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

Blogging

'Baby wrapped in a green blanket', by our Poppy

Today's brief comments come out of thoughts sparked by Sarah Stewart, who is a tech-savvy teacher-midwife based in New Zealand, and a compulsive blogger. Sarah is the person behind the Virtual International Day of the Midwife - a 24-hour webinar now in its fourth year, bringing together midwives and students literally around the globe.

Sarah has announced to her readers that "I am currently in the process of writing a paper about this blog and how I use it to reflect, and how the wonderful comments you leave enhances my learning. I plan to submit it to an academic journal for publication. ..."

I also use blogging to reflect and work through issues in midwifery. I love the fact that blogs are in the public domain, because I consider that anything I have to say as a professional midwife should be able to be said openly. In that sense I also welcome critique of anything I have written or said. 

When I first started writing blogs, the topics I chose were simply the topics I had discussed with women who came to see me, who wanted me to be their midwife. As I wrote I used the language and the discussion that I would bring to professional clinical discussions.   Since those early blogs I have commented on and explored my reflecting on many issues that come up in the life of a woman who is also a midwife, a mother, and a thinker.

My mother used to say, "If you always tell the truth, you don't have to remember what you said." That sort of truth-telling is what I am referring to in finding my voice on the www.

In June 2007 I wrote a brief post 'Natural birthing in Australia today'. A few days later I titled my post 'The culture of birthing'. I wrote:

I am asking for a total change in the culture of birthing, changing the focus of all the care from the provider to the woman. We seek a new culture that recognises the natural order in pregnancy, birth and nurture of the baby as superior to any artificially contrived system. ...

The culture of birth will change only when women reclaim their authority for their own bodies; only when the message that ‘birth is not an illness’ is heard. The role of maternity professionals will then change from being predominantly carers of sick people to agents of health promotion, working together to enable women to improve their health through pregnancy and birth, and to have strong, healthy and resilient families.

These words were true then, and I am happy to publish them again today, almost five years later.  I expect I will still say the same thing in five years' time! 

^^^^^^^^

I wonder if I am unusual in that I have not embraced other forms of social media to the degree that I am happy to use blogging?

Yes, I have a fb account, but the only people I have 'friended' are family and a few close folk who are something more than 'friends'.  I don't like the implications of a stock-standard 'friend' category that seems to me to be on offer there. It doesn't ring true to me.

Some years ago I decided to swallow my pride and have a go at twitter.  I lasted about 2 days! [that's probably an exaggeration - I'm sure it's all recorded somewhere!]  I felt that I was playing an inane game that was without direction.  I was offended by the word 'twitter'.   If I was going to write my thoughts they needed to be of more significance than the incoordinated noises coming from the canaries in a cage!  (I did name the canaries Tweet, Twitter 1, and Twitter 2)

That's all I'll say about today's social media.  My name appears on other systems too, but I haven't a clue how to make them worth while for me or anyone else.  Perhaps someone will tell me I am wrong - that there are wonders in store for those who find the key? 



Thankyou for your comments

Fear of Home Birth in Doctors and Obstetric Iatrogenesis

LINK Fear of Home Birth in Doctors and Obstetric Iatrogenesis

Author: Lokugamage, Amali

Source: International Journal of Childbirth, Volume 1, Number 4, 2011 , pp. 263-272(10)

Abstract:
Home births are physiological births and form part of the social model of birth. Doctors, traditionally, have been very fearful of out-of-hospital birth, and physiological births happen less frequently in obstetric units. Normal/physiological birth contributes to improving public health, and doctors are often not aware of the extent of this benefit. Normal birth leads to adaptive physiological function in the baby (endocrine, immune system, thyroid function, respiration, neurology, temperature regulation), more mother and baby bonding, and promotes higher breastfeeding rates, which in turn lead to better lifelong emotional and physical health in babies. Normal birth affirms health, promotes empowerment in mothers, and is a societal event that has been linked to promoting positive emotional qualities in society via the birthing hormone, oxytocin. Training within the medical model constrains doctors' appreciation of normal birth. Experience of complications, a lack of awareness of the evidence surrounding home birth, compounded by failure to understand the concept of iatrogenesis, perpetuates fear of home birth among doctors.
http://www.ingentaconnect.com/content/springer/ijc/2011/00000001/00000004/art00007


www.theheartinthewomb.com

Thankyou for your comments

"MIDWIVES SAVE LIVES" webinar 5 May

Message from Sarah Stewart 

Just a quick note to tell you about this year's Annual Virtual International Day of the Midwife (VIDM). We are now accepting EOI for presenters so please let us know if you'd like to be involved.

The Virtual International Day of the Midwife (VIDM) celebrates the International Day of the Midwife by bringing midwives and others from across the globe together using online electronic media (http://internationaldayofthemidwife.wikispaces.com).

A variety of live online events are presented every hour for 24 hours on the 5th of May 2012 starting at 10am New Zealand time via web-conferencing facilities. These may include presentations about latest research or practice issues, informal discussions, panel discussions, meetings or story-telling.

The organising committee are now calling for Expressions of Interest (EOI) to present at the VIDM eVent. This year's theme is MIDWIVES SAVE LIVES. However, we will consider any topic as long as it is of interest to midwives and people interested in childbirth.

While the EOI must be in English, we welcome presentations on the day in other languages. We also welcome EOI from non-midwives and midwifery students. Presenters need not be experienced in using electronic media - members of the organising committee will be able to give support. Please provide a short paragraph (no more than 150 words) describing your presentation and the form it will take (for example, you may wish to use a PowerPoint presentation).

Please also include your status (eg midwife, non-midwife, midwifery student), country of origin and language of presentation. Your presentation or session should:
• Have a clear aim or purpose
• Focus on maternity care or midwifery
• Be of interest to an international audience
• Be appropriate for web conferencing

If you would like to give a presentation, please indicate what country and time zone you are available in your EOI.
Please note: We will be using the web-conferencing platform Adobe Connect. All sessions will be facilitated by an experienced online facilitator so you will be supported at every stage.

Please submit your EOI by 10th March 2012 by one of these methods:
• Email to Sarah Stewart sarahstewart07@gmail.com
• Add it to the VIDM wiki
• Add to the VIDM Facebook page
• Via Twitter

making birth safer

... for the mother and her baby.

All maternity professionals are expected to act in a way that protects the wellbeing and safety of mother and baby. That's a reasonable expectation of any society. Midwives have guidelines and codes of practice and decision-making frameworks that are all structured around principles of safety and quality. 

The tragic death of a woman, Caroline Lovell, after giving birth at home in a Melbourne suburb, has thrust homebirth midwifery into the media spotlight. I have written about the breaking news at the MIPP blog. One comment summed up the situation,

"A tragic event is made sadder by the tendency of traditional media to suggest a causal link between the setting for this birth and the poor mother's passing before the facts have come to light."

I do not have information about the facts of this case, and I therefore cannot form an opinion.  I have heard the TV reports, read the newspaper reports and online commentators, and had conversations with other midwives and members of the community who have heard rumors.  A TV reporter who spoke to me before recording an interview told me that a leading legal person in Victoria had commented that she considered homebirth midwives to be "cultish".  I reject this notion.   There is nothing at all cultish in professional midwifery as described in international and Australian definitions and standards: the standards against which all midwives are judged. 


I am hoping that whatever tests are done, the autopsy, coroner's inquiry and report, and the investigations by the Nursing and Midwifery Board of Australia will satisfy my need, as a member of this community, to be confident that in this case, there was no professional negligence or unprofessional conduct.  I would have this expectation regardless of where the death occurred.

Many women have contacted their midwives with messages of love and support.  Women have also told their midwives that they are being questioned by concerned family members about their plan for homebirth.

The decision to give birth at home is made by the mother, with professional advice from her midwife.  If the labour is not progressing well, it's crucial that decisions about transferring care to hospital are made in a timely fashion.  This is the midwife's responsibility - not the woman's choice.  A labouring woman cannot be expected to monitor her own progress.  A mother and baby have limited reserves.  When the demands of the birthing process become more than the mother or baby can be reasonably expected to cope with under natural situations, the best option is to transfer care to a hospital which provides emergency obstetric care.  There can be no guarantees of particular outcomes. 

Dear reader, I have only touched on these deep and potentially unsettling issues.  The intense media interest in this case passed quickly.  However, midwives who are ready to learn from each situation will not forget.

The reports by Coroners are placed on the public record.  For example, a baby death in hospital from perinatal asphyxia. 

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

on a personal note

Picture taken yesterday, at the home of friends

Today Noel and I are celebrating 39 years of marriage. Thirty-nine years of shared life is worth noting, and I thank God for this man!

I'm not going to try to delve deeply into personal matters, but I do want to draw attention to the importance of a stable and supportive home base. A midwife who intends to provide primary care for women across the childbearing continuum, including the occasional disruption and uncertainty that come with spontaneous birthing, needs security and stability within her home and family life. Of course this can't be guaranteed - situations can change in an instant.



Most of the women who call our home phone to speak to me get the opportunity to speak with Noel.  He's my gatekeeper when I have been out all night, and need a sleep.  He's my receptionist when I'm out, or when I'm having a shower.  When a mother and baby come for the 6 week postnatal 'show and tell' visit, he usually manages to say hello, and offer congratualtions on the new baby.

Noel's qualifications are in Veterinary science.  His Masters and PhD work at Michigan State University in the 1970s investigated the protective effect of colostrum for the newborn calf.  He demonstrated that a calf who received colostrum in the first days of life was protected against 'scours' - the term used for gastroenteritis in the dairy, responsible for high rates of death of calves.  At that time, newborn dairy calves were removed from the cows immediately after birth, and fed with 'milk replacer' - a substitute milk similar to the formula milks made up for human babies.  Noel's research also demonstrated the phenomenon of 'gut closure': the brief time immediately after birth when macro molecules are able to pass across the intestinal wall directly into the blood.  The time and significance of gut closure in human infants is still unknown. 

I believe I have benefited a great deal from Noel's studies and academic work.  The principle that the natural physiological processes across the childbearing continuum are truly awesome, and truly worth protecting, has strong foundation in my mind.  Those who remember the 1960s and 70s will recall the infatuation in health care with what they saw as science - that science could provide smart alternatives to anything natural, from clothing fabrics to human milk.  Women were being told they no longer needed to be burdened with tedious natural tasks such as breast feeding.  Women could control when they had babies, and what they did for the babies they bore.  Intellectual theorists of the 60s and 70s hailed female-male equality as the new societal standard.

The reality that was ignored in attempts to free women from the burden of nourishing their babies was that being a mother can be GOOD!  That maternal instinct is a strong force, under hormonal direction, that enables a woman to want to stay with her baby; to respond to the baby in a loving and nurturing way; to give the baby access to her breast whenever and wherever the baby is hungry or needs comfort.  Interruptions in physiological processes inevitably interfere with hormonal states, leading to non-physiological and often adverse outcomes. 

I had not learnt about maternal instinct in the midwifery course that I had completed just months before the birth of my first child.  The midwifery teachers were older single women, as were most of midwives in senior positions in the hospital.

I am looking forward to continued learning about the beauty and desirability of hormonally-mediated maternal behavioural patterns. 



Thankyou for your comments

Breastfeeding well from the start

1977, with my son Paul

Breastfeeding is PLAN A. 

Breastfeeding is what a woman's body expects to be doing, whether her mind agrees or not, and it's what a baby expects to be doing, from the start. Anything else is a variation from the biological, hormonally determined, norm. Anything else is a compromise, as far as the natural physiological processes are concerned.

Although breastfeeding is 'natural', it's not simple. For many women and babies, it's not easy. For many women, alternatives appear attractive.

Today I want to focus on breastfeeding well from the start. This is not possible for all mothers and babies, but it is possible for most. As with 'Plan A' in birth, 'Plan A' breastfeeding can best be achieved when the mother, the midwife, and all involved, accept and work in harmony with sensitive natural processes. As with 'Plan A' birth, 'Plan A' breastfeeding can be interferred with by a well-intentioned but misinformed person, resulting in distress for all and possibly long-term consequences.

The midwife who understands these truths will protect the mother-baby pair during pregnancy, labour and birth, anticipating the wonders and challenges that lie ahead; will support the woman and baby as they learn about and explore each other from the moment of birth; and guard the bond between mother and baby after birth, guiding and instructing the new mother only when the need arises.

The title of this post, 'breastfeeding well from the start', puts breastfeeding into the context of a continuum.  Breastfeeding is a relationship, not an act.  The same word, 'breastfeeding' describes what the baby is doing, and what the mother is doing.  Yet the actions taken by the two participants are very different.

Consider the breastfeeding continuum within the series of firsts:
. the first moment
... the first hour
..... the first day
....... the first week
......... the first month
.......... the first year

Breastfeeding well from the start is, like any other natural phenomenon, most likely to continue on the right track if it starts on the right track.  By this I mean, the mother and baby who are well at the onset of labour; who proceed spontaneously, without medical stimulants or emotional coaching or analgesia or anaesthesia to a normal birth; who experience the wonder of falling in love in the moments after birth, bringing with it a huge surge of the love hormone, oxytocin; enabling the mother to release her baby's placenta without excess blood loss, and enabling the baby to use his senses of sight, smell, taste and touch to search for the breast and achieve a deep attachment; suckle, and swallow the sweet, precious colostrum.  This is usually happening in the first hour after birth, before anyone else has held the newborn. 

The first hour quickly passes, and the first day unfolds.  Mother may pass the precious little person to the father, or another trusted family member, so that she is able to empty her bladder, and wash herself.  She needs to eat and drink, and rest.  Each time baby is alert, the instinctive actions of both mother and baby culminate in breastfeeding.  Baby goes to sleep, and mother can't because she is too high!

2011.  Bec and James (18mo)

The first day opens out into the first week.  Baby works strongly and confidently at the breast, and soon the breasts are swelling and producing a bountiful flow.  Baby's feeding and sleeping pattern changes, as does the colour of his stool.  Mother sleeps well between breastfeeds at night, and is quickly returning to strength.  She accepts the closeness of the relationship between herself and her child.  Someone asks "Do you feed your baby on demand?" and she has to think what that might mean.  Not really - her baby has never learnt to demand a feed.  She looks at her baby, or her baby looks at her, makes a sound or a movement of his mouth, and together they proceed with the most satisfying and beautiful work that either knows about.

And so it goes, through the first month, and the first year, or two, or ...



Thankyou for your comments

Looking forward

From time to time I have taken the opportunity on this blog to write about the complex and often challenging position I and other midwives have found ourselves in as we work through and apply government 'reforms' and changes to our practices.

Now, at the end of the first week of January 2012, I want to summarise my position as a midwife, attending individual women for birth and associated prenatal and postnatal care, and what developments I expect and hope for in the coming year.

Firstly, on the positive side of the ledger:

• Babies are being born, and thriving - beautifully.
• Women are being transformed in the process of giving birth.  That's a wonderful thing to witness.
• Collaborative arrangements are being set up with a couple of supportive GP-obstetricians, who are happy to give women referrals for the midwifery services they choose.
• Collaborative arrangements are being set up occasionally with obstetricians, after the woman and baby have been discharged from hospital, enabling one-to-one postnatal care for the woman.
• Medicare rebates are being paid to women who use the services of participating midwives.
• I am happy to bulk bill additional antenatal and postnatal visits, which continue until the baby is 6-7 weeks old.

On the negative side of the ledger:

• Some public hospitals at which women make homebirth back-up bookings are refusing to acknowledge the collaboration in the way that has been spelt out in the legislative determination, in that there is, for example, no provision for a 'specified medical practitioner', who is "a medical practitioner employed or engaged by a hospital authority and authorised by the hospital authority to participate in a collaborative arrangement.", or any acknowledgment "when the midwife gives a copy of the hospital booking letter (however described) for the patient to a named medical practitioner — acknowledgement that the named medical practitioner has received the copy" ...   
• Midwives eligible for Medicare are required to sign an undertaking to complete a course in pharmacology within 18 months, yet there is no such course accredited.  
• No midwives have access arrangements to privately attend women admitted in hospitals.  This means that women who choose to give birth in hospital, with their private midwife in attendance, must accept the hospital's employed midwife as the leading midwife at the time of the birth.  This situation can lead to unnecessary conflict.
• There is no insurance product to indemnify midwives attending women privately for home birth.  The government has exempted midwives from the requirement until 2013, and we don't know what (if?) plans are afoot to rectify the situation.

Logically, indemnity insurance does not change outcomes - it simply provides a pot of money that can be fought over in the law courts, should there be an adverse outcome.   I consider the only solution to the insurance problem is to set up a no-fault compensation scheme, to which all health professionals contribute, which provides a suitable level of financial support to those who suffer disability or loss, separate completely from the apportioning of blame.

Midwives who face regulatory or coroner's inquiries into incidents in which they were involved are being advised to obtain legal representation.  While ideally a professional should be investigated by peers, it seems that the process of investigation into conduct is becoming increasingly formalised, with inherent costs and isolation of the practitioners.

I have recently accepted a role as Vice President in Australian Private Midwives Association (APMA), which represents private midwives nationally.  I have been a member of this organisation, and have written and edited the APMA blog for the past couple of years.  It is a privilege for me to work alongside the President Marie Heath and the other committee members.  Keep an eye on that blog if you are interested in the national private midwifery scene.

I continue my involvement in Midwives in Private Practice (MIPP), which represents midwives practising privately mainly in Victoria.  See the MIPP blog.  MIPP is a participating organisation in Maternity Coalition (MC).  The concept of partnership between the woman and the midwife is carried through into the relationship between MC and MIPP. 

There are plenty of challenges to keep me busy in the midwifery profession broadly, as long as I have the (physical, mental, spiritual) strength to continue my practice.  I enjoy consulting with women and attending them professionally in their homes, mentoring  other midwives, giving lectures to midwifery students at Deakin University School of Nursing and Midwifery, and my involvement in the Professional Development Unit at Deakin.

Family and home responsibilities keep me busy, and my beautiful grand-children remind me of the every-changing needs of our most precious resource.

Thankyou for your comments

Simple pleasure

My life as a midwife brings the personal and the professional into an unpredictable, ever-changing mix. As long as I have mothers and babies on my books, I am conscious of the possibility that I may be called out at any time. This is particularly important to me at Christmas time.

Today is Boxing Day, and I am reflecting on our family's Christmas celebration. I want to record here a few of the simple pleasures that I experienced this Christmas. I call them simple, because they happen without any fanfare or note, but actually these pleasures are part of a wonderfully complex natural order that is ours to enjoy.

• I treasure the births of two babies in recent days, with all the struggles and challenges birth brings. The knowledge that a young mother can confidently nourish and nurture her child, with loving support from the baby's father, gives me great pleasure. 
• I treasure the singing of carols, reading of the scriptures, and reflecting on the reason for the celebrations.
• I treasure the feasting: meals with family and close friends, sharing good food and fellowship. 
• I treasure being able to take food from our garden and include it in the festive meals: eggs, herbs, peas, spinach, broccoli, leek, spring onion. 
• I treasure the special festive foods that we make and eat: the stuffed turkey, the pudding in a cloth, the big fruit cake, the decorated gingerbread house 
• I treasure the special family gatherings: this year we had a memorable performance of the Owl and the Pussycat from our seven-year old Poppy, who has realised that she can read even nonsense words like 'runcible'.

There are many more simple pleasures that come to mind.  Yet I know, dear reader, that this time of year also brings its share of pain and sorrow for many people.  Families with fractured relationships, and people suffering illness.  The experience of loneliness and loss will often destroy pleasure and suck hope out of life.  There is no simple answer, no easy fix, when sadness and fear threaten to overwhelm us. 

With this in mind, whether times are easy or difficult, I am reminded that the principles for a life of integrity are, "to act with justice, to love kindness (mercy), and to walk humbly with our God." (Micah6:8)

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 womb-baby's heart

 A couple of weeks ago I reflected briefly upon some of the uncertainties that parents face, especially when an abnormality is detected in their womb-baby.  I linked to the evolving story, as told by Petrina and Dave on their blog, whose womb-baby's heart was in distress; whose little body was distended with fluid that the wee heart was failing to direct through the tiny body.

We are a family who believe in the power of prayer, and we are asking GOD to protect this unborn child and mother; to guide the minds and hands of the professional care providers, and to bring blessing through this difficult time.


Some years ago a young couple spoke to me about their womb-baby, who had been diagnosed with a serious heart defect at the 19 week anomaly scan.  They had been anticipating the wonder and joy of the birth of their first child.  Instead they experienced unutterable shock.  They had been advised to abort the baby.  They quickly and confidently declined the offer.

Our faith community at that time united in prayer for the young couple, and for their womb-baby.  We prayed for him each time he had surgery, and we have watched him grow. 

This week his story has been told in a Herald Sun newspaper article.

IN Melbourne's eastern suburbs on Friday, a boy called Kush will join classmates at a graduation dinner celebrating the end of his primary school years. Last year, he qualified for his school's cross-country competition and he plays cricket every weekend.
He's a kid who was never expected to live long enough to even start primary school, let alone finish it. This little chap functions on only three heart chambers. He's cheeky and smart and he has a mile-wide smile.
He has endured four open-heart surgeries - the first was when he was just five weeks old.
At 19 weeks gestation, medics discovered he had a serious congenital heart defect. They recommended termination because of the likelihood he would die early and painfully.
But his parents would not consider abortion.

In reflecting about our young friend Kush, and about Petrina and Dave and their womb-baby, I want to encourage midwives to remember that the life of a baby in the womb, even a womb-baby who has an imperfect heart, is a gift from God to that family.  As they learn to do whatever is possible to promote health and wellness, they also learn to accept the possibility of loss of a child - a journey that one would never choose.  These are life lessons, and are the lessons our parents and grandparents had to learn, in a different time, when the possibilities of restorative medical and surgical interventions were vastly less than they are today.

I am sure it has been difficult for Petrina and Dave to share their journey, often not knowing what the next day will bring, with an open audience.  Yet I sense that they and others will be helped, as a little network forms around a tiny and less than perfectly functioning womb-baby's heart, knowing that they are not alone. 

In a society which pretty well assumes that it's *best* that a baby who may not survive birth should be aborted - terminated - I honor parents who stand against the prevailing trend, and treasure the life of that womb-child.


Thankyou for your comments

HYPOGLYCAEMIA and newborn babies

From time to time I have an opportunity to participate in a Baby Friendly Health Initiative (BFHI) assessment of a maternity hospital.   I have participated in BFHI since the early 1990s. Today I am reflecting on one such recent assessment, and the importance of protecting, promoting and supporting breastfeeding.

BFHI is a global initiative of WHO and UNICEF. Hospitals implement infant feeding policies consistent with the 'Ten Steps to Successful Breastfeeding', and ethical marketing practices for the distribution of artificial milk formulas for babies.

Hypoglycaemia (low blood sugar) is the *diagnosis* under which many breastfed babies in Australian hospitals receive formula feeds in the first hours of their lives. Babies of mothers with poorly managed diabetes - that is, mothers whose blood sugar levels are abnormally high - can become very ill very quickly when their sugar supply is abruptly cut off at birth. Please refer to the Women's hospital CPG on infant management of Hypoglycaemia 1. for further review of definition and management guidelines. The brief comments I wish to make in this post will be made with consideration of that CPG as a statement of the way I understand contemporary practice.

Definition of terms

Hypoglycaemia: There is a lack of consensus on a definition of neonatal hypoglycaemia. It is recommended that clinical practice be guided by operational thresholds (i.e. blood glucose levels at which clinical interventions should be considered). Clinical signs which suggest clinically significant hypoglycaemia are non-specific and include jitteriness, irritability, high pitched cry, cyanotic episodes, apnoea, seizures, lethargy, hypotonia or poor feeding.

When BFHI assessors visit a hospital, we have a series of questionnaires that are designed to gauge the hospital's compliance with the global BFHI criteria. Midwives, doctors, and other staff who advise women on breastfeeding are asked to state three acceptable medical reasons for use of breastmilk substitutes. The usual response includes 'hypoglycaemia'. The assessor is required to explore the meaning of 'hypoglycaemia' further to check if the staff member is confident of what is an acceptable reason.

The BFHI acceptable medical reasons include

• newborn infants who are at risk of hypoglycaemia by virtue of impaired metabolic adaptation or increased glucose demand (such as those who are preterm, small for gestational age, or who have experienced significant hypoxic/ischaemic stress, those who are ill and those whose mothers are diabetic) if their blood sugar fails to respond to optimal breastfeeding or breast milk feeding.

Usually the hospital's own clinical practice guidelines will be quoted. The assessor is able to then check the hospital's guideline on management of babies with hypoglycaemia. 

Why is this important?

The short answer:  Diabetes.


A longer (incomplete) answer:
'Hypoglycaemia' is one of the main reasons for breastfed babies in hospital receiving formula feeds.  Diabetes and hypoglycaemia are closely linked, and breastfeeding may prevent the development of diabetes later in the child's life.

A hospital that has a breastfeeding policy consistent with the BFHI '10 Steps to successful breastfeeding' is required to implement management guidelines for hypoglycaemia that are consistent with the breastfeeding policy. The 'steps' in which a hospital's management of suspected hypoglycaemia has a potential to interfere with the establishment of breastfeeding are:

Step 1: Have a written breastfeeding policy that is routinely communicated to all healthcare staff

"exclusive breastfeeding in the first six months of life

• protects against chronic conditions in the future such as type-1 diabetes, ulcerative colitis and Chron's disease

Breastfeeding during infancy is associated with

• ... lower prevalence of type-2 diabetes, overweight and obesity during adolescence and adult life
  ..." [from BFHI Australia Booklet 1, p16]

Step 2: Train all healthcare staff in skills necessary to implement this policy

Protecting, promoting and supporting the natural physiological processes in birth and nurture of a baby requires skill and commitment by all care providers.

 
Step 3: Inform all pregnant women about the benefits and management of breastfeeding

Women who are well informed will be able to make informed decisions about any interventions that are recommended in the care of themselves or their babies.  Those who know they are at risk of having babies who develop hypoglycaemia are able to take some measures to avert the need for breastmilk substitutes, including careful dietary measures and avoidance of sugary foods.

Step 6: Give newborn infants no food or drink other than breastmilk, unless medically indicated.

The hospital's definition of 'medically indicated' must be consistent with the BFHI acceptable medical reasons.  Also, note the need for true blood sugar level to confirm hypoglycaemia.

Step 7: Practise rooming-in - allow mothers and infants to remain together 24 hours a day

Babies identified as 'at risk' who are asymptomatic should stay close to their mothers and breastfeed normally. 

• infant with risk factors for hypoglycaemia but no clinical signs - blood sugar level < 2.0 mmol/L [Women's CPG]

Step 8: Encourage breastfeeding on demand


Step 9: Give no artificial teats or dummies to breastfeeding infants

The hospital policy and guidelines need to be reviewed critically at regular intervals, by people who are well informed and who are skilled at asking good questions.  

The protection of breastfeeding in potentially complex clinical situations is not a yes-no, black or white situation.  Guidelines can, and often do, help us to avoid unnecessary and potentially harmful interventions into normal physiological breastfeeding situations.

For example, a baby weighing 4 Kg at birth may in some cases be at risk of hypoglycaemia, and in other cases be healthy, consistent with the size of his or her parents and siblings.  In the latter case a clinical judgment would be made by the midwife, not to measure blood glucose levels as this baby is judged to be a well, term infant.


Thankyou for your comments

A letter to obstetricians

I have sent letters to obstetricians practising in my area.

Re: Medicare rebates for private midwifery services

Dear Dr XXXX
I am writing to inform you of my current private midwifery practice since obtaining notation as a Medicare ‘eligible’ midwife. 

Examples of the services I am able to provide are:
• a part of the woman’s care such as postnatal only (after discharge from hospital)

• antenatal care that is shared with an obstetrician or hospital,
• primary maternity care for the whole episode of care, whether the woman is planning to give birth at hospital or in the home.
[Note: At present midwives do not have visiting access/clinical privileges in hospitals. However, this is a goal to which public hospitals are working, through the Three Centres group project on ‘Collaborative arrangements with eligible midwives for Victorian public hospitals’. I am a member of the Expert Reference Group for this project, and am keen to see privately practising midwives able to obtain visiting access in hospitals.]

Medicare scheduled fees and rebates for private midwifery services are listed on the attached document Health Insurance (Midwife and Nurse Practitioner) Determination 2010 Health Insurance Act 1973 Part 1 Midwifery services and fees – revised 1 November 2011.

Since becoming eligible for Medicare, I have found that some women appreciate more postnatal visits in their homes, with Medicare rebates making the service more affordable, than was previously the case. Rebates are available for postnatal consultations in the six weeks following the birth, and for a 6-7 week review. I am now able to write referrals to obstetricians and paediatricians, and request tests and investigations related to childbirth. I do not yet have PBS authorisation, and Victorian law is yet to be amended to enable midwives to prescribe.

In order for women to claim Medicare rebate on fees for antenatal and postnatal visits the participating midwife is required to document a collaborative arrangement, by which a specified medical practitioner is identified as the person to whom the woman will be referred if indicated. Referral is one type of collaborative arrangement, described in Section 5(1) that the “patient is referred, in writing, to the midwife for midwifery treatment”, in this case antenatal and/or postnatal services, and that [Section 5 (2)]: “For subsection (1), the arrangement must provide for: (a) consultation between the midwife and an obstetric specified medical practitioner; and (b) referral of a patient to a specified medical practitioner; and (c) transfer of a patient’s care to an obstetric specified medical practitioner.”

That is, the collaborative arrangement to be entered into is that I, the midwife, will provide midwifery services (treatment), with consultation and referral to you when/if indicated. Under such collaborative arrangement, I am required to send you (the named medical practitioner) a Maternity Care Plan (proforma attached), results of any tests and investigations, and referrals.

Also I am required to send a discharge summary to you and the patient’s GP.

I would appreciate your support through referral or other collaborative arrangements. I am happy to make an appointment to meet with you and discuss this with you further if you wish.

There is a small number of midwives in Victoria who now have Medicare provider numbers, and others who are waiting for their applications to be processed. I anticipate gradual expansion of private midwifery services in response to the government’s maternity reforms.

Thankyou for considering this request.
With best regards
Joy Johnston

Attachments: 
Health Insurance (Midwife and Nurse Practitioner) Determination 2010
Maternity Care Plan proforma

When women choose maternity options against the recommendations of their midwife

Having written a post on the new ACM Position Statement on Homebirth Services 2011, together with a 'guidance' document and literature review, for the APMA blog yesterday evening, I find that my mind is dwelling on the situations in which women "choose a planned homebirth when this is not recommended by a health care provider."

What are the forces that are exerted within our communities, pulling women, and midwives, toward professionally acceptable standards and actions?

How does a midwife make a clear and timely call, telling the woman who has employed her to provide homebirth services, that homebirth is no longer recommended?

Where is the cut-off, between low- and high-risk? 



The ACM National Midwifery Guidelines for Consultation and Referral (ACM Guidelines 2008 - which are available to download free as a .pdf) set out situations in which a midwife is expected to consult with, and refer a woman to, an appropriate medical/obstetric service provider.  Conditions listed under category C, requiring referral, include chronic hypertension, pre-eclampsia, multiple pregnancy, breech presentation at Term, coagulation disorders, diabetes requiring Insulin treatment, and many other medical and obstetric conditions and complications that may co-exist with the pregnancy, or arise during pregnancy, birth, or the postnatal period.  A woman experiencing these complications requires coordinated maternity care from a team of medical, midwifery, and possibly other disciplines.

Another all-too-common-today situation is a woman who has had caesarean surgery for one or more previous births.  According to the ACM Guidelines (2008), previous caesarean is category B, meaning that the midwife is required to facilitate consultation with a medical or other health care provider.  The ACM Guidelines do not attempt to differentiate between those for whom homebirth is not recommended. 

The South Australian Report of the Maternal, Perinatal and Infant Mortality Committee on maternal, perinatal and post-neonatal deaths in 2009 recommendations state clearly that "A previous caesarean section and breech presentation are contraindications for home birth."

As noted at the APMA blog, obstetrician Andrew Pesce has given advice on a way forward for those who want to bring homebirth into mainstream maternity care, with:

"Until those individuals and groups which advocate for publicly funded home birth unambiguously and publicly state home birth is unsuitable for high risk pregnancies, their advocacy will remain at the fringes of the maternity system."

  

It's clear to me that there are important conversations that the midwife needs to take responsibility for, when complications or new risk factors are identified.  The midwife's professional duty of care requires that the situation, and a plan of action, be clearly outlined and any questions responded to, to the best of the midwife's ability.   The woman's response can be to agree, to disagree, or to explore further.  Simple questions that I encourage women to ask, if at any time someone wants to interrupt the physiological processes are:

• What do you want to do?
• Why do you want to do that?
• What is likely to happen if I say "no"?

The partnership between a midwife and a woman requires honesty and trust both ways.  A woman who fears that her midwife may 'make' her transfer to hospital, for some trivial reason, will not make an informed decision.  Similarly a woman who takes no responsibility for her own decisions, but puts herself meekly in the hands of her midwife, is not making informed decisions.  Trust always has limits.  Midwifery is not a cult; midwives can not ask for blind acquiescence.

As a wise colleague put it,  

"I find the 'trust birth' claim far too naive ... but I think a lot of women in their bubble want to believe it. Perhaps all our easy access to IT - internet/emailgroups/facebook etc has something to do with which women choose homebirth now and why and who and how cult followings get supported, possibly blindly."

I wonder today if some women are misusing maternity care, and abusing the trust of their midwives, in a cult-like way that over-rides partnership, and puts the woman's experience first and foremost. 

 

Thankyou for your comments

Learning Medicare

My mind has been challenged recently as I have attempted to learn the technology associated with Medicare rebates.

I decided that a portable EFTPOS machine would be the best means of processing bulk billing and client rebates through Medicare.  This process requires a lot of technical support - well beyond my skill. The bank sent the machine, and set it up for me. 

The next step was for Kirsty, a lovely lady who works for Medicare, to enter my provider number, and the item numbers for my work.  Kirsty worked through it with me, and I watched her process one claim, then did one myself.  Those payments have now shown up on the bank account statement.

Yesterday I took the machine to a postnatal visit, and attempted to process the bulk bill payment on the spot.  It didn't work.  I obtained a signed authorisation from the client, determined to work it out.

Today I opened the manual, followed multiple instruction steps, and identified the point at which I had been stumped.  I was able to complete the transaction.  YAY!


Medicare has offered me the immediate opportunity to do more postnatal work for my clients.  This is great.  I am thankful.