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

Hospital back-up for planned homebirth

This post is a continuation from the MIPP midwivesVictoria blog

Midwives in this part of the world use the public maternity hospitals to make backup arrangements when we are planning homebirth. As a general rule, we plan to use the hospital nearest to the woman's home, that has the capacity to provide emergency obstetric services at any time of the day or night.

My home is situated about 20K East of the Melbourne CBD - about 30 minutes' drive from the Women's Hospital in Parkville. It takes approximately the same amount of time for me to get to either of the other two major 'tertiary' referral centres: the Mercy in Heidelberg, and Monash in Clayton. Box Hill hospital's Birralee Maternity Unit is about 15 minutes' drive from my home; the Angliss in Ferntree Gully is about 30 minutes.

I am happy to attend any hospital, either when my client requires transfer from planned homebirth to obstetric/hospital care, or when a woman in my care chooses to give birth at that hospital. The focus of a midwife's care is the *woman* - not the planned place of birth. I have often said to other midwives, and to women in my care, that *homebirth* is not an outcome. It's a location - a setting for birth.

The importance of having a plan for transfer to hospital from planned homebirth has been highlighted since the new regulatory authority AHPRA has been set up, with a long list of codes, guidelines, and statements that define a midwife's practice.  The NMBA Safety and Quality Framework for Privately Practising Midwives attending homebirths  has a requirement for  "Clearly articulated referral pathways for referral and /or consultation in accordance with ACM Consultation and Referral Guidelines."

Homebirth is the unique domain of women who intend to give birth without medical intervention, establishing labour spontaneously at Term, and progressing to birth without the need for medical or surgical assistance.  Babies born under such conditions are usually well, and require little or no assistance to make the transition from the womb to the outside world.

The midwife's role in planned homebirth is to determine when, and if, complications arise.  At that point the decision may need to be made to transfer to hospital.  Such a decision cannot be made at the time of booking, or even at Term prior to the onset of labour.  The decision-making process is an ongoing, dynamic one, which must take into account all the related factors at that point in time.


Your comments are welcome.

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