Prescribing

It was reported last week in the Australian that

Midwives still await PBS script training

by: Adam Cresswell, Health editor

From: The Australian April 20, 2012

MIDWIVES have not written a single prescription under the Pharmaceutical Benefits Scheme, nearly 18 months after they were supposed to begin, because no training courses exist to teach them safe prescribing.

Link


There are approximately 200 midwives nationally who have achieved eligibility for Medicare (MBS) and pharmaceutical benefits (PBS) - 'prescribing'.  Each of these midwives were required to sign an undertaking to the Nursing and Midwifery Board that we would
"undertake, and successfully complete, within 18 months of recognition as an eligible midwife:-

1. an accredited and approved program of study determined by the Board to develop midwives' skills and knowledge in prescribing; or
2. a program that is substantially equivalent ...  

A few midwives have completed university courses that have been accepted as 'substantially equivalent' to such an approved program of study as determined by the Board.  They have completed courses that have been accredited and approved for Nurse Practitioners, and submitted a comprehensive 'mapping' of the course against the standard set by the Board.

Many midwives, including yours truly, are waiting for (1) an 'accredited and approved program of study' before launching into this endeavour.  It is unlikely that midwives who have not commenced their course of study within 6 months of receiving notation as eligible for Medicare will be able to complete their courses within the required 18 months of recognition. 

protecting and enhancing the chance of a natural birth

Today I received a message from a midwife who has read some of my blog thoughts, who has asked me:

What do you think are the most important rules for protecting and enhancing the chance of a natural birth?

Where do I begin?

Perhaps there are no rules.

Rules tend to exclude some, and anyone who has been with woman will know that when a woman discovers her own strength, she seeks to organise her life so that she will not be denied that potential when she is at the peak of her labour. Perhaps the only 'rule' is an active decision making process that has the wellbeing of mother and baby at its centre.

There is no safer or more satisfying, fulfilling way for most women to give birth than to proceed as far as they reasonably can without medical or surgical assistance. Years ago, when I was experiencing my own intellectual awakening to the wonderful potential of our bodies in bearing, birthing, and nurturing our babies, I read some reports on birthing from the UK Health Department. One of the messages these reports promoted was that women want the 3C's: choice, control, and continuity.

Yes, I agreed!

So I worked hard to promote choice, control, and continuity in maternity care. But as I explored my own practice, and the midwifery literature, I have had to re-think each of the 3C's.

Choice is very limited. There is really only one choice: to promote health and intentionally work in harmony with the natural processes - this is what I call 'Plan A'. Any other notion of choice has little connection with reality.

Control must be relinquished. The only way most women can progress without medical assistance in the most demanding part of labour is when they surrender the neo-cortical thinking, relinquishing mind control to the powerful hormonally mediated intuitive processes within their bodies.

Continuity is an ideal that cannot be guaranteed. I mean real continuity of carer, with the midwife primary carer who is personally committed to the individual woman and who forms a partnership based on reciprocity and trust with that woman. This is the way I try to work, and with a very small caseload, I have been privileged to attend almost every birth that I have been booked for. But it is idealistic. I have been blessed with a robust body and good health. I won't labour this point. I recognise that mainstream publicly funded maternity services will need to trade off some of the idealism of continuity for the realism of sustainability.

So, dear reader, what rules are there to protect and enhance a woman's birthing potential?

The parallel of healthy natural birth and breastfeeding is obvious to me. In both, the midwife's role is to protect, promote and support the physiological processes, and when an intervention is made, to restore normality, restore to the mother her own body's health-affirming prerogative, as soon as possible. This requires education, skill, personal will power, intelligent action and much more. It's not a matter of sitting back and letting nature take its course, because we know that the natural course often leads to chaos. It's a matter of knowing and intentionally guiding at times. That's midwifery. It's a matter of the midwife-woman partnership having an intention to work with 'Plan A', and knowing when to move to 'Plan B'.


Thankyou for your comments

The Heart in the Womb

Book Review
The Heart in the Womb 
Amali Lokugamage, 2011

I have thoroughly enjoyed reading The Heart in the Womb, which the author, Amali Lokugamage kindly sent to me for review.

This is a wonderful title, 'The Heart in the Womb'.  Of course we know that the baby's heart is in the womb, but it seems that Amali Lokugamage has discovered another heart - her own centre of being - within her womb, as her baby developed.

The book has a compelling sub-title 'An exploration of the Roots of Human Love and Social Cohesion'.  I am fascinated by Amali's comments about her own development in loving, as her thinking mind surrendered to deeper, hormonally mediated processes.  As a midwife, I see evidence of 'roots' of 'human love and social cohesion' being put down in many lives at the time of childbirth.  I would love to see a sequel to this account in ?5, 10, and 20 years' time, continuing to explore human love and social cohesion, developing from the roots put down by Amali's son.

This is a very personal account, bringing a significant and seldom-heard perspective to the natural birth/homebirth debate; that of an obstetrician (and a very impressive much more!). "I was prompted to write about this very personal experience because, prior to my pregnancy, I was never fully able to understand why a woman would actively choose to give birth at home, outside of a hospital safety-net."

This is a complex account, weaving together knowledge and comment about Western, Eastern, and alternative maternity and health practices. As I followed Amali along her pregnancy-birthing journey, parts of the story were very familiar to me, and parts were from another place.

I have often pondered the fact that a person who has a great deal of skill in the field of obstetrics can be blind to the basics of physiological birthing.  This is a mass-blindness within maternity care providers, and it isn't limited to obstetricians.  Midwives who work in birth centres have told me that they couldn't possibly attend home birth because the woman might bleed!  That bright red emergency button on the wall represents security!  It can be pushed and every available midwife or doctor will rush to the room and provide assistance; the "hospital safety-net" that Amali refers to. 

I found the account of the multiple modalities of treatment and preparation that Amali selected very interesting.  Interesting because I am, quite openly, a non-believer in many popular alternative medicines that other maternity care providers have embraced, including homeopathy, kinesiology, reiki ...  I do not have confidence in acupuncture or acupressure. When I have experienced it, either personally or observing it in a woman, it has not seemed to 'work'!  If birth is not an illness, why, I ask, do we need so many treatments? 

I do not encourage women to learn meditation or other practices derived from various religions.  I encourage them to explore their own understanding of faith, love, and social connection within families.  I do not ask women to learn self-hypnosis, although I quickly acknowledge the 'hypnotic' altered state of consciousness that many women enter as they go deeply into their labours.   I do not encourage women to undertake childbirth education courses that seem to make them into mini-midwives, trying to understand the minutae of bodily and mind functions, particularly in labour.  I have personally come through the Grantly Dick-Read - Lamaze - Leboyer eras, talking about Pavlov's dogs and psychoprophylaxis, and now I don't teach those processes at all.  When someone asks me if they should learn patterns of breathing I ask them if they have studied breathing to assist when making love.  There's usually a puzzled look.  "So why should you learn how to breathe when you are giving birth?" 

Amali's account of her multiple advisors, care providers, and guides in her journey towards birth seems to have led her on an action research project.  It must have cost a lot! I felt exhausted just following along.

Dear Reader, please forgive me if I seem to have used this review to get on a soap box.  As I said, I have thoroughly enjoyed reading The Heart in the Womb, and I hope you do too.




Copies of this book can be accessed from:
Australia 1
Australia 2
Book Depository - UK but ships free world wide
Amazon  
E books
Kindle
Itune
Epub

Thankyou for your comments

granny-midwife

From time to time I have used pictures of our beautiful grand-babies, and today I have another to share.

The all-nighter

1983 - I worked night shifts at the Women's

Although I haven't seen this one listed in midwifery skills or competencies, it's a reality for any midwife who accepts bookings from individual women. In order to be 'with woman', I need to be with her on her time-table, and that often means missing a night's sleep. As a labour progresses and the woman accepts the diminished activity of her front-brain, environmental distractions are also minimised.

Picture the scene: dim light, a warm glow from the wood burnt low in the fireplace, and a woman labouring on her knees in an inflatable plastic birth pool. She moans softly and moves her bottom in big slow circles as contractions ebb and flow, then rests her head on her arms, eyes closed, re-entering her resting state without comment or any record being made. Someone is near her - sitting quietly and also dropping off to sleep from time to time. Other members of the birthing team are similarly occupying couches or chairs, through minutes or hours of the night. Then the labour changes, and everyone is aroused, refreshed, and I am ready to complete my part of the work at hand.

Another scene is a hospital birthing room. Again, lighting is reduced and all is quiet. The labouring woman, and her husband, are sleeping. She has laboured with slow progress, and when she lies down, the interval between her contractions increases greatly. She needs to replenish her energy reserves before the next bout of active labour. I am resting on a chair, eyes closed, dropping into sleep as is evidenced by an occasional snore! I am also very weary. I know that the fetal head is high because the labour is so positional - strong when mother is upright, and slow when the weight of the womb is taken away from the cervix and the birth canal.

Today I am reflecting on the way a woman and midwife navigate the night-time terrain, because I have come from an all-nighter last night.  The ability to rest and re-charge as the night progresses is essential for both mother and midwife.

When I worked night shifts in midwifery it would have been unthinkable to admit to falling asleep on the job.  If a woman in my care was having a sleep I would have plenty of other jobs to attend to, or perhaps it would be time for meal break.  Of course tiredness was an issue, especially on the first night, and especially in the 'wee hours', somewhere between 2 and 4 am, when everything and everyone went quiet.  But these days, working in partnership with individual women, it's the norm, and I believe it's the right thing to do.  My body and mind accompany the woman through the phases and stages of labour. 

Thankyou for your comments