The passage of time

It seems to me that time has become more of a currency - a commodity of value - as I have got older.  Today I am going to take (approximately) big 10 to 15-year steps back in my memory, to illustrate how I have learnt to value time.  I hope this is more than a self-obsessed reflection (navel-gazing) - I hope it encourages readers to plan to use your own strengths over your expected life journey.

Yesterday I sat next to a friend who is 96 years old.  "How are you, Joyce?" I asked.  "I'm well," she said, "just old."

It is good to belong to a community - to have friends from age groups across the span of time.  It amazes me that a person like Joyce has been 'old' for the time it has taken me to develop and practise as a midwife.  Another friend, a woman in her early 90s named Margaret, was a registered nurse.  In her 80s she was still working in a nursing home, looking after many people who were years younger than her.  These grand ladies set a high standard for 'young ones' like me to follow.  I wonder if I will be able to say, with dry humor, "I'm well - just old" in 15, 20, or 30 years from now!

Most of the time I don't feel old now, even though the government has given me a seniors card.  Most of the time I am able to enjoy work, family, garden, friends - a pretty full life.  But when I miss out on a night's sleep I am reminded that there are lots of younger midwives, all fired up with a strong professional commitment, and keen to practise.  Also, they don't mind staying up all night.


About 20 years ago I took a redundancy package from St George's hospital in Kew, where I had been working as an associate charge midwife.  I joined Midwives in Private Practice (MiPP), and asked a few of the independent midwives (Annie Sprague, Chris Shanahan, and Robyn Thompson) if I could learn from them.  With their support, and the support of women in their care, I attended births in the home for the first time, and decided I was ready to take my own bookings.  I remember noticing little things - that the front door remained closed, and noone who was not invited came anywhere near the labouring woman; that the baby didn't have a plastic name tag on its arm and leg.

I told myself, "I have at least 15 years ahead of me, before I will need to think about retiring.  I am a midwife: I understand midwifery.  I am a mother: I gave birth to and nurtured my four children.  I can guide women, make clinical decisions, and write, teach, and guide other midwives.  I want to practise midwifery in a one-to-one relationship with each woman in my care."  

About 10 years before that, in the early 1980s, I was working night shifts at the Women's Hospital in Carlton.  In a quiet moment I mused to a colleague "One day I would like to work with just a few women, and work with them through the pregnancy, the birth, and postnatally."  (Back then we didn't have words like 'continuity of care', or even the definition of the midwife, and we didn't have the research upon which to base such aspirations.  It was my 'gut feeling'.)

About 10 years before that, in the early 1970s, I went through an amazingly fast journey, of leaving my home in Brisbane, coming to Melbourne to study midwifery, meeting the love of my life (the day after arriving in Melbourne), then (in quick succession): engaged, married, pregnant, graduate, move to USA, and give birth.  No time to consolidate my midwifery learning in a formal sense, but plenty of  maternity-related 'prac' as our babies came into our lives.  (a side note: Noel's graduate studies added to my maternity-related learning, as his research demonstrated the protective effect of colostrum on the newborn calf.  That was new knowledge in the 1970s!)

My mother was a wonderful support to me when our second daughter, Bec, was born.

I would like to conclude this post by telling you, dear reader, that I did not know when I studied midwifery that I would become a good midwife.  In journeying along life's path, I discovered the wonder of love, and of new life.  I have been surprised at how blessed I have been.   God, the Creator and giver of life, has been good to me.

I expect that the 'midwife' in me will continue for as long as mind and body function.  The midwife who is guardian of the mothers and babies; who has skill and knowledge that can be shared in a way that makes sense.  Even when I have ceased receiving calls in the wee hours, to attend the labouring woman, my heart will follow them in their journeys of discovery about the meaning of life.



Thankyou for your comments

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

'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.



Thankyou for your comments

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.