Tuesday, October 25, 2011

what are the boundaries for homebirth midwifery practice?

The short answer:
"I don't know."
The midwife purist answer:
"I am 'with woman', not 'with' or committed to a setting for birth or a model of care. The midwife is able to provide primary maternity care throughout the continuum for any woman who proceeds spontaneously through pregnancy, birth, and the postnatal period, and to advise on potential complications and refer the woman to specialist services if the need arises."
The midwife pessimist answer:
"I must restrict my practice to 'low risk' women, or I am likely to face complaints and even suspension of my registration, and loss of my ability to earn a living while complaints are investigated."
My answer:
"I'm not prepared to define boundaries. I am willing to explore possibilities with any woman who asks me."
For example:
"I am starting the process of looking for support for a home birth. My first two children were born via c-sections (breech, then a failed hospital VBAC). I am wondering if HBA2C something that you can support?"

Similarly, a colleague midwife called me to discuss her client whose pregnancy has now gone past 42 weeks. Is it 'safe' (for the mother, the baby, and the midwife), to proceed with a plan for homebirth after 42 weeks?

Am I being evasive, even dishonest, in saying that I do not want to give a yes or no?  I don't think so.

Here's what I hope to achieve:
  • Optimal outcomes, and the best level of care possible for each mother and baby.  I surely do not want any adverse outcomes. 
  • Each mother feeling safe, and confident in making decisions as her pregnancy-birthing journey unfolds.
  • Each mother feeling respected, even when and if the journey leads her on a pathway that she would not have chosen.

I acknowledge that the only place where I can act as the responsible professional care giver is, at present, the woman's own home.  Hospital visiting access for midwives is 'in the pipeline', so to speak, but I'm not holding my breath. 

I have attended many women in labour after Caesarean birth.  Some have given birth spontaneously at home, while others have transferred to hospital for the birth.  Some of the hospital births have been spontaneous, and some assisted medically, physically, or surgically. 

The confidence I need to have in each woman and baby, as they progress in pregnancy and labour, and in the crucial moments and hours after birth, is "Are you well?"  "Is the mother well; is the baby well?"

When the answer is "Yes", I can be confident to continue under natural, physiological processes.

When the answer is "No", or "possibly not" or even "I'm not sure", I must move into a new state of alertness and planning, and inform the mother as to my recommended plan of action.  That's the only way a mother can make an informed decision.  I can't make the decision for her.  Her husband can't either, although of course there is often a shared decision-making process entered into willingly by the woman.

Midwives have often said that we sit on our hands.  We refrain from all unnecessary interruption, interference, and intervention, as we observe a labouring woman.  Our skill is in enabling and encouraging the woman to continue working with her own body.  However, a capable midwife also recognises when intervention is required, and acts confidently and appropriately.  The non-interventionist intention of a midwife must always be balanced by skill and knowledge, and an ability to act in the interests of mother and baby when indicated.

Returing to the question: "I am wondering if HBA2C something that you can support?"
Yes, it is.  My role as a midwife is to be 'with woman'.  If that woman makes an informed decision to plan homebirth, and asks me to be with her, I can support her plan.  However, in accepting the role as midwife to that woman, I am not committing to home birth, or even to natural birth.  Those decisions are yet to be made, and will be made by the woman as events unfold.

And the other question, "Is it 'safe' to proceed with a plan for homebirth after 42 weeks?"

For some women it is, and for some women, definitely not.  I must advise the woman on her own position, to the best of my ability.  I encourage the woman to listen to other voices of expert advice: the doctor at the hospital where she has a booking, for instance.  The woman must make the decision that she considers best at that point in time.

Thankyou for your comments

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