Tuesday, October 10, 2017

Replacing the midwife?

The woman found it difficult to trust anyone.  Very difficult.  Her anxieties about bad people and bad things were overwhelming.  'They' were likely to force her to take medicines that were bad.  The bacteria and viruses in public spaces were bad.  The 'system' would force her to have surgery that she didn't want.

The woman became pregnant.  She had been pregnant a couple of times previously, but had terminated those pregnancies early.  She wasn't ready then.  For some reason this baby stayed in place and before long she was experiencing new feelings - movements.  Her need to control must have been weakened as the maternal and placental hormone levels surged.

She was strong and healthy, and avoided anything that sounded like professional maternity care.  But she was curious, and a bit of a geek, well versed in all things digital, so a couple of ultrasound scans were arranged through a local medical practice.  Fascinated by the imaging, she asked lots of questions of the technician.

The woman found a new world opening up in cyber space.  Groups and forums, with varying levels of security, brought a host of information and options, as well as a sense of belonging.  It wasn't long before she found herself linked to a network of like-minded women, or at least she thought they were.  One was close to giving birth, and described her plans to bring together a supportive group of women, all with positive energy, so that she could give birth in a state of ecstasy.

The woman found a fetal monitoring device on e-bay.   She bought it, strapped it on, and listened to the rapid wop-wop-wop, with occasional kicks or hicoughs to break the monotony.  Over time the woman was becoming more excited about the thought of 'free' birth.  It ticked all her boxes.  And a couple of friends from the online community had told her they would help her.  These women were experienced, from their own births especially.

****************

This story is based on real people; real events.  I do not want to describe it further.  The reader can envisage the possibilities.

There have always been people with anxiety neuroses and other aspects of mental health impairment.  The distrust and fear of everything bad, as this woman experienced, is not new.   A midwife who earns the respect and trust of a woman whose mental state is fragile may be able to support and empower her in a restorative way, as she prepares to bring a baby into her life.

The element that has recently been added, in some cases triggering the perfect storm, is the information overload that has been unleashed via the internet and social media.

In this story there has been no midwife, no systematic maternity care or surveillance.  Babies will eventually be born, even if there is noone providing care or checking health and development.  In this world of distrust the midwife is seen as a medical person, and anything medical is to be avoided and not trusted.  But, you will say, surely the ultrasound scans are medical?  Surely the strapped on monitoring device is medical?  Of course.  This world is not always logical.  The fragments of professional knowledge that can be shared digitally from person to person via social media can give a sense of great knowledge, especially to the novice who is just beginning to navigate the terrain.

In my experience this woman did seek out midwifery care, quite late in her pregnancy.  That's how I come to know about her.  There was no development of a mutually trusting relationship or partnership.  Distrust was worse than the germ-phobia.  My professional guidance was received at arms length, and it was being checked against the mirage of wisdom of the team of guides.  On the positive side of the ledger was a healthy baby and a physically healthy mother, and a process that does not submit to intellectual control, but is driven by wonderfully powerful physical and physiological-hormonal forces.

888888888888888888888888

Now imagine ....
  • that a digital device was developed to replace the personal midwife
  • that this device could be strapped on or implanted or otherwise attached to the woman 
  • that this device monitored and recorded all the physical observations recommended in maternity care
  • that this device provided the woman with a real time decision making guide
  • that the information recorded by this device could be accessed remotely, by whom-ever the woman chose to share it with
  •  ... and so on   

It sounds so realistic, so do-able, that now I'm getting anxious.

Already many women in labour are connected to continuous electronic fetal monitoring devices that record the baby's heart rate and the time/duration of maternal contractions, maternal pulse and blood pressure.  Already those machines are linked to a monitor that is usually stationed at the 'desk' of the birth suite, and can be looked at by whoever is at the desk: a midwife, obstetrician, or someone else.  Already digital cameras exist that could be placed in the woman's vagina to record the dilatation of the cervix and the progress of the presenting part.

Our society has embraced technological interventions in pregnancy and birth to such a degree that these points I have imagined are not really fanciful.  We have the technology.  Someone just needs to put it together.  And just as our world is preparing for driver-less cars, the medico-legal world is ready to embrace technology that would give a new level of assurance, accountability, and what would be seen as less chance of human error.  Although research has failed to support improved outcomes from routine continuous electronic fetal monitoring, few women avoid it in maternity care.

The next step with the introduction of this unnamed device is that a woman who cannot trust the 'system' could see this as useful for her DIY 'free' birth.  Just as she strapped on the monitor at 26 weeks' gestation and listened to the rapid thudding of that tiny heart, she would likely see this device as something that would give her confidence, without the threat of 'bad' things happening at the hands of an un-trusted other person or system.

Yes, the system is full of flaws.  Yes, there are people with the title 'midwife' or 'doctor' who do not understand the woman's fears  and anxieties.  I hope maternity services will be reformed around care that centres on the needs of the individual woman, and enables her to trust the care she receives, and understand the imperfections as they arise.


I would like to think that a device will not replace the midwife.

Thursday, December 08, 2016

Coroner's reports and expert witness



'Midwives and the medicolegal system'

·       [These are the notes I prepared for a talk given at MAMA Caulfield today.]

INTRODUCTION
My interest – 
§  a midwife in private practice 1992-2015.  Included many births that would be called ‘high risk’ today – grand multipara, births after caesareans, previous history of haemorrhage, undiagnosed twins and breech births.
§  Activism around the laws and regulations relevant to midwifery, particularly in the 1990s and 2000s.
§  Appointed to the (then) Nurses Board of Victoria. 
§  Ongoing, as a member of this society, a mother, grandmother &c, and a lifelong learner.  Reflecting on cases, and learning what happened, why, what could have been done differently, what would I do differently next time this happens


EXERCISE: Write down any phrases or sayings you can think of relevant to birth & midwifery (you don’t have to agree with them)
·       “Birth is not an illness”

·       “In normal birth there should be a valid reason to interfere with the natural process.”

·       “A midwife sits on her hands”

·       “Hands off the breech”

·       “My body, my baby, my birth”

·       “with woman”

·       “wise woman, sage femme”

·       Every woman needs a midwife

·       Choice, control, continuity of carer



LEARNING FROM CORONER’S REPORTS
A few links:
Planned homebirths in NSW*

*Note the finding that "Characterising these homebirths as a patient’s choice misrepresents the patient’s knowledge base in making that (uninformed, or not sufficiently informed) decision, and misunderstands the role of the professional in explaining risk and recommending safe practice"
Facebook site ‘Childbirth and the Law – Australia’ – “...This group is for discussing developments in the law about pregnancy and childbirth in Australia. It is not a forum for soliciting or giving legal advice or legal information.”



CASE STUDIES
Examples of cases for which I have provided expert witness review on behalf of the legal team for one of the parties to litigation.

CASE 1:
Baby developed cerebral palsy, and was suing the hospital.  Baby was born in hospital, vaginal birth after induction of labour at 38 weeks.  At about 3 hours after birth the mother discovered that her baby had become floppy and was not breathing.  Immediate resuscitation attempts and transfer to SCN, and appeared to recover well.

Opinion:
“Following your consideration of the material,:
(1) Please provide your opinion as to whether the midwives at [Hospital], in their treatment and management of the plaintiff , acted in a manner that was widely accepted in Australia by a significant number of respected midwives, as competent professional practice in the circumstances.
(2) If you are of the opinion that the midwives at [H] acted in a manner that was widely accepted in Australia as competent professional practice, please outline the basis of your opinion the practice was ‘widely accepted’.  Please note that as a matter of law, peer professional opinion does not have to be universally accepted to be considered widely accepted.
(3) Please provide your opinion on each of the allegations of negligence made against [H] in paragraph (xx) of the Statement of Claims.



CASE 2:
Baby developed cerebral palsy after VBAC complicated by shoulder dystocia. Parents had begun proceedings against private midwife who was primary carer for planned homebirth, transferred in second stage to hospital. 

Based on the facts outlined in this case, I was asked whether I consider that:
(a)        M’s [Midwife’s] management of W’s [Woman’s] pregnancy and labour was in accordance with what would be widely accepted by peer opinion as competent professional practice.
(b)        it was appropriate for M to agree to manage the labour as a home birth.
(c)        M should have transferred W to hospital earlier.  If so, when and on the basis of what signs of symptoms?
(d)        there were any indications prior to x:xx pm (the time of birth) of possible shoulder dystocia or an increased risk of shoulder dystocia.





CASE 3:
Medical negligence claim in which the doctor [D] disputes key aspects of the records made by the hospital midwives [M] at the time of birth of baby [B] who was delivered by Ventouse extraction, had Apgar scores of 1 at 1min and 3 at 5min, and developed cerebral palsy.  B has commenced a claim against Doctor D and the hospital.

My report addressed the following questions:
1.     In relation to the actions of the hospital staff, we ask you to examine the partogram and the other records made by the nursing staff and comment on their adequacy,
2.     We note the plaintiff pleads in paragraph [x] of the Statement of Claim that between 03:00 and 06:00 hours there was a reduction in the variability of the foetal heart rate.  In your opinion, should the midwives have contacted Dr [D] prior to his attendance at 06:30 hours?
3.     We note the hospital staff recorded “B.S.” (we assume this means blood-stained liquor) at 03:00 hours and “mec” (we assume this means meconium) at 03:30 hours, and “B.S.” and “mec” at 04:30 /05:00 hours.  Should the midwives have contacted Dr [D] and informed him of these developments?
4.     Any other comments you wish to make on the midwives’ management.
5.     We would be grateful if you could please confine your comments to the midwives’ management.  An obstetric expert will provide a view on Dr [D]’s management.



WATCH OUT!

  • 1.     Mother’s rights vs baby’s (fetal) rights “my body, my baby, my birth”. Decision-making (not ‘choice’) Informed refusal, uninformed, or not sufficiently informed decision.
  • 2.     Communication and social media – huge change in past decade.  What’s in store?
  • 3.     True believer – ‘choice’, ‘control’, informed consent, non-intervention, natural, even ‘breast is best’
  • 4.     What it means to the midwife to plan for homebirth.
  • 5.     Lack of respect for the amazing processes of pregnancy, birth and nurture of the baby


CONCLUSION
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 (or mother) will not do well, but it's impossible to predict where that point is.  Midwives accept and embrace this uncertainty, as we work in harmony with natural physiological processes which usually lead to spontaneous birth, or alternately as we intervene and interrupt that natural process. 

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.


***************

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.