Reflecting on yesterday's webinar

great artwork from our girl!

Yesterday, 5 May, was International Midwives' Day, and I was very pleased to participate in a global webinar organised by Sarah Stewart, and hosted by the Otago Polytechnic University in New Zealand.  Click here for the program, and to find links to the recordings of all the sessions.

I heard most of the first 10 hours of program, which continued through the night; 24 hours in all.  My mind was overloaded when I stopped.  I look forward to listening to other presentations.

Through the night I found myself churning through what I consider to be idealistic midwifery. This matter concerned me as I listened to some of the presentations, and as I engaged with others in the 'comment' function by which participants were able to type in questions or comments.  I could not help comparing the situation of under-resourced independent midwives in Pakistan, with what I know of Australian independent midwifery.

Idealistic midwifery presents the woman as someone who will achieve whatever she chooses, whatever she really wants, if she goes about it the right way.  The idealistic midwife seems to believe in a perfect world, where women have a goddess status, where there are no regulatory or societal boundaries, and where the woman's choice is the only important issue.

A necessary by-product of idealistic midwifery seems to be the demonising of hospitals, doctors, medical interventions, and anything else that I might have referred to as 'Plan B'. 

I cannot accept the setting of the bar so high.  I accept that there will be some who need more than I as the midwife can offer.

The world in which we live and work has expectations of medical management.  There are many reasons why some women feel the need to give birth in hospital, to accept medical analgesics or antibiotics or IV fluids, or induction of labour or active management of the third stage.  I cannot appoint myself as judge and jury for each case.  I must respect that these are the result of mainstream care practices, leading to care decisions made by these women and their midwife or doctor.  When a woman in my care agrees that transfer to hospital is appropriate, the processes we must go through will be different from those at the woman's home, and so they should be.

The midwife in a primary care setting today, whether it's in Melbourne or in a developing country, has the opportunity to prepare women to accept the birthing work of their bodies, and to use their own natural resources to the best of their ability.  'Plan A' is essentially the same, across time and culture.  Women give birth spontaneously today the same way as our ancestor-mothers did hundreds of years ago.

'Plan B' is totally different for midwives and mothers in different parts of the world and different times.  It's a matter of availability of resources and emergency medical care.  While in my practice I can refer a woman to a well staffed and equipped, modern obstetric hospital where a team of highly trained and supported experts will address whatever the emerging complication or condition is, my sister-midwives in less well resourced parts of the world will face a very different 'Plan B'.  My friend who is working as a midwife with MSF in Africa has told me she had never imagined as many dead babies or dead mothers as she has seen in that place.

Idealistic midwifery ignores the fact that illness and infection and complication can strike down even the fittest and strongest among us.  Idealistic midwifery fails to notice that even people who eat well and exercise can become ill.  Idealistic midwifery forgets that the midwife's primary goal is the wellbeing and safety of mother and child.  Not natural birth, wonderful as that is; or drug-free birthing, or any other standard we might aim for.

Ideals are great.  Where there are no ideals, no vision, the prevailing culture can quickly over-ride, and principles be forgotten.  But ideals must be tempered with realism.  Life is often best when we can accept being 'good enough', doing our best with what we have, rather than being disappointed that we don't achieve perfection.
 
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

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.