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
Saturday, July 30, 2011
Saturday, July 16, 2011
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]
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.
(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.
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
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.
Monday, July 4, 2011
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
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:
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
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
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