Wednesday, February 1, 2012

'Coming out' of the hospital

A colleague who is in the process of establishing a private midwifery practice wrote: "I am feeling very disillusioned with the whole hospital system at the moment. ... Women do not have choice in hospitals." 

My colleague went on to describe a couple of instances in which women who she accompanied to hospital experienced intimidation and bullying which led them to accepting interferences that they did not want, and were, understandably, unhappy with their experiences.

This midwife is a skilled, competent midwife with years of experience in hospital-based midwifery. She asked me if I think the solution to her dilemmas is to guide women into planning homebirth.  I said no, I don't think that's the answer,

Understanding normal physiological birth (Plan A) from the woman's and baby's perspective is, I believe, the key to working as a midwife, 'with woman', and without fear of the hospital. I'm not suggesting that an experienced midwife does not understand normal birth, but what I am saying is that having become acclimatised to hospital processes and rituals can diminish the midwife's focus on the woman, as she has always previously been required to work according to the service's guidelines and protocols.  As the midwife 'comes out' of the hospital, and shifts her focus from the service to the woman who knows and trusts her individually, she will become strong in her identity as a professional midwife.

Whether it's a first baby, third baby, or a vaginal birth after caesarean (VBAC), or any other situation in which the woman intends to labour spontaneously, once everyone accepts the process of spontaneous onset of labour and getting established in labour, not interfering without a valid reason,  it’s usually not difficult to go to hospital and complete the birthing there.  Plan A all the way, if that's possible at the time.

I recently wrote about vbac at the mipp blog so won’t repeat that here. Many midwives feel disillusioned with the hospital system, and they have experienced no alternative so they quickly start to feel trapped. I think the thinking of the disillusioned midwife (or student) may be too much in the framework of being part of the system in the way they want the doctors and the other midwives to work with them, such as in respecting women's 'choice'.

'Choice' is a concept that is misunderstood in maternity care. Midwives talk about 'informed choice', and become frustrated when a woman who wants spontaneous unmedicated birth is quickly put on the managed care conveyor belt, and ends up with augmentation, epidural, 'and the lot'.

A midwife who has become independent of the system, and independent in her thought processes actually has a new way of looking critically at birth and learning how to adapt her knowledge to suit the individual woman in her care. The focus of the midwife changes subtly, and she learns how to work effectively so that the wellbeing of mother and child is always first in her mind, at the same time as she uses knowledge and skill to work in harmony with, and protect, delicate natural processes. The private midwife's role takes into account the standard responses that are part of mainstream obstetric managed care, and the midwife expertly protects and guides the woman to understand how she can accept what she needs and decline, without becoming anxious or defensive, what she doesn’t.

For example, I spoke Linda (not her real name) who had achieved vbac for her last baby by just refusing everything and I mean everything – she is very (wonderfully) stubborn! Understandably Linda wants to have an unmedicated spontaneous birth for this baby too. I spoke to Linda about the various interventions that are considered standard practice in the hospital for vbac, and asked her to tell me how she felt about each one.

When we got to having intravenous (IV) access, Linda could only think about it getting in the way and being annoyingly painful when she moved her hand. Linda was interested that the IV cannula could be sited at her wrist, and she could have full movement of her hand. She came around to an understanding that it could be to her advantage, if "they" were happy for her to get on with her labour. She knows that her veins are difficult to access at the best of times, and siting the IV cannula might be something that can be taken care of in early labour rather than being a major source of interruption in the most demanding time.

Does Linda have choice in hospital? Yes. She can choose to refuse the intervention. Or, she can make an informed decision to accept an IV cannula that is positioned carefully so as not to impede her activity or movement.

This is a very simple example of how a midwife and woman work in partnership. The midwife knows and understands the system, and at strategic points gives the woman guidance that assists her in making informed decisions, and feeling she has authority for her natural birthing process.  The midwife has 'come out' of the system/hospital and is learning how to use the system to benefit her client.

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