Andrea’s Diary

Today I set out on the start the Midwifery Intensives Tour. It is always busy getting everything ready for these events (hence the few Diary entries over the past week) and it is good to be on the road at last. We have hundreds of midwives booked in and a full program over the next 12 days.

Travelling with my good friends Lynne Staff, Maggie Banks and Vicki Chan always gives me a great deal of pleasure. There is lots of time to share stories, talk politics, compare notes and discuss ideas, especially as the tour will involve a lot of plane travel between the capital cities.

Tonight over dinner we were talking about the language issues (always a central theme of any workshop on birth) and the difference between “caesarean birth” and “caesarean delivery”. Maggie feels that we should still retain the term “caesarean delivery” because that puts the power where it is - with the doctor. I agree, but also think that we should try and get rid of the term “delivery” altogether. I appreciate that making the distinction between what women do (birth) and doctors do(deliver) is important, but to expect midwives to remember the distinction may be too hard. Perhaps one solution would be to re-label it as “caesarean surgery” and avoid both terms. Of course, women are still having a baby, even when surgery is involved, and a baby is still being birthed, even if it is through an incision rather than a vagina. Tricky!

We also talked about the way posterior positioned babies are becoming a major issue, to the point that women are now scared when their baby is positioned this way. Much fuss is being made about “optimal foetal positioning” as a way of avoiding this “catastrophic” position of the baby, and elective caesareans are also being performed because of the baby’s position, especially when it is thought to be a large baby. All this emphasis on getting the baby “lined up favourably” is setting women up for fear and drama if the baby chooses to lie some other way. Whatever the position of the baby, it can be born vaginally (almost always), and women will find ways of working with their bodies and their babies to get them around and down towards birth. If we start alarming women regarding the position of the baby, their bodies will seize up with fright, the pain will increase and an epidural will most likely be needed. An epidural is the worst possible solution for both the woman and her baby, because she needs mobility and freedom to work with her pelvis and baby that is completely impossible with an epidural and all the additional straps and drips that come with it. Talking to women about these issues during the pregnancy is a major role of the midwife, and getting these messages across to midwives will be a major part of this program.

Meanwhile, I can see will have many fun conversations during these next days.

I have been reading recently of a new drug that is being trialed for relieving pain in labour. Remifentanil is a member of the opiate family, delivered intravenously, via patient controlled analgesia, It is most commonly used during induction of a general anaesthetic, has a rapid onset, a short duration of action, and a half life of around 3 minutes.

Despite its rapid transfer to the patient, it is expected to have little effect on the fetus because of its rapid metabolism. When administered as a continuous infusion, remifentanil crosses the placenta rapidly and is quickly metabolised and redistributed in the fetus. With bolus doses, there were no reports of associated increases in respiratory depression in the newborn or lower Apgar scores.

It was initially used for women for whom an epidural was contraindicated and this led to the PCA method of delivery. Women learn to anticipate a contraction and “top up” their own dosage in preparation for the anticipated pain.

There are no controlled studies regarding the use of remifentanil in labour and it is again a classic case of bringing in a treatment with no prior investigations,. No-one knows if it is safe for the unborn or newborn baby or its effects on the woman in labour. It has been pointed out that remifentanil is not approved for obstetric use, but it is still being promoted, however, for use when an epidural is contraindicated.

Watch out for this one - doctors love a new “toy” top play with and women can be easily convinced to try it, even if not approved or shown to be safe, if they think they will not be able to manage the pain of labour without drugs of some kind. It will be interesting to see if it takes off and who decides to use it. Where there is money to be made, sales will be pushed and the health and well being of women and babies often takes a back seat.

An expectant mother called me today wanting to know where she could attend “breathing classes” for labour. I gently explored what she was actually seeking, as some women call all prenatal programs “breathing classes” but she did indeed expect to have to learn how to breathe in labour.

I explained that teaching women to breathe was something that we no longer advocated ( we gave up including it in our training courses and classes in 1984) for two good reasons: women already know how to breathe and will continue to do this during labour and birth, and there is evidence that breathing in an artificial, structured way can alter a woman’s blood chemistry (something that could present problems in labour). She was a bit taken aback by this explanation, but was still keen to attend some classes nevertheless. I gave her the name of one of the independent educators in her area, as she said all the local hospital programs were fully booked. As she is 31 weeks pregnant, I hope she can find a program that can accommodate her dates (and learn how well she will labour without any props, given a chance).

It is no wonder that women still think that the classes are primarily focussed on “the breathing”. So many of the books that are targeted at pregnant women mention breathing of some kind. It is a hangover from the psychoprophylaxis methods (popularised by the Lamaze organisation in America) that burst onto the scene in the 60s and 70s, promising painless childbirth if rigid breathing patterns were learned in pregnancy and practised throughout labour. Although many of these ideas have now been modified (there has never been any proof that they work or reduce the level of pain killing drugs taken by labouring women), it seems that authors cannot let the concept go, and still make reference to “breathing” in the many books that proliferate in this market.

Any suggestion that women would need to learn special breathing for labour is not only ridiculous but undermining. Women’s bodies are quite capable of altering the rate and depth of breathing to provide enough oxygen for the work going on in their bodies and for their baby. You don’t hear of athletes going to special “breathing classes” so they can run effective races, and animals the whole world over manage without preparation of any kind. Why would human beings be so poorly developed that they had to learn how to perform this most basic function?

I’ve been working today on preparing the material for our “Midwifery Intensives: Keeping birth normal” tour, which starts in just over a week. This will be an exciting program and our three speakers, Maggie Banks, Vicki Chan and Lynne Staff have put together wonderful presentations.

Each will present a paper in the morning, and in the afternoon, facilitate a workshop session where skills and tips can be discussed and worked on.

Vicki Chan will tackle the subject of occipito-posterior labours, Maggie Banks will cover the management of vaginal breech births and Lynne Staff will explore ways to promote and support vaginal birth after a previous caesarean. All are topics that are relevant to the rising caesarean birth rate, and it is the development of confidence and competence of midwives so they can keep birth normal when these conditions are present that is the aim of this program.

The toolkit for working with OP labours looks very exciting. I know the slides that Maggie and Lynne have prepared of normal births with either breech babies or VBAC women are wonderful and inspiring. It is going to be an exhilarating day! Last minute registrations can be taken (but not for the Melbourne event - it is sold out!).

We were discussing the rising Australian caesarean section rate during the workshop in Brisbane yesterday. There doesn’t seem to be the same level of concern in this country compared with the UK, where strenuous efforts have finally halted the rise there, with reports that for the first time in many years, the rate has remained steady over the past 12 months.

The high level of private obstetrics in Australia is likely to the main reason why no-one is worried it more women have surgical births. In the UK, private obstetrics is very limited, but the doctors still have enormous power over the maternity service, issuing guidelines that in many ways undermine the role of midwives by imposing very restrictive, obstetric orientated practice requirements on them.

Just before I left the UK, there was an interesting article in the Evening Standard (Tuesday March 30). It was titled “The shocking truth about Caesareans?” and was written by Michel Odent. He outlined the implications of caesarean birth on the emotional and physical development of the baby. For the first time in human history up to one third of babies are being born in ways that completely bypass the hormonal influences of normal labour. He suggests that this lack of exposure to the maternal hormones during birth may be the underlying cause of increasing rates of autism in children and a reduced capacity in women to love their children. He also points out that surgical births mean that babies are born in germ free environments and miss out on the beneficial exposure to the maternal bacteria and antibodies they would normal pick up during the journey down the birth canal. This lack of exposure means the baby’s intestinal system is vulnerable to colonisation by less favourable bacteria which may weaken the baby’s defences to illness later.

He quotes a number of studies that reveal that drug addiction, suicide, anorexia and juvenile crime are all higher when babies are born by caesarean section. The effects on the genetic makeup over several generations is also raised, if the trend to surgical birth is not stemmed.

Michel will be again visiting Australia next year and will no doubt expand on these themes during his presentation on our Future Birth tour in April 2005. It promises to be a very thought provoking presentation and will, I hope, be influential in igniting a fierce debate about the rising caesarean rate in this country.

A large package of information arrived for me today from our UK office. It contained a number of research papers, reports and package insert information regarding the use of Entonox (nitrous oxide and oxygen), the “gas” often used for easing labour pain.

The information has been gathered by a British midwife who is concerned that midwives are offering labouring women this gas, unaware of the implications for themselves. This midwife, who wants to remain anonymous at this point, has herself experienced unwanted effects from the gas, and feels that her employers are not taking her concerns seriously. She has embarked on a mammoth effort to uncover everything that she can about the uses and effects of this drug, and has forwarded copies to me so that I can write it up for publication in a suitable midwifery journal. She wants her colleagues warned of the health risks of being exposed to nitrous oxide on a regular basis, as happens in British labour wards (and many Australian ones as well).

At the same time, the makers in Britain, BOC Gases, have begun an advertising campaign to promote its use. It is hard to imagine why this might be necessary, because it is a staple measure for managing pain in all British hospitals, and is even used at home births and during water births. Apparently they feel that midwives are not using it correctly, and recommend that women be encouraged to start breathing it before the contractions start, rather than waiting for the contraction to begin, as has been the practice to date. This would mean that women would inhale a larger quantity of the gas, in anticipation of contractions. It would also mean that the air in the room would have a greater level of gas circulating, from the machine itself and also from the exhalations of the labouring woman.

It will take me some time to sift through this interesting material and to pull and article together. Whilst I am concerned about the effects that this drug has on midwives (and who only receive it indirectly) the effects on the woman using it, and her unborn baby also need to be exposed. The lack of research on the effects on newborns has been the basis of statements that “it is safe” for the unborn, but in my mind this is a false claim. Just because there is no research does not prove safety, it proves that we don’t know, because no investigations have ever been undertaken.

I am looking forward to sifting through this pile of information, and to checking the various websites that have also been suggested as useful sources of background details. This is one project that will go to the top of my “urgent” list. I will keep you posted.

Over the Easter holiday I have been having a lovely quiet time catching up on my reading. I always seem to have a pile of midwifery journals waiting to be read, and for once, I am determined to reduce this pile to zero.

One article caught my eye. It described the British NICE (National Institute for Clinical Excellence) guidelines that recommended that once a woman’s pregnancy has passed 40 weeks , she should have her membranes swept to encourage cervical ripening and perhaps initiate labour. This involves a finger being introduced into the softened cervix and then circled around inside, between the membranes and the wall of the uterus. The aim is to loosen the membranes and at the same time, to stretch the cervix. It is thought that this will help the “ripening” process and perhaps reduce the necessity for an induction, a procedure with well documented adverse effects for mother and baby.

As a result of this recommendation (not based on any solid research, as I understand it), many midwives in Britain are now performing this invasive procedure in prenatal clinics. Although it may help avoid an induction, there are also risks, mainly of accidental membrane rupture, infection and bleeding. In addition, it can be painful for the woman, not to mention potentially threatening. Many women would interpret this as a gross invasion of personal space, and find it deeply distressing.

I remember many years ago (25 plus years), during my first visit to Darwin, hearing of the local obstetrician who routinely performed “strip and stretch” manoeuvres on all the women in his practice from 38 weeks onwards. His proud boast was that he rarely needed to induce any labours. The midwives, however, reported that many women would call the hospital in tears, complaining of pain and bleeding after each prenatal visit. In those days, the idea of “informed consent” was sketchy at best, and these women didn’t know that this was what was being done to them - they thought they were just having an “internal” done. This obstetrician has now retired, but on subsequent visits, over many years, I heard the ongoing saga of this abuse of women and their bodies.

Why are midwives now being coerced into performing this invasive, painful and unnecessary procedure? To an outsider, a “cervical sweep” looks a lot like sexual abuse, and it is certainly physical abuse. Midwives should think carefully before falling for the obstetricians (NICE) guidelines that clearly are not based on woman centred care, but obstetric and hospital needs. The basic tenet still applies to midwives: “First do no harm”……

The workshop I am currently facilitating in Sydney has a high proportion of students in the group. This is always refreshing and enjoyable, as they often ask challenging questions and are keen to explore issues in ways that experienced midwives find different.

The gap between the academic world and the reality of the hospital experience was a theme that emerged strongly yesterday. These students are learning all about woman centred care in their courses, but find that in the hospital, it is mainly doctors centred care that they are witnessing.

The experience to be gained form their placements varies widely as well. One student (from the UK, doing her five week practical in a Sydney teaching hospital) was able to see many water births which she would have missed out on in her local area in Britain. A couple of the local students, however, have found themselves in hospitals where routines rule and policies are rigidly enforced, with no consideration of the issues of informed consent or even the necessity for the practices being carried out. They have been shocked by the behaviours of their midwifery colleagues (often just as bad or even worse than the doctors) and this is not a good omen for the future of midwifery practice. The current shortages and resultant stressful working conditions are no doubt a contributing factor in these reactions, but this can be no excuse for midwives trampling on women’s rights and placing themselves and their employers at risk of litigation.

I have often said that “informed choice” is a myth, and the stories being recounted by midwives in this current group reinforce my opinion. I find it hard to imagine treating another woman in this fashion - basic human dignity and respect are apparently in short supply in many hospital maternity units. The sooner we remove birth from these institutional settings and make the home birth option a reality for women everywhere, the better for our families and society.

Another goody waiting on my desk when I returned was a VBAC (Vaginal Birth After Caesarean) video from the US. This had been sent to us with a view to including it in our catalogue.

There is certainly a need for better information for parents on the issue of VBAC. Many women are talked into an unnecessary repeat caesarean when they have a very good chance (up to 80%) of having a perfectly straightforward vaginal birth. The main obstacles to increasing the VBAC rate are the convenience factor for doctors and hospitals, lack of confidence in supporting VBACs by caregivers, and women’s not unreasonable reluctance to be branded as a “trial of labour”.

Many women have suffered deep emotional trauma as a result of unexpected caesareans, and may be grieving from the questioning of their competence to birth successfully. It is our ability to give birth that is central to female sexuality, and any doubts cast on our capacity give birth well strike at the heart of our self image as women. These feelings may not be overtly recognised, but may be very real, influencing a woman’s willingness to once again be put to the test during the next labour.

Fathers are often traumatised by an emergency caesarean as well. It is very unlikely that anyone will have helped the father to resolve his feelings and his emotional state may also put pressure on his partner to accept a scheduled caesarean birth, rather than opt for a less predictable vaginal birth.

The video explored some of these issues. Fathers were not mentioned and there were no views of a VBAC labour that could be used as a teaching tool for women. The brief views of a “normal” birth showed the woman flat on her back. The baby (with a scalp electrode in place) was man handled out by an obstetrician, sucked out vigorously, whisked away to be tidied and wrapped tightly before being presented to the mother. It was a complete contrast to the midwife led births that we aim for in Australia and the UK. There were echos of “push, push” going on in the background and a large number of family and friends urging the woman on and celebrating afterwards. It was far from the “active birth” that we aim for here.

This is one video we won’t be stocking. I am hopeful that a video in the making in Queensland will be much more useful in promoting normal birth after caesarean, and show the benefits to be gained from supportive midwifery care. I feel it will be worth waiting for!

My in-tray was brimming with interesting articles/books/videos and letters when I reached my desk in Sydney. Some of these are worth sharing with you over the coming week.

The most exciting surprise was the Japanese edition of “Empowering Women”, which has finally been published. This project has been underway for some time, the idea for a Japanese edition being conceived way back in 1999. Yumi Okoso is an independent childbirth educator in Japan, whom I had met in 1997 when I presented a four day workshop for educators in Tokyo. We stayed in touch, and Yumi suggested that she translate this book into Japanese, as a guide for other educators and also for women who were interested in the topic.

In 2002 I signed a contract with a Japanese publisher, with Yumi to translate. It has taken some time, but at last it has arrived. It is strange to see familiar diagrams with Japanese characters instead of English!

I hope that it proves useful to those working in the Japanese birth services, as it has done in English speaking countries. I now need to get on with the Portugese and Spanish versions!