In the first few days of life ...

In the first few days of life ...

I have been visiting a mother and her baby - her first child - daily since the birth on Wednesday afternoon. "What's news-worthy about that?" you may ask. That's what midwives do.

This young woman and her little one are making good progress in all the developments and transitions that are normal and necessary for the continued wellbeing of each, and of the two of them as a little team.

This young woman, and her husband, felt exhausted after a sleepless night in early labour. They are still exhausted after three more nights in which the little chap has worked strongly at his mummy's breast to get the wonderful colostrum into his stomach. They tell me they haven't had much sleep. But they look wonderful! Less than 3 days after giving birth, this young woman and her infant have pretty well mastered the complex art of breastfeeding. Baby is taking his fill of milk, settling down to sleep, and waking up a couple of hours later to do it all again. Baby is strong, and that's good!

Breastfeeding is a huge challenge for a new mother-baby pair. Nurture, nourishment, bonding, wellbeing and contentment are all inextricably linked to that basic mother-skill of putting a baby to the breast, and that basic baby-skill of drawing milk from the breast.

This little one spent the first hour or so of life skin to skin, resting on his mother's chest. He made brief attempts at breastfeeding during that period, but didn't achieve much active sucking. He was born at home, and after a few hours I left him in the care of his parents. I gave the mother the standard advice, that she should feed him when ever he was awake and interested.

The next day I visited in the morning, and was told that attempts at breastfeeding had not been very successful. The little one was eagerly sucking on his lower lip and tongue. The instinct to suck was strong - he just hadn't worked out what he was meant to be sucking. With a little assistance he took the breast and stayed there, sucking strongly and consistently.

Over the next two days both mother and baby learnt from each other. The powerful intuitive forces that exist in the minds of both baby and mother brought these two together, and they worked it out. My visits brought encouragement and reassurance, but I could see that the wonderful natural processes were working well.

This is one of the great moments in midwifery - to realise that they are doing it themselves, and doing it well.



Thankyou for your comments

Birth Plan and Birth Preparation checklist

[This is the checklist that I review with women in my care at our Birth Preparation meeting at about 36 weeks]

BIRTH PLAN

A BIRTH PLAN is a guide for those who are with you when decisions need to be made.

A simple Birth Plan has two components, A and B.

PLAN A: “I am intending to give birth under my own power, and will do all I can to achieve the best outcomes for myself and my baby.”

PLAN B: “If medical intervention is recommended in order to achieve the best outcomes for myself and my baby, I need to be given the following information in order to make an informed decision:
• What do you want to do? [procedure, test, intervention, advice …]
• Why do you want to do that?
• What is likely to happen if I say 'no' - if I don't allow you to do IT?”
With this decision-making process you will only allow interventions that you believe are best for you and your baby.

BIRTH PREPARATION

(This list is only a guide – Please raise with your midwife any issues that you consider to be important)

LABOUR AND BIRTH:
1. Planned place of birth?
2. Backup hospital (for planned homebirth)?
3. Do you have a written birth plan?
4. Who do you want with you in labour and birth?
5. Information about complications.
6. Ruptured membranes and the risk of infection.
7. Options/preferences for pain management/relief.
8. Immediate contact with the baby.
9. Cutting the baby’s cord.
10. Blood loss, oxytocics.
11. Third Stage, caring for the placenta.

AFTER BABY HAS BEEN BORN
1. How long does my midwife stay?
2. Midwife’s involvement if hospital birth.
3. Assistance with baby care and breastfeeding.
4. Milk supply, meeting baby’s needs, breast fullness, expressing milk.
5. Blood loss, after pains, involution of the womb.
6. Healing of perineal tear, regaining muscle tone.
7. Vitamin K?
8. Newborn screening test?
9. Hepatitis B vaccine for baby?
10. Support at home – meals, cleaning, other children ...
11. Maternal and Child Health services? Community services and support groups.
12. Sexuality and contraception after having a baby.

Access to medical services

Midwives working in modern cities have excellent access to medical services when and if they are needed. The catchment in which most of my clients live is well serviced by public hospitals that are leaders in complex obstetrics and neonatal care. I live within a 20 kilometer radius of Melbourne's three 'tertiary' (now called Level 5) hospitals: the Women's, Monash Clayton, and the Mercy. I am also close to Box Hill and the Angliss. Within about an hour's drive I can expand my access to medical services to include Dandenong, Casey, Frankston, Sandringham, Mercy Werribee, Sunshine, and Northern. [click here for map]

In reflecting on this level of access, I am thinking of my friend and colleague Jacinta, who is working as a midwife with MSF in a very remote town in central Africa. If you click to her blog, you will read that at present the service has

"no OBS/GYN and no surgeon, so there is no-one in Aweil who can do a caesarean section. One of the other MSF OCs has a surgeon in Gogrial, a very bumpy 2-3 hr drive away, so we can transfer there BUT only between the hours of 7 AM – 3 PM due to curfews in place for security reasons."

I plan to reflect more on access to medical services, and write about it here, after I have done the postnatal visits today.


[some days later]

I have had a few attempts at composing the rest of this post, and deleted them. The reality in my world is a different reality from that of previous generations of my family, and from that of remote places in Australia, Africa, or the frozen Canadian wilderness.

If a woman in my care needs medical intervention, it's available 24/7; it's considered to be at the level of world best practice; and if there are adverse outcomes, everyone involved expects questions to be asked by peers and regulaory authorities.

Australian privately practising midwives are coming under serious scrutiny even when outcomes are good, as in the recent case of a midwife who attended a woman for VBAC (vaginal birth after caesarean) at home. That midwife has been denied the right to continue her private practice while the case is being investigated. See the post on HBAC at Homebirth Australia's FB site.
Other midwives have experienced lengthy periods of suspension or restrictions to their practices, when in the minds of their peers they have provided excellent midwifery care.

Women who are looking for a midwife in Melbourne today often ask lots of questions, “what would you do if ... (breech, twins, post maturity &c)” Those who have experienced Caesarean birth may ask the midwife under what conditions she will agree to attend HBAC.

My answer is that I don’t have a fixed answer. Decision making is an ongoing process, rather than a concept of ‘choice’. The safety and wellbeing of mother and baby are the guiding principles for every midwife. The midwife's duty of care is a different issue from the mother's autonomy over her own body. Sometimes the midwife and the mother will disagree on the best course of action – we have to live with that.


Modern society has become accustomed to Caesarean births. The national rate of Caeareans in this country is approximately 30%. There is a small but significant number of women who are strongly motivated to planning VBAC in their own homes, and their desire is to find a midwife who has the skill and the willingness to work with that plan.

The Australian College of Midwives (ACM) position on homebirth is that:

"Women have the right to choose where and how they wish to give birth. ... Whatever place of birth a woman chooses, a women and her family have the right to expect that the care she receives is provided by appropriately skilled attendants and is safe."

The difference of opinion between competing care providers for births after Caesarean is mainly in an assessment of risk. See MidwivesVictoria blog for a midwifery perspective that considers the woman and her baby to be at low risk, and midwifery care in the home to be optimal, provided the pregnancy and labour progress without complication.

Medical/obstetric care, which includes care provided in most hospital settings, considers the risk of harm to mother and baby in births after caesarean to be such that requires continuous electronic monitoring in labour. This intervention is intended to give the best possible level of surveillance, with the intention that if the baby shows signs of distress there is the option of emergency caesarean surgery. Midwives working in the home do not have continuous electronic monitoring, and rely other methods of monitoring progress and wellbeing of both mother and baby.

For more discussion on VBAC and risk, go to the posts on this blog in July and August 2010, for example, here.

With an estimated risk of 1 in 2000 for catastrophic harm (discussed here), such as death or serious brain injury to the baby from hypoxia, and death or serious haemorrhage of the mother, any midwife or doctor providing care in planned vbac must be conscious of the possibility of an escalation of complications.



Thankyou for your comments

Why I chose homebirth

This guest post was written by Miranda Davies.

Almost 3 weeks ago, I gave birth to my second child at home, a gorgeous little boy, in the bath at home, with my husband and two midwives present. It was an amazing experience that I will cherish forever.

I cannot describe how wonderful it is to be able to give birth in the comfort of your own home, at your own pace without people trying to interfere or tell you what to do. I came to understand what it meant for ‘me’ to be in charge of giving birth, no one would do it for me, which is so far removed from the concept of the Dr. or midwife ‘delivering’ the baby. Yet I was also well aware that I was in good hands if something was so come up, which meant I felt very safe.

When I first became pregnant I could not have imagined ending up having my baby at home. Homebirth sounded like an ideal situation, but we don’t have much exposure to it in our society. It is assumed that you see a Doctor and have your baby in hospital. Towards the end of my first pregnancy I watched ‘The business of being born’. It immediately clicked with me. My husband and I both thought that having a homebirth just made sense, not this time around, but in the future. The birth of my first child went reasonably smoothly with only a relatively small amount of intervention.

When we got pregnant again for the second time, we once again discussed the idea of homebirth, but were not 100% sure. We knew that we wanted midwife care; I firmly believe that for healthy pregnancies an obstetrician is overkill, pregnancy is not an illness. I also knew that the rates of intervention are significantly lower with a midwife. In 2008 a Cochrane review was published examining the outcomes of midwife compared to other models of care http://www2.cochrane.org/reviews/en/ab004667.html if you are interested.

It was only because a friend also became pregnant at the same time and was certain she would have a homebirth that it suddenly did not seem such a far-fetched idea. Given my job (as an epidemiologist) I became very interested in looking up original research papers that looked at the outcomes of planned homebirths, reasons for complications and risk factors etc. The more I read the more confident I felt about the safety side of having a homebirth.

It also became very apparent to me that many of the things that are ‘standard care’ in hospital were not things I necessarily wanted or had good evidence for doing them. I became aware that I would most likely have a battle on my hands, which really isn’t conducive to good birthing!

It was suggested that I read ‘Ina May's guide to childbirth’. I finished the birth stories section and realised I wanted my birth to be like those in the book! And if I wanted that I really needed to have a homebirth with a midwife that believed that 95% of the time pregnancy and childbirth are totally natural processes.

But how to pick a midwife? Given my background/job my main concern was a midwife who was a bit too ‘hippy’. I wanted to know that if I really did need to go to hospital the call would be made and early on. It was probably a bit of a silly concern as no midwife would put a mother or baby in harms way to maintain ‘natural childbirth’. I now attribute this thought to the media portrayal of homebirth midwives. The deal sealer for me was a connection with a girl I went to school with. Joy had been present at the birth of her daughter and also her sister’s child at home. I emailed Joy that same day and arranged to meet. As soon as we started chatting I was certain this was perfect for us, lucky for me my husband agreed!

I had my first antenatal appointment at 24weeks. It was in stark contrast to any appointment I had had in hospital. Firstly it was about an hour long and in the comfort of Joy’s home. I didn’t wait for an hour with 30 other pregnant women just to be rushed through with a quick ‘how are you feeling?’, blood pressure check, measure and heart rate check. My appointments weren’t filled with comments about me being either ‘too big’ or ‘too small’. They were a time where Joy and I got to know each other, we chatted about all manner of things, feelings, fears, statistics, certain protocols and philosophies. These are the things that are important, yet are things that are now lost. Busy Obstetricians and midwives don’t have the time to sit and really get to know you and what you want, there is only time to tick all the necessary questions and tests off the list.

Choosing an independent midwife and homebirth really are no brainers. You get the continuity of care through your pregnancy, labour and post-natal period. Having experienced both sides of it, I can tell you the level of care is far superior. You have someone who comes to your house when you are in labour, brings all the medical gear for if something crops up and more importantly has the experience and knowledge to let you know its all going fine and that you can stay at home or that maybe something isn’t going as expected and it is time to go to the hospital. There are no strangers and no shift changes. There is no pressure to ‘deliver’ a certain way, to get out of the pool, to have your waters broken or that IV put in. No one is telling you ‘your baby is not in an optimal position’ or you are ‘ONLY 3 cm’ neither of which are helpful. A wonderful thing that Joy said to me was ‘if you make it an issue it will become one’ very wise words that in many ways can bear weight to the high intervention outcomes of childbirth we see today.

I am not a crazy hippy, I did not have a terrible first birth, and I’m not anti the medical establishment. I went to university and have a PhD epidemiology and biostatistics. I like to research the choices I make in life and like things to be backed up with strong evidence. I feel like I am one of the few that know a secret. Being able to give birth your way, at your pace, free of inhibitions so you can get into your ‘labour song’ (as Janie called it), in a location you feel safe in, with people you already know and trust, is probably the most amazing and empowering thing a woman (and her partner) can ever do.

If even a small part of you thinks you might like care from an independent midwife and/or a homebirth, I say go for it, you wont be disappointed.



Thankyou for your comments

Action on maternal mortality in developing countries

Talk point: Maternal health - can MDG5 be achieved by 2015?

A global shortage of midwives is reducing the chances of countries hitting millennium development goal 5 to reduce by three-quarters the maternal mortality rate. Tell us what you think about maternal and child health, and the progress of the MDGs

Click on this link to guardian.co.uk for an insightful series of videos addressing maternal death rates and maternity care in Africa and Nepal.


A midwife from Melbourne, who is working with MSF in the African country of South Sudan, wrote recently:

"In the short time I had been in Aweil, I had seen more miscarriages, more stillbirths, more premature births resulting in death than in my 8 years as a midwife in Australia. I was faced with doing things that caused me so much distress and heartache. To balance this somewhat, I have seen more twin births (nearly all of them vaginal) here than in Melbourne – it seems to be a norm in Africa, maybe to balance all the other babies who die. It is difficult here – for all who live here – and part of the work is to try to get women to the hospital sooner so that their bodies, which are already so depleted in so many ways, are not left recovering with no baby, as they have stayed away too long. This is all too familiar a story. They are in labour for 3-4 days at home, they come to us with a baby that’s already dead. There are also many who come with their babies still alive but then they seem to give up right at the end and we can’t resuscitate them. It is normal for there to be meconium stained liquor. Too many dead babies…The women have many pregnancies, and their bodies don’t often have time to recover before they’re expected to be pregnant again. So, we are also looking to do education in antenatal clinics, trying to encourage women to come earlier to the hospital."

Thankyou for your comments

Transfer from home to hospital

A transfer from planned home birth, to hospital, can bring challenges to both the mother and the midwife, testing the partnership and trust between them.

From time to time, and at times unexpectedly, I need to arrange transfer to hospital. Being able to transfer care, without anxiety, from midwife-led primary care in the woman's home, to medically supervised specialist care in hospital is one of the most basic 'acts' that a midwife must be able to carry out in protecting the wellbeing of mother and baby.

Midwives working in hospital-based homebirth programs, and even birth centres, have a strict set of rules to follow. Any clinical finding that could be interpreted as an unacceptable 'risk' (such as previous caesarean surgery) or an escalation in 'risk' for mother or baby (such as meconium stained liquor) means that the midwife has no choice other than to follow the risk management process set down by the hospital.

Midwives working independently, in a private employment relationship with each woman, are able to consider the situation more broadly. This does not mean that midwives practising privately are unconcerned about risk. But it can allow a more holistic (whole-person) assessment of the situation, often meaning that the woman who is considered unacceptable for 'low risk' hospital-managed models (homebirth or birth centre) is able to proceed without any complication to giving birth to a healthy baby in her home, in the care of a midwife.

A publication that has guided and informed my practice in a significant way since the mid-1990s is the World Health Organisation (WHO)'s Care in Normal Birth: A Practical Guide (1996).

This paper does not primarily deal with the issue of 'home birth' or 'hospital birth': it focuses on 'normal birth'. That's a really important point. If birth is normal, the place of birth is of little consequence as long as the mother's and baby's needs are met. The midwife is fully able to attend such a birth, providing appropriate care.

The WHO (1996) paper provides a clear discussion of the 'Risk approach in Maternity Care' (p3), stating that

"An assessment of need and of what might be called "birthing potential" is the foundation for good decision making for birth, the beginning of good care. What is known as the "risk approach" has dominated decisions about birth, its place, its type and the caregiver for decades now (Enkin 1994). The problem with many such systems is that they have resulted in a disproportionately high number of women being categorised as "at risk", with a concominant risk of having a high level of intervention in the birth. A further problem is that, despite scrupulous categorisation, the risk approach fails signally to identify many of the women who will in fact need care for complications in childbirth. By the same token, many women identified as "high risk" go on to have perfectly normal, uneventful births."

The picture of the process of ongoing decision making in the birth process is described in some detail, including this series of highlighted paragraphs:

"Risk assessment is not a once-only measure, but a procedure continuing throughout pregnancy and labour. At any moment early complications may become apparent and may induce the decision to refer a woman to a higher level of care." (p3)

"We define normal birth as: spontaneous in onset, low risk at the start of labour and remaining so throughout labour and delivery. The infant born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth mother and infant are in good condition.
However, as the labour and delivery of many high-risk pregnant women have a norml course, a number of recommendations in this papeer also apply ot the care of these women." (p4)

"In normal birth there should be a valid reason to interfere with the natural process." (p4)

In recent years I have perceived a strong movement by the birthing consumer movement in this country, whereby a woman's 'choice' has become the guiding principle in calls for better maternity care. Choice that is not balanced by the critical judgment of a skilled midwife or other professional can be more dangerous than Russian roulette. A midwife cannot provide optimal maternity care if the woman's choice is more important than any other factor.

A woman giving birth has only one real choice: to either do it herself, or to submit to the medical care available. If there is a valid reason to interfere in the natural process, the midwife is bound to advise that intervention, even when it clearly goes against the woman's 'choice' or wishes.

This is often the situation when a midwife recommends transfer from home to hospital.

One of the key principles articulated by midwives in practising privately for planned home birth addresses the time of transfer:

"We support seamless and reliable processes by which midwives are able to make hospital bookings for women planning homebirth, and arrange transfer to the hospital in a timely way when needed."

[APMA Position Statement on Planned Home Births with a Midwife]

Thankyou for your comments

A new book from Michel Odent - part 2

[Continuing on from the previous post]

Having now finished, and enjoyed this book, there's one additional point I would like to explore. It's a small detail.

In the epilogue, Odent indulges in some fanciful thoughts about childbirth in the land of Utopia, January 2031. [That's only 20 years from now, and my grandchildren may be having babies at that time!]

This chapter has appeared previously in Odent's newsletter, and republished with permission at the midwivesVictoria blog in 2009.

My interest in this utopian dream was piqued by a question "What if the prerequisite to be qualified as an obstetrician would also be to have a personal experience of giving birth without any medical intervention and to consider birth as a positive experience?"

... at which time the participants in this utopian scenario all shouted "Eureka!"

Odent has previously proposed this prerequesite for the authentic midwife. It's idealistic, but fascinating.

My response, which may be influenced by personal bias, culture, and anything else, is to immediately say "no way!" as far as obstetricians are concerned.

Obstetricians should perhaps be required to have major abdominal surgery after 36 hours of sleepless activity, then be required to tend to a little creature who needs all that a newborn baby needs. Even that would not start to mimic the emotional/hormonal cocktail that a new mother experiences.

A midwife is 'with woman', bringing a special partnership to the childbearing event that allows the woman to proceed under natural physiological influences without fear. This allows her body to do whatever it needs in the growing and birthing and nurturing of a baby.

There is no similar concept of 'partnership' in medical/obstetric ethics or standards. The doctor/obstetrician is required to be an independent thinker, who brings special surgical skill to births that would not do well under natural physiological processes. The doctor is not there to be 'with' the woman.

For this reason I reject any suggestion that the obstetrician in the utopian setting would be someone with "a personal experience of giving birth without any medical intervention and to consider birth as a positive experience." Indeed, if an obstetrician had that level of experience, I would suggest that obstetrican could also be admitted to the profession of midwifery.



Thankyou for your comments

A new book from Michel Odent

I am, once more, enjoying a book written by Michel Odent, the French doctor who has contributed an enormous amount to my understanding of the physiology of normal birth.

Last week I sat in a workshop and listened to Michel speak, without notes or anything remotely modern, such as a data projector, for three hours. It required a lot of concentration to understand his accent, which seems more 'French' than it was a few years ago, the last time I heard him speak. There was also a problem with the microphone, which didn't help. I chatted with him at lunch time, and he autographed my copy of his new book.

This octogenarian champion of birth physiology is not going to please many of his readers all the time. For instance, he has come down hard on the natural childbirth movement, for its penchant for birth videos, its teachings about 'support', its masculinization of the birth room, and much much more. You will have to read the book to get the full picture. Here is a brief quote from p47-48:

Language is a specifically human stimulant of the [neo]cortex. This implies that in situations associated with intense activity of archaic brain structures, such as giving birth, exposure to language should be avoided. ... Of course, after thousands of years of culturally controlled childbirth, silence as a basic need cannot be accepted overnight. It is all the more difficult today since many theories that are at the root of 'natural childbirth' movements have reinforced a deep-rooted cultural conditioning and have introduced to the birthing place a guide (a 'coach') who does not hesitate to use language.

There are statements that will not please midwife intellectuals and researchers, particularly his apparent uncritical acceptance of recent publications such as the meta analysis by Wax et al (2010) which report increased adverse outcomes for women at low risk who plan home birth (see p60). This study has been strongly criticised for its methodology and conclusions.

When reading this book I detect an idealism that seems to suggest that all women will be fine if only they can progress within an appropriate setting that is silent, unstimulating, free of husband and other onlookers, free of language, and with a midwife who is knitting in the corner. There seems to be an avoidance of recognition of the midwife's role in detecting complications and accessing appropriate specialis care when progress is abnormal. I am willing to understand this apparent bias as an assumption that readers already know about such matters.

There is a very interesting discussion around the phenomen of two midwives attending a birth together. This practice is widely promoted in Melbourne by hospitals and independent midwives: indeed some of my colleagues have told me that they consider it unwise and possibly unsafe for me to attend a birth as a solo midwife. Don't I know there could be two people needing my attention at once?

Another obstacle is a deep-rooted tendency to introduce without any caution several people around the labouring woman. This tendency is as old as the socialisation of childbirth. In many societies one of the women around plays the role of the midwife, often accompanied by relatives or neighbours. Traditionally the midwife is an autonomous, very independent person. There are proverbs, in places as diverse as Persia or SOuth America, claiming that the presence of two midwives makes the birth difficult. In Persia, they used to say: When there are two midwives, the baby's head is crooked". (p63)

A further comment in the context of people who have been introduced into the birthing room:

"The doula phenomenon is such a sudden international phenomenon that it must be analysed and interpreted in the context of the twenty-first century." (p 63),

and

As long as the studies [about doulas] were conducted in low-income Hispanic populations [in the US], the statistical results clearly confirmed the positive effects of the presence of a doula. The findings were different in the context of middle-class American populations, ... where the presence of a doula had no impact on the rates of caesarean deliverise and other operative deliveries." (p64)

I have not yet finished reading 'Childbirth in the age of plastics', but wanted to get these comments up on the blog pronto!


Thankyou for your comments

Vernix

Vernix covering the face of a precious newborn baby

After every birth I find something of value upon which to reflect. It may be something unexpected, or it may have been the ordinary-ness of the whole event. Ordinary, yet extra-ordinary. It may have been something about myself, and my personal ability to fulfil the role of midwife. And my reflective review may take place at several different levels.

I love returning to homes as midwife for the second time, and more. It's a wonderfully privileged place for me. The mother knows me, and I know her, in a deeper way than the first time 'round.

The picture in my mind now is a mother whose second baby is nursing contentedly, naked against her warm, naked breast. It's a mild autumn day outside, with some light rain, and occasional sunshine. We are in the bright, airy room that is a closed-in verandah at the rear of the house. The setup is very much the same as it was three years ago when this mother gave birth for the first time.

I had been called out a few hours earlier, and had worked with the mother; my few words and actions being carefully chosen to act in hamony with the wonderful natural process that was progressing and unfolding. But that's another story. Today I am thinking about vernix. The little one of today's reflection was born with thick slathers of the white creamy substance on her back, and sizeable globs of it in the water of the birthing pool.

I know I'm not the only midwife who is fascinated by, and has a special love for, vernix. Not the vernix on the baby's skin. That stays there, and has often disappeared, apparently absorbed by the baby's and mother's skin, when we take another look at the baby after a couple of hours. Water birth has made the vernix that has separated from the baby more accessible than it used to be. The vernix in waterbirth floats to the surface of the water, while in conventional births this vernix ends up on the absorbant under-sheet with amniotic fluid, blood, and anything else that issued from the mother's body at the time of birth.

I don't know if it's an old wives' tale, but I heard a long time ago that midwives in France would collect vernix for use in the cosmetic industry. A blob of vernix is, to me, an attractive little bonus to glean when all the hard work of birthing has been done. I scoop up a bit of it, and apply it, usually to my arms. A few years ago I was conscious of a small scaly patch of skin that had been for some time on my forehead, and I rubbed vernix into it. Having grown up in the Queensland sub-tropics, sun exposure has left my skin with some damage. The skin healed over soon after.

It's likely that any readers who are interested enough to read a post about vernix will also use an internet search engine and see what comes up. That's how I came upon a very interesting, comprehensive paper:

Vernix Caseosa: The Ultimate Natural Cosmetic?
By: Johann W. Wiechers, PhD, JW Solutions; and Bernard Gabard, PhD, Iderma
Posted: August 31, 2009, from the September 2009 issue of Cosmetics & Toiletries.

The authors of this paper also state that "rumor has it that midwives apply some of the vernix caseosa they remove to their own hands, rendering them soft and well-hydrated."



Your comments are, as always, welcome.

Midwife-blogger

Midwife-blogger is the title of my presentation to be given at the global 24-hour Virtual International Midwives Day webinar, Thursday 5th May, hosted by midwife Sarah Stewart in New Zealand.

I have been maintaining midwifery blogs since 2006, with the aim of recording and sharing midwifery skill and knowledge, promotion of normal birth, and making critical comment on current issues in maternity care.

In the mid-1990s, as I was establishing my private midwifery practice, I kept a hand-written journal with photographs and other mementos from many of the births I attended. This journal became the source for the chapters of ‘The Midwife’s Journal’, which has been a section of my website since 1997. The Midwife’s Journal was my first attempt to use electronic media. I sought to write about my personal journey through the terrain of childbearing, rather than make a record of birth stories.

Blogs and web-based books such as The Midwife’s Journal are readily translated into e-books. My two midwifery e-books are Midwifery from my heart, published in 2010, and Mother Daughter and Midwife, published in 2011. I have more e-books planned.

I would like to encourage midwives to use reflective writing as an aid to developing a strong midwife identity, and in processing both the joys and challenges and sadnesses that we face on a daily basis. A blog can be set up with open access, or to be accessed only by those who the owner permits. Privacy issues must be considered, of course.

Today I have received a very special email message from a young woman in London. This is what she wrote:

I wanted to send you an email and whilst searching for your address I came across the beautiful birth story you wrote about me in your journal (Homebirth Far From Home). I am so grateful you did that as it brings back such wonderful memories, and makes me so proud. Thank you.

The reason I wanted to email you was to let you know that I have just completed my midwifery training and will be starting a job at Kings College Hospital in London in June. I chose to apply KCH because of their 7% home birth rate (one of the highest in the UK) and the strong philosophy that permeates their care in keeping birth normal.

I know I have said it before but I wanted to let you know what an inspiration and role model you have been to me on this journey. Although we live on opposite sides of the planet, and [her son's] birth was over 12 years ago I still feel that you have played a strong part in my success at starting and completing the rewarding but often challenging training involved. You have also influenced my every day practice and my belief in the power of women to birth their babies as they choose.

With much love and respect,
[name]

Dear reader, can you imagine how wonderful it is to receive this letter?

I have just now gone back to the account of 'Homebirth Far From Home', and my eyes are moist as I recall that beautiful young woman giving birth confidently to her strong and healthy child. I feel totally privileged to know that my brief role with her more than 12 years ago has contributed to the development of a new midwife who is about to set out on her professional career.

As women give birth to their babies, midwives beget baby midwives.

Midwives who are reading this, let me encourage you now to treasure every experience you have when being 'with woman'. One of those women may, with your support, begin or progress in the journey towards becoming a midwife herself.



Thankyou, dear reader, for your comments.

Shared antenatal care at the Women's

Changes that are being implemented in midwives' practices, with the availablity of Medicare funding (I am still being patient - I have not yet received notation as eligible for Medicare), have led me and some colleagues to apply to be recognised as Shared Care affiliates at public hospitals. I have recently received my certificate from the Women's. Click here for more detail on Shared Maternity Care.

General practice doctors who have qualifications in obstetrics (GP-Obs) are usually the providers of Shared Care at public hospitals. The Shared Care Affiliate provides regular check-ups, and orders blood tests and other investigations for women who are planning to give birth at the hospital. The Shared Care Affiliate does not usually have any involvement in the acute care, from onset of labour to discharge of mother and baby.

Shared Care with a midwife at the Women's is available for women who live in the catchment area. It is possible that, with Medicare rebates for antenatal and post natal care, some women will choose to have their antenatal and postnatal visits with a midwife, without having the expectation that the midwife will also attend them in labour. However, midwives who provide primary care are, by definition, committed to working with a woman through the continuum or pre, intra, and postnatal care. When a midwife is a Shared Care affiliate at a hospital, she is also able to provide midwifery care during labour at home, to attend hospital and be 'with woman' through the birth, and support the amazing transitions that a mother and her baby go through in the early days and weeks after birth.




Thankyou for your comments

Homebirth, freebirth, and doulas ... a broken maternity system

The latest issue of Women and Birth, the journal of the Australian College of Midwives, contains a paper by midwife academic Hannah Dahlen and two colleagues, M Jackson and J Stevens, titled:
Homebirth, freebirth and doulas: casualty and consequences of a broken maternity system.

First MOTHERBABY group gathering for 2011

We sat around the table thismorning with cups of tea and glasses of water and listened to each other. What a delight it is to welcome a new baby into our world, and today we welcomed three into our little group. Arwen, Matthew, and Scarlett are pictured here with their mothers.

Reflecting on midwifery practice

Matilda is on the ball!  (it's never too early to prepare for good birthing)

In preparing for my recent professional practice review, I was able to identify several incidents in which I believed it was important for me as the midwife to act within my professional skill to ensure the safety and wellbeing of the mother and/or baby. In other incidents I engaged collaboratively with specialist maternity care providers, also with the goal of ensuring safety and wellbeing.

'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.

Reviewing the past couple of years

To Daddy

A couple of years ago the federal Health Minister announced a Maternity Services Review, declaring that the government intended to provide “More Choice in Maternity Care – Access to Medicare [funding] and PBS [prescribing] for Midwives”. The monopoly of government funding for maternity care being available only for services provided by doctors and hospitals was to be broken.

Midwifery exam, 1973

click to enlarge

I found this exam paper when going through an old file.
I read through the questions, and this is what I noticed:

• Questions on breech presentation: diagnosis, ECV, indications for Caesarean section, and foetal risks associated with [vaginal] breech delivery.
• A question on [vaginal] delivery of the second twin.
• Questions on anaemia, fundus not equal to dates, varicose veins, onset of second stage, increasing parity, indications for forceps, polyhydramnios, placenta succenturiata, inversion of the uterus, and infants with sticky eyes, thrush, physiological jaundice, and cephalhaematoma.

Global Forum, Day 6

Spring roses in our garden

For the online discussion, click here.
Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum.

Today's question: Over the weekend we would like you to continue to discuss the question:

“If Traditional Birth Attendants are available, what practices or tasks should they undertake to reduce maternal and neonatal mortality and morbidity?”

Global Forum, Day 5

For the online discussion, click here.
Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum.

Today's question:

“If Traditional Birth Attendants are available, what practices or tasks should they undertake to reduce maternal and neonatal mortality and morbidity?”

Global Forum, Day 4

For the online discussion, click here. The forum community is continuing to grow with 624 members from 86 countries!
Optimizing the roles of health workers to improve MDGs 4 and 5 discussion forum.

Today's question:
Today we will continue to discuss the role of the lay health workers. However, we would like you to elaborate more on the specific issues below:
- What wider social roles, such as promoting female empowerment, should lay health workers take on in communities?
- What approaches that have been used in different settings to motivate and retain lay health workers, to improve the quality of the services they deliver and to promote the delivery of high priority services for maternal and newborn health?