Friday, December 31, 2010

'hands-off'?

I don't know who first came up with the idea of the 'hands-off' midwife: the midwife who has a good set of hands and knows how to sit on them.

Midwives are not universally 'hands-off' when we should be, nor are we always 'hands-on' when we ought to be. That latter point is what I am attempting to write about today.


Midwives in the early colonial Melbourne town were disliked by the medical establishment for being "meddlesome midwives" (from memory, that's from Janet McCalman's Sex and Suffering - my copy has been borrowed!) In the early 1800s, germs were poorly understood, and the safest birth was indeed one that proceeded spontaneously without any 'hands-on' 'help', particularly when the hand entered the woman's body, from any sort of attendant. That truth has not changed, despite knowledge of sepsis, anti-sepsis, asepsis, and antibiotics.

A long time ago, about 2000 years ago, a Chinese teacher Tao Te Ching wrote:
You are a midwife.
You are assisting at someone else's birth.
Do good without show or fuss.
Facilitate what is happening rather than what you think ought to be happening.
If you must, take the lead.
Lead so that the mother is helped, yet still free and in charge.
When the babe is born the mother will rightly say "We did it ourselves."

In summary, a midwife will be 'hands-off', and not interfere in normal birth, without a valid reason.

A similarly long time ago, a Greek physician named Soranus, in the first century AD, wrote
What persons are fit to become midwives?
This paragraph is of use to prevent fruitless work and the teaching of unfit persons too accommodatingly. A suitable person will be literate, with her wits about her, possessed of a good memory, loving work, respectable and generally not unduly handicapped as regards her senses, sound of limb, robust, and, according to some people, endowed with long slim fingers and short nails at her fingertips. ... Long and slim fingers and short nails are necessary to touch a deep lying inflammation without causing too much pain. This skill, however, can also be acquired through zealous endeavor and practice in her work.



There's something special about a midwife's hands, isn't there?
[Any midwives reading this, how do you rate?]

It seems clear to me that the hands of a midwife, and the use or non-use of our hands, have always been significant to midwife's role in being guardian of the next generation of the human kind.

In today's world, a midwife's hands may not only touch, massage, palpate, measure, press, assess, and receive; but it's the hands of midwives that attach labouring women to any number of plastic tubes coming out of orifices, natural or artificial; that link women's labouring bodies to machines and pumps and monitors; and therby inhibit the natural workings of that woman's body in giving birth to her baby.

In a society that boasts at least 30% caesarean rate, midwives assist doctors in the surgery and postnatal nursing of women and their babies.

It would be irrational and unsafe for a midwife, in attendance at a caesarean birth or in the hours and days following, to try to be 'hands off'.

It is also irrational and unsafe for any midwife, at any time in the birthing continuum, to have a 'hands-off' philosophy when complications have been detected.

Does that ever happen? you ask. Yes.

There are times when the mother's plan for 'natural', physiological birth seems to over-ride professional clinical decision making. I have seen this happen in hospitals, when there are clear indications of complications, such as antepartum haemorrhage, post maturity, meconium stained liquor, poor progress - all at the same time.

When a labouring woman, with recognised complications, is resisting the surgical pathway that is becoming increasingly more reasonable over time, the midwife's duty demands courage and integrity on the part of the midwife. It's not easy to say to a woman, who has consistently planned and prepared for 'natural' birth, that 'natural' is no longer a safe choice. It's not easy to say to a woman who has rejected previous advice by doctors or midwives, that her situation is becoming more complex, and surgery appears to be the only reasonable option.

It's not easy for a midwife to challenge another midwife who appears to be ignoring indications for obstetric referral and transfer of care.

As long as a woman and her baby are well, they have 'Plan A' as the most reasonable option for labour and birth. 'Plan A' is DIY - do it yourself. There is no call for intervention, or for frequent monitoring, or for guidance, or anything else by the midwife in 'Plan A'. That's the 'hands-off' time for the midwife, who retreats into the shadows, and either sits on her hands or gets on with her knitting.

But when the woman or her baby has crossed the 'wellness' line - when the midwife detects abnormality, or complication: that's the time to get active, and facilitate the safe and effective birth of that baby in the most appropriate manner. There is no time then for 'hands-off'.

Midwifery is not about what's easy for the midwife or the woman. It's not about following birth plans or lists of preferences. The midwife's relationship with the woman, a partnership, must always enable objectivity and professional clear thinking by the midwife. The midwife should have the courage to challenge the woman, and continue to challenge if necessary, if the woman does not understand the implications of her chosen care plan. As Dr Soranus said, the midwife should be "with her wits about her".

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