy mother the baby is unlikely to thrive; without a strong, confident, and capable midwife, the woman is unlikely to progress safely along the pathway to birth: a mystery journey each time.
Today's world offers women a potentially overwhelming burden of knowledge about aspects of birth, without preparing a woman for the real job, which includes giving birth and nurturing their young. Women are bombarded with an array of mainstream and alternative treatments, for their bodies, their minds, their relationships ...
By the way, I am referring to the woman, because only the woman can give birth.
A woman (or couple) may attend childbirth education classes at a hospital, independent childbirth education, exercise classes on balls, exercise classes in a yoga studio, exercise classes in the local swimming pool, and video sessions with commentaries by consumers, professionals, and lay activists to name a few. They may follow pregnancy-birth related social media groups and forums. She may see her primary maternity care provider for basic check-ups, as well as a naturopath and homeopath and acupuncturist and chiro or osteo or any number of other therapists and healers, each of whom offer to have some part of her body in tip-top shape for the big event, but none of whom can offer what the midwife does.
I said it's a potentially overwhelming burden of knowledge about aspects of birth. I rarely see women coming to birth with calm confidence in the wonderful processes that our minds can not fully grasp no matter how hard we try. I see a father anxiously coaching the woman who is carrying his child, telling he how to move or what to relax. I wonder where he obtained this knowledge. I hear recorded voices of unknown strangers who guide visualisation of climbing a mountain or a flower opening.
One mother who gave birth about a week ago had confidence. I have been with her for several of her babies. She is a beautiful, gentle woman who invests herself fully in her family, and avoids the public gaze. Her preparation for birth included good food, adequate rest, and work about her home.
As the labour became strong this mother withdrew from her children, knowing that they were all in bed and quiet. I rested on the couch. Then she invited me into her bedroom: "it won't be long now," she told me.
Quietly and steadily she guided her baby down and out. There was a cry as the little one's head passed over the perineal threshold - the older children said they heard it. Shortly afterwards there was another cry, as the newborn took air into her lungs and made that amazing transition from placental to lung circulation. The third stage proceeded without the need for any medical intervention, and there was minimal blood loss. When I visited this mother she was sitting outside in the gentle spring sunshine. I saw a well mother, with a well baby at her breast.
In telling this story I have not mentioned the buzz word of the day: collaboration. Those in authority today will insist that collaboration is the key to safe maternity care.
Yes, there was a collaborative arrangement in place, a letter of referral from a suitably qualified doctor, enabling this mother to claim some Medicare rebate on my fees. The birth plan was, as is usually the case in primary maternity care for planned homebirth, to proceed under normal physiological conditions, working in harmony with the natural processes, unless complications were to arise. We planned to go to the nearest suitable public maternity hospital without delay for urgent obstetric concerns, or to refer to a local doctor for non-urgent medical indications. This is basic midwifery. The baby is born safely; the mother recovers quickly; all without medical (or midwifery) intervention.
Thankyou for your comments.
Sunday, September 23, 2012
Women's rights in childbearing
I took a consultation paper on birth registration, and the latest issue of MIDIRS with me in the plane yesterday. The flight from Melbourne to Brisbane takes about two hours, which fits well with my capacity to stay focused on a topic.
The issues around women's rights in childbearing have been promoted by many writers and film makers. A multi-disciplinary international conference on human rights in childbirth was held in the Netherlands a few months ago, spurred on by outrage at developments in Hungary with relation to criminal proceedings against doctor-midwife Agnes Gereb.
Australian birthing activists are planning to meet in Sydney next month for a special meeting on Childbirth and the Law.
It seems that women and childbirth activists in the UK are learning how to demand homebirth services within their public maternity care system. Barrister Elizabeth Prochaska wrote:
The debate around women's rights in childbearing are confused and complicated by the whole spectrum of risk and professional duty of care. Women in Australia who are within cooee [an Aussie slang word for reasonable distance] of a publicly funded homebirth service will often experience extremely narrow definitions of wellness, or exclusion criteria, which make many ineligible for homebirth. For example, a woman who declines a test, such as ultrasound, or glucose, or group B Streptococcus, may be unacceptable for homebirth. Similarly a woman who indicates that she plans to decline active management of the third stage, can be excluded.
In these cases it seems fanciful to argue women's rights, when the hospital simply uses narrow risk management protocols to exclude them. They are no longer 'low risk'.
Similarly, the options for women who have had one or more previous caesarean births, are woefully inadequate. A woman planning vbac is ideally cared for in her home as her labour establishes, with a known and experienced midwife in attendance. The decisions about home or hospital birth can be made as labour progresses (or doesn't, as the case may be).
Midwifery services today use the term 'evidence based' without challenge. The exclusion of women from birth centres and homebirth programs is considered 'evidence based'. Rarely does anyone ask, "what evidence is that?"
A recent update of the Cochrane review , the centre of excellence in medical evidence, states:
An article in MIDIRS that prompted my thoughts today is titled Women's Rights in Childbearing, by Nadine Edwards. Nadine is vice-chair of the UK maternity organisation AIMS, and a director of the Pregnancy and Parents Centre, Edinburgh.
In 'Women's rights in childbearing' (Edwards, 2012), there is considerable focus on the rights of women to give birth at home unattended: free birth. The article reports that UK authorities support a woman's 'right' to give birth "without medical or professional help. ... it is legal as long as the birth is not attended or the responsibility for care is assumed or undertaken by an unqualified individual. ... the woman assumes responsibility for her birth."
Recently a young woman spoke to me about being asked by a woman to attend birth, as a doula, without a midwife being present. The limits of responsibility in such a situation are in no way defined or clear. It's clear to me that the Australian authorities will jump at the opportunity to close any opportunity for unregulated birth attendants, whatever they call themselves, to replace the highly regulated midwife. Unfortunately it will take adverse outcomes to test the limits of women's rights.
The issues around women's rights in childbearing have been promoted by many writers and film makers. A multi-disciplinary international conference on human rights in childbirth was held in the Netherlands a few months ago, spurred on by outrage at developments in Hungary with relation to criminal proceedings against doctor-midwife Agnes Gereb.
Australian birthing activists are planning to meet in Sydney next month for a special meeting on Childbirth and the Law.
Who decides how and where a baby is born? Who bears the risks of childbirth? What legal rights do women have to choose how they give birth? These are just a few of the issues that will be discussed at the upcoming Childbirth and Law Forum on Friday 12 October 2012 at Riverside Theatre, Parramatta.
The Childbirth and Law Forum will begin at 2pm with presentations from two speakers who will discuss the legal issues facing childbirth today in Australia. (Homebirth Australia press release)
It seems that women and childbirth activists in the UK are learning how to demand homebirth services within their public maternity care system. Barrister Elizabeth Prochaska wrote:
A recent case of mine shows that it is worth fighting decisions to refuse to provide a home birth (even at a late stage in pregnancy). A large London hospital suspended its home birth service for a month due to staff shortages and informed women who had planned home births that they would be transferred to hospital by ambulance regardless of whether or not they consented to transfer. AIMS put a coupe in contact with me who had been promised a home birth by the hospital. With only a few weeks before their baby was due, they decided to threaten legal action, relying on a legitimate expectation and the Ternovsky case. The hospital rapidly backed down and agreed to provide independent midwives to attend all the affected women at home. (Prochaska E. AIMS Journal, vol 24, no2, 2012, pp6-7.)
The debate around women's rights in childbearing are confused and complicated by the whole spectrum of risk and professional duty of care. Women in Australia who are within cooee [an Aussie slang word for reasonable distance] of a publicly funded homebirth service will often experience extremely narrow definitions of wellness, or exclusion criteria, which make many ineligible for homebirth. For example, a woman who declines a test, such as ultrasound, or glucose, or group B Streptococcus, may be unacceptable for homebirth. Similarly a woman who indicates that she plans to decline active management of the third stage, can be excluded.
In these cases it seems fanciful to argue women's rights, when the hospital simply uses narrow risk management protocols to exclude them. They are no longer 'low risk'.
Similarly, the options for women who have had one or more previous caesarean births, are woefully inadequate. A woman planning vbac is ideally cared for in her home as her labour establishes, with a known and experienced midwife in attendance. The decisions about home or hospital birth can be made as labour progresses (or doesn't, as the case may be).
Midwifery services today use the term 'evidence based' without challenge. The exclusion of women from birth centres and homebirth programs is considered 'evidence based'. Rarely does anyone ask, "what evidence is that?"
A recent update of the Cochrane review , the centre of excellence in medical evidence, states:
There is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women. ...
Most pregnancies among healthy women are normal, and most births could take place without unnecessary medical intervention. However, it is not possible to predict with certainty that absolutely no complications will occur in the course of a birth. Thus, in many countries it is believed that the safest option for all women is to give birth at hospital. In a few countries it is believed that as long as the woman is followed during pregnancy and assisted by a midwife during birth, transfer between home and hospital, if needed, is uncomplicated. In these countries home birth is an integrated part of maternity care. It seems increasingly clear that impatience and easy access to many medical procedures at hospital may lead to increased levels of intervention which in turn may lead to new interventions and finally to unnecessary complications. [emphasis added] In a planned home birth assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary these drawbacks are avoided while the benefit of access to medical intervention when needed is maintained. Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications.Benefits and harms of planned hospital birth compared with planned home birth for low-risk pregnant women
An article in MIDIRS that prompted my thoughts today is titled Women's Rights in Childbearing, by Nadine Edwards. Nadine is vice-chair of the UK maternity organisation AIMS, and a director of the Pregnancy and Parents Centre, Edinburgh.
In 'Women's rights in childbearing' (Edwards, 2012), there is considerable focus on the rights of women to give birth at home unattended: free birth. The article reports that UK authorities support a woman's 'right' to give birth "without medical or professional help. ... it is legal as long as the birth is not attended or the responsibility for care is assumed or undertaken by an unqualified individual. ... the woman assumes responsibility for her birth."
Recently a young woman spoke to me about being asked by a woman to attend birth, as a doula, without a midwife being present. The limits of responsibility in such a situation are in no way defined or clear. It's clear to me that the Australian authorities will jump at the opportunity to close any opportunity for unregulated birth attendants, whatever they call themselves, to replace the highly regulated midwife. Unfortunately it will take adverse outcomes to test the limits of women's rights.
Tuesday, September 11, 2012
Social Media and midwives
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| Two of my precious grand-daughters, Poppy and Amelie |
This blog site provides ample evidence of my commitment to and fascination with openly available websites. This blog is a notice board; a library; a magazine; an ongoing journal of my opinions and comments about midwifery and about life. It is also an ongoing record of special people in my life, such as the two precious little girls pictured today.
I began this blog in 2006, and it sat, unused and dormant, until mid-2007. At that time I felt a strong need to communicate with young women, particularly those who searched the internet for information in preparation for the births of their babies, and I realised I could do this as a blogger. From time to time over the years I had received emails, usually from women in other countries, thanking me for The Midwife's Journal, which they had found on my old website. A woman from Holland referred to The Midwife's Journal, which had been written at least 10 years prior (ie before the word blog existed in my vocabulary, at least), as a 'blog'.
It occurred to me then that I could continue The Midwife's Journal as villagemidwife, the blogger.
These are the headings from that new beginning [link]:
- Natural birthing in Australia today
- The culture of birthing
- Vaginal breech birth
- Who let the dads in?
- Nurture and nourishment of the newborn baby
- Paternal behaviours
- Mother-infant bonding, and maternal instincts
- Giving birth
- The life of the unborn child in the womb, and imprinting at birth
- Commenting on some of life's big moments
- Midwife for Christ’s birth
- You are free, my dove
- The homeborn newborn: how do mothers manage breastfeeding when there's noone to show them what to do?
- Protecting normal birth
- Why protect normal birth?
- Birth Trauma
The regulator for health professionals in this country has announced a review of its social media policy:
The National Boards will consult publicly on social media policy in coming months The National Boards in the National Registration and Accreditation Scheme (National Scheme) will release a consultation paper on a social media policy in October/November 2012.
A draft of the social media policy has been released as a preliminary consultation paper to targeted stakeholders for initial feedback, ahead of a wider public release. The preliminary consultation process aims to ‘road test’ the initial draft to weigh operational impact, issues or initial concerns. We are pleased that this early draft is generating a lot of interest, especially on social media. National Boards are monitoring feedback closely and will take the issues raised into account when refining the draft social media policy before it is released for public consultation on the National Boards’ websites.
If you would like to contribute feedback on the preliminary draft social media policy, please email your considerations to socialmediaconsult@ahpra.gov.au by close of business 14 September 2012. When the formal public consultation process opens, the National Boards encourage feedback from registered health practitioners and members of the community on the draft social media policy. The National Boards will publish the public consultation document on their websites, and will encourage wider distribution to seek extensive feedback.
Until then, visit the News section of the National Board websites (via www.ahpra.gov.au) for updates on past and current consultations, general communiqués from National Boards, media releases and more.
I have read the draft policy, which reminds health practitioners that in using social media, we must comply with the National Law, Advertising Guidelines and the code of conduct.
Midwives who in recent years had published testimonials at their websites have found themselves being directed to the law that prohibits the use of testimonials. Birth Stories, on the other hand, seem to be permitted.
There will be times when I have used experience from real life in my writings, and it is possible that some of those who read my accounts may at times recognise the woman, even if I have been careful not to identify her. Whether this could, in a narrowly defined mindset, be seen as a breach of privacy, is yet to be seen.
There is nothing sinister about blogging, or any other aspect of social media, per se. The medium is neither good nor bad: it's simply a medium. The content is what can be anything from wholesome and useful, to trivial navel gazing self absorption, to defamatory and destructive. The author has the ability to communicate in a way that is useful, or not. I hope to continue writing in this medium, and I hope there are readers who value the material posted and thoughts expressed.
Your comments are, as always, welcome.
Friday, September 07, 2012
availability of midwives for homebirths
Today I would like to explore a few issues around the availability of midwives to provide professional services for homebirth, and suggest what I see as a way forward.
These issues come under different headings, such as risk, cost, and practical matters such as distance the midwife needs to travel.
'Risk' - however defined - is a major obstacle. The narrow definition of risk declares that every birth carries substantial risk, and that the only responsible place for birth to take place is in hospital. This narrow mindedness is not informed by evidence or by logic.
The next level of risk puts it this way: It's OK to plan homebirth if everything is normal, and excludes significant numbers of women in the birthing population, such as those who have had a previous caesarean birth.
With the increased availability of publicly funded, hospital based homebirth programs, women who decline some 'standard' test or investigation are excluded. A woman who makes what she considers to be an informed decision to avoid exposing her unborn child to routine ultrasound is told she is not permitted to continue in the homebirth program. Similarly, a woman who indicates her desire to have an unmedicated/unmanaged third stage is told she can do that in hospital, but not at home.
Most readers of this blog probably realise that these restrictions that exist in our world today are based more on fear of birth than potential risk to the woman or her baby.
These distorted and uninformed responses to perceived risk should be discussed critically by midwives who understand the protective effect that is achieved when a well woman works in harmony with natural physiological processes. Yet midwives say very little.
These distorted and uninformed responses to perceived risk should be addressed logically and carefully by the maternity decision-makers in mainstream hospitals, providing suitable pathways for women whose risk status is not at the bottom of the ladder. An obvious pathway is that a midwife who the woman trusts is available to attend as primary carer throughout the episode of care. Yet the only place a woman can have her own midwife as her primary carer is in privately attended homebirth. Public hospitals in Melbourne seem to be more committed than ever to preventing midwives from having clinical privileges/visiting access. When midwives do attend a woman in a public hospital they often experience rudeness and disrespect towards the woman and themselves.
$$ Cost is significant in private homebirth. While the midwives need to make enough money to sustain their practices, the cost of the service needs to be acceptable to the women who employ midwives. Medicare rebates for antenatal and postnatal services are small by comparison with the fees that midwives are charging. For example, a woman in my care will pay me approximately $2,500 for the episode of care, and may receive $500-$700 in Medicare rebate. The Medicare rebate for intrapartum midwifery services is limited to hospital births with a Medicare-eligible midwife, and as mentioned, that is not an option.
The other factor in cost of private homebirth is the number of midwives. Traditionally midwives have often worked in pairs, and many of my colleagues, particularly around Melbourne, require two midwives to be booked for homebirth, bringing the expected cost of the booking to $5000 or more. A recent statement by a Sydney midwife-academic to a coroner's inquest indicated her belief that two midwives are an essential part of planned homebirth. I disagree. Strongly!
I have been told that some women who want to plan homebirth have chosen an unregulated woman (doula) as a cheaper alternative to two midwives. I cannot support this option - it scares me. I wonder if midwives who demand the 'two midwives' rule feel any responsibility for the apparently increasing rates of planned 'freebirth', either with or without a doula? A doula speaking to me recently indicated that a woman she has met is considering freebirth, "with me there just to support her".
Practical matters: the main one that comes to mind is the distance across this wide brown land. Gone are the days of the village midwife on her bike. Each time I visit a client, I am using precious fuel. Likewise, each time a woman comes to me. If a woman lives closer to another private midwife, I will always ask her to consider employing that midwife. (An exception is a few special women who I have attended on several occasions over the years. I have become a part of those families, and it's lovely to return for the birth of the next baby.)
Speaking practically, there's no reason why midwives in every town and city across this country should not be able and willing to attend women locally for birth, guiding the women as to their need to be attended in hospital, or at home. Ageing midwives like me should not be needing to drive an hour or two in our cars to get to the women.
Yet the culture of fear and distrust of birth has destroyed midwives' confidence in their own ability to be 'with woman'.
What am I saying?
I believe midwives need to take more assertive action to promote and protect normal birth, including homebirth.
These issues come under different headings, such as risk, cost, and practical matters such as distance the midwife needs to travel.
'Risk' - however defined - is a major obstacle. The narrow definition of risk declares that every birth carries substantial risk, and that the only responsible place for birth to take place is in hospital. This narrow mindedness is not informed by evidence or by logic.
The next level of risk puts it this way: It's OK to plan homebirth if everything is normal, and excludes significant numbers of women in the birthing population, such as those who have had a previous caesarean birth.
With the increased availability of publicly funded, hospital based homebirth programs, women who decline some 'standard' test or investigation are excluded. A woman who makes what she considers to be an informed decision to avoid exposing her unborn child to routine ultrasound is told she is not permitted to continue in the homebirth program. Similarly, a woman who indicates her desire to have an unmedicated/unmanaged third stage is told she can do that in hospital, but not at home.
Most readers of this blog probably realise that these restrictions that exist in our world today are based more on fear of birth than potential risk to the woman or her baby.
These distorted and uninformed responses to perceived risk should be discussed critically by midwives who understand the protective effect that is achieved when a well woman works in harmony with natural physiological processes. Yet midwives say very little.
These distorted and uninformed responses to perceived risk should be addressed logically and carefully by the maternity decision-makers in mainstream hospitals, providing suitable pathways for women whose risk status is not at the bottom of the ladder. An obvious pathway is that a midwife who the woman trusts is available to attend as primary carer throughout the episode of care. Yet the only place a woman can have her own midwife as her primary carer is in privately attended homebirth. Public hospitals in Melbourne seem to be more committed than ever to preventing midwives from having clinical privileges/visiting access. When midwives do attend a woman in a public hospital they often experience rudeness and disrespect towards the woman and themselves.
$$ Cost is significant in private homebirth. While the midwives need to make enough money to sustain their practices, the cost of the service needs to be acceptable to the women who employ midwives. Medicare rebates for antenatal and postnatal services are small by comparison with the fees that midwives are charging. For example, a woman in my care will pay me approximately $2,500 for the episode of care, and may receive $500-$700 in Medicare rebate. The Medicare rebate for intrapartum midwifery services is limited to hospital births with a Medicare-eligible midwife, and as mentioned, that is not an option.
The other factor in cost of private homebirth is the number of midwives. Traditionally midwives have often worked in pairs, and many of my colleagues, particularly around Melbourne, require two midwives to be booked for homebirth, bringing the expected cost of the booking to $5000 or more. A recent statement by a Sydney midwife-academic to a coroner's inquest indicated her belief that two midwives are an essential part of planned homebirth. I disagree. Strongly!
I have been told that some women who want to plan homebirth have chosen an unregulated woman (doula) as a cheaper alternative to two midwives. I cannot support this option - it scares me. I wonder if midwives who demand the 'two midwives' rule feel any responsibility for the apparently increasing rates of planned 'freebirth', either with or without a doula? A doula speaking to me recently indicated that a woman she has met is considering freebirth, "with me there just to support her".
Practical matters: the main one that comes to mind is the distance across this wide brown land. Gone are the days of the village midwife on her bike. Each time I visit a client, I am using precious fuel. Likewise, each time a woman comes to me. If a woman lives closer to another private midwife, I will always ask her to consider employing that midwife. (An exception is a few special women who I have attended on several occasions over the years. I have become a part of those families, and it's lovely to return for the birth of the next baby.)
Speaking practically, there's no reason why midwives in every town and city across this country should not be able and willing to attend women locally for birth, guiding the women as to their need to be attended in hospital, or at home. Ageing midwives like me should not be needing to drive an hour or two in our cars to get to the women.
Yet the culture of fear and distrust of birth has destroyed midwives' confidence in their own ability to be 'with woman'.
What am I saying?
I believe midwives need to take more assertive action to promote and protect normal birth, including homebirth.
- midwives need to think critically about risk
- midwives need to work to make primary maternity care by a known midwife affordable
- midwives need to wake up to their capacity to provide midwifery services in homes and hospitals, for all women.
Tuesday, August 28, 2012
Getting information
I have been pondering the question of how do women get the information they want in relation to their maternity decisions.
We have always talked, shared, and explored 'women's business' - in the past over the back fence, or over a cup of tea. These days it's via social networking, via the iPhone or tablet. The details of the horrible nausea, or the results of the most recent ultrasound scan, complete with picture, are updated for all one's 'friends' to see, and many check the 'like' button. Questions are asked at internet forums, and there seems to be no shortage of guides who are willing to assist the inquirer with their tried and true remedies. Women wanting to get pregnant can download their 'fertility tracker' free! (How did we get pregnant before we had fertility trackers?)
Today I entered 'nausea and vomiting in pregnancy' in a search engine, and got more than 1.3 million hits. Take your pick from ginger, vitamin B6, acupuncture, ...
The first site I went to told me that morning sickness is "generally considered to be the result of a combination of elevated oestrogen levels and low blood sugar" [that's news to me!]
So, how does someone get reliable information about a pregnancy issue? How does one make informed choices? How should a midwife advise a woman who is experiencing nausea, retching, and vomiting in early pregnancy?
Midwife academics Lisa McKenna and Meredith McIntyre published a literature review on the use of
over-the-counter medicines by pregnant women.
The authors reported that ‘preparations used included cold cures,
antihistamines, pain killers, herbal teas, antacids and laxatives – all of which
are easy to obtain … and are considered
as low risk [of causing any harm to the developing fetus].’ (McKenna and McIntyre 2006, p637) A Cochrane review by Matthews and colleagues (2010) reported a
lack of high-quality evidence to support professional advice on complementary
and alternative treatments for nausea and vomiting in early pregnancy.
I
have found in practice that many women who seek primary care from a midwife,
especially a midwife who attends homebirths, will have established patterns of
alternative health care, including self-care, which the woman may not mention unless specific questions are asked. The
scientific paradigm that midwives and many other regulated health professionals
follow in understanding evidence may not be accepted or understood by people
who follow alternative health care systems. To complicate matters even more, there are many midwives and doctors who have integrated alternative therapies into allopathic models of care.
In reviewing over the counter medicines for pregnant women, I came across the RANZCOG College Statement (C-Obs25) on evidence
supporting vitamin and mineral supplementation in pregnancy and lactation. I recommend this statement for those who are seeking reliable information on folate, vitamin B12, B-group vitamins, vitamin D, vitamin K, and minerals such as Iron, Calcium, and Iodine.
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