Monday, November 21, 2016

Thanksgiving

This time of the year is a time of thanksgiving in our home.  I thank God for another year in the life of the man I love, and another year since I first became a mother.

In 1973 we experienced our first Thanksgiving feast in the USA.  It must have been November 22 that year, and we were invited to spend the day with Noel's major professor and his wife.  The food that I remember was roast turkey with all the trimmings including cranberry sauce; warm apple juice that had been pressed from the fruit locally, with sticks of cinnamon floating in the pot; sweet potatoes with a whole lot of brown sugar added to make them even sweeter, corn on the cob, apple pie topped off with some sort of cream that came out of a pressure pack - we were taken on a culinary voyage of discovery.  The food - most of which we had never experienced before - was wonderful!


 Another memory from that day was that I was coming into labour.  The tightenings of my womb were becoming stronger and more regular, and I was excited.  But not too excited to enjoy the feast, which I think primed me for the work ahead.  Our first child, who we named Miriam, was born in the evening of the next day.


The Thanksgiving tradition in North America recalls the pilgrim immigrants who had established a home for themselves in the new world, where they hoped to be free to live their lives and follow their faith.  They thanked their God for preserving their lives, often through grave difficulties, and for giving them hope for the future.


Yesterday we had our own family 'Thanksgiving' afternoon tea.  We celebrate the two birthdays, which come each year at this time.   We have much to celebrate and be thankful for.


My mother used to often remind me to "count your blessings".  As I progress through the years of my life, the magnitude and number of blessings has often become more clear to me.


The photo of the seven beautiful 'blessings', lined up on the old pew near our front door, will hold me in that state of thankfulness. 


Wednesday, November 16, 2016

Spring in Kyneton

Nothing deep and meaningful today.  It's springtime, and I need a place to post some of the pictures I took today in the garden.
Bonsai Japanese Maples

various Bonsai pots

Japanese Maple

Bonsai pines

Wattle




... and a nice new sand pit in the shade of the birch trees.

Friday, October 21, 2016

Idealism and midwifery - continued

In the previous posting on this topic, I attempted to introduce the notion that idealism around the birth of a baby impacts on what we do and how we do it in both negative and positive ways.


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I have recently noticed a degree of idealism around the circumstances of a birth that has left me troubled.  That has led me back to writing to you, dear blog reader, as has been my custom for many years.

To set the scene, there is a social media group that focuses on childbirth and the law.  The usual contributors to the discussions in this group are midwives, a few lawyers, and childbirth educators, lay birth attendants, and women who from time to time take an activist position, particularly in relation to natural birth.

From time to time I or someone else will post a link to a Coroners report of interest to the group, such as the death of a baby soon after birth.  Recently a report was released by the Victorian coroner, on the death of baby Martha from complications in a spontaneous breech birth.  A few weeks ago the New South Wales Coroner reported on the death of baby NA, also from complications in a spontaneous breech birth.

Readers who follow the links provided will see that these two cases have little in common, except the tragic loss of a baby's life.

The matter that disturbed me in reviewing both cases, and that I call idealistic, naive, and uninformed, is the notion expressed strongly in the group that a mother might have avoided the birthing complications had she been left undisturbed, "truly unhindered".

The sort of midwifery I have practised for many years, with a high degree of safety, includes respect for the woman's need to feel unwatched.  Ina May (Gaskin)'s rule, that sphincters work best at home and when unobserved is a truism that midwives love to quote.  Michel Odent has spent his life after obstetrics teaching us that the human woman is a mammal, and has similar needs to other mammals.  World Health Organisation published an excellent handbook on normal birth in the 1990s, stating that "In normal birth there should be a valid reason to interfere with the natural process."

Somehow the pendulum has swung, in the natural birth community at least, to promote non-interference in an extreme way.  There seems to be a growing group of mothers who believe they themselves and their babies are better off if there is no professional (midwife or doctor) who will intervene in the progress of their labours and births.

When a baby is presenting feet or bottom first (breech) it's not a normal birth - even though it may be spontaneous and natural, and even though there may be no adverse outcomes.  Under the WHO normal birth rule quoted above, there may be (in spontaneous breech birth) a valid reason for interfering with the natural process.  The skilled midwife recognises points at which an intervention (interference) with the natural process is optimal and may be life saving.  There is no time then to call for assistance.  A baby being born breech whose head has become entrapped needs to be released immediately. This urgency, which does not happen in the same way when a baby comes out head first, is what has driven the medical world to preference of caesarean birth for breech babies.

The person who thinks that a woman who is totally unhindered and relaxed can birth a baby smoother and faster than the alternative situation does not understand that death and life are in the balance at the time of birth.  

Nature is under no obligation to be kind, or to give us the outcomes we want.


Thursday, October 20, 2016

Idealism and midwifery

It's very easy to find evidence of idealism in anything that pertains to the birth of a baby.  After all, a new life is being brought into our world: precious, full of potential, carrying a unique blend of special characteristics of both parents - both families - into the future.

Idealism happens to some of us time and time again.  Each time I gave birth I found myself wanting to make this world better for that wee one.  I wanted to be a better mother.  I wanted us as a family to provide a better home. 

...   and then, after a few sleepless hours, with a baby who was simply doing what all healthy babies must do, which is to find food, my idealism was truly tested.  My beloved, lying wearily beside me in our bed, had no adequate solution either. 

Over time I became reconciled to the huge gulf between the ideal and the actual.  I learnt that it was, in fact, advantageous for a baby to come into this imperfect world, where the mother, despite her best intentions, is unable to solve every problem.  A world where the baby learns that there are times when both parents are unable to perform to their usual capacity; where there's no-one making eye contact or vowing their love; where even a dripping moist nipple at the end of a full breast fails miserably to meet the need.

If the home was always ideal, how would the child ever cope with the real world?

Conversely, if the mother did not have idealism deep in her heart; if she did not want the best she could possibly provide for her family, how would any child thrive?
_________________________________

A similar dilemma exists in midwifery.

The ideal is that each woman receives a primary level of professional care from a known and trusted midwife.  The ideal is that the woman and the midwife work in a special partnership that provides optimal care and achieves optimal outcomes for mother and child.   The ideal is that the mother's body will function without illness or complication.  The ideal is that the midwife's wisdom will enhance the woman's acceptance of new and primal terrain that must be traversed. 

The reality may be very different.

Our lives are often messed up, at all levels of our physical, social, psychological, and spiritual existence.   In fact, I have been amazed at how often the processes of pregnancy and birth and nurture of the newborn come together in beautiful harmony, demonstrating the wonder of creation.  The way our bodies function in health, as finely integrated systems, is good.   Illness and disease have, to a greater or lesser degree, corrupted this state of goodness.

Dear reader, I need to sign off now, but will plan to return to this theme as soon as I can.



Monday, June 13, 2016

Are we nearing the end of the villagemidwife era?

Dear reader
In seeking to answer this question, are we nearing the end of the villagemidwife era?, I would like to take you today on a reflective journey.  Please come with me along memory lane - not just our memories, but including our mothers' and grandmothers', and more.  If you would like to leave comment at this blogpage, please do so, and thankyou.

What do you know about your own birth?  If you have given birth, how does that compare with your mother's experience of giving birth?


In my lifetime, and within the broad scope of my culture, the person called midwife has progressed from a midwifery nurse, whose language included 'confinement' and the 'lying in' period, and who was required to work under medical supervision, to a highly regulated modern professional who has endorsement that enables access to public funding, hospitals, and prescribing certain medicines.  My generation of midwives experienced a movement to claim midwifery as a profession distinct from nursing.  This can be seen in the two documents pictured below, both from 1973.  The graduation certificate, from the Royal Women's Hospital in Melbourne, states boldly that I have graduated as a midwife from the hospital's School of Midwifery.  In contrast, the Certificate of Registration, issued by the Nurses Board of Victoria in the same year, declared that I was a MIDWIFERY NURSE. 

Graduation as a midwife 1973

Registration as a midwifery nurse 1973

My mother was also a midwife.  In her lifetime Penicillin was discovered, and surgical interventions in birth became safer than they had been.  My mother's generation of midwives taught young women to scald cow's milk, and add sugar and water, making it a tolerable food to replace the mother's own milk - something that became all too easy!

My grandmothers were not midwives, but they gave birth to their babies in the care of midwives who attended them at home or in a private 'nursing home', strictly enforcing requirements for bed rest, and stayed for a couple of weeks afterwards.

One of my great grand-mothers, Angelina White, died 'in childbed'.  Her death was two weeks after the birth of her child, probably from sepsis and haemorrhage: the sort of illness that I would treat with antibiotics.  My grandfather was only four years old when his mother died.



So, what do I mean by the villagemidwife era?

In the beginning, some women learnt that unique and life-affirming skill of accompanying women through their childbearing event.  Those women learnt to work in harmony with amazing, hormonally mediated natural processes; learnt how to teach others enough to prepare well, without becoming overwhelmed; learnt how to reduce and minimise fear and anxiety, so that the labouring woman accepted the work of labour; learnt how to support without interrupting the processes of mother-baby attachment, ensuring strong bonds and resilient families.  The image in my mind is that of a midwife who was known and recognised by her community as being the guardian of the next generation of mothers and babies.

I discovered the villagemidwife model soon after I set up my private midwifery practice in the early 1990s.   I was providing clinical support to a group of RMIT midwifery students at Box Hill Hospital at the time.  A midwife at the hospital asked a student "What would the villagemidwife do?", when faced with a particular challenge.

The villagemidwife then, as now, is known and recognised by her community as being the guardian of the next generation of mothers and babies. 

It was an absolute privilege for me to, over the years, return to families as their known and trusted midwife.   I also felt deeply privileged to guide women in their first birthing - a significant challenge.  And to support - and dare I say 'help' - women who felt violated in their previous birth.

Yet I need to also tell you about the other side of this coin.

There were many frustrations.   My 'village' had no boundaries.  Working with a caseload, on call 24/7 is the big commitment made by a midwife, but it is not easy.  Some of the births I committed to required me to travel one or two hours, often driving through the night.  One morning as I made my way home along Burwood Highway after a birth in the Dandenongs I realised with only moments to spare that I was heading for a tree.  A micro-second of sleep had almost robbed me of life.   I had learnt over the years of hospital night shifts to eat an apple slowly as I traveled home, giving a steady supply of sugar to my weary brain.  I could usually make an apple last the distance.  But my 'stay awake' strategies were not perfect!

I would not take a long distance booking if the mother could find a midwife who was closer.  Not only was the travel costly on my time and energy, but it meant I might not be able to provide as much postnatal care as I would have wished.  

There was a reality that I had to face - my 'village' needed to give me enough work to pay the bills.  There were times when I accepted bookings that required distance travel, or that put several women due in the same week.   There was no way of predicting when babies would be born.  Many times I would look at the calendar - two due this week, one due the following week, and one the week after that.  Then, all of a sudden, four babies would be born within a couple of days.   Add to that the travel from one side of Melbourne to the other, with crowded suburban roads to cross: not the ideal!

The commitment I made to the women in my care meant that my children had to get on without me, sometimes at special times in their lives.  I missed a couple of Paul's birthdays - to the same mother who gave birth to two of her children on that day several years apart!   There were a few occasions when I had to ask another midwife to cover for me, but the very thought of not being able to keep my commitment to that mother caused me deep sorrow.  One birth I missed when I needed to travel to Brisbane when my Dad was dying.  The fact is that the caseload commitment of a midwife is a very difficult commitment to make.

Last month I decided not to renew my midwife registration. More than a year ago I decided not to renew my professional indemnity insurance, so although I was registered I was not able to practise midwifery. During the past 18 months I have lived quietly, gradually recovering from the physical and emotional burnout that developed gradually over several years. I have been enjoying the beautiful grandchildren (and their parents) that God has sent into our care, the change of the seasons, the garden, and many simple life challenges.

It's ten years since I began writing the villagemidwife blog, telling stories and making comment on midwifery issues. It's about 20 years since I wrote what I called The Midwife's Journal http://www.aitex.com.au/joy/journal/contents.htm. These stories were initially written by hand in a book, often while I could still smell the amniotic fluid on my arms, and while the oxytocin and other wonderful hormones of life soared in my body, and I added precious photos - in the pre-digital camera days. 

During these years of writing and reflecting, I have felt that I am in a position of guardianship, recording and discussing life from the midwife's perspective. I am thankful that advances in computer technology in my lifetime have made it easy for me to do this in a systematic and retrievable way.
Although I am no longer able to do the work of the villagemidwife, I do not think I have lost the ability to think about life from this unique perspective.

I have not yet answered the question at the head of this post.  Perhaps that's for another day! 

I would appreciate comment from anyone who reads this post. Thankyou.

Saturday, April 30, 2016

thoughts on motherhood


Women contemplating motherhood face enormous challenges.  Pregnancy and childbirth are just the beginning.

Many Australian women tell me that they are angry when the 'system' dictates what they can and can't do.
"It's my body; my baby", they say.
"Surely I know what's best for myself and my baby!"
"Surely you're not allowed to not allow me?"

Women also tell me that they have deep sadness as they remember and reflect upon their experiences in birth.  "I know I needed a repeat caesarean.  But I felt like a piece of meat on a slab.  My baby was taken to the Nursery, while I was in Recovery.  I didn't see him for a couple of hours, and that still makes me sad.  I was afraid for him, and wanted him with me.  If I could have had a natural birth, I would have."

Natural birth has become the ultimate, longed-for experience in childbirth.

Unmedicated, physiological birth; uninterrupted, ecstatic, even orgasmic.
No clamping of the umbilical cord.  No separation of mother and baby - at all!  Not just the first hour, but as long as it takes.

Achieved by only a few.

Who wouldn't want to join that exclusive club?

Not only does the mother appreciate the physical, emotional and hormonal bonuses of working in harmony with amazing natural processes in birth, but the baby also joins in, without any prompting, in this unique primal dance.  


The point I am trying to make, and the main reason I am writing this post, is that there's a problem - women can't pick and choose their maternity journey.  My comments may seem predictable.  How many times have I written this sort of thing, since I started blogging in 2006?  

  • The choices or decisions in maternity are quite simple - to intervene or not.  The biological processes in pregnancy, birth and lactation will continue as time passes.  
  • Once interventions have occurred it may be difficult to return to the natural, healthy process.
  • Undesired outcomes including death may occur, with or without medical or surgical interventions.

I have heard childbirth educators who teach that women who really want natural birth need to surround themselves with a team of supporters who will not waver in their support.  "The chain is only as strong as its weakest link," they say.  "If your supporters (including friends, husband, photographer, carer for children, doula, midwives) stop believing in you, they will cause you to give up just when you should be strong!"

This sort of advice is appalling.

Noone can predict a childbearing journey.  Natural birth is not something that can be ordered like a saleable commodity.  Women can't pick and choose.  A woman's pain in labour may be an indication of serious complication which, if nothing is done to relieve it, has catastrophic consequences.  A woman who shuts down her own responses to pain, and blocks the empathy and care of her supporters is ignoring natural processes at her peril.  A midwife who is disengaged, and sits on her hands rather than guide a woman on in labour, or, make the call to escalate care, is negligent or incompetent.  This might be as 'simple' as, without words, guiding a labouring woman to change her position, thereby moving from the transition to the second stage.  It may be as profound as telling the woman that you are now advising medical intervention, with all that that means.


Advice on childbirth has multiplied in recent years, with social media and internet communications.  A childbirth blog that has (literally) thousands of 'like's, tells us that "The legal authority in childbirth lies with the woman giving birth, not the providers ..." [link]

That's nonsense. 

There is a legal and ethical 'duty of care' that providers (midwife or doctor or other health care providers) are required to take very seriously.   It's an ongoing responsibility that the care provider carries as long as they are in attendance or other relationship such as in phone contact with the recipient of care.

This doesn't mean that all advice or decisions by providers are necessarily 'best practice' or acceptable to the woman.  Some providers maintain practices that are out of date, and believe they should intervene when others consider the progress to be uncomplicated and not requiring intervention.  Some providers (midwives and doctors) take large caseloads that result in cutting corners and burnout.  Human error is a constant threat.  These factors are balanced, to a degree, by the legal right of a competent woman to decline any intervention on herself (but not necessarily on her baby after birth).

We can talk about the legal and ethical standard for informed consent, but the hospitals/doctors/midwives know that they are much more likely to be defending their actions to their indemnity provider or the coroner or AHPRA.  


And there's the uneven playing field. The provider does *it* many times every day, while the woman is doing it for the first (or whatever) time - and takes the 'outcomes' (including pelvic floor damage, surgical wounds, infection, and many other types of morbidity, not to mention mortality) home.
 


Becoming a mother - bearing and nurturing a child - is an awesome and privileged position for any woman to be in.  Our bodies are wonderfully made.  

But, we can't pick and choose what happens in our maternity journeys.

The most healthy and 'low risk' pregnancy can suddenly and unpredictably be subject to life-threatening complications.  Alternatively, a woman with recognised risk factors can proceed without any complication.

Decision-making in the childbearing continuum is an ongoing process.  The woman who can trust her care provider enough to challenge or seek further discussion when any decision point has been reached is, I believe, in the best position.  The woman who believes she is alone, and has to be strong  and resist intervention or professional advice 'no matter what', is likely to be overwhelmed with fear and may make decisions that are not in her best interest.

Wednesday, December 16, 2015

The death of a baby

Today I would like to comment on a case in which the baby died after induction of labour in a tertiary level obstetric hospital. 

It's a well staffed, well equipped modern facility, with all the bells and whistles.   It's a hospital where doctors and midwives and nurses are  being taught their professions, where evidence based practice is treated seriously.

This death was reported to the Victorian Coroner, who carried out an inquest and has recently published her findings.  The baby's name is Kylie.  I would like to refer to her by her name, as she is at the centre of the picture.  Other people will be referred to by their role.

I am writing about this sad case because it has a number of features are important in understanding an unexpected adverse event.  Please note that I don't have any inside knowledge.  I don't know any of the midwives or doctors who cared for Kylie or her mother, and I don't know anyone who knows Kylie's parents or family.  My source is the Coroner's report which has been placed on the public record. 


A layperson reading the report may well ask how was this allowed to happen?  Why was no action taken until (obviously, with the benefit of hindsight) too late, to hasten the birth of baby Kylie?  What's the point of having continuous CTG monitoring if the plan is to press on, even when the most basic understanding of cardio tocography indicates that baby Kylie was distressed? 

That's the big question

Although birth is not an illness, the process carries potential for damage and death.  In birth there is a finite point after which the baby will not do well, but it's impossible to predict where that point is.  Midwives have to accept and embrace this uncertainty, as we work in harmony with natural physiological processes which usually lead to spontaneous birth.  The decisions we make in the clinical setting take unpredictable and sometimes quick changes into account.


The language used to describe a CTG trace, such as 'non-reassuring', is, I think, deliberately vague.  We are all confident when we see a CTG trace that ticks all the boxes.  'Reassuring'!   It's the non-reassuring ones, placed in context with all the other clinical features, that challenge decision-making.  A normal trace now can not predict the condition of the baby in 2 hours' time, or 10 minutes, or any time in the future.


I found the record of the evidence of the obstetric experts very interesting (#70 onwards). Some hospitals/obstetricians have a low tolerance for non-reassuring traces.  Historically the CTG machine has become the catalyst for high rates of caesarean births, and many babies come out pink and complaining about the whole process, suggesting that the surgery was not really necessary.  The ability of the midwives and doctors who are providing professional care to know which mother-baby pair is progressing well, and who needs surgical intervention is a skill that cannot be overvalued.  The big teaching hospitals such as this one set up their guidelines that the staff are bound to follow with this in mind.
 
The idea of a chronically compromised fetus who may not have done well even if the baby had been delivered earlier is worth thinking about.  



Will this death, and the related report, lead to an even greater rate of elective surgery to avoid the possibility of low fetal reserves?  How many mothers will be operated on without valid reason, giving them and their children the increased life-long consequences of caesarean surgery?  More importantly, will the lives of babies like little Kylie be protected as they make their transition from mother's womb to our world? 



My response to this report is from a midwife perspective. For 20 or so years until my retirement last year I have been attending homebirths, without access to CTG at the primary care level. A midwife attending homebirth will usually listen to the fetal heart sounds using a doppler sonicaid machine after a contraction, and consider that observation within the context of other clinical features. If there are 'non-reassuring' features of that auscultation, such as a deceleration, it's a decision point that can have profound consequences.